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Literature Review: The Healthcare Delivery Model and Various Factors Which Affect the Rate of MACE Incidence and the Amount of DTB Time Among STEMI Patients

Problem Statement

When treating ST-elevation myocardial infarction (STEMI), door-to-door balloon (DTB) time is crucial in determining patient outcomes. An increased risk of major adverse cardiac events (MACE), which might lead to unfavorable patient outcomes, is directly correlated with any DTB time delays. The King Fahad Medical City (KFMC), located in Riyadh, Saudi Arabia, has two main entry points for patients with STEMI: the emergency rooms (ER) and the red crescent (RC). The question of whether ER and RC STEMI patients who are admitted to the KFMC Riyadh have different DTB timings and MACE incidence rates is still open.

Theoretical Framework

This framework is dependent on the way healthcare is delivered and a number of other variables that have an impact on the risk of MACE occurrence and the length of DTB in STEMI patients. The framework is made up of three parts, each of which has an impact on the severity of STEMI and how quickly treatment can be started. The patient-related factors in the framework include demographics, clinical presentation, time the patient first entered a care facility, and medical history. The second category is hospital-related variables, which include things like staff training, hospital resources, and management procedures for STEMI patients.

Literature Review

Door to Balloon

According to one of the research by (Tsukui et al., 2018), the goal of the research was to identify the variables influencing both short and long DTBT, The outcome was swift, and DTBT was linked to transfers from nearby clinics and hospitals. Additionally, their research may indicate a present limitation in Japan’s ambulance system, which disallows the use of a pre-hospital ECG equipment. The development of pre-hospital ECG technologies would be necessary for improved treatment of STEMI.

Another research by Liu et al. (2021) looked at the factors influencing various DTB time components and the impact of the mode of transportation on DTB time at a specific tertiary institution. It was discovered that arrival by emergency ambulance was associated with a reduced DTB for STEMI patients as compared to arrival by conventional forms of transportation. To increase the usage of emergency ambulances for suspected heart attacks and improve outcomes, public education is necessary.

According to a research (Krishnan et al., 2021) carried out in India and The relevance of the permission period in the Indian setting must be reinforced by further research in other states, since this study uncovers the previously unknown entity of consent time as a crucial predictor of the D2B time. According to a research by Foo et al. (2019), a longer door-to-balloon wait increases the population’s risk of negative outcomes.

The purpose of this study was to evaluate the predictive value of D2B time in STEMI patients who underwent primary percutaneous coronary intervention. While another study demonstrates that the survival benefit of reducing D2B time was consistently observed, even when it was reduced by 60 to 90 minutes, shortening D2B time was significantly associated with this survival benefit. 2019 (Park et al.)

In a study by (Zahler et al., 2019), researchers investigated the possible implications of further shortening DBT intervals below the 90-minute cut-off on both short- and long-term outcomes among STEMI patients following primary PCI. STEMI patients who had primary PCI within 90 minutes of arrival had decreased 1-year mortality, according to independent research.

This study was conducted in Iran to determine the impact of the (STEMI) code on patients with ST-segment elevation myocardial infarction’s door-to-balloon time. The findings showed that as the door-to-balloon time decreased, the emergency department’s bed occupancy rate decreased, allowing for the admission of more patients.(Namdar and others, 2021)


Coronary artery disease (CAD) is one of the major causes of death worldwide, claim Seyedian et al. (2020). In order to improve the connection between platelets, acute stenosis, and microcirculation, the Von Willebrand factor (VWF) is essential. The purpose of the research is to compare people with and without diabetes to see how much VWF affects their daily lives. 65 participants were included in the trial; 32 of them had diabetes while the other 33 did not. VWF was used to examine the patients. The sample’s VWF levels, fasting blood glucose levels, and blood groups were assessed at the Angiography and Echocardiography departments. During their hospital stay, the patients received angiography, percutaneous coronary intervention, and echocardiography. Those who required surgery had coronary artery bypass (CABG) grafting as well. Anterior ST examination for myocardial infarction (STEMI), limb ischemia, heart failure, death, and other major cardiovascular events (MACE) was performed on the patients after 40 days. The researchers discovered that diabetes individuals had high levels of VWF and that MACE was positively correlated with high VWF levels. The research deduced from these results that individuals with diabetes who had high VWF levels had an increased risk of cardiovascular problems and would benefit from taking drugs that reduce VWF levels.

