Door-to-balloon

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Door-to-balloon is a time measurement in emergency cardiac care (ECC), specifically in the treatment of ST segment elevation myocardial infarction (or STEMI). The interval starts with the patient's arrival in the emergency department, and ends when a catheter guidewire crosses the culprit lesion in the cardiac cath lab. Because of the adage that "time is muscle", meaning that delays in treating a myocardial infarction increase the likelihood and amount of cardiac muscle damage due to localised hypoxia,[1][2][3][4] ACC/AHA guidelines recommend a door-to-balloon interval of no more than 90 minutes.[5] Currently fewer than half of STEMI patients receive reperfusion with primary percutaneous coronary intervention within the guideline-recommended timeframe.[6][7] It has become a core quality measure for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).[8][9][10]

Improving door-to-balloon times

Door to Balloon (D2B) Initiative

The benefit of prompt, expertly performed primary percutaneous coronary intervention over thrombolytic therapy for acute ST elevation myocardial infarction is now well established.[11] Few hospitals can provide PCI within the 90 minute interval,[12] which prompted the American College of Cardiology (ACC) to launch a national Door to Balloon (D2B) Initiative in November of 2006. The D2B Alliance seeks to "take the extraordinary performance of a few hospitals and make it the ordinary performance of every hospital."[13] Over 800 hospitals have joined the D2B Alliance as of March 16, 2007.[14]

The D2B Alliance advocates six key evidence-based strategies and one optional strategy to help reduce door-to-balloon times:[13][15]

  1. ED physician activates the cath lab
  2. Single-call activation system activates the cath lab
  3. Cath lab team is available within 20-30 minutes
  4. Prompt data feedback
  5. Senior management commitment
  6. Team based approach
  7. (Optional) Prehospital 12 lead ECG activates the cath lab

Practical strategies at your site to reduce Door-to-Balloon times

The following strategies can be utilized to reduce door to balloon times:

  1. Have emergency medical service (EMS) personnel activate the cardiac catheterization laboratory directly
  2. Require that nurses, technicians and physicians remain within 30 minutes of the hospital while on call
  3. Require that nurses, technicians and physicians sleep in the hospital while on call
  4. Optimize door to EKG and EKG to decision times
  5. Activate the cardiac catheterization laboratory team with a single phone call using batch paging
  6. Have a "sterile table" prepared in the cardiac catheterization laboratory so that no time is wasted gathering equipment and supplies.
  7. Ask the CCU nurse and or ER nurse to assist the cath lab nurse in transporting and readying the patient for cardiac catheterization.
  8. Do not perform right heart catheterization or left heart catheterization before the intervention
  9. Only obtain venous access if the patient is hemodynamically unstable or if there is likely going to be the need to a temporary pacemaker
  10. Perform angiography of the culprit lesion first. There is a lack of consensus on this point. Some operators prefer to perform angiography of the non-culprit lesion first to assess the extent of disease. The Editor-In-Chief, CM Gibson prefers to assess the non-culprit lesion first. The non-culprit lesion may in fact turn out to be the culprit lesion.

Mission: Lifeline

On May 30, 2007, the American Heart Association launched 'Mission: Lifeline', a "community-based initiative aimed at quickly activating the appropriate chain of events critical to opening a blocked artery to the heart that is causing a heart attack."[16] It is seen as complementary to the ACC's D2B Initiative.[17] The program will concentrate on patient education to make the public more aware of the signs of a heart attack and the importance of calling 9-1-1 for emergency medical services (EMS) for transport to the hospital.[16] In addition, the program will attempt to improve the diagnosis of STEMI patients by EMS personnel.[16] According to Alice Jacobs, MD, who led the work group that addressed STEMI systems,[18] when patients arrive at non-PCI hospitals they will stay on the EMS stretcher with paramedics in attendance while a determination is made as to whether or not the patient will be transferred.[18] For walk-in STEMI patients at non-PCI hospitals, EMS calls to transfer the patient to a PCI hospital should be handled with the same urgency as a 9-1-1 call.[18]

EMS-to-balloon (E2B)

