First medical contact-to-balloon time and in-hospital outcomes of primary percutaneous coronary intervention for ST-elevation myocardial infarction in Jenin, Palestine: a retrospective cohort study (2023–2024)

Abstract

Background

Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion strategy for ST-elevation myocardial infarction (STEMI) when it can be delivered quickly. In Jenin governorate, most patients are first assessed at a single non-PCI governmental hospital before transfer to a PCI-capable center, and transfers may be slowed by movement restrictions, including Israeli checkpoints and road closures. We assessed adherence to the guideline first medical contact-to-balloon (FMC2B) target (≤ 120 min) and its association with in-hospital outcomes.

Methods

We retrospectively included consecutive adults with confirmed STEMI who underwent PPCI after inter-hospital transfer from Jenin Government Hospital to Ibn Sina Hospital between 1 January 2023 and 31 December 2024. First medical contact (FMC) was defined as the first documented physician assessment time at the referring emergency department. Patients who self-presented directly to the PCI center or were treated outside the transfer-to-PPCI pathway were excluded. The primary outcome was FMC2B ≤ 120 min. Secondary outcomes were in-hospital major adverse cardiac events (MACE: death, reinfarction, or heart failure). Multivariable logistic regression was used to evaluate predictors of delayed reperfusion and MACE.

Results

The final cohort included 202 patients (mean age 56.8 ± 11.2 years; 89.6% men). Median FMC2B was 124 min (IQR 91–166) and 47.5% (95% CI 40.7–54.4) achieved FMC2B ≤ 120 min. The largest component of delay was the FMC-to-PCI-center arrival interval (median 67 min, IQR 47–111). In-hospital MACE occurred in 15.8% (n = 32) and was higher when FMC2B was > 120 min than when it was ≤ 120 min (22.6% vs. 8.3%, p = 0.007). After adjustment, FMC2B > 120 min remained independently associated with MACE (OR 3.54, 95% CI 1.39–8.99).

Conclusions

In this transfer-dependent STEMI system, fewer than half of patients met the FMC2B ≤ 120-minute target, and delayed reperfusion was associated with worse in-hospital outcomes. Quality improvement should focus on faster diagnosis and transfer coordination, along with early cath-lab activation, to reduce system delays.

Background

ST-elevation myocardial infarction (STEMI) is a time-critical emergency caused by acute coronary artery occlusion. Rapid reperfusion limits infarct size and improves survival [1]. Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion strategy when it can be delivered promptly [2, 3].

International guidelines emphasize system time metrics to standardize care. For patients who require inter-hospital transfer, the recommended system goal is first medical contact-to-balloon (FMC2B) ≤ 120 min [2, 3]. Longer system reperfusion times are consistently linked with worse outcomes across health systems [4, 5].

Achieving timely PPCI remains challenging in many low- and middle-income settings and in regions with limited prehospital services, fragmented referral pathways, or restricted movement. In the Middle East and North Africa, registry data show that patients often present at a relatively young age with a high burden of cardiovascular risk factors and that key performance indicators vary widely across countries [6].

PCI outcomes have been described in other parts of Palestine (e.g., a PCI cohort from Nablus) [7], but Jenin-specific data on transfer-dependent STEMI reperfusion timelines remain scarce. Jenin governorate operates in a particularly challenging environment. In the northern West Bank, including Jenin, Palestinians face movement restrictions such as Israeli checkpoints, road gates, and road closures; during periods of heightened Israeli military activity/attacks, these restrictions and road disruptions may intensify, delaying access to emergency services and ambulance transport [8–10]. In Jenin, the referral pathway is also centralized: Jenin Government Hospital (JGH) is the only governmental hospital in the governorate and serves as the main emergency receiving and referral (triage) center. Most insured patients must first present to JGH to obtain transfer authorization, whereas a smaller proportion self-present directly to the PCI center. During the study period, JGH did not operate an on-site fibrinolysis pathway, making transfer for PPCI the routine reperfusion strategy for eligible patients. These structural and contextual factors may contribute to delays in first medical contact-to-balloon (FMC2B) time. However, systematic data describing reperfusion delays and associated outcomes in this setting remain limited.

