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research-article2015
CNU0010.1177/1474515115577294CNU577294European Journal of Cardiovascular NursingMartin et al.

EUROPEAN
SOCIETY OF
Original Article CARDIOLOGY ®

European Journal of Cardiovascular Nursing

The impact on long term health


1­–8
© The European Society of Cardiology 2015
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DOI: 10.1177/1474515115577294

a period of process change to reduce cnu.sagepub.com

door to balloon time

Lorelle Martin1,2, Maria Murphy1,2, Andrew Scanlon1, David Clark1


and Omar Farouque1

Abstract
Background: Guidelines for the management of ST-segment elevation myocardial infarction (STEMI) recommend a
‘door to balloon time’ (DTBT) within 90 minutes. It is unclear whether strategies to reduce DTBT translate to improved
longer-term health outcomes for STEMI patients.
Aims: This study sought to determine whether implemented strategies to improve timely management of STEMI reduced
DTBT and impacted upon health outcomes such as length of stay, unplanned readmission and 12-month mortality.
Predictors of timely management for STEMI were also examined.
Methods: A five-year review was undertaken on primary percutaneous coronary intervention for STEMI in one tertiary
hospital. Comparisons were made between process change groups and DTBT. Logistic regression identified predictors
of timely management.
Results: 470 STEMI patients underwent immediate primary percutaneous coronary intervention. Process change
improved the median DTBT (109 min vs. 72 min, p<0.001) with no significant effect on length of stay (p=0.83), unplanned
cardiac readmissions (p=0.68) or 12-month mortality (9.0% vs. 8.6%, p=0.64). Those receiving timely treatment (i.e.
DTBT< 90 min) were younger (p<0.05), male (p<0.03), presented via ambulance (p<0.004), during business hours
(p<0.0001) and had a lower Thrombolysis In Myocardial Infarction score (p<0.006). Timely treatment was associated
with lower 12-month mortality (3.7% vs. 15.7%, p<0.0001) and increased uptake of inpatient cardiac rehabilitation
(p<0.005), with length of stay and unplanned readmission similar between groups (p=NS).
Conclusions: Process changes improved DTBT but had no effect on length of stay, readmission rate or 12-month
mortality. Yet, timely management was critical to 12-month outcomes. Further studies are required to explore the
barriers to timely treatment.

Keywords
Myocardial infarction, time, outcomes

Date received: 17 June 2014; revised: 10 February 2015; accepted: 22 February 2015

Introduction
Prompt reperfusion of the culprit coronary lesion using 1LaTrobe University School of Nursing, Melbourne, Australia
primary percutaneous coronary intervention (PPCI) is the 2Department of Cardiology, Austin Health, Heidelberg, Australia
preferred treatment strategy in ST-segment elevation myo-
Corresponding author:
cardial infarction (STEMI).1-3 The time dependent nature Lorelle Martin, Department of Cardiology, Austin Health, 145 Studley
of restoring epicardial blood flow using PPCI is well rec- Rd, Level 5 Cardiology Diagnostics, Heidelberg 3084, Australia.
ognised with time to treatment, or door to balloon time Email: lorelle.martin@austin.org.au

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2 European Journal of Cardiovascular Nursing

