Intended for healthcare professionals


Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: national cohort study

BMJ 2009; 338 doi: (Published 19 May 2009) Cite this as: BMJ 2009;338:b1807
  1. Saif S Rathore, MD/PhD student1,
  2. Jeptha P Curtis, assistant professor2,
  3. Jersey Chen, assistant professor2,
  4. Yongfei Wang, statistician3,
  5. Brahmajee K Nallamothu, assistant professor4,
  6. Andrew J Epstein, assistant professor5,
  7. Harlan M Krumholz, Harold H Hines Jr professor of medicine (cardiology) and epidemiology and public health236,
  8. for the National Cardiovascular Data Registry
  1. 1MD/PhD Program, Yale University School of Medicine, 367 Cedar Street, 316 ESH, New Haven, Connecticut 06510
  2. 2Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 3 FMP, PO Box 208017, New Haven, Connecticut 06520
  3. 3Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, One Church Street, Suite 200, New Haven, Connecticut 06510
  4. 4Cardiovascular Center, CVC Cardiovascular Medicine, University of Michigan Medical School, SPC 5869, 1500 E Medical Center Drive, Ann Arbor, Michigan 48109
  5. 5Section of Health Policy and Administration, Yale School of Public Health, 60 College Street, Room 301, PO Box 208034, New Haven, Connecticut 06520
  6. 6Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, PO Box 208088, New Haven, Connecticut 06520
  1. Correspondence to: S S Rathore saif.rathore{at}
  • Accepted 28 January 2009


Objective To 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.

Design Prospective cohort study of patients enrolled in the American College of Cardiology National Cardiovascular Data Registry, 2005-6.

Setting Acute care hospitals.

Participants 43 801 patients with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention.

Main outcome measure Mortality in hospital.

Results Median 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.

Conclusion Any 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.


  • Contributors: SSR, JPC, JC, BKN, HMK were responsible for conception and design. HMK acquired the data, which were analysed and interpreted by all authors. SSR drafted the manuscript, which was critically revised by all authors. SSR and YW were responsible for statistical analyses. HMK obtained funding and supervised the study. JPC and HMK provided administrative, technical, and material support. SSR, YW, and HMK are guarantors.

  • Funding and statement of independence from funding sources: This manuscript is the result of an unfunded analysis of the American College of Cardiology National Cardiovascular Data Registry. Although the sponsor was responsible for data collection, data management, and review of the manuscript before submission, they had no role in the design or conduct of this study, data analysis, interpretation of the data, manuscript preparation, or approval of the manuscript. SSR and JPC are supported, in part, by CTSA Grant Number UL1 RR024139 from the National Institutes of Health’s Center for Research Resources. SSR is also supported by the National Institute of General Medical Sciences Medical Scientist Training Program grant 5T32GM07205.

  • Competing interests: None declared.

  • Ethical approval: Analysis of the American College of Cardiology National Cardiovascular Data Registry database was approved by the Yale University School of Medicine Human Investigation Committee, New Haven, Connecticut.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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