Although incorporating a prehospital 12 lead ECG into critical pathways for STEMI patients is listed as an optional strategy by the D2B Alliance, the fastest median door-to-balloon times have been achieved by hospitals with paramedics who perform 12 lead ECGs in the field.[19] EMS can play a key role in reducing the first-medical-contact-to-balloon time, sometimes referred to as EMS-to-balloon (E2B) time,[20] by performing a 12 lead ECG in the field and using this information to triage the patient to the most appropriate medical facility.[21][22][23]

Depending on how the prehospital 12 lead ECG program is structured, the 12 lead ECG can be transmitted to the receiving hospital for physician interpretation, interpreted on-site by appropriately trained paramedics, or interpreted on-site by paramedics with the help of computerized interpretive algorithms.[24] Some EMS systems utilize a combination of all three methods.[20] Prior notification of an in-bound STEMI patient enables time saving decisions to be made prior to the patient's arrival. This may include a "cardiac alert" or "STEMI alert" that calls in off duty personnel in areas where the cardiac cath lab is not staffed 24 hours a day.[20] The 30-30-30 rule takes the goal of achieving a 90 minute door-to-balloon time and divides it into three equal time segments. Each STEMI care provider (EMS, the emergency department, and the cardiac cath lab) has 30 minutes to complete its assigned tasks and seamlessly "hand off" the STEMI patient to the next provider.[20] In some locations, the emergency department may be bypassed altogether.[25]

In some locations, a prehospital 12 lead ECG may be transmitted to the emergency department with the use of a Bluetooth capable cardiac monitor and cell phone.

Common themes in hospitals achieving rapid door-to-balloon times

Bradley et al. (Circulation 2006) performed a qualitative analysis of 11 hospitals in the National Registry of Myocardial Infarction that had median door-to-ballon times = or < 90 minutes. They identified 8 themes that were present in all 11 hospitals:[7]

  1. An explicit goal of reducing door-to-balloon times
  2. Visible support of senior management
  3. Innovative, standardized protocols
  4. Flexibility in implementing standardized protocols
  5. Uncompromising individual clinical leaders
  6. Collaborative interdisciplinary teams
  7. Data feedback to monitor progress and identify problems or successes
  8. Organizational culture that fostered persistence despite challenges and setbacks

Criteria for an ideal primary PCI center

Granger et al. (Circulation 2007) identified the following criteria of an ideal primary PCI center.[24]

Institutional resources

  1. Primary PCI is the routine treatment for eligible STEMI patients 24 hours a day, 7 days a week
  2. Primary PCI is performed as soon as possible
  3. Institution is capable of providing supportive care to STEMI patients and handling complications
  4. Written commitment by hospital administration to support the program
    1. Identifies physician director for PCI program
    2. Creates multidisciplinary group that includes input from all relevant stakeholders, including cardiology, emergency medicine, nursing, and EMS
  5. Institution designs and implements a continuing education program
  6. For institution without on-site surgical backup, there is a written agreement with tertiary institution and EMS to provide for rapid transfer of STEMI patients when needed

Physician resources

  1. Interventional cardiologists meet ACC/AHA criteria for competence
  2. Interventional cardiologists participate in, and are responsive to formal on-call schedule

Program requirements

  1. Minimum of 36 primary PCI procedures and 400 total PCI procedures annually
  2. Program is described in a "manual of operations" that is compliant with ACC/AHA guidelines
  3. Mechanisms for monitoring program performance and ongoing quality improvement activities

Other features of ideal system

  1. Robust data collection and feedback including door-to-balloon time, first door-to-balloon time (for transferred patients), and the proportion of eligible patients receiving some form of reperfusion therapy
  2. Earliest possible activation of the cardiac cath lab, based on prehospital ECG whenever possible, and direct referral to PCI-hospital based on field diagnosis of STEMI
  3. Standardized ED protocols for STEMI management
  4. Single phone call activation of cath lab that does not depend on cardiologist interpretation of ECG

Gaps and barriers to timely access to primary PCI

Granger et al. (Circulation 2007) identified the following barriers to timely access to primary PCI.[24]