(DTBT), representing a major determinant of mortality a discharge diagnosis of STEMI, that is, ICD-10 code I20
and morbidity.4-7 and I21. Exclusion criteria were all those who did not pre-
Both national and international guidelines for the man- sent to the emergency department with STEMI criteria.
agement of STEMI suggest a DTBT timeframe of ⩽ 90 A chart audit tool was devised. Baseline characteristics
min from hospital presentation to first device.1-3 More such as age, gender and modifiable cardiac risk factors
recently, evidence-based strategies to achieve a DTBT ⩽ were recorded. Clinical risk profile was assessed using the
90 min have been incorporated into these guidelines. Thrombolysis In Myocardial Infarction (TIMI) risk score.
Strategies include a single call activation within the hospi- This composite scoring system uses age, risk factors, onset
tal setting and pre-hospital activation such as transmission of symptoms, location of infarct and Killip class to deter-
of ECG by paramedics to alert the cardiac catheterisation mine the clinical risk on admission to hospital.18
laboratory.8 There are published examples of the effect Presentation characteristics were of interest to assist in
implementation of these system-based strategies has on identifying potential sources of time delay to treatment
reducing DTBT and 30-day mortality.9-16 However, there is revealed in the literature.19-22 Time of day and day of week
limited data on the impact these strategies have on longer- were recorded, along with the mode of transport to hospi-
term health outcomes. tal, that is, self-presentation or presentation via ambulance
One metropolitan Australian hospital implemented two with or without pre-hospital notification. A presentation
process changes over a period of 18 months that synthesised within the operating hours of the Cardiac Catheterisation
some of these system-based strategies to improve DTBT. Laboratory (Monday to Friday 0800–1800 hours) was
The first process change introduced a single and simultane- defined as ‘in hours’; anything outside this time was con-
ous page to the cardiology team to facilitate rapid access to sidered ‘out of hours’. The time from onset of symptoms to
the cardiac catheterisation laboratory for PPCI; this was hospital door time was also recorded to assess concord-
called the ‘Cath Lab Code’. The second process change ance with the national guidelines, with the ideal timeframe
integrated the Cath Lab Code with a pre-hospital notifica- being 60–180 min.1
tion system activated by paramedics in the field. Prior to The DTBT was a primary endpoint for this study. For
these process changes, no coordinated approach to facilitate the most part DTBT was documented prospectively. At the
care for STEMI patients upon arrival to this hospital were in start of this study there was no official structure in place to
place. Prospective collection of DTBT on STEMI patients expedite the management of the STEMI patient. The base-
occurred prior to these process changes and continued line DTBT of ‘usual care’ was established, and used to
throughout the implementation of process changes. assess concordance with the national and international
What is novel and interesting about this study is that the guidelines.1-3 The study continued in context of two pro-
cohort of consecutive STEMI patients were evaluated in cess changes to improve DTBT in the cardiac catheterisa-
several ways. The objective of this study was to assess tion laboratory. These patients had their individual DTBT
whether the implementation of process change to improve measured prospectively at the time of treatment.
timely treatment had any impact on long-term health out- Immediate health outcomes such as in-hospital mortal-
comes. Additional aims were to reveal barriers to timely ity and length of stay in days were also endpoints in this
management of STEMI and identify the predictors of a study, along with completion of inpatient cardiac rehabili-
DTBT ⩽ 90 min. tation for the indexed admission. These variables were
recorded to provide a comparison between the cohort stud-
ied and the literature, which reports that timely percutane-
Methods ous intervention is associated with reduced length of stays
Study design and population and in-hospital mortality.16,23
Importantly, long-term health outcomes also formed
This study was conducted with the approval of institu- part of the primary endpoints of this study, specifically:
tional Human Research and Ethics Committees (HRECs) 30-day mortality, 12-month mortality, unplanned cardiac
and conforms with the principles outlined in the Declaration admissions up to one-year post index admission. The
of Helsinki.17 An observational-correlational method was Melbourne Interventional Group registry24 provided mor-
used with a retrospective cohort design. The relationship tality rates and unplanned cardiac admission rates up to 12
between DTBT and both in-hospital and long-term health months post indexed admission. The uptake of the adjunc-
outcomes was examined on a population of 470 consecu- tive services such as the outpatient based cardiac rehabili-
tive STEMI patients that received PPCI using a retrospec- tation programme was also documented sourcing the
tive chart review. The timeframe for this review was hospital’s cardiac rehabilitation department database.
between December 2006 and April 2011. The pre process
period was until March 2008. The post process change
Data validity
occurred after this time. Inclusion criteria for this study
were all STEMIs who presented to the emergency depart- There were several measures taken to ensure validity of the
ment at this centre, proceeded to have a PPCI and recorded data. Accurate DTBT was ensured by regular calibration of

