Door-to-device time and mortality in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention: insight from real world data of Thai PCI Registry

BACKGROUND: Timely reperfusion therapy is recommended for patients with ST-segment elevation myocardial infarction (STEMI), and system delay <90 minutes and door-to-device (D2D) time <60 minutes are recommended by the 2017 ESC Guidelines for the management of STEMI patients and have been proposed as a performance measure for triaging patients for primary percutaneous coronary intervention (PCI). However, previous research produced contradictory results regarding the association between D2D time and mortality. Therefore, this study aimed to examine the associations between D2D time and mortality in Thailand. METHODS: This cohort study included STEMI patients treated with primary PCI in 39 PCI centres in Thailand from February 27, 2018, to August 1, 2019. Patients were eligible if they met the following criteria: primary STEMI diagnosis, symptom onset within 12 hours, and ST-segment elevation of at least 0.1 mV in 2 or more contiguous leads (at least 0.2 mV in V1–V3) or a new left bundle branch block. RESULTS: Within 12 hours of symptom onset, 3,874 patients underwent primary PCI. The median D2D time was 54 minutes [interquartile range (IQR) 29–90], and there was a significant difference between patients transferred from other hospitals (44 minutes, IQR 25–77, n=2,871) and patients presented directly to PCI centres (81 minutes, IQR 56–129, n=1,003) (P<0.001). Overall, in-hospital mortality was 7.8%. In a multivariable analysis, adjusting for other predictors of mortality and stratifying according to intervals of D2D time, cumulative in-hospital mortality was significantly higher in patients with a D2D time greater than 90 minutes [hazard ratio (HR) 1.5, 95% confidence interval (CI): 1.0–2.1, P=0.046] but not associated with D2D time shorter than 60 minutes (HR 1.2, 95% CI: 0.8–1.8, P=0.319). CONCLUSIONS: A D2D time greater than 90 minutes was related to in-hospital mortality in patients with STEMI treated with primary PCI, but a D2D time less than 60 minutes was not consistently associated with D2D time-improved survival in real-world, contemporary practice in Thailand.