  1. Busy PCI hospitals may have to divert patients
  2. Significant delays in ED diagnosis of STEMI may occur, particularly when patient does not arrive by EMS
  3. Manpower and financial considerations may prevent smaller PCI programs from providing primary PCI for STEMI 24 hours a day
  4. Reimbursement for optimal coordination of STEMI patients needs to be realigned to reflect performance
  5. In most PCI centers, cath lab staff is off-site during off hours, requiring a mandate that staff report with 20-30 minutes of cath lab activation

2013 Revised and 2009 and 2007 Focused Updates: ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction (DO NOT EDIT)[26][27][5]

Regional Systems of STEMI Care, Triage, Transfer for PCI, Reperfusion Therapy, and Time-to-Treatment Goals (DO NOT EDIT)[26][27]

Class I
"1. All communities should create and maintain a regional system of STEMI care that includes assessment and continuous quality improvement of emergency medical services and hospital-based activities. Performance can be facilitated by participating in programs such as Mission: Lifeline and the Door-to-Balloon Alliance.[28][29][30][31] (Level of Evidence: B)"
"2. Emergency medical services transport directly to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI, with an ideal FMC-to-device time system goal of 90 minutes or less.[31][32][33] (Level of Evidence: B)"
"3. Immediate transfer to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI who initially arrive at or are transported to a non–PCI-capable hospital, with an FMC-to-device time system goal of 120 minutes or less. [34][35][36][37] (Level of Evidence: B)"
"4. Immediate transfer to a PCI-capable hospital for coronary angiography is recommended for suitable patients with STEMI who develop cardiogenic shock or acute severe HF, irrespective of the time delay from MI onset. [38](Level of Evidence: B)"
"5. In the absence of contraindications, fibrinolytic therapy should be administered to patients with STEMI at non–PCI-capable hospitals when the anticipated FMC-to-device time at a PCI-capable hospital exceeds 120 minutes because of unavoidable delays.[39][40][41] (Level of Evidence: B)"
"6. When fibrinolytic therapy is indicated or chosen as the primary reperfusion strategy, it should be administered within 30 minutes of hospital arrival.[42][43][44][45][46] (Level of Evidence: B)"
Class IIa
"1. It is reasonable for high-risk patients who receive fibrinolytic therapy as primary reperfusion therapy at a non–PCI-capable facility to be transferred as soon as possible to a PCI-capable facility where PCI can be performed either when needed or as a pharmacoinvasive strategy. Consideration should be given to initiating a preparatory antithrombotic (anticoagulant plus antiplatelet) regimen before and during patient transfer to the catheterization laboratory. [47][48](Level of Evidence: B)"
"2. Urgent transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who demonstrate evidence of failed reperfusion or reocclusion after fibrinolytic therapy.[49][50][51][52][53][54][55](Level of Evidence: B)"
"3. Transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who have received fibrinolytic therapy even when hemodynamically stable and with clinical evidence of successful reperfusion. Angiography can be performed as soon as logistically feasible at the receiving hospital, and ideally within 24 hours, but should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy. [56][57][58][59][60][61](Level of Evidence: B)"
Class IIb
"1. Patients who are not at high risk who receive fibrinolytic therapy as primary reperfusion therapy at a non–PCI-capable facility may be considered for transfer as soon as possible to a PCI-capable facility where PCI can be performed either when needed or as a pharmacoinvasive strategy. Consideration should be given to initiating a preparatory antithrombotic (anticoagulant plus antiplatelet) regimen before and during patient transfer to the catheterization laboratory. (Level of Evidence: C)"

Reperfusion (DO NOT EDIT) [26][5]

Class I
"1. Reperfusion therapy should be administered to all eligible patients with STEMI with symptom onset within the prior 12 hours.[39][62] (Level of Evidence: A)"
"2. STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 minutes of first medical contact as a systems goal. (Level of Evidence: A)"
"3. STEMI patients presenting to a hospital without PCI capability and who cannot be transferred to a PCI center and undergo PCI within 90 minutes of first medical contact should be treated with fibrinolytic therapy within 30 minutes of hospital presentation as a systems goal unless fibrinolytic therapy is contraindicated. (Level of Evidence: B)"
Class IIa
"1. Reperfusion therapy is reasonable for patients with STEMI and symptom onset within the prior 12 to 24 hours who have clinical and/or ECG evidence of ongoing ischemia. Primary PCI is the preferred strategy in this population. [39][63][64](Level of Evidence: B)"

