Mayo Clinic Proceedings Home

Aggressive Measures to Decrease “Door to Balloon” Time and Incidence of Unnecessary Cardiac Catheterization: Potential Risks and Role of Quality Improvement

Published:November 05, 2015DOI:



      To assess the impact of an aggressive protocol to decrease the time from hospital arrival to onset of reperfusion therapy (“door to balloon [DTB] time”) on the incidence of false-positive (FP) diagnosis of ST-segment elevation myocardial infarction (STEMI) and in-hospital mortality.

      Patients and Methods

      The study population included 1031 consecutive patients with presumed STEMI and confirmed ST-segment elevation who underwent emergent catheterization between July 1, 2008, and December 1, 2012, On July 1, 2009, we instituted an aggressive protocol to reduce DTB time. A quality improvement (QI) initiative was introduced on January 1, 2011, to maintain short DTB while improving outcomes. Outcomes were compared before and after the initiation of the DTB time protocol and similarly before and after the QI initiative. Outcomes were DTB time, the incidence of FP-STEMI, and in-hospital mortality. A review of the emergency catheterization database for the 10-year period from January 1, 2001, through December 31, 2010, was performed for historical comparison.


      Of the 1031 consecutive patients with presumed STEMI who were assessed, 170 were considered to have FP-STEMI. The median DTB time decreased significantly from 76 to 61 minutes with the aggressive DTB time protocol (P=.001), accompanied by an increase of FP-STEMI (7.7% vs 16.5%; P=.02). Although a nonsignificant reduction of in-hospital mortality occurred in patients with true-positive STEMI (P=.60), a significant increase in in-hospital mortality was seen in patients with FP-STEMI (P=.03). After the QI initiative, a shorter DTB time (59 minutes) was maintained while decreasing FP-STEMI in-hospital mortality.


      Aggressive measures to reduce DTB time were associated with an increased incidence of FP-STEMI and FP-STEMI in-hospital mortality. Efforts to reduce DTB time should be monitored systematically to avoid unnecessary procedures that may delay other appropriate therapies in critically ill patients.

      Abbreviations and Acronyms:

