DefinePK

Abstract

The study by Hussain et al. [1] offers important insight into a critical determinant of STEMI outcomes: door-to-balloon (D2B) time. This prospective single-center analysis reinforces the established global consensus that rapid reperfusion significantly improves outcomes in patients undergoing primary percutaneous coronary intervention (PCI). In doing so, it situates this universal principle within the distinct challenges of Pakistan’s healthcare system, where data on STEMI care processes remain relatively limited.
Numerous registries and randomized clinical trials have consistently demonstrated that minimizing ischemic time reduces infarct size, preserves left ventricular function, and lowers mortality rates [2,3]. Echoing this evidence, Hussain et al. report significantly lower in-hospital mortality (3.3%) and major adverse cardiac events (6.7%) in patients with D2B times under 60 minutes compared to those whose treatment exceeded 90 minutes (20% and 30%, respectively). These findings affirm that faster reperfusion is not only desirable but lifesaving.
What distinguishes this study is its contextual relevance. While international benchmarks have long set the standard for STEMI care, translating these into low- and middle-income country (LMIC) settings is often impeded by infrastructure limitations. Prior observations from institutions such as the Peshawar Institute of Cardiology and the National Institute of Cardiovascular Diseases (NICVD) have highlighted systemic inefficiencies including delayed triage, underdeveloped emergency medical services (EMS), and lack of coordinated STEMI networks [4,5]. Hussain et al. underscore these familiar obstacles but also demonstrate that improvements in D2B performance are achievable even within existing hospital frameworks [1].
An especially meaningful contribution of this study is its stratified analysis by comorbidity status. Patients with hypertension, diabetes, and hyperlipidemia experienced longer D2B times, suggesting that complex clinical profiles may contribute to treatment delays, potentially through diagnostic ambiguity or procedural hesitations [6]. This highlights the urgent need for streamlined, risk-adapted care pathways—an approach consistent with the ethos of precision medicine.
The study also prompts renewed attention to pre-hospital delays, which are not captured in D2B metrics but critically influence total ischemic time. While the investigation begins at the point of hospital arrival, it is well recognized that patient hesitation, transport delays, and lack of EMS coordination erode valuable treatment time [7]. International experience demonstrates that integrating EMS systems, tele-ECG triage, and regional STEMI networks can dramatically reduce total ischemic time and should be prioritized in Pakistan [8].
These findings support the call for broader structural and policy reforms. High-volume tertiary facilities—such as Hayatabad Medical Complex—should consider implementing rapid triage algorithms, 24/7 catheterization lab teams, and real-time D2B performance monitoring systems [8]. At a national level, the establishment of a standardized STEMI registry, akin to the NCDR (USA) or MINAP (UK), could play a transformative role in benchmarking quality and harmonizing care [9,10]. In this regard, the recent launch of the Cardiac Registry of Pakistan (CROP) represents a pivotal advancement. However, widespread adoption and consistent reporting across all PCI-performing centers are essential for its impact to be realized.
While the study is strengthened by its prospective design and focus on clinically meaningful endpoints, certain limitations must be acknowledged. Being a single-center study, generalizability is restricted. Retrospective data extraction also introduces potential documentation bias. Moreover, the exclusion of total ischemic time and lack of long-term follow-up limit the assessment of sustained outcomes. Nevertheless, the study provides clear, focused evidence to support the use of D2B time as a key quality metric in the care of STEMI patients in Pakistan.
Hussain et al. offer compelling, context-specific evidence that underscores the critical importance of reducing D2B time to improve survival and reduce adverse outcomes in STEMI patients [1]. Their findings support the international guideline-recommended target of <90 minutes and suggest that achieving D2B within 60 minutes may yield even greater benefit [11]. In a country burdened by rising cardiovascular disease, optimizing reperfusion strategies is not merely a technical goal—it is a public health imperative. Moving forward, efforts must be directed toward emergency system reform, investment in EMS infrastructure, and public education campaigns to ensure that no minute is wasted in the race to save the myocardium.
References

Hussain I, Waqas M, Khan MN, Parkash C, Memon S, Zada S. Impact of Door-to-Balloon Time on Outcomes in STEMI Patients Undergoing Primary PCI. Pak Heart J. 2025;58(02):141-147. DOI: 10.47144/phj.v58i2.2919
De Luca G, Suryapranata H, Ottervanger JP, Antman EM. Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts. Circulation. 2004;109(10):1223-5. DOI: 10.1161/01.CIR.0000121424.76486.20
Owens JA, Moturi S. Pharmacologic treatment of pediatric insomnia. Child Adolesc Psychiatr Clin N Am. 2009;18(4):1001-16. DOI: 10.1016/j.chc.2009.04.009
Khan N, Jan MW, Ullah R. The Influence of Presentation Timing and Door to Balloon Timing on the Clinical Outcomes in Primary Percutaneous Coronary Intervention: Influence of Presentation Timing and Door to Balloon Timing. Pak J Health Sci. 2023:181-6. DOI: 10.54393/pjhs.v4i10.1125
Mansoor B, Osama MI, Ali A, Malik F, Buzdar AW, Asadullah RU. Efficacy of Primary Percutaneous Coronary Intervention (PCI) Performed Through a Transradial Approach in Patients with ST-Segment Elevation Myocardial Infarction (STEMI) at a Tertiary Care Cardiac Center. Pak J Med Health Sci. 2023;17(04):498-502. DOI: 10.53350/pjmhs2023174498
Liu Z, Lim MJ, Pek PP, Wong ASL, Tan KBK, Yeo KK, et al. Improved door-to-balloon time for primary percutaneous coronary intervention for patients conveyed via emergency ambulance service. Ann Acad Med Singap. 2021;50(9):671-8. DOI: 10.47102/annals-acadmedsg.2021153
Belfort R, Harrison SA, Brown K, Darland C, Finch J, Hardies J, et al. A placebo-controlled trial of pioglitazone in subjects with nonalcoholic steatohepatitis. N Engl J Med. 2006;355(22):2297-307. DOI: 10.1056/NEJMoa060326
Fox KA, Carruthers KF, Dunbar DR, Graham C, Manning JR, De Raedt H, et al. Underestimated and under-recognized: the late consequences of acute coronary syndrome (GRACE UK-Belgian Study). Eur Heart J. 2010;31(22):2755-64. DOI: 10.1093/eurheartj/ehq326
Tsukui T, Sakakura K, Taniguchi Y, Yamamoto K, Seguchi M, Wada H, et al. Association between the Door-to-balloon Time and Mid-term Clinical Outcomes in Patients with ST-Segment Elevation Myocardial Infarction. Intern Med. 2020;59(13):1597-603. DOI: 10.2169/internalmedicine.4287-19
Yamada T, Takahashi A, Mizuguchi Y, Hashimoto S, Taniguchi N, Nakajima S, et al. Impact of shorter door-to-balloon time on prognosis of patients with STEMI-single-center analysis with a large proportion of the patients treated within 30 min. Cardiovasc Interv Ther. 2019;34(2):97-104. DOI: 10.1007/s12928-018-0521-1
Chew NW, Sia CH, Wee HL, Benedict LJ, Rastogi S, Kojodjojo P, et al. Impact of the COVID-19 Pandemic on Door-to-Balloon Time for Primary Percutaneous Coronary Intervention　- Results From the Singapore Western STEMI Network. Circ J. 2021;85(2):139-49. DOI: 10.1253/circj.CJ-20-0800