References

  1. ↑ Soon CY, Chan WX, Tan HC (2007). "The impact of time-to-balloon on outcomes in patients undergoing modern primary angioplasty for acute myocardial infarction". Singapore medical journal. 48 (2): 131–6. PMID 17304392.
  2. ↑ Arntz HR, Bossaert L, Filippatos GS (2005). "European Resuscitation Council guidelines for resuscitation 2005. Section 5. Initial management of acute coronary syndromes". Resuscitation. 67 Suppl 1: S87–96. doi:10.1016/j.resuscitation.2005.10.003. PMID 16321718.
  3. ↑ De Luca G, van't Hof AW, de Boer MJ; et al. (2004). "Time-to-treatment significantly affects the extent of ST-segment resolution and myocardial blush in patients with acute myocardial infarction treated by primary angioplasty". Eur. Heart J. 25 (12): 1009–13. doi:10.1016/j.ehj.2004.03.021. PMID 15191770.
  4. ↑ Cannon CP, Gibson CM, Lambrew CT; et al. (2000). "Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction". JAMA. 283 (22): 2941–7. PMID 10865271.
  5. ↑ 5.0 5.1 5.2 Antman EM, Hand M, Armstrong PW; et al. (2008). "2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee". Circulation. 117 (2): 296–329. doi:10.1161/CIRCULATIONAHA.107.188209. PMID 18071078. Unknown parameter |month= ignored (help)
  6. ↑ Gibson CM, Pride YB, Frederick PD; et al. (2008). "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. 156 (6): 1035–44. doi:10.1016/j.ahj.2008.07.029. PMID 19032997. Unknown parameter |month= ignored (help)
  7. ↑ 7.0 7.1 Bradley EH, Curry LA, Webster TR; et al. (2006). "Achieving rapid door-to-balloon times: how top hospitals improve complex clinical systems". Circulation. 113 (8): 1079–85. doi:10.1161/CIRCULATIONAHA.105.590133. PMID 16490818.
  8. ↑ National Hospital Quality Measures/The Joint Commission Core Measures Joint Commission on Accreditation of Healthcare Organizations, Retrieved on June 30, 2007.
  9. ↑ Larson DM, Sharkey SW, Unger BT, Henry TD (2005). "Implementation of acute myocardial infarction guidelines in community hospitals". Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 12 (6): 522–7. doi:10.1197/j.aem.2005.01.008. PMID 15930403.
  10. ↑ Williams SC, Schmaltz SP, Morton DJ, Koss RG, Loeb JM (2005). "Quality of care in U.S. hospitals as reflected by standardized measures, 2002-2004". N. Engl. J. Med. 353 (3): 255–64. doi:10.1056/NEJMsa043778. PMID 16034011.
  11. ↑ Keeley EC, Boura JA, Grines CL. (2003). "Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials". Lancet. 361 (9351): 13–20. PMID 12517460.
  12. ↑ Bradley EH, Herrin J, Wang Y; et al. (2006). "Strategies for reducing the door-to-balloon time in acute myocardial infarction". N. Engl. J. Med. 355 (22): 2308–20. doi:10.1056/NEJMsa063117. PMID 17101617. Unknown parameter |month= ignored (help)
  13. ↑ 13.0 13.1 John Brush, MD, "The D2B Alliance for Quality," STEMI Systems Issue Two, May 2007. Accessed July 2, 2007.
  14. ↑ "D2B: An Alliance for Quality". American College of Cardiology. 2006. Unknown parameter |accessyear= ignored (|access-date= suggested) (help); Unknown parameter |accessmonthday= ignored (help)
  15. ↑ "D2B Strategies Checklist". American College of Cardiology. 2006. Unknown parameter |accessyear= ignored (|access-date= suggested) (help); Unknown parameter |accessmonthday= ignored (help)
  16. ↑ 16.0 16.1 16.2 "Mission: Lifeline - a new plan to decrease deaths from major heart blockages," American Heart Association, May 31, 2007. Accessed July 3, 2007.
  17. ↑ ACC Targets STEMI Times with Emergency CV Care 2007, Accessed July 3, 2007.