The National Library of Medicine (2020) reports that the door-to-balloon time (DTBT), which is fewer than 90 minutes, is recommended by the STEMI standards that are currently in place. Even Nevertheless, certain individuals can have unfavorable medical results, making the therapy targets crucial for the patients. The goal of this research is to manage the variables that lead to poor clinical outcomes in STEMI patients with DTBTs of less than 90 minutes. 383 STEMI patients with DTBTs of fewer than 90 minutes made up the study’s entire sample. The study’s primary outcome was the definition of MACE as a composite of the majority of reported fatalities, acute heart failure requiring hospitalization, and acute myocardial infarction. The research discovered that whereas the radical approach is negatively linked with MACE, mechanical support is associated with MACE.

(2020) Kinsara et al. Show that not all Saudi Arabian patients with STEMI are treated with central percutaneous coronary procedures (PPCI). The Saudi Acute Myocardial Infarction Registry’s (STARS) STEMI patient management strategies were the subject of the study. PPCI, thrombolytic treatment, conservative care, and revascularization are a few of the strategies mentioned. The care of the three groups of STEMI patients was as follows: PPCI for the first group, revascularization for the second, and conservative therapy for the third. Information was gathered at staging one month and one year after the patient was discharged. The research discovered that treating STEMI patients depends on risk factors and better access to the PPCI in hospitals.

In their research, Chen et al. (2023) found that even when given prompt treatment, patients with acute STEMI who receive primary percutaneous coronary interventions (PCI) had a higher risk of MACE. The goal of the research is to identify patient-specific independent predictions of MACE and its predictive values after a primary PCI. A retrospective research was conducted on 151 patients who were having PCI and had acute STEMI. With an area under the curve of 0.778, the research indicated that the prediction technique had high discernment. The decision curves and the calibrations were used to examine the clinical utility and the effective calibration.

Arrival Mode

The emergency room (ER) is one of the mechanisms of STEMI patient presentation to healthcare institutions, according to a research by McLaren et al. (2021). Despite a considerable drop in the number of patients in the ER, the research finds that COVID-19 was linked to a longer ST-Elevation Myocardial Infarction (STEMI) reperfusion delay. However, there was little evidence available on the ER’s role in the delays. As a result, the authors decided to assess the standard of the ED and STEMI delays throughout the pandemic’s first two waves. The study team used a multi-centered retrospective chart review methodology from two separate metropolitan academic medical facilities. The ER volumes, the COVID-19 tests and cases listed in the hospital databases, and the ER code for STEMI—which had a cath lab culprit lesion—were all collected by the researchers. Then, throughout different pandemic stages, they assessed the door-to-door Electrocardiogram (ECG) time and the ECG activation period. The research discovered that while there was no appreciable variation in the volume of the ED or the quality parameters of STEMI, COVID-19 instances began to increase at the time of the wave. The research came to the conclusion that EDs can identify reperfusion delays during and after pandemics by using both estimated time of arrival (ETA) and days to the event (DTE) indicators.

Another research by Redwood et al. (2021) investigates the impact of ambulance transportation on the outcomes and reperfusion time for STEMI patients. The authors center their discussion on a research that was conducted between 2013 and 2018 at three hospitals in Sydney. The study’s researchers were able to examine data from 1297 subjects. They discovered that patients who used ambulances to get to the hospitals reported a lengthier door-to-balloon time than those who used alternative forms of transportation. Negative patient outcomes including heart failure and increased death rates were linked to the delays. Because delays are likely to have a negative impact on patient outcomes, the researchers emphasize the advantages of reducing the time required for reperfusion of STEMI patients. They also recommend better options than ambulance transportation for STEMI patients and highlight the advantages of other transportation strategies, such private transportation, which cuts down on door-to-door balloon times. The need of further study on the best mode of transportation for STEMI patients as well as strategies for enhancing patient outcomes is emphasized by the authors in their conclusion.

In order to enhance health quality, Li et al.’s research from 2021 looks at the effects of programs aiming to shorten treatment wait times for STEMI patients who arrive at the hospital by various means. Information from 33 different general hospitals in China was evaluated by the researchers. They also assessed how the effort will affect healthcare during public health crises and catastrophes. The researchers determined the various ways STEMI patients arrive at hospitals and how this delays the start of therapy. According to the research, patients who arrived at the hospital by ambulance saw comparatively little treatment delays as compared to those who came through other modes of transportation, such as private transportation or by foot. The researchers discovered that activities for bettering the quality of healthcare improved the decrease of treatment delays for patients arriving by all modes.