      DTB (“door to balloon”), ECG (electrocardiography), FP (false-positive), QI (quality improvement), STEMI (ST-segment elevation myocardial infarction), TP (true-positive)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Mayo Clinic Proceedings
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Keeley E.C.
        • Boura J.A.
        • Grines C.L.
        Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials.
        Lancet. 2003; 361: 13-20
        • Berger P.B.
        • Ellis S.G.
        • Holmes Jr., D.R.
        • et al.
        Relationship between delay in performing direct coronary angioplasty and early clinical outcome in patients with acute myocardial infarction: results from the Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes (GUSTO-IIb) trial.
        Circulation. 1999; 100: 14-20
        • Brodie B.R.
        • Gersh B.J.
        • Stuckey T.
        • et al.
        When is door-to-balloon time critical? analysis from the HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) and CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) trials.
        J Am Coll Cardiol. 2010; 56 ([published correction appears in J Am Coll Cardiol. 2010;56(14):1168]): 407-413
        • Brodie B.R.
        • Stuckey T.D.
        • Wall T.C.
        • et al.
        Importance of time to reperfusion for 30-day and late survival and recovery of left ventricular function after primary angioplasty for acute myocardial infarction.
        J Am Coll Cardiol. 1998; 32: 1312-1319
        • Cannon C.P.
        • Gibson C.M.
        • Lambrew C.T.
        • et al.
        Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction.
        JAMA. 2000; 283: 2941-2947
        • Lambert L.
        • Brown K.
        • Segal E.
        • Brophy J.
        • Rodes-Cabau J.
        • Bogaty P.
        Association between timeliness of reperfusion therapy and clinical outcomes in ST-elevation myocardial infarction.
        JAMA. 2010; 303: 2148-2155
        • McNamara R.L.
        • Wang Y.
        • Herrin J.
        • et al.
        • NRMI Investigators
        Effect of door-to-balloon time on mortality in patients with ST-segment elevation myocardial infarction.
        J Am Coll Cardiol. 2006; 47: 2180-2186
        • Rathore S.S.
        • Curtis J.P.
        • Chen J.
        • et al.
        • National Cardiovascular Data Registry
        Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: national cohort study.
        BMJ. 2009; 338: b1807
        • Ryan T.J.
        • Antman E.M.
        • Brooks N.H.
        • et al.
        1999 Update: ACC/AHA Guidelines for the Management of Patients With Acute Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction).
        J Am Coll Cardiol. 1999; 34: 890-911
        • Gibson C.M.
        • Pride Y.B.
        • Frederick P.D.
        • et al.
        Trends in reperfusion strategies, door-to-needle and door-to-balloon times, and in-hospital mortality among patients with ST-segment elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from 1990 to 2006.
        Am Heart J. 2008; 156: 1035-1044
        • Bradley E.H.
        • Nallamothu B.K.
        • Herrin J.
        • et al.
        National efforts to improve door-to-balloon time results from the Door-to-Balloon Alliance.
        J Am Coll Cardiol. 2009; 54: 2423-2429
        • O'Gara P.T.
        • Kushner F.G.
        • Ascheim D.D.
        • et al.
        2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary; a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
        Circulation. 2013; 127: 529-555
        • Rogers W.J.
        • Canto J.G.
        • Lambrew C.T.
        • et al.
        Temporal trends in the treatment of over 1.5 million patients with myocardial infarction in the US from 1990 through 1999: the National Registry of Myocardial Infarction 1, 2 and 3.
        J Am Coll Cardiol. 2000; 36: 2056-2063
        • Barnes G.D.
        • Katz A.
        • Desmond J.S.
        • et al.
        False activation of the cardiac catheterization laboratory for primary PCI.
        Am J Manag Care. 2013; 19: 671-675
        • Masoudi F.A.
        Measuring the quality of primary PCI for ST-segment elevation myocardial infarction: time for balance.
        JAMA. 2007; 298 ([editorial]): 2790-2791
        • Grines C.L.
        • Schreiber T.
        Primary percutaneous coronary intervention: the deception of delay.
        J Am Coll Cardiol. 2013; 61 ([editorial]): 1696-1697
        • Larson D.M.
        • Menssen K.M.
        • Sharkey S.W.
        • et al.
        “False-positive” cardiac catheterization laboratory activation among patients with suspected ST-segment elevation myocardial infarction.
        JAMA. 2007; 298: 2754-2760
        • Bradley E.H.
        • Herrin J.
        • Wang Y.
        • et al.
        Strategies for reducing the door-to-balloon time in acute myocardial infarction.
        N Engl J Med. 2006; 355: 2308-2320
        • Krumholz H.M.
        • Bradley E.H.
        • Nallamothu B.K.
        • et al.
        A campaign to improve the timeliness of primary percutaneous coronary intervention: Door-to-Balloon: An Alliance for Quality.
        JACC Cardiovasc Interv. 2008; 1: 97-104
        • Bates E.R.
        • Jacobs A.K.
        Time to treatment in patients with STEMI.
        N Engl J Med. 2013; 369: 889-892
        • Thygesen K.
        • Alpert J.S.
        • Jaffe A.S.
        • Simoons M.L.
        • Chaitman B.R.
        • White H.D.
        • Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction
        Third universal definition of myocardial infarction.
        Circulation. 2012; 126: 2020-2035
        • Wang K.
        • Asinger R.W.
        • Marriott H.J.
        ST-segment elevation in conditions other than acute myocardial infarction.
        N Engl J Med. 2003; 349: 2128-2135
        • Smith S.B.
        • Geske J.B.
        • Maguire J.M.
        • Zane N.A.
        • Carter R.E.
        • Morgenthaler T.I.
        Early anticoagulation is associated with reduced mortality for acute pulmonary embolism.
        Chest. 2010; 137: 1382-1390
        • Mooney M.R.
        • Unger B.T.
        • Boland L.L.
        • et al.
        Therapeutic hypothermia after out-of-hospital cardiac arrest: evaluation of a regional system to increase access to cooling.
        Circulation. 2011; 124: 206-214
        • Anderson H.V.
        • Shaw R.E.
        • Brindis R.G.
        • et al.
        A contemporary overview of percutaneous coronary interventions: the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR).
        J Am Coll Cardiol. 2002; 39: 1096-1103
        • McCabe J.M.
        • Armstrong E.J.
        • Kulkarni A.
        • et al.
        Prevalence and factors associated with false-positive ST-segment elevation myocardial infarction diagnoses at primary percutaneous coronary intervention–capable centers: a report from the Activate-SF Registry.
        Arch Intern Med. 2012; 172: 864-871
        • Gaba D.M.
        • Howard S.K.
        Patient safety: fatigue among clinicians and the safety of patients.
        N Engl J Med. 2002; 347: 1249-1255
        • Menees D.S.
        • Peterson E.D.
        • Wang Y.
        • et al.
        Door-to-balloon time and mortality among patients undergoing primary PCI.
        N Engl J Med. 2013; 369: 901-909
        • Flynn A.
        • Moscucci M.
        • Share D.
        • et al.
        Trends in door-to-balloon time and mortality in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.
        Arch Intern Med. 2010; 170: 1842-1849