  18. ↑ 18.0 18.1 18.2 Michael O'Riordan, "AHA Announces Mission: Lifeline, a New Initiative to Improve Systems of Care for STEMI Patients," Heartwire (a professional news service of WebMD), May 31, 2007. Accessed July 3, 2007.
  19. ↑ Bradley EH, Roumanis SA, Radford MJ; et al. (2005). "Achieving door-to-balloon times that meet quality guidelines: how do successful hospitals do it?". J. Am. Coll. Cardiol. 46 (7): 1236–41. doi:10.1016/j.jacc.2005.07.009. PMID 16198837.
  20. ↑ 20.0 20.1 20.2 20.3 Rokos I. and Bouthillet T., "The emergency medical systems-to-balloon (E2B) challenge: building on the foundations of the D2B Alliance," STEMI Systems, Issue Two, May 2007. Accessed June 16, 2007.
  21. ↑ Rokos IC, Larson DM, Henry TD; et al. (2006). "Rationale for establishing regional ST-elevation myocardial infarction receiving center (SRC) networks". Am. Heart J. 152 (4): 661–7. doi:10.1016/j.ahj.2006.06.001. PMID 16996830.
  22. ↑ Moyer P, Feldman J, Levine J; et al. (2004). "Implications of the Mechanical (PCI) vs Thrombolytic Controversy for ST Segment Elevation Myocardial Infarction on the Organization of Emergency Medical Services: The Boston EMS Experience". Crit Pathw Cardiol. 3 (2): 53–61. doi:10.1097/01.hpc.0000128714.35330.6d. PMID 18340140. Unknown parameter |month= ignored (help)
  23. ↑ Henry TD, Atkins JM, Cunningham MS; et al. (2006). "ST-segment elevation myocardial infarction: recommendations on triage of patients to heart attack centers: is it time for a national policy for the treatment of ST-segment elevation myocardial infarction?". J. Am. Coll. Cardiol. 47 (7): 1339–45. doi:10.1016/j.jacc.2005.05.101. PMID 16580518. Unknown parameter |month= ignored (help)
  24. ↑ 24.0 24.1 24.2 Granger CB, Henry TD, Bates WE, Cercek B, Weaver WD, Williams DO (2007). "Development of Systems of Care for ST-Elevation Myocardial Infarction Patients. The Primary Percutaneous Coronary Intervention (ST-Elevation Myocardial Infarction-Receiving) Hospital Perspective". doi:10.1161/CIRCULATIONAHA.107.184049. PMID 17538039.
  25. ↑ David Jaslow, MD, "Out-of-Hospital STEMI Alert - If Time is Muscle, What's Taking So Long? EMS Responder, March 2007. Accessed July 3, 2007.
  26. ↑ 26.0 26.1 26.2 O'Gara PT, Kushner FG, Ascheim DD; et al. (2012). "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. doi:10.1161/CIR.0b013e3182742c84. PMID 23247303. Unknown parameter |month= ignored (help)
  27. ↑ 27.0 27.1 Kushner FG, Hand M, Smith SC, King SB, Anderson JL, Antman EM; et al. (2009). "2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (updating the 2005 Guideline and 2007 Focused Update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 120 (22): 2271–306. doi:10.1161/CIRCULATIONAHA.109.192663. PMID 19923169.
  28. ↑ Aguirre FV, Varghese JJ, Kelley MP; et al. (2008). "Rural interhospital transfer of ST-elevation myocardial infarction patients for percutaneous coronary revascularization: the Stat Heart Program". Circulation. 117 (9): 1145–52. doi:10.1161/CIRCULATIONAHA.107.728519. PMID 18268151. Unknown parameter |month= ignored (help)
  29. ↑ Henry TD, Sharkey SW, Burke MN; et al. (2007). "A regional system to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction". Circulation. 116 (7): 721–8. doi:10.1161/CIRCULATIONAHA.107.694141. PMID 17673457. Unknown parameter |month= ignored (help)
  30. ↑ Jollis JG, Roettig ML, Aluko AO; et al. (2007). "Implementation of a statewide system for coronary reperfusion for ST-segment elevation myocardial infarction". JAMA. 298 (20): 2371–80. doi:10.1001/jama.298.20.joc70124. PMID 17982184. Unknown parameter |month= ignored (help)
