Door-to-balloon times vary widely across low- and middle-income countries, review finds

The review, which searched PubMed and Embase from inception to 1 August 2026, compiled evidence on door-to-balloon (D2B) times in adults with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI).

The analysis included 24 studies covering 29,319 patients across 11 low- and middle-income country settings. Conventional study-level D2B estimates ranged from 34 to 169 minutes, a spread the authors describe as substantial variation in performance. Among the 17 studies whose conventional estimates could be classified against the 90-minute benchmark, 12 reported values consistently within the target and five reported values exceeding it. Three further studies reported subgroup or intervention-period estimates that straddled the threshold. Because of substantial clinical and methodological heterogeneity, the findings were synthesised narratively rather than pooled statistically, and risk of bias was assessed with the Newcastle-Ottawa Scale.

The review also catalogued what helps and what hinders rapid reperfusion in these settings. Reported facilitators included continuous pPCI availability, single-call activation of the catheterisation laboratory, simulation-based team training, direct transfer from the emergency department to the catheterisation laboratory, regular audit and feedback, arrival by ambulance, and organised referral networks. Reported barriers included delayed patient presentation, interhospital transfer, limited use of emergency medical services, reduced out-of-hours capacity, financial and administrative processes, delays in obtaining treatment consent, and movement or transport restrictions.

Clinical outcomes varied markedly as well. Crude in-hospital mortality across the included studies ranged from 1.0% to 24.3%. Several studies reported associations between longer reperfusion intervals and mortality, major adverse cardiovascular events, or myocardial injury. As an observational synthesis, these associations do not establish that reducing D2B time alone would eliminate the outcome differences, but they align with the review’s central recommendation: quality-improvement programmes should address total ischaemic time rather than D2B time in isolation, since prehospital delay, transfer logistics, and administrative hurdles all contribute to the interval between artery occlusion and reperfusion.

The authors conclude that D2B performance differs substantially across low- and middle-income settings, and that protocolised activation, round-the-clock pPCI capability, multidisciplinary training, and coordinated referral pathways were the measures reported alongside shorter treatment intervals. The review is published as open access, with the version shared early as citable, peer-reviewed accepted research subject to further editorial edits before the final Version of Record.

Subject of Research: Door-to-balloon reperfusion times, determinants of delay, and clinical outcomes in STEMI patients undergoing primary PCI in low- and middle-income countries

Article Title: Door-to-balloon performance, determinants, and clinical outcomes in low- and middle-income countries: a systematic review

Article References: Jamileh, E., Soliman, A. M., Elmewafy, A., Natesan, T. A., Katrib, M., Gire, N., Hosseni, K., & Antoun, I. (2026). Door-to-balloon performance, determinants, and clinical outcomes in low- and middle-income countries: a systematic review. BMC Cardiovascular Disorders. https://doi.org/10.1186/s12872-026-06926-y

Image Credits: AI Generated

DOI: 10.1186/s12872-026-06926-y

Keywords: STEMI, door-to-balloon time, primary PCI, low- and middle-income countries, systematic review, reperfusion delay, in-hospital mortality, quality improvement, emergency medical services, catheterisation laboratory, Door-to-balloon, performance