Door-to-Balloon Time in Patients with ST-Segment Elevation Myocardial Infarction (STEMI) in Iran: A Systematic Review and Meta-Analysis
Abstract
Background: Myocardial infarction is a severe cardiovascular condition that necessitates prompt reperfusion therapies, particularly primary percutaneous coronary intervention (PCI), to prevent irreversible myocardial damage and associated complications. This study aimed to determine the average door-to-balloon (D2B) time in Iranian hospital emergency departments through a systematic review and meta-analysis.
Methods: Following the PRISMA guideline, the protocol for this study was registered in PROSPERO (CRD420251171966). A comprehensive search with no time restrictions was conducted through the end of September 2025 in data resources such as PubMed, Scopus, Web of Science, Google Scholar, SID, and Magiran. A random-effects model was used for the meta-analysis, and heterogeneity among studies was assessed using the I² index. Publication bias was evaluated with Begg test.
Results: Of 154 initial articles retrieved, 13 studies met the eligibility criteria and were included in the final analysis. The pooled mean D2B time was 85.05 minutes (95% CI, 75.32 to 94.78). A significant level of heterogeneity was observed among the included studies. Meta-regression analysis indicated a decreasing trend in D2B time over the years.
Conclusion: The results of this study indicate that the average D2B time in Iran aligns with global standards. However, significant variability among hospitals highlights systemic gaps in STEMI care. Addressing these gaps requires coordinated emergency-PCI teams, nationwide 24/7 services, ongoing training, and uniform quality standards.
1. Domienik-Karłowicz J, Kupczyńska K, Michalski B, et al. Fourth universal definition of myocardial infarction. Selected messages from the European Society of Cardiology document and lessons learned from the new guidelines on ST-segment elevation myocardial infarction and non-ST-segment elevation-acute coronary syndrome. Cardiology journal. 2021;28(2):195-201.
2. Lambert B, Denson F, Baumgarten K, Parker D, Badakhsh R. Centers for Disease Control and Prevention (CDC) Hospital-Acquired Infections. Optimizing Widely Reported Hospital Quality and Safety Grades: An Ochsner Quality and Value Playbook. Springer; 2022:95-109.
3. Beyranvand MR, Manhoobi H, Shahraz S, Kolahi A-A. Myocardial infarction in Iran: Epidemiology, management, and prognosis. The Journal of Tehran University Heart Center. 2023;18(2):82.
4. Akbar H, Mountfort S. Acute ST-segment elevation myocardial infarction (STEMI). StatPearls. 2024;
5. Stopyra JP, Snavely AC, Ashburn NP, Supples MW, Miller CD, Mahler SA. Delayed first medical contact to reperfusion time increases mortality in rural emergency medical services patients with ST‐elevation myocardial infarction. Academic Emergency Medicine. 2023;30(11):1101-9.
6. Wang Q, Zan C, Li F, et al. The impact of admission modes on the treatment outcome and in-hospital mortality rate of STEMI patients undergoing PPCI. Scientific Reports. 2024;14(1):18932.
7. Zeng X, Chen L, Chandra A, et al. Narrative review: updates and strategies for reducing door-to-balloon time in ST-elevation myocardial infarction care. Frontiers in Cardiovascular Medicine. 2025;12:1509365.
8. Murrone A, Oliva F, Scotto di Uccio F, Gulizia MM, Gabrielli D, Colivicchi F. Timing of coronary angiography in non-ST-elevation acute coronary syndrome: comment to the 2021 ACC/AHA/SCAI guideline. Giornale Italiano di Cardiologia (2006). 2022;23(5):316-8.
9. Partow-Navid R, Prasitlumkum N, Mukherjee A, Varadarajan P, Pai RG. Management of ST elevation myocardial infarction (STEMI) in different settings. International Journal of Angiology. 2021;30(01):067-75.
10. Emami M, Mirzamohamadi S, Heidari A, Aein A, Salarifar M, Nematipour E. Evaluation of the Causes of Door-to-Balloon Time Delays in Patients with ST-Elevation Myocardial Infarction at Tehran Heart Center. The Journal of Tehran University Heart Center. 2023;18(1):68.
11. Herrera C. A systematic review of factors predicting door-to-balloon time in ST-segment elevation myocardial infarction treated with percutaneous intervention %J American Heart Journal. 2011;162(5):730-41.
12. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Bmj. 2009;339.