  31. ↑ 31.0 31.1 Le May MR, So DY, Dionne R; et al. (2008). "A citywide protocol for primary PCI in ST-segment elevation myocardial infarction". N. Engl. J. Med. 358 (3): 231–40. doi:10.1056/NEJMoa073102. PMID 18199862. Unknown parameter |month= ignored (help)
  32. ↑ Rokos IC, French WJ, Koenig WJ; et al. (2009). "Integration of pre-hospital electrocardiograms and ST-elevation myocardial infarction receiving center (SRC) networks: impact on Door-to-Balloon times across 10 independent regions". JACC Cardiovasc Interv. 2 (4): 339–46. doi:10.1016/j.jcin.2008.11.013. PMID 19463447. Unknown parameter |month= ignored (help)
  33. ↑ Sørensen JT, Terkelsen CJ, Nørgaard BL; et al. (2011). "Urban and rural implementation of pre-hospital diagnosis and direct referral for primary percutaneous coronary intervention in patients with acute ST-elevation myocardial infarction". Eur. Heart J. 32 (4): 430–6. doi:10.1093/eurheartj/ehq437. PMID 21138933. Unknown parameter |month= ignored (help)
  34. ↑ Andersen HR, Nielsen TT, Vesterlund T; et al. (2003). "Danish multicenter randomized study on fibrinolytic therapy versus acute coronary angioplasty in acute myocardial infarction: rationale and design of the DANish trial in Acute Myocardial Infarction-2 (DANAMI-2)". Am. Heart J. 146 (2): 234–41. doi:10.1016/S0002-8703(03)00316-8. PMID 12891190. Unknown parameter |month= ignored (help)
  35. ↑ Dalby M, Bouzamondo A, Lechat P, Montalescot G (2003). "Transfer for primary angioplasty versus immediate thrombolysis in acute myocardial infarction: a meta-analysis". Circulation. 108 (15): 1809–14. doi:10.1161/01.CIR.0000091088.63921.8C. PMID 14530206. Unknown parameter |month= ignored (help)
  36. ↑ Andersen HR, Nielsen TT, Rasmussen K; et al. (2003). "A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction". N. Engl. J. Med. 349 (8): 733–42. doi:10.1056/NEJMoa025142. PMID 12930925. Unknown parameter |month= ignored (help)
  37. ↑ Nielsen PH, Terkelsen CJ, Nielsen TT; et al. (2011). "System delay and timing of intervention in acute myocardial infarction (from the Danish Acute Myocardial Infarction-2 [DANAMI-2] trial)". Am. J. Cardiol. 108 (6): 776–81. doi:10.1016/j.amjcard.2011.05.007. PMID 21757183. Unknown parameter |month= ignored (help)
  38. ↑ Hochman JS, Sleeper LA, White HD; et al. (2001). "One-year survival following early revascularization for cardiogenic shock". JAMA. 285 (2): 190–2. PMID 11176812. Unknown parameter |month= ignored (help)
  39. ↑ 39.0 39.1 39.2 "Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group". Lancet. 343 (8893): 311–22. 1994. PMID 7905143. Unknown parameter |month= ignored (help)
  40. ↑ Nallamothu BK, Bates ER (2003). "Percutaneous coronary intervention versus fibrinolytic therapy in acute myocardial infarction: is timing (almost) everything?". Am. J. Cardiol. 92 (7): 824–6. PMID 14516884. Unknown parameter |month= ignored (help)
  41. ↑ Pinto DS, Kirtane AJ, Nallamothu BK; et al. (2006). "Hospital delays in reperfusion for ST-elevation myocardial infarction: implications when selecting a reperfusion strategy". Circulation. 114 (19): 2019–25. doi:10.1161/CIRCULATIONAHA.106.638353. PMID 17075010. Unknown parameter |month= ignored (help)
  42. ↑ Boersma E, Maas AC, Deckers JW, Simoons ML (1996). "Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour". Lancet. 348 (9030): 771–5. doi:10.1016/S0140-6736(96)02514-7. PMID 8813982. Unknown parameter |month= ignored (help)