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Martin et al. 3

the 12 lead ECG machines in the emergency department Results


and weekly calibration of the wall clocks in the Cardiac
Catheterisation Laboratory to this website: http://www. Between December 2006 and April 2011, the total number
timeanddate.com/worldclock/city. In this study, ‘door time’ of patients admitted via the emergency department with
remained defined as first medical contact in the emergency STEMI to the cardiac catheterisation laboratory for PPCI
department, and balloon time was defined as the time of and included in this study was 470. There were 362 (77%)
first balloon inflation or aspiration device.25 These time- males and the mean age of the total cohort was 64±13 years.
frames were prospectively documented and confirmed by Comparison between the process change groups is sum-
the audit team manager. The collected data was entered marised in Table 1. There was homogeneity for all baseline
onto a password protected Microsoft Excel spreadsheet. clinical characteristics when comparing groups. Timely
Data was entered by one and checked by another clinician management of STEMI improved by 37 min post imple-
to ensure data input accuracy. mentation of process change (median (IQR1–3) DTBT
109 (76–136) min vs.72 (48–97) min, p<0.001).
Additionally, the percentage of patients achieving a DTBT
Statistical analysis < 90 min improved (37% vs. 69%, p<0.0001). The median
Statistical analysis was performed using Statistical (IQR1–3) length of stay was similar between groups 4
Package for Social Sciences (SPSS) version 19 for Mac (3–5) vs. 4 (3–5) days, p=0.83. Readmission rates was also
(SPPS Inc., IL, USA). Descriptive statistics were calcu- similar between groups (12.8% vs. 11.1%, p=0.68) of
lated to summarise the characteristics of the cohort. patients having at least one unplanned cardiac readmis-
Categorical variables were expressed as counts and per- sion. Interestingly, the unadjusted mortality rate between
centages. Continuous variables were expressed as mean ± groups revealed a numerically higher rate for the post pro-
standard deviation (SD) or median and inter-quartile range cess change group for two of the three indexed timeframes,
(IQR) as appropriate. Statistical significance was set at α = although this was not statistically significant: in-hospital
0.05. Inferential statistics were used to investigate the rela- (5.1% vs. 7.6%, p=0.31); 30-day mortality (5.1% vs. 8.0%,
tionship between the discrete variables generated from the p=0.42). In contrast, the non-statistically significant trend
chart audit. In particular, a comparison was undertaken for of less mortality for the post process change group was at
patients who presented pre process change and those who 12 months (9.0% vs. 8.6%, p=0.64).
presented post the implementation of the Cath Lab Code. The comparison between patients who received timely
Additionally, a comparison was made between all those care (i.e. DTBT ⩽ 90 min) and those who did not is sum-
who recorded a DTBT ⩽ 90 min and all those who marised in Table 2. Patients with DTBT ⩽ 90 min were
recorded a DTBT > 90 min. younger (63.0 ± 12.6 vs. 65.5± 14.2 years, p=0.05) and were
Further analysis was performed using logistic regres- male (81% vs. 73%, p<0.03). Those who recorded timely
sion to determine predictors of DTBT ⩽ 90 min. The vari- DTBT presented during business hours (55% vs. 32%,
ables used were the statistically significant variables from p<0.0001) and via ambulance (84% vs. 73%, p<0.004).
univariate analysis of the data. Logistic regression is Patients who reported chest pain on arrival were more likely
reported to assist in determining which variables affect the to have a DTBT ⩽ 90 min (90% vs. 83%, p<0.01). Patients
probability of a particular outcome.26 The goodness of fit who had a TIMI risk score < 5 were more likely to receive
statistic was tested using the Hosmer–Lemeshow test to timely treatment; 62% vs. 38%, p<0.006. Interestingly, cur-
ascertain whether the proportions of the variables tested rent smokers were also more likely to receive timely man-
were of equal magnitude.27,28 agement (42% vs. 33%, p=0.05). Patients with a DTBT ⩽ 90
A power calculation was used to ensure this study was min were more likely to receive inpatient cardiac rehabilita-
sufficiently powered. The improvement in time to treat- tion (88% vs. 78%, p<0.005). There was no statistically sig-
ment or DTBT was considered a primary endpoint. The nificant difference in length of stay between groups (4 (3–5)
recommended sample size to determine efficacy of the vs. 4 (3–5) days, p=0.39) or number of unplanned cardiac
new Cath Lab Code and pre-hospital notification admissions to 12 months (11.7% vs. 11.7%, p=0.72). Patients
systems was calculated to be 102 patients using the soft- who had a DTBT ⩽ 90 min recorded an improved survival
ware freely available at http://www.raosoft.com/sample- advantage over the three indexed timeframes: in-hospital
size.html. This was based on the data from existing (3.7% vs. 11.2%, p<0.001); 30-day mortality (3.7% vs.
hospital data which stated the median DTBT prior to any 11.7%, p<0.001); 12-month mortality (3.7% vs. 15.7%,
process change was 109 minutes for 156 consecutive p<0.0001).
patients. Additionally, the response distribution figure Predictors of a DTBT ⩽90 min were determined using
was based on the 2006 American Heart Association and logistic regression and are summarised in Table 3 and
American College of Cardiology (AHA/ACC) recom- Appendix 1 in the Supplementary Material. Patients who
mendations that a DTBT <90 min should be achieved presented to hospital post the implementation of process
75% of the time. change were more likely to receive timely management

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4 European Journal of Cardiovascular Nursing

Table 1.  Comparison of pre process change and post process change groups.