13. Downes MJ, Brennan ML, Williams HC, Dean RS. Development of a critical appraisal tool to assess the quality of cross-sectional studies (AXIS). BMJ open. 2016;6(12):e011458.
14. Peterson J, Welch V, Losos M, Tugwell P. The Newcastle-Ottawa scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa: Ottawa Hospital Research Institute. 2011;2(1):1-12.
15. Kf S. CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials. Ann Intern Med. 2010;152:1-7.
16. Falsoleiman H, Fatehi GH, Dehghani M, et al. Clinical outcome, and survival between primary percutaneous coronary intervention versus fibrinolysis in patients older than 60 years with acute myocardial infarction. Heart views : the official journal of the Gulf Heart Association. Oct 2012;13(4):129-31.
17. Reza Khosravi A, Hoseinabadi M, Pourmoghaddas M, et al. Primary percutaneous coronary intervention in the Isfahan province, Iran; A situation analysis and needs assessment. ARYA Atheroscler. Jan 2013;9(1):38-44.
18. Kassaian SE, Masoudkabir F, Sezavar H, et al. Clinical characteristics, management and 1-year outcomes of patients with acute coronary syndrome in Iran: The Iranian Project for Assessment of Coronary Events 2 (IPACE2). BMJ Open. Dec 15 2015;5(12):e007786.
19. Hosseini Y, Soheili A, Vatani KK, Rahmani AJMS. Assessment of time intervals from the moment of arrival in the emergency department until performing primary angioplasty in patients with acute myocardial infarction in Northwestern Iran. 2018;22:498-502.
20. Rezaee E, Hanifi N, Rohani M, Faghih Zadeh SJJoMUoMS. Effective Factors on Delayed Onset of Treatment in Patients with Acute Myocardial Infarction. 2018;28(163):66-76.
21. Yekefallah L, Pournorooz M, Noori H, Alipur M. Evaluation of door-to-balloon time for performing primary percutaneous coronary intervention in ST-segment elevation myocardial infarction patients transferred by pre-hospital emergency system in Tehran. Article. Iranian Journal of Nursing and Midwifery Research. 2019;24(4):281-5.
22. Heybar H, Alipour-Parsa SA, Khaheshi I, Zayeri ZD. Pentraxin level is the key to determine primary percutaneous coronary intervention (Pci) or fibrinolysis. Article. Cardiovascular and Hematological Disorders - Drug Targets. 2019;19(2):160-8.
23. Soleimani M, Soleimani A, Roohafza H, et al. The comparison of procedural and clinical outcomes of thrombolytic-facilitated and primary percutaneous coronary intervention in patients with acute ST-elevation myocardial infarction (STEMI): Findings from PROVE/ACS study. Article. ARYA Atherosclerosis. 2020;16(3):1-7.
24. Alizadeh R, Aghsaeifard Z, Sadeghi M, Hassani P, Saberian P. Effects of prehospital traige and diagnosis of st segment elevation myocardial infarction on mortality rate. Article. International Journal of General Medicine. 2020;13:569-575.
25. Namdar P, YekeFallah L, Jalalian F, Barikani A, Razaghpoor A. Improving Door-to-Balloon Time for Patients With Acute ST-Elevation Myocardial Infarction: A Controlled Clinical Trial. Current problems in cardiology. Mar 2021;46(3):100674.
26. Shahbazi H, Mahdavifar N, Jesmi Marghzar AA. Effects of COVID-19 Pandemic on the TreatmentManagement of ST-elevation Myocardial Infarction. Article. Evidence Based Care Journal. 2022;12(1):7-13.
27. Gharanjik S, Motadayen M, Hassanzadeh Makoei RH, et al. Comparison of the Success Rate of Treatment with Primary Percutaneous Coronary Intervention PCI versus Thrombolytic Treatment in Patients with ST-Elevation Myocardial Infarction in Local Hospitals in Iran. Article. Journal of Advances in Medical and Biomedical Research. 2023;31(144):32-9.
28. Hadizadeh N, Norouzi Z, Firouzi M, et al. Comparison of Time to Perform Primary Percutaneous Intervention in the Capital and a Provincial Capital. 2024;13(2):29-34.
29. Shahbazi H, Mahdavifar N, Jesmi AA. Effects of COVID-19 pandemic on the treatment management of ST-elevation myocardial infarction. Evidence Based Care. 2022;12(1):7-13.
