ED heart attack protocols save time and lives

Two studies published online in the Annals of Emergency Medicine describe new methods of achieving the door-to-balloon time of 90 minutes recommended by the American Heart Association.1,2

"Our research shows that when ED physicians are authorized to initiate the process leading to balloon angioplasty without waiting for consultation with a cardiologist, the door-to-balloon time drops dramatically, from 131 to 91 minutes," says Michael Kurz, MD, of Virginia Commonwealth University Medical Center in Richmond and lead author and researcher for one of the papers. "Given the considerable investment required to maintain an infrastructure capable of consistently meeting that 90-minute goal, it is very encouraging to find that emergency physicians can take the lead and save both money and lives — while costing virtually nothing."

Kurz and his team first studied door-to-balloon times for heart attack patients treated using the standard hospital protocol of cardiology consultation, followed by activation of the cardiac catheterization laboratory. Next, they enrolled 172 patients using a new protocol, in which the ED physician diagnosed the heart attack and then activated the cardiac catheterization (or angioplasty) team with one phone call, without consulting a cardiologist first.

In a similar study, ED physicians devised a heart attack protocol that involved concurrent activation of the cardiac catheterization team and cardiologist by the ED physician, reducing door-to-balloon times on average from 147 minutes to 106 minutes.

Although the 90-minute recommendation has been in place for over a decade, the standard protocol requiring a cardiologist to diagnose the heart attack and then assemble the team to perform the angioplasty has proven too time-consuming. Aveh Bastani, MD, of Troy (MI) Beaumont Hospital, one of the co-authors of the second paper, says that ED physicians play a central role in diagnosing and treating heart attack patients, but historically they have lost critical time by sequentially paging first the interventional cardiologist and then the cardiac catheterization team. "With the concurrent activation group, 39% of patients had a door-to-balloon time of less than 90 minutes, compared with 16% in the serial activation group," Bastani says.


  1. Kurz MC, Babcock C, Sinha S, et al. The impact of emergency physician-initiated primary percutaneous coronary intervention of mean door-to-balloon time in patients with ST-segment-elevation myocardial infarction. Ann Emerg Med 2007; DOI: 10. 1016/j.ann emergmed.2007.03.018.
  2. Kraft PL, Newman S, Hanson D, et al. Emergency physician discretion to activate the cardiac catheterization team decreased door-to-balloon time for acute ST-elevation myocardial infarction. Ann Emerg Med 2007; DOI: 10, 1016/j.annemergmed.2007.03.013.