Reducing door-to-balloon time in ST-segment elevation myocardial infarction: are we missing the forest for the trees?

occlusion. Thus, from a mechanistic perspective, achieving early vessel patency limits the extent of myocardial injury. The term ‘door-to-balloon (DTB) time’, defined as the time from first medical contact to the time of first coronary device deployment, has become a mantra of STEMI management. First medical contact, often poorly characterized in the field, is usually defined by time of hospital door arrival. Clinical trial and observational data have shown that shorter DTB times correlate with improved outcomes [6–8]. In the GUSTO-IIb clinical trial, 30-day mortality was 1.0% for PPCI performed within 60 min of study enrollment, 3.7% for PPCI between 61 and 75 min, 4.0% for PPCI between 76 and 90 min and 6.4% for PPCI performed after 90 min, the odds of death increasing 1.6-fold for each increasing time interval. A recent large registry study analyzed data from 43,801 patients in the American College of Cardiology (ACC) National Cardiovascular Data Registry (NCDR) and showed that adjusted in-hospital mortality was 3.5, 4.3, 5.6 and 7.0% for DTB times of 30, 60, 90 and 120 min, respectively [9]. Current ACC/American Heart Association (AHA) and European Society of Cardiology guidelines both recommend that PPCI be performed within 90 min of the patient’s first contact with m edical personnel [1,10].