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Effect of Early Door to Balloon Time on Treatment with Adjunctive Therapy and Resultant Procedural Success in STEMI

Jeffrey Cook, Rajinder Marok, Peter Stecy, Kathleen Magurany, Nancy Davis and Lloyd W. Klein

Objectives: We studied whether earlier door-to-balloon (DTB) times affected use of standard adjunct medications (Rx), and the effect of differential Rx on PCI success. Background: Striving for earlier DTB times in STEMI is important, but rushing may negatively impact pt management. We studied whether earlier DTB times negatively affected use of standard adjunct Rx, pre-PCI chest x-ray (CXR), and the effect on PCI success.

Methods: 227 pts diagnosed with STEMI were taken directly for angiography. Rx use between 3 grps were compared: Grp A=DTB>90 (n=156), Grp B=DTB<90 (n=71), Grp C =DTB<60 (n=12). Differential Rx patterns were evaluated for effect on PCI success. Optimal PCI result was defined as post-PCI TIMI 3 flow and stenosis <50% in the infarct vessel.

Results: Fewer pts received all Rx pre-PCI in Grp B than in Grp A, 1.4% vs. 9.6% (p=0.02), including B-blk, 53.5% vs. 67.3% (p=0.01) heparin infusion (GTT), 19.7% vs. 46.8% (p<0.001), and IIb/IIIa GTT, 12.6 vs. 28.2% (p<0.01). Shorter DTB reduced duration of pre-PCI heparin and IIb/IIIa Rx (p<0.01), and performance of CXR, grps A/B/C at 89.7%/ 61.2%/ 41.7% (p<0.0001). When adjusted for other variables, DTB<90 was a significant predictor of less heparin GTT use, OR 0.3 ([0.17-0.55], p<0.0001). Pts in Q4 (>66min) of heparin pretreatment had more optimal PCI result (65.0%), vs. Q1 (0-30min) (41.0%) (p=0.02). Pts receiving heparin GTT had optimal results 66.2% vs. 50.0% (p=0.02), and higher TIMI 3 flow (69.8% vs. 53.2%, p=0.02). In this cohort, there was no significant difference in mortality based on DTB group, though use of B-blk and IIb/IIIa medications improved mortality and cardiac mortality, respectively.

Conclusion: In this cohort, earlier DTB times led to less complete adjunctive Rx and omission of diagnostic steps. Shorter pretreatment with heparin, and omission of heparin GTT, predicted less favorable procedural outcomes.