Demographics and baseline characteristics Pre process change n=156 Post process change p value
n (% within group) unless n=314 n (% within group)
stated otherwise unless stated otherwise
Age (mean ± SD), years 63±13 64±13 0.40
Symptom onset (medianIQR1–3), min 114(75–227) 114(76–286) 0.28
Sex 0.17
Male 115 (74%) 249 (80%)  
Female 41 (26%) 65 (20%)  
Type of presentation to hospital 0.60
Self presentation 34 (22%) 62 (20%)  
Ambulance 122 (78%) 252 (80%)  
Time of day 0.24
In operating hours 77 (49%) 137 (44%)  
Out of operating hours 79 (51%) 177 (56%)  
First cardiac admission 116 (74%) 250 (80%) 0.17
Chest pain on admission 138 (89%) 273 (87%) 0.85
TIMI risk score < 5 112 (72%) 214 (68%) 0.46
Location of infarct 0.67
Anterior 67 (42%) 137(44%)  
Inferior 73 (47%) 154 (49%)  
Other 16 (11%) 23 (7%)  
Family history 55 (35%) 130 (41%) 0.20
Hypertension 80 (51%) 178 (57%) 0.27
Diabetes 37 (24%) 57 (18%) 0.14
Lipids 83 (54%) 143 (46%) 0.10
Smoker 50 (32%) 130 (41%) 0.06
Intra aortic balloon pump pre PCI 13 (8.3%) 19 (6.1%) 0.36
DTBT (medianIQR1–3), min 109(76–136) 72(48–97) 0.001
DTBT < 90 min 57 (37%) 216 (69%) 0.0001
Health outcomes  
Length of stay (medianIQR1–3), days 4(3–5) 4(3–5) 0.83
Inpatient cardiac rehab 140 (90%) 252 (80%) 0.06
Outpatient cardiac rehab 76 (49%) 140 (45%) 0.45
In-hospital mortality 8 (5.1%) 24 (7.6%) 0.31
30-day mortality 8 (5.1%) 25 (8.0%) 0.42
12-month mortality 14 (9.0%) 27 (8.6%) 0.64
Unplanned cardiac re-admission to 12 months 20 (12.8%) 35 (11.1%) 0.68

DTBT: door to balloon time; IQR: inter-quartile range; PCI: percutaneous coronary intervention; TIMI: Thrombolysis In Myocardial Infarction

(odds ratio (OR) 5.61, confidence interval (CI) 3.53–8.92, changes were implemented. The achievement of timely
p<0.0001). Presenting during business hours (OR 3.90, CI treatment, that is, DTBT < 90 min, also improved by 32%
2.49–6.10, p<0.0001) and via ambulance (OR 2.61, CI 1.57– once strategies were put in place. Our findings reaffirm the
4.33, p<0.0001) was also a predictor of timely care. conclusions of previous studies evaluating the effect pro-
Presenting with chest pain was a strong predictor of DTBT cess change has on DTBT and that a coordinated approach
⩽ 90 min (OR 2.02, CI 1.31–3.13, p<0.002), along with a before and upon arrival at hospital improves systems of
TIMI risk score < 5 (OR 2.36, CI 1.49–3.74, p<0.0001). care for the STEMI patient.9-16
One of the primary endpoints of this study was mortal-
ity, in particular long-term (12-month) mortality. The
Discussion implementation of strategies to reduce DTBT had no effect
This study examined the health outcomes to 12 months for on 12-month unadjusted mortality for this cohort. Indeed
patients presenting to hospital with STEMI and receiving mortality rates were higher in the post process change
PPCI, whilst hospital processes changed to improve group until 12 months, when it was numerically lower with
DTBT. Findings from this study demonstrated a statisti- no statistically significant difference identified (9.0% vs.
cally significant and 37 min decrease in time when process 8.6%, p=0.64). This finding concurred with the results of a

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Martin et al. 5

Table 2.  Comparison of DTBT ⩽ and > 90 min groups.