  43. ↑ Chareonthaitawee P, Gibbons RJ, Roberts RS, Christian TF, Burns R, Yusuf S (2000). "The impact of time to thrombolytic treatment on outcome in patients with acute myocardial infarction. For the CORE investigators (Collaborative Organisation for RheothRx Evaluation)". Heart. 84 (2): 142–8. PMC 1760917. PMID 10908248. Unknown parameter |month= ignored (help)
  44. ↑ McNamara RL, Herrin J, Wang Y; et al. (2007). "Impact of delay in door-to-needle time on mortality in patients with ST-segment elevation myocardial infarction". Am. J. Cardiol. 100 (8): 1227–32. doi:10.1016/j.amjcard.2007.05.043. PMC 2715362. PMID 17920362. Unknown parameter |month= ignored (help)
  45. ↑ Milavetz JJ, Giebel DW, Christian TF, Schwartz RS, Holmes DR, Gibbons RJ (1998). "Time to therapy and salvage in myocardial infarction". J. Am. Coll. Cardiol. 31 (6): 1246–51. PMID 9581715. Unknown parameter |month= ignored (help)
  46. ↑ Newby LK, Rutsch WR, Califf RM; et al. (1996). "Time from symptom onset to treatment and outcomes after thrombolytic therapy. GUSTO-1 Investigators". J. Am. Coll. Cardiol. 27 (7): 1646–55. PMID 8636549. Unknown parameter |month= ignored (help)
  47. ↑ Cantor WJ, Fitchett D, Borgundvaag B, et al. Routine early angioplasty after fibrinolysis for acute myocardial infarction. N Engl J Med. 2009; 360: 2705–18.
  48. ↑ Di Mario C, Dudek D, Piscione F, et al. Immediate angioplasty versus standard therapy with rescue angioplasty after thrombolysis in the Combined Abciximab REteplase Stent Study in Acute Myocardial Infarction (CARESS-in-AMI): an open, prospective, randomised, multicentre trial. Lancet. 2008; 371: 559–68.
  49. ↑ Gershlick AH, Stephens-Lloyd A, Hughes S; et al. (2005). "Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction". N. Engl. J. Med. 353 (26): 2758–68. doi:10.1056/NEJMoa050849. PMID 16382062. Unknown parameter |month= ignored (help)
  50. ↑ Sutton AG, Campbell PG, Graham R; et al. (2004). "A randomized trial of rescue angioplasty versus a conservative approach for failed fibrinolysis in ST-segment elevation myocardial infarction: the Middlesbrough Early Revascularization to Limit INfarction (MERLIN) trial". J. Am. Coll. Cardiol. 44 (2): 287–96. doi:10.1016/j.jacc.2003.12.059. PMID 15261920. Unknown parameter |month= ignored (help)
  51. ↑ Gibson CM, Murphy SA, Rizzo MJ; et al. (1999). "Relationship between TIMI frame count and clinical outcomes after thrombolytic administration. Thrombolysis In Myocardial Infarction (TIMI) Study Group". Circulation. 99 (15): 1945–50. PMID 10208996. Unknown parameter |month= ignored (help)
  52. ↑ Gibson CM, Cannon CP, Murphy SA, Marble SJ, Barron HV, Braunwald E (2002). "Relationship of the TIMI myocardial perfusion grades, flow grades, frame count, and percutaneous coronary intervention to long-term outcomes after thrombolytic administration in acute myocardial infarction". Circulation. 105 (16): 1909–13. PMID 11997276. Unknown parameter |month= ignored (help)
  53. ↑ Sutton AG, Campbell PG, Price DJ; et al. (2000). "Failure of thrombolysis by streptokinase: detection with a simple electrocardiographic method". Heart. 84 (2): 149–56. PMC 1760890. PMID 10908249. Unknown parameter |month= ignored (help)
  54. ↑ Wijeysundera HC, Vijayaraghavan R, Nallamothu BK; et al. (2007). "Rescue angioplasty or repeat fibrinolysis after failed fibrinolytic therapy for ST-segment myocardial infarction: a meta-analysis of randomized trials". J. Am. Coll. Cardiol. 49 (4): 422–30. doi:10.1016/j.jacc.2006.09.033. PMID 17258087. Unknown parameter |month= ignored (help)