We evaluated FMC2B performance for transferred STEMI patients treated with PPCI in Jenin during 2023–2024 and examined the association between delay and in-hospital outcomes.

Methods

Study design and setting

We conducted a retrospective cohort study at Ibn Sina Hospital, a PCI-capable tertiary care center that provides PPCI for Jenin governorate, Palestine. Jenin Government Hospital (JGH) is the only governmental hospital in the governorate and functions as the main emergency receiving and referral (triage) center. Most insured patients with suspected STEMI are required to present first to JGH to obtain referral/authorization for transfer, whereas a smaller proportion of patients self-present directly to the PCI center. During the study period, JGH did not have an operational fibrinolysis service/pathway; therefore, PPCI after inter-hospital transfer was the default reperfusion strategy for eligible patients in this referral network.

Inter-hospital transfer in this region can be affected by movement restrictions, including Israeli checkpoints and temporary road closures, as well as periods of intensified Israeli military operations/attacks that disrupt road access in the northern West Bank [8–10]. In addition, the JGH emergency department is staffed by a limited number of resident physicians per shift relative to the volume of acute cases, which may prolong triage, STEMI recognition, and activation of transfer pathways, particularly during off-hours. We selected the study period (1 January 2023 to 31 December 2024) because catheterization laboratory and emergency department timestamp documentation was complete and consistently available for these years.

Study population

All adults (≥ 18 years) who underwent emergent coronary angiography with intent for PPCI between 1 January 2023 and 31 December 2024 were identified from catheterization laboratory logs at Ibn Sina Hospital. Three investigators independently reviewed records to confirm STEMI diagnosis according to contemporary guideline criteria [2, 3] and to verify inter-hospital transfer from JGH. Patients were excluded if STEMI criteria were not met on chart review, if they were directly admitted to the PCI center without prior evaluation at JGH, or if essential time variables (FMC or balloon/device time) were missing. Because the study frame was intentionally limited to the transfer-to-PPCI pathway, patients who self-presented directly to Ibn Sina Hospital, were managed without transfer, or received fibrinolytic therapy outside this pathway were not included.

Figure 1 shows cohort derivation.

Fig. 1.

Study flow diagram of included patients

Data sources and definitions

Data were abstracted from catheterization laboratory records and electronic medical records at Ibn Sina Hospital, and from JGH emergency department records for first-contact and transfer timestamps. FMC was defined as the first documented physician assessment time in the JGH emergency department record. Balloon time was defined as the first balloon inflation or device deployment time recorded in the catheterization laboratory report.

Derived time intervals included FMC2B time (primary performance metric), FMC-to-PCI-center arrival time, and PCI-center door-to-balloon time. Presentation time was categorized as regular hours (08:00–16:00) or off-hours (all other times).

Variables and outcomes

Collected variables included age, sex, cardiovascular risk factors, prior coronary revascularization, infarct location, admission vital signs, and Killip class. Coronary anatomy (including multivessel disease) was recorded from angiographic reports.

The primary outcome was FMC2B ≤ 120 min, consistent with guideline-recommended system targets for transferred patients [2, 3]. The secondary outcome was in-hospital major adverse cardiac events (MACE), defined as a composite of all-cause in-hospital mortality, reinfarction, or heart failure during the index hospitalization. Reinfarction and heart failure were defined based on clinician-documented diagnosis in the medical record and corresponding management changes.

Statistical analysis

Analyses were performed using SPSS (version 27.0). Continuous variables were assessed for normality using histograms and the Shapiro–Wilk test. Normally distributed variables are presented as mean ± SD and compared using independent-samples t tests; non-normally distributed variables are presented as median (IQR) and compared using the Mann–Whitney U test. Categorical variables are presented as n (%) and compared using chi-square or Fisher’s exact tests.