30. Soleimani M, Soleimani A, Roohafza H, et al. The comparison of procedural and clinical outcomes of thrombolytic-facilitated and primary percutaneous coronary intervention in patients with acute ST-elevation myocardial infarction (STEMI): Findings from PROVE/ACS study. ARYA atherosclerosis. 2020;16(3):123.
31. Camp-Rogers T, Dante S, Kontos MC, Roberts CS, Kreisa L, Kurz MC. The impact of prehospital activation of the cardiac catheterization team on time to treatment for patients presenting with ST-segment-elevation myocardial infarction. The American journal of emergency medicine. 2011;29(9):1117-24.
32. Squire BT, Tamayo-Sarver JH, Rashi P, Koenig W, Niemann JT. Effect of prehospital cardiac catheterization lab activation on door-to-balloon time, mortality, and false-positive activation. Prehospital emergency care. 2014;18(1):1-8.
33. Rezaee E, Hanifi N, Rohani M, Faghih Zadeh S. Effective Factors on Delayed Onset of Treatment in Patients with Acute Myocardial Infarction. Journal of Mazandaran University of Medical Sciences. 2018;28(163):66-76.
34. Khosravi AR, Hoseinabadi M, Pourmoghaddas M, et al. Primary percutaneous coronary intervention in the Isfahan province, Iran; A situation analysis and needs assessment. ARYA atherosclerosis. 2013;9(1):38.
35. Hadizadeh N, Norouzi Z, Firouzi M, et al. Comparison of Time to Perform Primary Percutaneous Intervention in the Capital and a Provincial Capital. Research in Cardiovascular Medicine. 2024;13(2):29-34.
36. Kassaian SE, Masoudkabir F, Sezavar H, et al. Clinical characteristics, management and 1-year outcomes of patients with acute coronary syndrome in Iran: the Iranian Project for Assessment of Coronary Events 2 (IPACE2). BMJ open. 2015;5(12):e007786.
37. Rathod KS, Jain AK, Firoozi S, et al. Outcome of inter-hospital transfer versus direct admission for primary percutaneous coronary intervention: An observational study of 25,315 patients with ST-elevation myocardial infarction from the London Heart Attack Group. European Heart Journal: Acute Cardiovascular Care. 2020;9(8):948-57.
38. Gharanjik S, Motedayen M, Hasanzadeh Makoui R, et al. Comparison of the Success Rate of Treatment with Primary Percutaneous Coronary Intervention PCI versus Thrombolytic Treatment in Patients with ST-Elevation Myocardial Infarction in Local Hospitals in Iran. Journal of Advances in Medical and Biomedical Research. 2023;31(144):32-9.
39. Namdar P, YekeFallah L, Jalalian F, Barikani A, Razaghpoor A. Improving door-to-balloon time for patients with acute ST-elevation myocardial infarction: a controlled clinical trial. Current Problems in Cardiology. 2021;46(3):100674.
2. Lambert B, Denson F, Baumgarten K, Parker D, Badakhsh R. Centers for Disease Control and Prevention (CDC) Hospital-Acquired Infections. Optimizing Widely Reported Hospital Quality and Safety Grades: An Ochsner Quality and Value Playbook. Springer; 2022:95-109.
3. Beyranvand MR, Manhoobi H, Shahraz S, Kolahi A-A. Myocardial infarction in Iran: Epidemiology, management, and prognosis. The Journal of Tehran University Heart Center. 2023;18(2):82.
4. Akbar H, Mountfort S. Acute ST-segment elevation myocardial infarction (STEMI). StatPearls. 2024;
5. Stopyra JP, Snavely AC, Ashburn NP, Supples MW, Miller CD, Mahler SA. Delayed first medical contact to reperfusion time increases mortality in rural emergency medical services patients with ST‐elevation myocardial infarction. Academic Emergency Medicine. 2023;30(11):1101-9.
6. Wang Q, Zan C, Li F, et al. The impact of admission modes on the treatment outcome and in-hospital mortality rate of STEMI patients undergoing PPCI. Scientific Reports. 2024;14(1):18932.
7. Zeng X, Chen L, Chandra A, et al. Narrative review: updates and strategies for reducing door-to-balloon time in ST-elevation myocardial infarction care. Frontiers in Cardiovascular Medicine. 2025;12:1509365.
8. Murrone A, Oliva F, Scotto di Uccio F, Gulizia MM, Gabrielli D, Colivicchi F. Timing of coronary angiography in non-ST-elevation acute coronary syndrome: comment to the 2021 ACC/AHA/SCAI guideline. Giornale Italiano di Cardiologia (2006). 2022;23(5):316-8.
