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Great Door to Balloon Time

Interesting but sad case that bypassed the ED but about which we later heard.

An elderly female with previous coronary artery disease, diabetes, and hypertension called EMS for chest pain. Then she has a syncopal event in front of her husband.

Medics arrived and found the patient in ventricular tachycardia.  They cardioverted her back to sinus rhythm, but she was still hypotensive. EMS transports her as a sudden cardiac arrest to a STEMI facility.

The patient is taken directly to cath lab which had already been activated due to the EMS report of a “code STEMI.”
During the angiogram, the patient remained unstable, went in and out of ventricular tachycardia, and remained markedly hypotensive, requiring fluid resuscitation and pressors. The angiogram showed severe three vessel disease.

Cardiologists couldn’t get the patient stable despite pressors, IV fluids, multiple defibrillations, and ACLS drugs.

Then the cardiology fellow notes that the patient’s abdomen seemed to be distended – moreso since the case started. They directed the cardiac catheter down the aorta and injected dye while doing cineangiography.  It showed contrast material going into the patient’s peritoneal cavity.

Shortly afterwards, while making arrangements for the patient to be taken to surgery, she died on the table.

The rest of the history came out when the husband was informed of his wife’s death. The night before, the patient had been seen at a different hospital for evaluation of abdominal pain.  They diagnosed her with “obstipation” and sent her home.

Some of you are probably wondering how cardiologists missed the ruptured abdominal aneurysm when they inserted the catheter into the groin and advanced it up the aorta into her heart. Radial access is all the rage these days, so initial access was through the arm and not through the leg. Therefore, the catheter didn’t pass through the lower aorta.

So why was the patient in ventricular tachycardia? The cardiologists surmised that the hypotension led to low cardiac perfusion, which, in the setting of severe CAD, caused chest pain, cardiac ischemia, and the arrhythmias.

The patient probably wouldn’t have survived surgical repair of her aneurysm, but one of the down sides to that holy grail of a short door to balloon time is that it is more difficult to obtain a complete history.

Ironic that sometimes hospital boards and/or administrators care more about their numbers than they do about the actual patients. When hospital boards or administrators pressure medical staff to meet unreasonably high standards for “door to balloon times,” perhaps lawyers need to start looking at the administrators and board members for reckless decisions that result in adverse patient outcomes.


This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.


  1. What a great case of good intentions gone bad. I also wonder with this “door to balloon” pressure whether we are causing complications in the cath lab. While the cardiologists are rushing to meet this relatively arbitrary “standard” are they taking enough time to correctly access the vasculature? Are the rates of psuedoanueysm, bleeding, and other complications higher in the “door to balloon” era than before?

    On the soapbox…elderly patient with an abdominal complaint = CT scan. Done and done. You aren’t going to cause cancer in this age group, their CTs are much higher yield for pathology than in younger patients, and the 10% mortality coming in the door is higher than a STEMI! (8-9%). Obviously you’ll want to go easy on the contrast and make sure you don’t put someone on dialysis but most things can be diagnosed from a non-contrasted CT. Off the soapbox…

  2. I appreciate and understand the premise of the article but I’m not sure this hypothetical patient would have gone straight to cath lab in most hospitals. In my ED it never would have happened.

    V tach converted to sinus rhythm, no mention of ST elevations. If I called our cardiologists with this presentation and no other information they would not rush to the cath lab.

  3. This would never have been a STEMI activation at my hospital since she was just in V-tach. She would come to us and would not be surprised if we made the diagnosis. Not saying we would have saved her though. I just mean that cases that are not straight forward should be treated as such.

  4. It’s still pretty freaking impressive that docs could keep someone alive who was massively bleeding into their chest cavity. And you wonder why everyone thinks it’s like TV where you can Frankenstein someone no matter how dead they are.

    And for the non-med folks in the room…how the heck do you fix it? Do you throw a stent in and sew the artery back up around it?

  5. agreed with previous. our cardiologists would’ve totally balked going to the cath lab with this one–since she didnt really have a STEMI…right?

  6. With hypoperfusion of severe triple vessel disease she probably was having a STEMI. The AAA couldn’t have massively ruptured or she wouldn’t have survived to EMS arrival, much less access of her radial artery. Regardless of the outcome this was most likely a very appropriate use of the code STEMI system.

    Was it unfortunate that the choice of access was radial? Yes. But that doesn’t negate the fact that many patients are saved by quick intervention. Patients with AAA’s die when their symptoms are mistaken for MI’s. We only have to look back at the famous case of Mr Ritter for that.

    Do not forget the trip to the ED the night before and the missed opportunity for diagnosis at that time. Why blame a good system for working as designed?

  7. I’m guessing that after they defibbed/”cardioverted” her the first time at home that the rhythm had ST elevations…

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