Author + information
- Stephen G. Ellis, MD* (, )
- Samar Kapadia, MD and
- Frederick Heupler, MD
- ↵*Cleveland Clinic, 9500 Euclid Avenue, J2-3, Cleveland, Ohio 44195
Numerous broad-based studies, including that from the U.S. National Registry of Myocardial Infarction (1), have convincingly shown a direct relationship between door-to-balloon time and in-hospital mortality for patients treated with primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. Presumably, the principal reason for this observation is that ischemic time, and hence infarct size, is limited by early reperfusion (2). Some data suggest, however, that the reduction in mortality is due to greater overall quality of care rather than reperfusion time per se (3).
Fast door-to-balloon times require a multidisciplinary system approach. This has been carefully studied and noted to include, when possible, paramedic electrocardiogram transfer to alert the receiving team, single-page activation of the on-call team, and a quality control program with system feedback, all of which, to a large degree, are under control of the emergency medical services–emergency room–interventional cardiology “system.” There are a number of factors that might adversely affect door-to-balloon time that are beyond the control of the team, including difficult consent process, need to exclude serious comorbidities that might influence concomitant drug therapy for primary percutaneous coronary intervention (e.g., intracranial hemorrhage for a patient found down and resuscitated), and cardiac arrest occurring between the time of emergency department arrival and initiation of percutaneous intervention. Some other potential causes for delay are well within the control of the interventionalist team, including weekend/off-hours staffing, skillful vascular access, and rapid cannulation of the infarct-related artery.
Door-to-balloon-time metrics can be appropriately used both for internal quality control and for external comparison. For internal quality control, the hospital might choose to exclude patients with certain comorbidities, and as long as they are consistent in doing so, they can track improvements in outcome and even compare among operators. For external comparison, however, particularly in the “pay for performance” era, the exclusion rules must be applied uniformly. Ideally, reasons for exclusion should not be subjective or easily “gamed.” Few, it would seem, would argue with these ground rules.
Therefore, when the most recent ACC NCDR-revised reasons for patient exclusion in door-to-balloon time analysis were announced (4)—most notably difficult vascular access or difficulty in crossing the culprit lesion, both highly subjective and easily used to explain a poor door-to-balloon time—it struck us as inappropriate. In fact, when we heard these exclusions described, our initial commentary was “this would allow for an abrogation of responsibility” or, more colorfully, “this is a weasel clause!”
Physicians are under fire from multiple quarters due to perceived lack of integrity arising from the activities of some of our colleagues. We call for a retraction of such subjective and easily manipulated exclusions immediately. Should that not be possible, or meet with illogical resistance, at a minimum, each site should be required to report the percentage of patients with ST-segment elevation myocardial infarction that were excluded from “reportable” door-to-balloon time.
- American College of Cardiology Foundation
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- American College of Cardiology National Cardiovascular Data Registry