9. Partow-Navid R, Prasitlumkum N, Mukherjee A, Varadarajan P, Pai RG. Management of ST elevation myocardial infarction (STEMI) in different settings. International Journal of Angiology. 2021;30(01):067-75.
10. Emami M, Mirzamohamadi S, Heidari A, Aein A, Salarifar M, Nematipour E. Evaluation of the Causes of Door-to-Balloon Time Delays in Patients with ST-Elevation Myocardial Infarction at Tehran Heart Center. The Journal of Tehran University Heart Center. 2023;18(1):68.
11. Herrera C. A systematic review of factors predicting door-to-balloon time in ST-segment elevation myocardial infarction treated with percutaneous intervention %J American Heart Journal. 2011;162(5):730-41.
12. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Bmj. 2009;339.
13. Downes MJ, Brennan ML, Williams HC, Dean RS. Development of a critical appraisal tool to assess the quality of cross-sectional studies (AXIS). BMJ open. 2016;6(12):e011458.
14. Peterson J, Welch V, Losos M, Tugwell P. The Newcastle-Ottawa scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa: Ottawa Hospital Research Institute. 2011;2(1):1-12.
15. Kf S. CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials. Ann Intern Med. 2010;152:1-7.
16. Falsoleiman H, Fatehi GH, Dehghani M, et al. Clinical outcome, and survival between primary percutaneous coronary intervention versus fibrinolysis in patients older than 60 years with acute myocardial infarction. Heart views : the official journal of the Gulf Heart Association. Oct 2012;13(4):129-31.
17. Reza Khosravi A, Hoseinabadi M, Pourmoghaddas M, et al. Primary percutaneous coronary intervention in the Isfahan province, Iran; A situation analysis and needs assessment. ARYA Atheroscler. Jan 2013;9(1):38-44.
18. Kassaian SE, Masoudkabir F, Sezavar H, et al. Clinical characteristics, management and 1-year outcomes of patients with acute coronary syndrome in Iran: The Iranian Project for Assessment of Coronary Events 2 (IPACE2). BMJ Open. Dec 15 2015;5(12):e007786.
19. Hosseini Y, Soheili A, Vatani KK, Rahmani AJMS. Assessment of time intervals from the moment of arrival in the emergency department until performing primary angioplasty in patients with acute myocardial infarction in Northwestern Iran. 2018;22:498-502.
20. Rezaee E, Hanifi N, Rohani M, Faghih Zadeh SJJoMUoMS. Effective Factors on Delayed Onset of Treatment in Patients with Acute Myocardial Infarction. 2018;28(163):66-76.
21. Yekefallah L, Pournorooz M, Noori H, Alipur M. Evaluation of door-to-balloon time for performing primary percutaneous coronary intervention in ST-segment elevation myocardial infarction patients transferred by pre-hospital emergency system in Tehran. Article. Iranian Journal of Nursing and Midwifery Research. 2019;24(4):281-5.
22. Heybar H, Alipour-Parsa SA, Khaheshi I, Zayeri ZD. Pentraxin level is the key to determine primary percutaneous coronary intervention (Pci) or fibrinolysis. Article. Cardiovascular and Hematological Disorders - Drug Targets. 2019;19(2):160-8.
23. Soleimani M, Soleimani A, Roohafza H, et al. The comparison of procedural and clinical outcomes of thrombolytic-facilitated and primary percutaneous coronary intervention in patients with acute ST-elevation myocardial infarction (STEMI): Findings from PROVE/ACS study. Article. ARYA Atherosclerosis. 2020;16(3):1-7.
24. Alizadeh R, Aghsaeifard Z, Sadeghi M, Hassani P, Saberian P. Effects of prehospital traige and diagnosis of st segment elevation myocardial infarction on mortality rate. Article. International Journal of General Medicine. 2020;13:569-575.
25. Namdar P, YekeFallah L, Jalalian F, Barikani A, Razaghpoor A. Improving Door-to-Balloon Time for Patients With Acute ST-Elevation Myocardial Infarction: A Controlled Clinical Trial. Current problems in cardiology. Mar 2021;46(3):100674.
26. Shahbazi H, Mahdavifar N, Jesmi Marghzar AA. Effects of COVID-19 Pandemic on the TreatmentManagement of ST-elevation Myocardial Infarction. Article. Evidence Based Care Journal. 2022;12(1):7-13.
