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Reduce door to needle, not door to balloon, times first
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     EDITOR—Primary angioplasty may well prove to be the gold standard for treatment of ST elevation myocardial infarctions in the future, as Smith advocates,1 but for the moment I foresee many factors against angioplasty. This is especially highlighted in the Isle of Wight, the main factor being the postcode lottery.

    Studies with an average door to balloon time of 1 hour and 56 minutes were conducted in the United States, where distances to centres that can perform angioplasties can be quite different from those in the United Kingdom. Additionally, the Isle of Wight is unique because a vehicle ferry is required to transport patients to a tertiary referral centre. Door to balloon times are hence significantly greater than 1 hour as the crossing itself is 55 minutes alone.

    I cannot see angioplasties ever becoming the gold standard until primary angioplasty centres are developed in district general hospitals. It requires time, money, and investment in angiography skills and laboratories: something the NHS perhaps lacks?

    In the interim period, surely the way forward is to reduce door to needle times, with pre-hospital thrombolysis a more practical approach?

    Sharif Hossain, senior house officer in medicine

    Cowes, Isle of Wight PO31 7FB sharif.hossain@doctors.org.uk

    Competing interests: None declared.

    References

    Smith D. Primary angioplasty should be first line treatment for acute myocardial infarction: FOR. BMJ 2004;328: 1254-6. (22 May.)