Butt et al. (2022) assert that a STEMI patient’s method of transportation has a critical role in the timing of Primary Percutaneous Coronary Interventions (PPCI) for patients who are suspected of having STEMI. In a particular PPCI center located in Ireland, the researchers examined the transient changes over an eight-year period. Additionally, they assessed how different transportation strategies affected PPCI timings. In comparison to other transportation strategies, such as private transportation methods, transfers within hospitals, or those that the general healthcare providers authorized, the researchers discovered that direct patient transfers using ambulances led to significant improvements in the PPCI timeline. A pre-hospital direct ambulance transfer was recommended as a highly efficient means of transportation by the study’s authors. It resulted in better results for STEMI patients by accelerating the PPCI timeframes.

In this research, Erol et al. 2021 examine the time lags between the onset of symptoms and the start of the treatment procedure for patients with acute myocardial infarction. (AMI). According on the information in the TURKMI registry, the researchers examine the numerous methods that patients use to go to hospitals. They also assessed the length of time that each phase of the therapy procedure takes. The researchers concentrate more on the various methods people use to get to hospitals and how these methods cause delays in the healing process. According to the research, patients who arrived at the hospital by ambulance had less delay in receiving medical attention than those who came through other modes of transportation. In order to decrease treatment delays and improve patient outcomes, the researchers advise hospitals to employ ambulances more often for AMI patient transfer.


Butt, Z., McGrath, B., Cadogan, D., Casserly, I., McCann, H., O’Neill, J., … & Blake, G. (2022). 2 Pre-hospital direct ambulance transfer has led to significant improvements in the timeliness of ppci in suspected stem: temporal trends over eight years in a designated PPCI centre.

Chen J, Qing H, Cui R, & Huang L (2023). In-hospital major adverse cardiovascular events after primary percutaneous coronary intervention in patients with acute ST-segment elevation myocardial infarction: a retrospective study under the China chest pain center (standard center) treatment system

Erol, M. K., Kayıkçıoğlu, M., Kılıçkap, M., Güler, A., Öztürk, Ö., Tuncay, B., … & Yavuzgil, O. (2021). Time delays in each step from symptom onset to treatment in acute myocardial infarction: Results from a nationwide TURKMI registry. Anatolian Journal of Cardiology25(5), 294.

Kinsara, A. J., Alsaleh, A., Taher, Z. A., Alshamiri, M., & Elshaer Sr, F. (2020). The Primary Management Strategies for ST-Elevation Myocardial Infarction Patients in Saudi Arabia: A Sub-Study of the Saudi Acute Myocardial Infarction Registry. Cureus12(11).!/

Li, N., Ma, J., Zhou, S., Dong, X., Maimaitiming, M., Jin, Y., & Zheng, Z. (2021, October). Can a healthcare quality improvement initiative reduce disparity in the treatment delay among ST-segment elevation myocardial infarction patients with different arrival modes? Evidence from 33 general hospitals and their anticipated impact on healthcare during disasters and public health emergencies. In Healthcare (Vol. 9, No. 11, p. 1462). MDPI.

McLaren, J. T., Taher, A. K., & Chartier, L. B. (2021). Flattening the other curve: Reducing emergency department STEMI delays during the COVID-19 pandemic. The American Journal of emergency medicine49, 367-372.

National Library of Medicine (2020) Factors associated with poor clinical outcomes of ST-elevation myocardial infarction in patients with door-to-balloon time <90 minutes

Redwood, E., Hyun, K., French, J. K., Kritharides, L., Ryan, M., Chew, D. P., … & Brieger, D. B. (2021). The influence of traveling to hospital by ambulance on reperfusion time and outcomes for patients with STEMI. The Medical Journal of Australia214(8), 377-378.

Seyedian, S. M., Soltani, F., Saki, N., Afshari, G., & Haybar, H. (2020). Effect of Von Willebrand antigen on mortality and major adverse cardiac events in diabetic and non-diabetic patients with anterior ST elevated myocardial infarction. Jundishapur Journal of Chronic Disease Care9(1)


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