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pandora rings Short door to balloon time was independently associated with a lower risk of a composite of death and congestive heart failure in patients with early presentation (adjusted hazard ratio 0.58, 0.38 to 0.87; P=0.009) but not in patients with delayed presentation (1.57, 1.12 to 2.18; P=0.008). A significant interaction was seen between door to balloon time and time to presentation (interaction P=0.01).Conclusions Short onset to balloon time was associated with better 3 year clinical outcome in patients with STEMI having primary percutaneous coronary intervention https://www.pandorajewellrycanada.ca/, whereas the benefit of short door to balloon time was limited to patients who presented early. Efforts to minimise onset to balloon time, including reduction of patient related delay, should be recommended to improve clinical outcome in STEMI patients.IntroductionPrimary percutaneous coronary intervention is considered to play a central role in the treatment of ST segment elevation myocardial infarction (STEMI).1 2 The American College of Cardiology/American Heart Association guideline for STEMI recommends primary percutaneous coronary intervention within 90 minutes of first medical contact, or door to balloon time, as a class 1 recommendation and also recommends a total ischaemic time within 120 minutes.3 4 The European Society of Cardiology guideline for STEMI recommends primary percutaneous coronary intervention within 120 minutes of first medical contact in all cases and within 90 minutes in patients presenting early (less than two hours) with a large infarct and low risk of bleeding.5 However, reports from previous studies are inconsistent regarding the effect of onset to balloon and door to balloon times on clinical outcomes in patients with STEMI having primary percutaneous coronary intervention.6 7 8 9 Several relatively small studies suggested a positive correlation between short onset to balloon time and decreased mortality,8 9 whereas the largest study, which enrolled more than 20000 patients (national registry of myocardial infarction in the United States), found that in hospital mortality did not increase with increasing delay in onset to balloon time time.6 7 Furthermore, short door to balloon time was associated with lower in hospital mortality regardless of time from symptom onset to presentation in the US study,6 7 whereas several other registries have reported the benefit of short door to balloon time to be limited to patients with early presentation.10 11 12In an attempt to resolve these conflicts about the onset to balloon time and door to balloon time, we evaluated the relation between the two times and the long term clinical outcome of patients with STEMI in a large observational database of patients with acute myocardial infarction in Japan.MethodsStudy populationThe Coronary REvascularization Demonstrating Outcome Study in Kyoto (CREDO Kyoto) acute myocardial infarction registry is a physician initiated, non company sponsored, multicentre registry that enrolled consecutive patients with acute myocardial infarction having coronary revascularisation within seven days of the onset of symptoms between January 2005 and December 2007 across 26 tertiary hospitals in Japan (supplementary appendix A) pandora rings.