27. Gharanjik S, Motadayen M, Hassanzadeh Makoei RH, et al. Comparison of the Success Rate of Treatment with Primary Percutaneous Coronary Intervention PCI versus Thrombolytic Treatment in Patients with ST-Elevation Myocardial Infarction in Local Hospitals in Iran. Article. Journal of Advances in Medical and Biomedical Research. 2023;31(144):32-9.
28. Hadizadeh N, Norouzi Z, Firouzi M, et al. Comparison of Time to Perform Primary Percutaneous Intervention in the Capital and a Provincial Capital. 2024;13(2):29-34.
29. Shahbazi H, Mahdavifar N, Jesmi AA. Effects of COVID-19 pandemic on the treatment management of ST-elevation myocardial infarction. Evidence Based Care. 2022;12(1):7-13.
30. Soleimani M, Soleimani A, Roohafza H, et al. The comparison of procedural and clinical outcomes of thrombolytic-facilitated and primary percutaneous coronary intervention in patients with acute ST-elevation myocardial infarction (STEMI): Findings from PROVE/ACS study. ARYA atherosclerosis. 2020;16(3):123.
31. Camp-Rogers T, Dante S, Kontos MC, Roberts CS, Kreisa L, Kurz MC. The impact of prehospital activation of the cardiac catheterization team on time to treatment for patients presenting with ST-segment-elevation myocardial infarction. The American journal of emergency medicine. 2011;29(9):1117-24.
32. Squire BT, Tamayo-Sarver JH, Rashi P, Koenig W, Niemann JT. Effect of prehospital cardiac catheterization lab activation on door-to-balloon time, mortality, and false-positive activation. Prehospital emergency care. 2014;18(1):1-8.
33. Rezaee E, Hanifi N, Rohani M, Faghih Zadeh S. Effective Factors on Delayed Onset of Treatment in Patients with Acute Myocardial Infarction. Journal of Mazandaran University of Medical Sciences. 2018;28(163):66-76.
34. Khosravi AR, Hoseinabadi M, Pourmoghaddas M, et al. Primary percutaneous coronary intervention in the Isfahan province, Iran; A situation analysis and needs assessment. ARYA atherosclerosis. 2013;9(1):38.
35. Hadizadeh N, Norouzi Z, Firouzi M, et al. Comparison of Time to Perform Primary Percutaneous Intervention in the Capital and a Provincial Capital. Research in Cardiovascular Medicine. 2024;13(2):29-34.
36. Kassaian SE, Masoudkabir F, Sezavar H, et al. Clinical characteristics, management and 1-year outcomes of patients with acute coronary syndrome in Iran: the Iranian Project for Assessment of Coronary Events 2 (IPACE2). BMJ open. 2015;5(12):e007786.
37. Rathod KS, Jain AK, Firoozi S, et al. Outcome of inter-hospital transfer versus direct admission for primary percutaneous coronary intervention: An observational study of 25,315 patients with ST-elevation myocardial infarction from the London Heart Attack Group. European Heart Journal: Acute Cardiovascular Care. 2020;9(8):948-57.
38. Gharanjik S, Motedayen M, Hasanzadeh Makoui R, et al. Comparison of the Success Rate of Treatment with Primary Percutaneous Coronary Intervention PCI versus Thrombolytic Treatment in Patients with ST-Elevation Myocardial Infarction in Local Hospitals in Iran. Journal of Advances in Medical and Biomedical Research. 2023;31(144):32-9.
39. Namdar P, YekeFallah L, Jalalian F, Barikani A, Razaghpoor A. Improving door-to-balloon time for patients with acute ST-elevation myocardial infarction: a controlled clinical trial. Current Problems in Cardiology. 2021;46(3):100674.
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| Issue | Vol 21 No 2 (2026) | |
| Section | Review Article(s) | |
| Keywords | ||
| Door-to-Balloon Time ST-Segment Elevation Myocardial Infarction (STEMI) Primary Percutaneous Coronary Intervention Systematic Review Meta-Analysis Iran | ||
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How to Cite
1.
Kargar S, Ebrahimi H, Sahebi A. Door-to-Balloon Time in Patients with ST-Segment Elevation Myocardial Infarction (STEMI) in Iran: A Systematic Review and Meta-Analysis. Res Heart Yield Transl Med. 2026;21(2):146-155.
