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It’s Not Over Yet: Addressing Part Two of the Door-to-Balloon Time Initiative’s Success


John P. Reilly, M.D., FSCAI

From the very first sign of a heart attack, the clock starts ticking in the race to save a patient’s heart muscle and even his or her life.

Thanks to technology and finely tuned systems of heart attack care that are now available in communities throughout the United States, we are getting faster all the time.

But sometimes we still lose the race.

During a heart attack, the heart is deprived of oxygen. The longer the heart goes with too little oxygen, the more muscle is lost, often irreversibly. This is what doctors mean when we say, “Time is muscle.” How quickly a patient receives treatment once heart attack symptoms appear often determines if he or she will make a full recovery, suffer heart muscle damage, or die.

Door to Balloon Signaled Success, or Did It?

This is why, a decade ago, healthcare professionals across the country set out to reduce the time it takes to treat heart attack patients once they arrive at the hospital. Since stopping a heart attack often involves balloon angioplasty to reopen the blocked artery, the effort was called the Door-to-Balloon (D2B) Initiative. This effort has prevented or limited heart damage for countless patients.

The D2B initiative involved making the healthcare system more efficient, more responsive and more effective, starting from the moment a heart attack patient comes to the attention of an emergency medical responder (EMR) answering a 9-1-1 call or presenting in the emergency department.  When D2B began, it often took more than two hours from the time a heart attack patient arrived at the hospital until he or she received life-saving treatment to reopen a blocked artery.

Now, 90 percent of patients who enter hospital doors receive treatment in less than 90 minutes and many are treated within 60, 30, even 15 minutes. [1]

D2B is one of healthcare’s greatest success stories. But, according to a new study [2], reducing D2B times has not been enough to significantly reduce mortality rates among heart attack patients.

What Happens Before the Hospital Door?

There are two sides to the time equation. Unfortunately, the part of the equation that has not improved enough is how long it takes patients to get to the hospital once heart attack symptoms start. Most patients wait two or more hours after heart attack symptoms appear to seek medical help. [3] Many patients are taking too long to call 9-1-1, placing themselves at risk of suffering irreversible heart damage or death.

We must do for Symptom-to-Door (S2D) Time what we have done so successfully for D2B. Revamping a system of care outside the hospital, however, is much different and perhaps more difficult than revamping a system of care within the hospital.

There have been myriad heart attack awareness programs, including online public education programs like, for which I am an editor, aimed at helping people understand the risks of heart attack, how to recognize the symptoms and why responding promptly is essential.

We have made progress. An increasing number of people know that chest pain, shortness of breath, nausea, fatigue, dizziness, and pain in the jaw, back or arm are often the first signs of heart attack. While I see more people who identified their symptoms early on, there are also many who remain unaware, are in denial or are just confused. Every day, I see patients who thought their symptoms “weren’t that bad” or explain them away as indigestion or a virus. I also see the toll that lost time takes in hearts damaged and lives lost.

Only 60 percent of patients contact emergency medical responders when experiencing symptoms. About 40 percent arrive at our hospitals on their own. [4] That’s dangerous, whether the patient is driving him- or herself. Or, even if a friend or relative is driving, it still represents a lost opportunity for treatment to begin in the ambulance, or to alert the doctors in the emergency room that a heart attack patient is on the way in.

Let’s Save More Hearts and Lives

To get started, here are a few thoughts on how we might reduce S2D:

  • We need a concerted national effort to reduce S2D time that establishes consistent messages rather than myriad programs offering incomplete or inconsistent information.
  • We must improve regional and statewide systems of care to coordinate heart attack care to ensure everyone gets the most expeditious care.
  • We need to better inform the people who are most at risk for heart attack or other heart issues about what symptoms to look for and what to do if they develop.
  • And, of course, we must continue our educational efforts, helping everyone to understand that if they are concerned they may be having a heart attack, then they should call 9-1-1 without delay and without concern about looking foolish if their symptoms turn out to be something other than a heart attack.  The alternative – sitting at home while having a heart attack, with heart muscle dying as the minutes tick by – would be far worse.

We’ve had remarkable success in reducing D2B times. But it’s not enough. To save hearts and lives, we must take on the other side of the heart attack challenge.

