The established goal in the treatment of myocardial infarction is early time to reperfusion, defined as within 90 minutes from the patient’s arrival in the emergency room. The most effective way to accomplish this goal is primary percutaneous coronary intervention (PCI), i.e., coronary angioplasty. The “Door-to-Balloon” (D2B) time initiative was launched by the American College of Cardiology in 2006, to encourage hospitals with PCI capability to comply with this standard.
Any delay in reperfusion greater than 90 minutes increases myocardial damage and mortality. Early reperfusion (less than 60 minutes) results in the most favorable outcomes for patients with ST-segment elevation myocardial infarction.
There may, however, be reasons why a patient is a not candidate for PCI. An anatomical reason such as a blockage in the left main artery, if severe enough, may prevent the physician from reaching the lesion causing the myocardial infraction downstream in the left anterior descending or circumflex vessels. A severely tortuous artery may prevent delivery of a balloon or stent. A wire may fail to cross a lesion if it is severely narrowed or the plaque causing the heart attack is severely disrupted. There may be other reasons not related to coronary anatomy which would favor surgical revascularization over percutaneous intervention such as concomitant valve disease requiring emergent correction or the patient’s inability to take antiplatelet therapy after PCI.
Percutaneous coronary intervention (coronary angioplasty) medical expert witness specialties include cardiology, interventional cardiology, and anesthesiology.