  55. ↑ Collet JP, Montalescot G, Le May M, Borentain M, Gershlick A (2006). "Percutaneous coronary intervention after fibrinolysis: a multiple meta-analyses approach according to the type of strategy". J. Am. Coll. Cardiol. 48 (7): 1326–35. doi:10.1016/j.jacc.2006.03.064. PMID 17010790. Unknown parameter |month= ignored (help)
  56. ↑ Bøhmer E, Hoffmann P, Abdelnoor M, Arnesen H, Halvorsen S (2010). "Efficacy and safety of immediate angioplasty versus ischemia-guided management after thrombolysis in acute myocardial infarction in areas with very long transfer distances results of the NORDISTEMI (NORwegian study on DIstrict treatment of ST-elevation myocardial infarction)". J. Am. Coll. Cardiol. 55 (2): 102–10. doi:10.1016/j.jacc.2009.08.007. PMID 19747792. Unknown parameter |month= ignored (help)
  57. ↑ Borgia F, Goodman SG, Halvorsen S; et al. (2010). "Early routine percutaneous coronary intervention after fibrinolysis vs. standard therapy in ST-segment elevation myocardial infarction: a meta-analysis". Eur. Heart J. 31 (17): 2156–69. doi:10.1093/eurheartj/ehq204. PMID 20601393. Unknown parameter |month= ignored (help)
  58. ↑ Cantor WJ, Fitchett D, Borgundvaag B; et al. (2009). "Routine early angioplasty after fibrinolysis for acute myocardial infarction". N. Engl. J. Med. 360 (26): 2705–18. doi:10.1056/NEJMoa0808276. PMID 19553646. Unknown parameter |month= ignored (help)
  59. ↑ Sosnowski C (2008). "[Commentary to the article: Di Mario C, Dudek D, Piscione F, et al.; CARESS-in-AMI (Combined Abciximab RE-teplase Stent Study in Acute Myocardial Infarction) Investigators. Immediate angioplasty versus standard therapy with rescue angioplasty after thrombolysis in the Combined Abciximab REteplase Stent Study in Acute Myocardial Infarction (CARESS-in-AMI): an open, prospective, randomised, multicentre trial. Lancet 2008; 371: 559-68]". Kardiol Pol (in Polish). 66 (4): 461–4, discussion 465–6. PMID 18634182. Unknown parameter |month= ignored (help)
  60. ↑ Fernandez-Avilés F, Alonso JJ, Castro-Beiras A; et al. (2004). "Routine invasive strategy within 24 hours of thrombolysis versus ischaemia-guided conservative approach for acute myocardial infarction with ST-segment elevation (GRACIA-1): a randomised controlled trial". Lancet. 364 (9439): 1045–53. doi:10.1016/S0140-6736(04)17059-1. PMID 15380963.
  61. ↑ White HD (2008). "Systems of care: need for hub-and-spoke systems for both primary and systematic percutaneous coronary intervention after fibrinolysis". Circulation. 118 (3): 219–22. doi:10.1161/CIRCULATIONAHA.108.790170. PMID 18625904. Unknown parameter |month= ignored (help)
  62. ↑ Keeley EC, Boura JA, Grines CL (2003). "Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials". Lancet. 361 (9351): 13–20. doi:10.1016/S0140-6736(03)12113-7. PMID 12517460. Unknown parameter |month= ignored (help)
  63. ↑ Schömig A, Mehilli J, Antoniucci D; et al. (2005). "Mechanical reperfusion in patients with acute myocardial infarction presenting more than 12 hours from symptom onset: a randomized controlled trial". JAMA. 293 (23): 2865–72. doi:10.1001/jama.293.23.2865. PMID 15956631. Unknown parameter |month= ignored (help)
  64. ↑ Gierlotka M, Gasior M, Wilczek K; et al. (2011). "Reperfusion by primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction within 12 to 24 hours of the onset of symptoms (from a prospective national observational study [PL-ACS])". Am. J. Cardiol. 107 (4): 501–8. doi:10.1016/j.amjcard.2010.10.008. PMID 21195380. Unknown parameter |month= ignored (help)

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