We’ve done it once. We can do it again.

1. Bates ER, Jacobs AK. Time to Treatment in Patients with STEMI. N Engl J Med 2013;369:889-892.
2. Menees DS, Peterson ED, Wang Y, et al. Door-to-balloon time and mortality among patients undergoing primary PCI. N Engl J Med 2013;369:901-9.
3.  Life After a Heart Attack. National Heart, Lung, and Blood Institute.


  1. Carolyn Thomas

    Couldn’t agree more – a speedy D2B time means little if your heart patient has been sitting at home for hours popping Tums and waiting for what seems like a really bad case of indigestion to go away.

    I’m a heart attack survivor who actually did go immediately to the ER for help, alarmed by my textbook MI signs (central chest pain, nausea, pain radiating down my left arm). Yet all my diagnostic tests appeared to be “normal” and I was sent home with a GERD misdiagnosis – feeling horribly embarrassed because I’d just made a great big fuss “over nothing”.

    Not wanting to make a fuss is tragically common, particularly in women, as Oregon researchers found in their 2005 study on women’s “treatment-seeking delay” behaviour in mid-heart attack, published in the American Journal of Critical Care. This study identified SIX distinct reasons given for treatment-seeking delay during MI. (I think I experienced at least five of them after being sent home with ongoing and increasingly debilitating MI symptoms). After all, a man with the letters M.D. after his name had told me quite emphatically: “it is NOT your heart!’

    Although my own experience was all about being misdiagnosed despite classic Hollywood Heart Attack symptoms, I’ve become more concerned since that experience in 2008 about the women I hear from whose vague and/or non-chest pain symptoms are not taken seriously, or dismissed as anxiety, indigestion, stress, pulled muscles, gall bladder problems, dehydration, menopause (a great all-purpose misdiagnosis!) etc etc.

    I think your four key points in reducing S2B time are excellent, but I’m wondering what your thoughts are in addressing those patients – both female and male – who present with non-chest pain? A flurry of recent studies appear to confirm that chest pain is what docs need to be looking for, and that vague MI symptoms may be more rare than previously thought. At least two Canadian studies have even trumpeted headlines like “The MYTH of women’s heart attack symptoms” in dismissing these vague/non-chest symptoms. How to counter this enduring bias towards looking for chest pain in the public perception?

  2. JP Reilly

    Thanks, Carolyn, I think that you are right. While some recent studies suggest less variability in how men and women report their heart symptoms, the fact is there are still differences. And those differences exist between genders and within a gender. There are probably many reasons for this. Some people are more stoic than others. We are familiar with the fact that people have different pain thresholds. And people express themselves differently. Some people are extremely precise, others speak more generally; some take 30 seconds to tell you something it takes 5 minutes for the next person to explain.

    While the studies you mention suggest that women don’t have “vague” symptoms, every internist has cared for a few patients who presented “atypically.” It is not a rare phenomenon for a woman (or a man) to deny that they are having chest pain, but describe the onset of nausea, palpitations, shortness of breath or some other symptom that turns out to be heart related.

    A balance must be struck. We must educate the community to be wary of the sudden onset of heart attack symptoms, without making them worry every time they belch. Which means that printing laundry lists of symptoms on a bulletin board or an advertisement is insufficient. We must make an investment in real education.

    How to do that is not easy, and I welcome suggestions.

  3. Carolyn Thomas

    Thanks Dr. R – excellent points! A way to help educate patients may be what I now tell all of my women’s heart health presentation audiences, which is: “You know your body. You KNOW when something is very wrong!” or conversely asking the powerful question: “How would you respond to these symptoms if it were your daughter experiencing them – instead of you?” That seductive combination of denial, dread, unwillingness to believe that something so serious could actually be happening to us (that’s the “managing an alternative hypothesis” tendency that the Oregon researchers identified in their treatment-seeking delay studies) – all combine to help talk ourselves out of paying attention to what’s actually happening.

    There will always be the “catastrophizers” who may interpret every belch as a death knell. I’m sure you’ve met them! My hunch however, is that – particularly for women heart patients – they may be far outnumbered by those who maddeningly exhibit one of the six delaying behaviours studied in Oregon.


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