Key result
Radial access reduces major adverse events ~40% vs femoral access in STEMI, but not NSTEACS.
Why the study?
The safety of radial access may translate into a mortality benefit in higher-risk patients such as those with STEMI, prompting an evaluation of the consistency of radial versus femoral access effects across STEMI and NSTEACS.
Does radial artery access reduce the composite of death, myocardial infarction, stroke, or non-CABG major bleeding compared with femoral artery access in patients with STEMI versus NSTEACS?
RCT (n=7,021)
Randomized
Does radial artery access reduce the composite of death, myocardial infarction, stroke, or non-CABG major bleeding compared with femoral artery access in patients with STEMI versus NSTEACS?
Radial artery access significantly reduced the primary composite outcome and all-cause mortality compared with femoral access in patients presenting with STEMI, particularly when performed by experienced radial operators, whereas no benefit was observed in NSTEACS patients.
Answers are grounded in this paper and cite their sources.
Radial access was associated with fewer events in STEMI; extends safety data but leaves open need for randomized confirmation.
OBJECTIVES The purpose of this study was to determine the consistency of the effects of radial artery access in patients with ST-segment elevation myocardial infarction (STEMI) and in those with non-ST-segment elevation acute coronary syndrome (NSTEACS). BACKGROUND The safety associated with radial access may translate into mortality benefit in higher-risk patients, such as those with STEMI. METHODS We compared efficacy and bleeding outcomes in patients randomized to radial versus femoral access in RIVAL (RadIal Vs femorAL access for coronary intervention trial) (N = 7,021) separately in those with STEMI (n = 1,958) and NSTEACS (n = 5,063). Interaction tests between access site and acute coronary syndrome type were performed. RESULTS Baseline characteristics were well matched between radial and femoral groups. There were significant interactions for the primary outcome of death/myocardial infarction/stroke/non-coronary artery bypass graft-related major bleeding (p = 0.025), the secondary outcome of death/myocardial infarction/stroke (p = 0.011) and mortality (p = 0.001). In STEMI patients, radial access reduced the primary outcome compared with femoral access (3.1% vs. 5.2%; hazard ratio [HR]: 0.60; p = 0.026). For NSTEACS, the rates were 3.8% and 3.5%, respectively (p = 0.49). In STEMI patients, death/myocardial infarction/stroke were also reduced with radial access (2.7% vs. 4.6%; HR 0.59; p = 0.031), as was all-cause mortality (1.3% vs. 3.2%; HR: 0.39; p = 0.006), with no difference in NSTEACS patients. Operator radial experience was greater in STEMI versus NSTEACS patients (400 vs. 326 cases/year, p < 0.0001). In primary PCI, mortality was reduced with radial access (1.4% vs. 3.1%; HR: 0.46; p = 0.041). CONCLUSIONS In patients with STEMI, radial artery access reduced the primary outcome and mortality. No such benefit was observed in patients with NSTEACS. The radial approach may be preferred in STEMI patients when the operator has considerable radial experience. (A Trial of Trans-radial Versus Trans-femoral Percutaneous Coronary Intervention (PCI) Access Site Approach in Patients With Unstable Angina or Myocardial Infarction Managed With an Invasive Strategy [RIVAL]; NCT01014273).
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Mehta et al. (2012) conducted an RCT in Acute coronary syndromes (STEMI and NSTEACS) (n=7,021). Radial artery access vs. Femoral artery access was evaluated on Composite of death, myocardial infarction, stroke, or non-coronary artery bypass graft-related major bleeding (HR 0.60, p=0.026). Radial artery access reduced the primary outcome vs femoral access in STEMI patients (3.1% vs 5.2%; HR 0.60; p=0.026), with no significant difference in NSTEACS (3.8% vs 3.5%; p=0.49).
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