Time to think beyond door to balloon time: significance of total ischemic time in STEMI

Abstract

Background Significance of total ischemic time (TIT) in the context of ST-segment elevation myocardial infarction (STEMI) is still controversial. Therefore, in this study, we have evaluate the association of TIT with immediate outcomes in STEMI patients in whom recommended door to balloon (DTB) time of less than 90 min was achieved. Results A total of 5730 patients were included in this study, out of which 80.9% were male and median age was 55 [61–48] years. The median DTB was observed to be 60 [75–45] min and onset of chest pain to emergency room (ER) arrival time was 180 [300–120] min. Prolonged TIT was associated with poor pre-procedure thrombolysis in myocardial infarction (TIMI) flow grade (p = 0.022), number of diseased vessels (p = 0.002), use of intra-aortic balloon pump (p = 0.003), and in-hospital mortality (p = 0.002). Mortality rate was 4.5%, 5.7%, and 7.8% for the patients with TIT of ≤ 120 min, 121 to 240 min, and > 240 min, respectively. Thirty days’ risk of mortality on TIMI score was 4.97 ± 7.09%, 5.01 ± 6.99%, and 7.12 ± 8.64% for the patients with TIT of ≤ 120 min, 121 to 240 min, and > 240 min, respectively. Conclusions Prolonged total ischemic was associated with higher in-hospital mortality. Therefore, TIT can also be considered in the matrix of focus, along with DTB time and other clinical determinants to improve the survival from STEMI.

Total Ischemic Time on In-Hospital Complication Predictor in ST-Elevation Myocardial Infarction (STEMI) Patients With Renal Dysfunction

“…Numerous studies have demonstrated the connection between TIT and the prognosis following PCI in patients with STEMI [16,22]. This study's key conclusion was the identification of a direct link between TIT and various in-hospital complications, such as pulmonary edema and cardiogenic shock.…”

Incremental prognostic value of speckle tracking echocardiography and early follow‐up echo assessment in predicting left ventricular recovery after reperfusion for ST‐segment elevation myocardial infarction (STEMI)

“…The duration of ischemia was demonstrated to be a major predictor of poor clinical outcomes in large therapeutic trials in STEMI patients utilising either thrombolysis or primary PCI 33 . Even when the optimal door‐to‐balloon time was met in a prior trial, a longer ischemia duration was associated with higher in‐hospital mortality 34 …”

Impact of Total Ischemic Time on Clinical Outcomes in Patients With ST-Elevation Myocardial Infarction: Lost Time Is Never Found Again

“…In this prospective study, we endeavored to assess the association of TIT with clinical outcomes in STEMI patients undergoing PCI and observed that the mortality rates were higher with prolonged TIT during the hospital stay and at one-year follow-up, but the values were not statistically significant. The high mortality with prolongation of ischemic time may be due to the fact that infarct size significantly affects myocardial tissue and continues to damage with each passing second of ischemic time [8][9][10][11]. As a result, even with optimal reperfusion (primary PCI), prolonged ischemic time may result in increased mortality as well as decreased myocardial salvage [11][12][13].…”

“…The high mortality with prolongation of ischemic time may be due to the fact that infarct size significantly affects myocardial tissue and continues to damage with each passing second of ischemic time [8][9][10][11]. As a result, even with optimal reperfusion (primary PCI), prolonged ischemic time may result in increased mortality as well as decreased myocardial salvage [11][12][13]. In this study, there were two (2.4%) cardiac deaths with prolonged TIT during the hospital stay, and this value was 6 (7.2%) at one-year follow-up.…”

“…Ample of evidence has confirmed TIT as an independent predictor of short- and long-term mortality in patients with STEMI [ 5 , 12 , 16 , 17 ]. A growing body of evidence has supported the concept that TIT can be a better prognostic factor of mortality as opposed to D2B time [ 11 , 17 , 18 ]; hence, recent emerging trends show the way toward more utilization of TIT as a quality indicator than D2B time in predicting mortality. Given that D2B time shortening is associated with reduction in mortality after primary PCI [ 19 ], it should not be regarded as the sole quality indicator.…”