Demographics and baseline characteristics DTBT ⩽ 90 min n=273 DTBT > 90 min n=197 n p value
n (% within group) unless (% within group) unless
stated otherwise stated otherwise
Age (mean ± SD), years 63.0 ± 12.6 65.5 ± 14.2 0.05
Symptom onset (medianIQR1–3), min 106(71–204) 149(85–309) 0.05
Sex 0.03
Male 221 (81%) 143 (73%)  
Female 52 (19%) 54 (27%)  
Type of presentation to hospital 0.004
Self presentation 43 (16%) 53 (27%)  
Ambulance 230 (84%) 144 (73%)  
Time of day 0.0001
In operating hours 151 (55%) 63 (32%)  
Out of operating hours 122 (45%) 134 (68%)  
First cardiac admission 220 (81%) 146 (74%) 0.09
Chest pain on admission 247 (90%) 167 (83%) 0.01
TIMI risk score < 5 203 (62%) 123 (38%) 0.006
Location of infarct 0.14
Anterior 108 (40%) 96 (49%)  
Inferior 145 (53%) 82 (42%)  
Other 20 (7%) 19 (9%)  
Family history 114 (42%) 71 (36%) 0.22
Hypertension 141 (52%) 117 (60%) 0.11
Diabetes 50 (18%) 44 (23%) 0.29
Lipids 138 (51%) 88 (45%) 0.26
Smoker 115 (42%) 65 (33%) 0.05
Intra aortic balloon pump 14 (5%) 18 (9%) 0.09
pre PCI
Health outcomes  
Length of stay (medianIQR1–3), days 4(3–5) 4(3–5) 0.39
Inpatient cardiac rehab 239 (88%) 153 (78%) 0.005
Outpatient cardiac rehab 134 (49%) 82 (42%) 0.546
In-hospital mortality 10 (3.7%) 22 (11.2%) 0.001
30-day mortality 10 (3.7%) 23 (11.7%) 0.001
12-month mortality 10 (3.7%) 31 (15.7%) 0.0001
Unplanned cardiac readmission (to 12 months) 32 (11.7%) 23 (11.7%) 0.72

DTBT: door to balloon time; IQR: inter-quartile range; PCI: percutaneous coronary intervention; TIMI: Thrombolysis In Myocardial Infarction

Table 3.  Logistic regression.

Predictors of a DTBT < 90 min p value OR CI


Post process change to STEMI 0.0001 5.61 3.53–8.92
In hours presentation 0.0001 3.90 2.49–6.10
Ambulance presentation to emergency department 0.0001 2.61 1.57–4.33
TIMI risk score <5 0.0001 2.36 1.49–3.74
Chest pain on admission 0.002 2.02 1.31–3.13

N=470; χ2 = 114.86; df = 5; p<0.001 with 72% of cases correctly classified by model Hosmer–Lemeshow test p =0.29; demonstrating goodness of fit.
CI: confidence interval; DTBT: door to balloon time; OR: odds ratio; STEMI: ST-segment elevation myocardial infarction; TIMI: Thrombolysis In
Myocardial Infarction

related study by Drew et al.29 The Drew study analysed the significant difference in mortality between the control
utilisation of a pre-hospital ECG programme using a ran- group and the experimental group for STEMI patients,
domised control design, and found no statistically p=0.08, or over their entire acute coronary syndrome

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6 European Journal of Cardiovascular Nursing

