Transradial Primary PCI Lowers Mortality in STEMI Patients

PARIS, France—Patients with ST-segment elevation myocardial infarction (STEMI) who receive primary percutaneous coronary intervention (PCI) via transradial access experience lower mortality and bleeding rates than those who undergo transfemoral interventions, according to the results of a large Swedish registry presented May 20 at EuroPCR 2011.

Researchers led by Goran K. Olivecrona, MD, PhD, of Skåne University Hospital (Lund, Sweden), performed a retrospective analysis of 21,339 STEMI patients from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) who received primary PCI from 2005 to 2010. During this time period, Dr. Olivecrona noted,  transradial access in such patients increased from around 12% to over 50%. The analysis excluded patients who received both radial and femoral punctures.

Almost three-fourths (71.6%) of the patients received transfemoral PCI (n = 15,290), as opposed to transradial (28.4%; n = 6,049). Transfemoral patients had more multivessel disease and less pharmacologic therapy including aspirin and clopidogrel loading as well as glycoprotein IIb/IIIa inhibitor and bivalirudin use, reflecting the evolution of adjunctive medication over time.

At both 30 days and 1 year, mortality was lower in transradial patients compared with those receiving transfemoral PCI. In addition, bleeding was lower in transradial patients, who also experienced a shorter hospital stay (table 1).

Table 1. SCAAR Outcomes

After multivariable adjustment, transradial PCI remained an independent predictor of lower 30-day mortality (OR 0.57; 95% CI 0.46-0.72), 1-year mortality (OR 0.78; 95% CI 0.64-0.96; P = 0.018), any bleeding (OR 0.43; 95% CI 0.31-0.61), and serious bleeding (OR 0.43; 95% CI 0.32-0.57).

In subgroup analysis, transradial PCI was associated with lower 30-day mortality for both males (OR 0.78; 95% CI 0.64-0.97; P = 0.022) and females (OR 0.66; 95% CI 0.51-0.86; P = 0.002). However, when broken down by age, transradial PCI predicted lower 30-day mortality primarily in the elderly, showing benefit in those aged 70 to 79 years (OR 0.70; 95% CI 0.53-0.93) and those aged greater than 80 years (OR 0.59; 95% CI 0.45-0.78).

“Radial access in this cohort of over 21,000 patients with STEMI treated with primary PCI . . . was associated with a lower adjusted all-cause mortality, a lower adjusted rate of bleeding complications, and a shorter hospital stay,” Dr. Olivecrona said. “This analysis corroborates the finding of a lower mortality rate in the STEMI subset of the RIVAL study.”

He called for a large, prospective, randomized trial to confirm whether primary PCI via transradial access reduces mortality.

Bivalirudin Use, Other Variables Difficult to Measure

In response to a question from session co-chair David O. Williams, MD, of Brigham and Women’s Hospital (Boston, MA), Dr. Olivecrona hypothesized that transradial access probably translates to lower mortality in the elderly due to fewer bleeding complications, but it is difficult to tease such an analysis out of the SCAAR data.

Commenting from the audience, Jeffrey W. Moses, MD, of Weill Cornell Medical College (New York, NY), noted that “by excluding the radial crossovers, obviously you bias the analysis. But there’s also a shift in practice patterns over this time. Have you looked at the time sensitivity? The bivalirudin itself can inject a reduction in mortality vs. GP IIb/IIIa inhibitors.”

“There are clearly problems associated with this study because it is observational and based on registry data,” Dr. Olivecrona responded. “What we have seen since 2005 is that there’s an increased use of bivalirudin, there’s less use of IIb/IIIa’s; there’s also more use of clopidogrel being given in the ambulance prior to arrival in the cath lab, and there’s also the learning curve of all the operators moving to the radial approach from transfemoral.”

It is because of these multiple differences inherent in an observational registry that the current study “forms the basis of what should be done, which is a prospective STEMI study using the radial vs. transfemoral approach,” he said.

 

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Source:
Olivecrona GK. Lower mortality with transradial PCI compared to transfemoral PCI in 21,000 patients with acute myocardial infarction: Results from the SCAAR database. Presented at: EuroPCR; May 20, 2011; Paris, France.

 

Disclosures:

• Dr. Olivecrona reports having served as a consultant for Abbott Vascular, B Braun, Cordis, Edwards Lifesciences, and Terumo.

 

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