Multivariable logistic regression was used to evaluate factors associated with delayed reperfusion (FMC2B > 120 min) and with in-hospital MACE. To reduce overfitting, we developed simplified models by selecting variables based on their clinical relevance and the total number of outcome events. For delayed reperfusion, the model included age, sex, Killip class (≥ II), and off-hours presentation. For in-hospital MACE, the model included age, sex, Killip class (≥ II), diabetes mellitus, multivessel disease, and FMC2B > 120 min. Adjusted odds ratios (OR) with 95% confidence intervals (CI) are reported. Two-sided p values < 0.05 were considered statistically significant.

Ethics and reporting

The study was approved by the Institutional Review Board of the Arab American University and by the Ibn Sina Hospital ethics committee. Administrative authorization was obtained from the Palestinian Ministry of Health to access JGH records. Due to the retrospective design, use of anonymized data, and minimal risk, informed consent was waived.

This manuscript is reported in accordance with the STROBE statement for cohort studies [11].

Results

Patient characteristics

Among 202 transferred patients with confirmed STEMI who underwent PPCI, mean age was 56.8 ± 11.2 years and 89.6% were men. Patients were stratified by FMC2B time (≤ 120 vs. > 120 min) (Table 1). Baseline demographics, risk factors, infarct location, hemodynamics, and Killip class were similar between groups.

Table 1.

Baseline characteristics by FMC2B performance

Characteristic	FMC2B ≤ 120 min (n = 96)	FMC2B > 120 min (n = 106)	Total (N = 202)	p value
Age, mean ± SD (years)	56.55 ± 12.34	56.97 ± 10.16	56.77 ± 11.22	0.793
Male sex, n (%)	86 (89.6)	95 (89.6)	181 (89.6)	0.99
Anterior STEMI, n (%)	49 (51.0)	60 (56.6)	109 (53.9)	0.48
Diabetes mellitus, n (%)	27 (28.1)	39 (36.8)	66 (32.7)	0.23
Hypertension, n (%)	50 (52.1)	55 (51.9)	105 (52.0)	1.00
Dyslipidemia, n (%)	21 (21.9)	34 (32.1)	55 (27.2)	0.12
Prior PCI or CABG, n (%)	29 (30.2)	36 (34.0)	65 (32.2)	0.65
Smoking status, n (%)				0.09
Active	80 (83.3)	76 (71.7)	156 (77.2)
Former	5 (5.2)	6 (5.6)	11 (5.4)
Never	11 (11.5)	24 (22.6)	35 (17.3)
Killip class on presentation, n (%)				0.91
I	65 (67.7)	75 (70.8)	140 (69.3)
II	20 (20.8)	20 (18.9)	40 (19.8)
III	10 (10.4)	9 (8.5)	19 (9.4)
IV	1 (1.0)	2 (1.9)	3 (1.5)
Heart rate, mean ± SD (bpm)	80.64 ± 16.50	81.63 ± 15.90	81.20 ± 16.20	0.663
Systolic blood pressure, mean ± SD (mmHg)	126.57 ± 23.27	126.33 ± 22.54	126.45 ± 22.90	0.940
Presentation time, n (%)				0.31
Regular hours	40 (41.7)	36 (34.0)	76 (37.6)
Off-hours	56 (58.3)	70 (66.0)	126 (62.4)
Multivessel disease, n (%)	6 (6.3)	22 (20.8)	28 (13.9)	0.004

Reperfusion time intervals

Median FMC2B time for the overall cohort was 124 min (IQR 91–166). Patients who met the 120-minute target had a median FMC2B time of 89 min (IQR 68–103), compared with 163 min (IQR 142–208) among those with delayed reperfusion. The largest component of delay was the interval from FMC to arrival at the PCI center. Door-to-balloon time at the PCI center was shorter but also differed between groups (Table 2).

Table 2.