sample of patients. More recently, Menees et al. reported explained by the fact that smokers have a higher propensity
similar findings for 30-day mortality rates on their registry for coronary thrombosis,37 which may lead to a presenta-
data for 96,738 STEMI patients undergoing PPCI for tion that is typical, contributing to rapid recognition of
STEMI. The Menees study concluded that in-hospital and symptoms and hence timely treatment. Further investiga-
30-day mortality remained virtually unchanged despite tion would be required to explore this notion.
improvements in DTBT over a four-year period with 515 Predictors of timely management of STEMI in this
participating hospitals.30 study were five-fold; presenting during business hours, pre-
There are several possible explanations for the lack of senting via ambulance, presenting with chest pain, record-
improvement in mortality post process change in our study, ing a TIMI risk score <5, and presenting to hospital after
some of which have been raised in a recent perspective the implementation of process change. This logistic regres-
article by Bates and Jacob.31 In our study, the reduced time sion model correctly classified cases 72% of the time with
in minutes was too small to reduce infarct size given the the Hosmer–Lemeshow test demonstrating goodness of fit,
total ischaemic time. Whilst total ischaemic time was not p=0.29.
specifically analysed in this study, importantly, onset of Presentation during the operating hours of the cardiac
symptoms was. The limitation with this metric is that onset catheterisation laboratory was found to be a predictor of
of symptoms was retrieved retrospectively from the patient DTBT ⩽ 90 min (OR 3.9, CI 2.496.1, p<0.0001). Time of
chart and was documented in 96% (n=454) of cases, mak- presentation has been thoroughly explored in the literature
ing precise evaluation of total ischaemic time reliant on and our findings were comparable to the effect this varia-
patient recall and clinician documentation. Pre-hospital ble has on timely intervention.20-22
delay that is primarily patient related is a significant bar- Presentation to hospital via ambulance was also a pre-
rier to timely treatment and an area that requires further dictor of expedited timely treatment (OR 2.6, CI 1.57–
exploration and operational definitions.32,33 This leads to 4.33, p<0.0001). This variable was dichotomised between
the second explanation, that initiation of treatment may self-presentation and any ambulance arrival, including
have been too late for some patients and hence skewed the arriving with pre-hospital notification. This finding con-
mortality benefit. Third, it is also feasible that the wide- curred with the literature, which demonstrates a strong
spread implementation over the past decade of evidence- association between pre-hospital notification, in particular,
based therapies for the management of STEMI has reduced and timely treatment.15
mortality as much as possible. Finally, this was an obser- Presenting with chest pain was also a predictor of a
vational study that examined association between groups, DTBT⩽ 90 min (OR 2.02, CI 1.31–3.13, p<0.002). The
not causality, reducing the ability to interpret the data. literature acknowledges that presenting symptoms in
This study also examined the difference between groups STEMI are often erratic, unpredictable and follow a pattern
for those who achieved timely treatment and those who did that differs in severity and quality from patient to patient.38
not, as measured by DTBT. There were several factors Therefore it follows that ischemic chest pain that is typical
found to influence timely reperfusion of the culprit coro- in nature is more recognisable, which once confirmed with
nary artery. Age was shown to be a barrier to timely treat- a 12-lead ECG leads to prompt treatment within the recom-
ment in this cohort. The mean age was found to be mended 90 minutes.
significantly higher for those who did not achieve timely A calculated TIMI risk score < 5 was a predictor of
treatment; 63 ± 12.6 vs. 66 ± 14.2 years, p<0.03. This dif- DTBT ⩽ 90 minutes (OR 2.36,CI 1.49-3.74, p<0.001). In
ference could be attributed to many factors, such as num- general, a TIMI risk score < 5 reflects a level of haemody-
ber of co-morbidities and functional limitations associated namic stability that would allow safe and prompt transport
with advancing age, which in turn could delay the decision from emergency department to the cardiac catheterisation
of appropriate care. laboratory and hence access to timely treatment.
Gender was also identified as a barrier to timely inter- Finally, presenting post process change to this single
vention. There were a higher percentage of women who site tertiary level hospital was a predictor of timely man-
had a DTBT > 90 min, p <0.03. One possible explanation agement for STEMI. As aforementioned, the process
for this difference could be attributed to age. Interestingly, changes implemented had a statistically significant effect
for this cohort females on average were 10 years older than on DTBT, and when included in the logistic regression
males; 72 ± 12 compared with 62 ± 13 years respectively. model were considered a predictor of timely treatment
Increased age for women presenting with STEMI is (OR 5.61, CI 3.53–8.92, p<0.0001); a finding strongly
reported in the literature, along with co-morbid conditions supported in the literature.9-16
and atypical presenting symptoms.34,35
An unexpected finding was that being a current smoker
Limitations
was associated with a lower DTBT, p=0.05. The literature
is sparse but cigarette smokers are reported as more likely The limitations of this research include the absence of ran-
to present with STEMI than NSTEMI.36 This may be partly domisation and the difficulty in blinding data where

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Martin et al. 7

exposure may be linked to hidden confounders, decreasing References


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The authors declare that there is no conflict of interest. myocardial infarction STEMI through the initiation of code
AMI. Intern Med J 2008; 38: 714–718.
Funding 14. Dorsch MF, Greenwood JP, Priestley C, et al. Direct ambu-
This research received no specific grant from any funding agency lance admission to the cardiac catheterization laboratory
in the public, commercial, or not-for-profit sectors. significantly reduces door-to-balloon times in primary

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