Treatment delay in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: A key process analysis of patient and program factors Shailja V. Parikh, MD, b Joshua A. Jacobi, MD, b Edwin Chu, BS, b Tayo A. Addo, MD, b John J. Warner, MD, b Kathleen A. Delaney, MD, b Darren K. McGuire, MD, MHSc, b,c James A. deLemos, MD, b,c Joaquin E. Cigarroa, MD, d Sabina A. Murphy, MPH, e and Ellen C. Keeley, MD a Charlottesville, VA; Dallas, TX; Portland, OR; and Boston, MA Background Most hospitals that perform primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) in the United States exceed the recommended door-to-balloon time. There is heightened interest in identifying and eliminating factors that introduce delay. Methods We performed a key process analysis of our primary PCI program, assessed the relative contribution of individual time intervals on total ischemic time, and identified predictors of delay. Results Median times and predictors of delay within each time interval were determined for the entire STEMI cohort (“real world”) and after exclusion of patients with atypical symptoms and/or presentations of STEMI that resulted in inherent delay in diagnosis and treatment (“ideal world”). Delays in therapy were symptom onset to presentation (120 minutes [interquartile range, IQR, 60-310 minutes, ideal world] and 150 minutes [IQR 60-360 minutes, real world]; predictors of delay were peripheral vascular disease, self-transportation, daytime and weekend presentation); door-to-balloon time (118.5 minutes [IQR 96-141 minutes, ideal world] and 125 minutes [IQR 100-170 minutes, real world]; predictors of delay were female sex, previous stroke, nighttime and weekend presentation, and cardiogenic shock); and symptom onset to first balloon inflation (272 minutes [IQR 187-465 minutes, ideal world] and 297 minutes [IQR 198-560 minutes, real world]; predictors of delay were peripheral vascular disease, weekend presentation, and self-transportation). Conclusions Key process analysis of a primary PCI program identifies treatment delays unique to the hospital and the patient population it serves. (Am Heart J 2008;155:290-7.) Primary percutaneous coronary intervention (PCI) is a highly effective reperfusion therapy for patients with STEMI provided it is performed rapidly in high-volume centers by experienced operators. 1 The shorter the delay from symptom onset to balloon inflation, the better the clinical outcomes including decreased rates of cardio- genic shock, left ventricular dysfunction, congestive heart failure, and death. 2-5 Although 80% of the adult population in the United States live within 60 minutes of a hospital capable of performing primary PCI, 6 only a minority of patients with STEMI undergo PCI within the 90-minute window as recommended by the American College of Cardiology/American Heart Association. 7 The total ischemic time (defined as the time from symptom onset to first balloon inflation and reestablish- ment of antegrade blood flow in the infarct-related artery) consists of 2 distinct time components: the time from symptom onset to the patient seeking medical attention and the time from first medical contact to performance of primary PCI. Minimizing overall delay in reperfusion therapy, therefore, must take into consideration the relative contributions from both the patient and the system. This key process analysis was performed to assess the relative contribution of each of the individual components of total ischemic time in patients with STEMI From the a Department of Internal Medicine, Division of Cardiology, University of Virginia Health System, Charlottesville, VA, b Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, c Department of Internal Medicine, Division of Cardiology, Donald W. Reynolds Cardiovascular Clinical Research Center at the University of Texas Southwestern Medical Center, Dallas, TX, d Department of Internal Medicine, Division of Cardiology, Oregon Health and Science University, Portland, OR, and e Department of Internal Medicine, Division of Cardiology, Brigham and Women's Hospital, Boston, MA. Submitted May 9, 2007; accepted October 12, 2007. Reprint requests: Ellen C. Keeley, MD, Department of Internal Medicine, Division of Cardiology, University of Virginia Health System, PO Box 800158, Charlottesville, VA 22908-0158. E-mail: keeley@virginia.edu 0002-8703/$ - see front matter © 2008, Mosby, Inc. All rights reserved. doi:10.1016/j.ahj.2007.10.021