Reperfusion time intervals and length of stay

Metric	Group	Median	IQR (Q1–Q3)
FMC to PCI-center arrival time (min)	Total (N = 202)	67.0	47.0–111.0
	FMC2B ≤ 120 min (n = 96)	49.5	34.75–63.25
	FMC2B > 120 min (n = 106)	106	75–146
Door-to-balloon time (min)	Total (N = 202)	47.0	25.0–71.0
	FMC2B ≤ 120 min (n = 96)	31.0	17.0–46.25
	FMC2B > 120 min (n = 106)	65.0	42.0–97.0
FMC2B time (min)	Total (N = 202)	124.0	91.0–166.0
	FMC2B ≤ 120 min (n = 96)	89.0	68.0–103.0
	FMC2B > 120 min (n = 106)	163.0	142.0–208.0
Length of hospital stay (days)	Total (N = 202)	2.0	1.0–3.0

In-hospital outcomes

FMC2B ≤ 120 min was achieved in 96 patients (47.5%; 95% CI 40.7–54.4). In-hospital MACE occurred in 15.8% (n = 32). MACE was more frequent among patients with FMC2B > 120 min than among those meeting the target (22.6% vs. 8.3%, p = 0.007) (Table 3). No patient in the study cohort had documented fibrinolytic therapy before PPCI, consistent with the absence of an operational fibrinolysis pathway at JGH during the study period. Individual components of MACE were numerically higher in the delayed group but did not reach statistical significance.

Table 3.

In-hospital outcomes by FMC2B performance

Outcome	FMC2B ≤ 120 min (n = 96)	FMC2B > 120 min (n = 106)	p value
MACE (composite)*	8 (8.3)	24 (22.6)	0.007
In-hospital mortality	0 (0.0)	2 (1.9)	0.50
Heart failure	7 (7.3)	15 (14.2)	0.17
Reinfarction	3 (3.1)	8 (7.5)	0.22

*Patients may have experienced more than one component event

Predictors of delayed reperfusion and MACE

In multivariable logistic regression, no examined baseline covariate was independently associated with delayed reperfusion (FMC2B > 120 min) (Table 4), suggesting that delays were primarily driven by system factors rather than patient presentation.

Table 4.

Multivariable logistic regression for delayed reperfusion (FMC2B > 120 min)

Predictor	Adjusted OR	95% CI	p value
Age (per year)	1.006	0.980–1.032	0.664
Killip class ≥ II	0.951	0.511–1.769	0.874
Off-hours presentation	1.609	0.883–2.934	0.120
Female sex	0.804	0.301–2.152	0.664

Delayed reperfusion (FMC2B > 120 min) was independently associated with higher odds of in-hospital MACE (adjusted OR 3.54, 95% CI 1.39–8.99). Female sex was also associated with MACE, however, this finding should be interpreted cautiously given the small number of women in the cohort (Table 5).

Table 5.

Multivariable logistic regression for in-hospital MACE

Predictor	Adjusted OR	95% CI	p value
Age (per year)	1.04	0.99–1.08	0.102
Killip class ≥ II	1.60	0.68–3.76	0.284
Multivessel disease	1.39	0.49–3.93	0.534
FMC2B > 120 min	3.54	1.39–8.99	0.007
Female sex	4.37	1.50–12.77	0.007
Diabetes mellitus	1.02	0.40–2.56	0.972

Discussion

Our key findings are that fewer than half of transferred STEMI patients met the guideline FMC2B target (≤ 120 min) and that FMC2B > 120 min was independently associated with higher in-hospital MACE. The main delay occurred before arrival at the PCI center, suggesting that early diagnosis/activation and the transfer segment are the main problems. Several local factors may contribute. First, Jenin’s STEMI pathway is centralized through a single governmental hospital (JGH) that functions as a triage and authorization gatekeeper for insured patients. This extra administrative step, together with a busy emergency department and limited staffing, can delay early ECG acquisition, physician assessment, and initiation of transfer. Second, Jenin faces movement restrictions that can delay ambulances, including Israeli checkpoints, road gates, and road closures; these constraints can worsen during periods of Israeli military operations/attacks and other security events, when road access becomes unpredictable [8–10]. Although we did not measure checkpoint or route-closure delays directly, the finding that the largest delay occurred before arrival at the PCI center is consistent with these system-level constraints.

