Abstract
Background
To investigate the relationship between arterial access site choice (radial versus femoral) and clinical outcomes among STEMI patients undergoing routine PCI after fibrinolysis.
Methods
Patient-level data from trials of STEMI patients evaluating routine PCI after fibrinolysis were included. The primary endpoint was 30-day major bleeding; secondary endpoints included 30-day death and re-infarction.
Results
1891 patients underwent PCI (trans-radial n = 338, trans-femoral n = 1553). Trans-radial PCI patients were less likely to be > 75 years (2% vs. 8%, p = 0.0001), heavier (median weight 82 [72–90] vs. 80 [70–90] kg, p = 0.0013) and more likely in Killip class I at presentation (87% vs. 82%, p = 0.03). At 30 days, trans-radial PCI was associated with a similar unadjusted risk for major bleeding (3.7% vs. 1.2%, Odds Ratio [OR] 0.43 [95% CI 0.13–1.48], p = 0.18), mortality (3.4% vs. 1.2%, OR 0.34 [0.09–1.28], p = 0.11) and re-infarction (3.9% vs. 4.7%, OR 1.25 [0.60–2.58], p = 0.56). In multivariable analysis, radial access was associated with similar estimates for bleeding and death/reinfarction risk.
Conclusions
In STEMI patients treated with fibrinolysis and undergoing an early routine invasive strategy, radial compared to femoral PCI is chosen in younger, less ill patients and is independently associated with similar risk of bleeding, re-infarction, and mortality.
Summary
This study evaluated the relationship between arterial access choice (radial versus femoral) and in-hospital and 30-day outcomes in patients undergoing routine PCI after fibrinolysis for STEMI. We included patient-level data from trials evaluating a strategy of routine PCI after fibrinolysis for STEMI. Of 1891 patients undergoing PCI, trans-radial access (n = 338) was chosen in younger, lower risk patients. At 30 days, trans-radial access was associated with a similar unadjusted and adjusted risk of major bleeding, re-infarction and mortality.
Highlights
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ST elevation myocardial infarction patients received fibrinolytic therapy.
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Radial versus femoral arterial access was compared in a non-randomized fashion.
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Patients then underwent percutaneous coronary intervention.
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30-day risks of major bleeding, re-infarction and mortality were similar.
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Introduction
Combined antithrombotic/antiplatelet therapy is a mainstay of treatment in patients presenting with acute coronary syndromes (ACS) . Although proven to reduce recurrent ischemic events, these therapies are associated with excess bleeding, a complication associated with subsequent adverse outcomes . In patients presenting with ST-elevation myocardial infarction (STEMI), the use of fibrinolytic therapy is associated with a lower risk of mortality (compared to placebo/control) but a higher risk of major bleeding . Primary percutaneous coronary intervention (PCI) has however superseded fibrinolysis as the preferred mode of reperfusion when delivered in a timely fashion . When access to primary PCI within current recommended timelines is not possible, fibrinolysis as the initial reperfusion strategy followed by routine angiography/PCI is associated with reductions in the rates of re-infarction and recurrent ischemia with no increase in the rates of stroke or major bleeding , and recent guideline recommendations for pursuing an invasive strategy post-lysis have reflected these data .
For ACS patients undergoing invasive therapy, bleeding complications occur in up to 5% with approximately one-third of major bleeds being related to the arterial access site . When compared to trans-femoral access, trans-radial access is associated with significant reductions in vascular access complications and bleeding . In STEMI patients undergoing primary PCI, trans-radial access leads to decreased bleeding and may result in a reduction in mortality . However, the impact of access-site choice on outcomes in STEMI patients undergoing routine PCI following fibrinolysis is unknown. This study analyzes patient-level data from the trials of routine PCI following fibrinolysis for STEMI in an attempt to further address this question.
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