• Saif S Rathore, Jeptha P Curtis, Jersey Chen, Yongfei Wang, Brahmajee K Nallamothu, Andrew J Epstein, Harlan M Krumholz, and National Cardiovascular Data Registry.
• Yale University School of Medicine, 367 Cedar Street, 316 ESH, New Haven, Connecticut 06510, USA. saif.rathore@yale.edu
• BMJ. 2009 Jan 1;338:b1807.

ObjectiveTo evaluate the association between door-to-balloon time and mortality in hospital in patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction to assess the incremental mortality benefit of reductions in door-to-balloon times of less than 90 minutes.DesignProspective cohort study of patients enrolled in the American College of Cardiology National Cardiovascular Data Registry, 2005-6.SettingAcute care hospitals.Participants43 801 patients with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention.Main Outcome MeasureMortality in hospital.ResultsMedian door-to-balloon time was 83 minutes (interquartile range 6-109, 57.9% treated within 90 minutes). Overall mortality in hospital was 4.6%. Multivariable logistic regression models with fractional polynomial models indicated that longer door-to-balloon times were associated with a higher adjusted risk of mortality in hospital in a continuous non-linear fashion (30 minutes=3.0%, 60 minutes=3.5%, 90 minutes=4.3%, 120 minutes=5.6%, 150 minutes=7.0%, 180 minutes=8.4%, P<0.001). A reduction in door-to-balloon time from 90 minutes to 60 minutes was associated with 0.8% lower mortality, and a reduction from 60 minutes to 30 minutes with a 0.5% lower mortality.ConclusionAny delay in primary percutaneous coronary intervention after a patient arrives at hospital is associated with higher mortality in hospital in those admitted with ST elevation myocardial infarction. Time to treatment should be as short as possible, even in centres currently providing primary percutaneous coronary intervention within 90 minutes.

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