Female patients experienced longer FMC2B times in univariable analyses. Sex-based delays in STEMI care have been described in other settings and may relate to differences in symptom presentation, lower perceived cardiovascular risk, and slower recognition or activation of reperfusion pathways. A systematic review found longer door-to-balloon and symptom-to-balloon times in women referred for primary PCI [12], and registry analyses have similarly reported delayed presentation and revascularization among women with STEMI treated with PCI [13]. In Jenin, these factors may be compounded by social roles and misconceptions that women are at lower risk of coronary disease; community education and clinician training that explicitly address women’s cardiac symptoms could help reduce sex-based disparities.

These Jenin-specific data show that system delay is not only a performance metric but is linked with patient outcomes in our setting, even when PCI-center door-to-balloon times are relatively short. Tracking FMC2B and its key components can therefore support local audit-and-feedback and targeted quality improvement.

No patient in this cohort received fibrinolytic therapy before transfer, so a direct comparison between fibrinolysis and delayed PPCI was not possible. This is clinically relevant because when FMC2B is expected to exceed guideline targets, a pharmaco-invasive strategy may be considered in other systems. Our results therefore underscore the importance of evaluating whether an operational thrombolysis pathway at the referring hospital could shorten total ischemic time in this setting.

The overall FMC2B performance observed in Jenin is comparable to, but slightly worse than, results from organized STEMI networks in higher-resource settings. In the Cologne Infarction Model registry, median contact-to-balloon time was 107 min (IQR 85–148) among patients first presenting to non-PCI hospitals [14]. In a large US registry analysis of transferred patients, the median overall door-to-balloon time from first-hospital arrival to PCI was 120 min (IQR 96–159), and prolonged door-in–door-out time at the referring hospital was associated with higher in-hospital mortality [5]. Together, these data suggest that transfer-dependent systems frequently struggle to meet time targets, and that measuring and improving the referring-hospital segment (e.g., door-in–door-out time) is a high-yield quality target.

We also could not compare transferred patients with self-referred patients because the study was intentionally restricted to the transfer-dependent pathway and FMC was defined from JGH emergency records. Patients who present directly to the PCI center follow a different care pathway and do not have a comparable JGH-based FMC timestamp. A future prospective, system-wide registry that captures both direct presenters and transferred patients would allow more complete comparison of baseline risk, treatment delays, and outcomes across pathways.

Our time-interval analysis also points to the transfer segment as the main driver of delay. This aligns with prior work showing that overall system delay is strongly associated with outcomes. In a Danish national registry, each additional hour of system delay (contact-to-PCI) was independently associated with higher long-term mortality [4]. These observations support focusing quality improvement on prehospital and inter-hospital processes rather than on cath-lab performance alone.

Regional data from the Middle East similarly highlight challenges with timeliness. In the Gulf RACE 2 registry analysis, median door-to-balloon time among PPCI-treated patients was 85 min and only 55% achieved door-to-balloon ≤ 90 min [15]. While door-to-balloon is not directly comparable to FMC2B in transfer patients, both metrics reflect opportunities to streamline activation and catheterization laboratory readiness.

The higher frequency of multivessel disease in the delayed group should be interpreted cautiously. Coronary anatomy is not known at the time of transfer decisions and is therefore unlikely to be a causal driver of prehospital delay. It may instead reflect unmeasured differences in comorbidity burden or referral patterns. Similarly, the association between female sex and MACE should be considered exploratory because the number of women was small and confidence intervals were wide.

The numerically higher reinfarction rate in the delayed group is biologically plausible, as longer ischemic time may be associated with larger infarct size, greater thrombotic burden, incomplete microvascular reperfusion, and a more unstable early post-procedural course. However, this finding should be interpreted cautiously because the absolute number of reinfarction events was small and the between-group difference was not statistically significant. Chance variation, residual confounding, and the higher prevalence of multivessel disease in the delayed group may also have contributed.

