be required in non-Western countries, including Japan. Specifically, several studies have emphasized the volumeoutcome relationship in the assessment of DTB time, but this trend may differ in universal health care. 18 Japan implemented social health insurance in 1961, and, consequently, primary PCI is performed far more aggressively compared with Western countries. 16 Hence, to assess country-specific gaps and identify areas for improvement, the aim of this study was to evaluate the current status of STEMI care with regard to DTB time in Japan, and further explore predictors associated with delay in DTB time using a large-scale, multicenter PCI registry.
Methods
DataWe obtained data from the Japan Cardiovascular DatabaseKeio interhospital Cardiovascular Studies (JCD-KiCS) P rimary percutaneous coronary intervention (PCI) is a life-saving treatment for ST-segment elevation myocardial infarction (STEMI), 1-3 and, importantly over the last decade, shorter patient-specific door-toballoon (DTB) time, which is the time interval from arrival at hospital to inflation of the balloon to restore coronary flow, is consistently associated with lower long-term mortality. 4,5 Consequently, clinical guidelines recommend DTB time ≤90 min, 6,7 and this is considered a key indicator for providing high-quality care in the USA. 8, 9 Studies from large-scale databases have identified predictors and strategies to allow individual hospitals and larger health-care systems to decrease DTB time. 10-14Based on these findings, DTB time has been successfully reduced in Western countries. These implications from Western countries, however, may be limited, 15 because of significant differences in patient characteristics 16 and PCIcapable facilities, 17 and therefore different strategies may Background: Door-to-balloon (DTB) time ≤90 min is an important quality indicator in the management of ST-elevation myocardial infarction (STEMI), but a considerable number of patients still do not meet this goal, particularly in countries outside the USA and Europe.