Door-to-balloon and door-to-needle time for ST-segment elevation myocardial infarction in the U.S.

n a recent thought-provoking commentary, Terkelsen et al. (1) rom Denmark recommended that the committee responsible for urther updates to the American College of Cardiology/American eart Association (ACC/AHA) guidelines for ST-segment eleation myocardial infarction (STEMI) and the D2B (Door-toalloon) Alliance shift focus toward initiates that would reduce ystem delay in primary percutaneous coronary intervention (PCI) atients. We are in strong support of such a system-based pproach to the management of STEMI patients at centers roviding full-time highly skilled and efficient care for these atients. We wish to corroborate their findings with the data vailable online at http://www.hospitalcompare.hhs.gov/, a quality nitiative tool created by the Centers for Medicare and Medicaid ervices, the Department of Health and Human Services, and the ospital Quality Alliance. Data on over 4,000 hospitals show that 27% of patients achieve door-to-needle (D2N) time of 30 min, and only 32% achieve D2N time of 90 min. Our analysis reveals a concerning trend orrelating neighborhood income with quality of care for STEMI atients as it relates to the D2B and D2N times. Of greater oncern is the overall rate of timely therapy, for both primary PCI nd fibrinolytic agents. Terkelsen et al. (1) comment on the current ontroversy regarding the acceptable PCI-related delay in deterining transfer to a PCI-capable hospital for primary PCI versus brinolysis. The meta-analysis from Nallamothu et al. (2,3) uggested a maximum of 60 min for PCI-related delay, after which brinolysis would result in greater benefit. This was incorporated n the 2004 ACC/AHA STEMI guidelines (4). Further metanalyses have suggested that PPCI was superior to fibrinolysis with ven longer PCI-related delays (5,6). Current literature (2) does ot provide a clear consensus on acceptable PCI-related delay, lthough the 2007 Focused Update of the ACC/AHA STEMI uidelines suggests a 40-min maximum acceptable PCI-related elay for patients living in the catchment area of non–PCI-capable ospitals. It also must be noted that these meta-analysis take into ccount a 30-min D2N time. Our analysis uncovers the very poor ates of provision of guideline-recommended care as it relates to brinolytic therapy. We believe that a closer look at the D2N times s warranted for a given institution before an automatic decision for pplying that strategy can be recommended if the PCI-related elay is prohibitive of a primary PCI strategy. This of course resents a very complex situation because the benefit of fibrinolytic herapy with a D2N 30 min compared with primary PCI when here is significant PCI-related delay is unclear.