From a systems perspective, several feasible interventions could reduce FMC2B time in this setting: (1) standardized STEMI activation and a single-call transfer protocol; (2) early cath-lab activation based on pre-transfer ECG transmission; (3) direct transfer to the cath-lab on arrival at the PCI center when appropriate; and (4) routine collection and audit of door-in–door-out time at the referring hospital as a key performance indicator. In settings where timely PPCI cannot be consistently achieved, a pharmaco-invasive strategy may be a pragmatic alternative. Evidence from Gaza suggests that a pharmacoinvasive approach is feasible and may reduce short-term composite outcomes compared with primary PCI when system constraints limit timeliness [16].

The low in-hospital mortality observed in both groups also warrants caution in interpretation. Several factors may explain this: the cohort was relatively young, most patients were Killip class I at presentation, and the study included only patients who survived to undergo angiography and PPCI at the receiving center. Patients who died before transfer, were too unstable to reach the cath lab, or were managed outside the PPCI pathway were not represented, which likely lowered the observed in-hospital mortality in comparison with broader all-comer STEMI registries. In addition, with only two deaths overall, random variation is substantial and mortality estimates are necessarily imprecise.

This study has several strengths. First, it provides the first detailed evaluation of FMC-to-balloon performance in a transfer-dependent STEMI system in Jenin. Second, the study includes complete time-stamp data from both the referring hospital and the PCI center, allowing precise measurement of system delays. Third, the cohort represents real-world practice in a conflict-affected healthcare environment, a setting that is rarely represented in STEMI systems-of-care research.

This study also has important limitations. First, its retrospective design is subject to incomplete documentation and potential misclassification of clinical events. Second, FMC was defined as first physician assessment time at the referring emergency department; this likely underestimates true system delay compared with guideline definitions that start at EMS contact. Third, we did not capture symptom onset time, prehospital ECG acquisition, or granular components of the transfer process (e.g., ambulance dispatch, authorization delays, or delays related to Israeli checkpoints, road closures, and active military operations/attacks), which limits attribution of specific bottlenecks. Fourth, this was a single-center study and outcomes were limited to the index hospitalization, so we could not assess long-term outcomes or out-of-hospital events. Fifth, the cohort included only patients who ultimately underwent transfer for PPCI; we therefore could not compare transferred patients with self-referred patients, nor could we compare delayed PPCI with fibrinolysis because no operational fibrinolysis pathway was available at JGH during the study period. Finally, the very low number of deaths and reinfarctions limited power for separate analyses of individual outcome components and likely contributed to imprecision in those estimates.

Conclusions

In a transfer-dependent STEMI pathway in Jenin, Palestine, fewer than half of patients achieved FMC2B ≤ 120 min, and delayed reperfusion was independently associated with worse in-hospital outcomes. Improving early recognition and transfer coordination, and measuring key prehospital intervals, are priorities to strengthen this emergent PPCI system.

Abbreviations

CABG

Coronary artery bypass grafting

CI

Confidence interval

DIDO

Door-in–door-out

FMC

First medical contact

FMC2B

First medical contact-to-balloon

IQR

Interquartile range

JGH

Jenin Government Hospital

MACE

Major adverse cardiac events

OR

Odds ratio

PCI

Percutaneous coronary intervention

PPCI

Primary percutaneous coronary intervention

STEMI

ST-elevation myocardial infarction

Authors’ contributions

HK conceptualized the study, designed the methodology, conducted data collection and analysis, and drafted the original manuscript. MJ participated in data collection and verification and contributed to manuscript revision. AA assisted in data collection and verification of clinical records. AS conducted the whole analysis. RT supervised the clinical aspects of the study, provided methodological guidance, and critically revised for intellectual content and enhanced the manuscript. RZ contributed to study supervision, interpretation of results, and final manuscript review. All authors read and approved the final manuscript.

Funding

Not applicable.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request, subject to approval by the Palestinian Ministry of Health.

Declarations

Ethics approval and consent to participate

Approved by the Institutional Review Board of the Arab American University and by the Ibn Sina Hospital ethics committee. Administrative authorization was obtained from the Palestinian Ministry of Health. Due to the retrospective design and use of anonymized data, informed consent was waived.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.