Health care system delay may increase risk of death for heart patients receiving reperfusion therapy


For patients with a certain type of heart attack, delay in the time between first contact with emergency medical service to initiation of therapy such as balloon angioplasty is associated with an increased risk of death, according to a study in the August 18th issue of JAMA.

Timely reperfusion therapy with either fibrinolysis (the dissolution of fibrin) or primary percutaneous coronary intervention (PCI) is recommended for patients with ST-segment elevation myocardial infarction (STEMI).


Door-to-balloon delay has been proposed as a performance measure in triaging patients for primary PCI. “However, focusing on the time from first contact with the health care system to the initiation of reperfusion therapy (system delay) may be more relevant, because it constitutes the total time to reperfusion modifiable by the health care system. No previous studies have focused on the association between system delay and outcome in patients with STEMI treated with primary PCI,” the authors write.


Dr Christian Juhl Terkelsen of Aarhus University Hospital in Denmark and colleagues assessed the associations between treatment, patient, system, and door-to-balloon delays and mortality in a large group of patients with STEMI treated with primary PCI. The study included data from Danish medical registries of patients with STEMI transported by emergency medical service and treated with primary PCI from January 2002 to December 2008 at three high-volume PCI centres in Western Denmark. Patients underwent primary PCI within 12 hours of symptom onset. The median follow-up time was 3.4 years.


The researchers found that when stratified according to intervals of system delay, long-term cumulative mortality was 15.4% in patients with system delays of up to an hour, 23.3% in those with delays of one to two hours, 28.1% in those with delays of two to three hours, and 30.8% in those with delays of three to four hours. “Health care system delay is valuable as a performance measure when patients with STEMI are treated with primary PCI, because it is associated with mortality, it constitutes the part of treatment delay modifiable by the health care system in the acute phase, and it applies to patients field-triaged directly to the PCI centre as well as to patients transferred from local hospitals,” researchers concluded. They added that “increased focus on the total health care system delay may be the key to further improving survival of these patients.”