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

To assess the impact of aggressive protocol to decrease door-to-balloon (DTB) time on the incidence of false-positive STEMI (FP-STEMI) and in-hospital mortality

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

OBJECTIVES: To assess the impact of aggressive protocol to decrease door-to-balloon (DTB) time on the incidence of false-positive STEMI (FP-STEMI) and in-hospital mortality. PATIENTS: Consecutive patients with presumed STEMI with confirmed ST-segment elevation that underwent emergent catheterization. METHODS: In July 1, 2009 we instituted an aggressive protocol to further reduce DTB time. A quality improvement (QI) initiative was initiated in January 1, 2010 to maintain short DTB while improving outcomes. Outcomes were compared before and after aggressive DTB 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 over the last 10 years (January 2001-December 2010) was carried out for historical comparison. RESULTS: Between July 1, 2008 and December 1, 2012, 1031 consecutive patients with presumed STEMI were assessed. Of these 170 were considered FP-STEMI. The median DTB time decreased from 76 to 61 minutes with the aggressive DTB protocol (P=. 001), accompanied by an increase of FP-STEMI (7.7% vs. 16.5%, p=.02). While TP-STEMI in-hospital mortality witnessed non-significant reduction, this was associated with a significant increase of FP-STEMI in-hospital mortality. After the QI initiative, a shorter DTB time (59 minutes) was maintained while decreasing FP-STEMI in-hospital mortality. CONCLUSION: 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 delays other appropriate therapies in critically ill patients