Curr Cardiol Rep (2015) 17: 30 DOI 10.1007/s11886-015-0585-9
INTERVENTIONAL CARDIOLOGY (S RAO, SECTION EDITOR)
Transradial Intervention in ST Elevation Myocardial Infarction Ahmad H. S. Mustafa & Eric Holroyd & Rob Butler & Doug Fraser & Magdi El-Omar & James Nolan & Mamas A. Mamas
Published online: 18 April 2015 # Springer Science+Business Media New York 2015
Abstract Primary percutaneous coronary intervention (PPCI) in ST elevation myocardial infarction (STEMI) represents the current gold standard reperfusion therapy. Recent advances in antiplatelet and anticoagulant therapy have reduced the risk of ischemic complications and mortality in PPCI although this has been at the expense of major bleeding complications. Access site-related bleeding complications account for up to 50 % of major peri-procedural bleeding complications in PCI. Increasing adoption of the radial artery as the default access site has been shown to markedly reduce such major bleeding complications and mortality in selected patient cohorts. Recent data has suggested that adoption of the transradial access site in STEMI PCI procedures is associated with significant reductions in major bleeding complications and mortality in both national registry data and randomised controlled trials. We provide an overview of this data and discuss the remaining uncertainties around the synergy between access site and contemporary antithrombotic and antiplatelet therapy in such patients. Finally, whilst adoption of the radial artery as the default access site in PPCI has yielded a similar reduction in mortality as observed in the switch from thrombolysis to PPCI in the past, its adoption as a default access site is not universal. We discuss the remaining obstaThis article is part of the Topical Collection on Interventional Cardiology A. H. S. Mustafa : D. Fraser : M. El-Omar : M. A. Mamas (*) Manchester Heart Centre, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Trust, Manchester, UK e-mail: [email protected] E. Holroyd : R. Butler : J. Nolan Department of Cardiology, University Hospital North Midlands, Stoke-on-Trent, UK J. Nolan : M. A. Mamas Keele Cardiovascular Research Group, Institutes of Science and Technology in Medicine and Primary Care, University of Keele, Stoke on Trent, UK
cles and challenges for more widespread adoption of the radial access site as the default access site in PPCI. Keywords Access site . Radial . STEMI . Bleeding . Outcomes
Introduction Primary percutaneous coronary intervention (PPCI) in ST elevation myocardial infarction (STEMI) represents the current gold standard reperfusion therapy in contemporary practice. Whilst recent advances in antiplatelet and anticoagulant therapy have reduced the risk of ischemic complications and mortality in PPCI, this has been at the expense of major bleeding complications [1]. Despite the lower rates of adverse events associated with the newer antithrombotic such as bivalirudin, the rates of major bleeding in STEMI remain significant with 30-day major bleeding event rates reported at 4.9 % (INFUSE-AMI and Horizons-AMI) [2, 3]. Major bleeding complications are associated with adverse outcomes, and a recent meta-analysis of 42 trials involving 533,333 patients has shown that major bleeding is independently associated with a threefold increase in mortality and major adverse cadiovascular events (MACEs) outcomes after adjustment for confounding variables [4••]. Access site-related bleeding continues to be an important source for major bleeding and contributes up to 50 % of reported major bleeding [5]. Transradial intervention (TRI) has recently been shown to reduce access site bleeding and mortality outcomes in selected cohorts of patients [6••, 7••] which has fuelled the interest in its adoption as the access site of choice in STEMI, in which patients are at highest risk of bleeding complications [8, 9••]. The radial artery is now recommended by SCAI and ESC guidelines as the primary access site for PCI when performed
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by experienced radial operators [10, 11]. This review will present the evidence in support for TRI in STEMI and highlight the challenges that remain after exploring this evidence.
Registry Data National registry data from North American and European databases have reported changes in access site selection from a national perspective and how these have influenced major bleeding and mortality outcomes [7••, 9••, 12]. One of the important findings from these registry data derived from national cohorts is the growth of the radial artery as the primary access site adopted during PPCI. For example, the percentage of STEMI patients undergoing PCI with a radial access site more than doubled (from 4.9 to 11.9 %) in New York over a period of 12 months between January 2009 and December 2010 [12]. The British Cardiovascular Intervention Society (BCIS) registry similarly reported an increase in transradial intervention (TRI) from 12.5 % in 2006 to 49.5 % in 2010. The growing trends in TRI in the setting of STEMI reflect the recent evidence in favour of TRI and the appearance of dedicated radial equipment. National registry data has consistently demonstrated that the reported increase in transradial access site utilisation is independently associated with a lower risk of in-hospital and 30-day mortality, major bleeding complications and vascular complications. For example, data from the National Cardiovascular Data Registry (NCDR) looking at 90,979 patients presenting for primary or rescue PCI, TRI (n=6159, 6.8 %) was associated with a lower risk of in-hospital mortality (odds ratio (OR): 0.76 95 % confidence interval (CI): 0.57 to 0.99), bleeding (OR: 0.62 95 % CI: 0.53 to 0.72) and vascular complications requiring procedural care (0.13 vs. 0.49 % p
INTERVENTIONAL CARDIOLOGY (S RAO, SECTION EDITOR)
Transradial Intervention in ST Elevation Myocardial Infarction Ahmad H. S. Mustafa & Eric Holroyd & Rob Butler & Doug Fraser & Magdi El-Omar & James Nolan & Mamas A. Mamas
Published online: 18 April 2015 # Springer Science+Business Media New York 2015
Abstract Primary percutaneous coronary intervention (PPCI) in ST elevation myocardial infarction (STEMI) represents the current gold standard reperfusion therapy. Recent advances in antiplatelet and anticoagulant therapy have reduced the risk of ischemic complications and mortality in PPCI although this has been at the expense of major bleeding complications. Access site-related bleeding complications account for up to 50 % of major peri-procedural bleeding complications in PCI. Increasing adoption of the radial artery as the default access site has been shown to markedly reduce such major bleeding complications and mortality in selected patient cohorts. Recent data has suggested that adoption of the transradial access site in STEMI PCI procedures is associated with significant reductions in major bleeding complications and mortality in both national registry data and randomised controlled trials. We provide an overview of this data and discuss the remaining uncertainties around the synergy between access site and contemporary antithrombotic and antiplatelet therapy in such patients. Finally, whilst adoption of the radial artery as the default access site in PPCI has yielded a similar reduction in mortality as observed in the switch from thrombolysis to PPCI in the past, its adoption as a default access site is not universal. We discuss the remaining obstaThis article is part of the Topical Collection on Interventional Cardiology A. H. S. Mustafa : D. Fraser : M. El-Omar : M. A. Mamas (*) Manchester Heart Centre, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Trust, Manchester, UK e-mail: [email protected] E. Holroyd : R. Butler : J. Nolan Department of Cardiology, University Hospital North Midlands, Stoke-on-Trent, UK J. Nolan : M. A. Mamas Keele Cardiovascular Research Group, Institutes of Science and Technology in Medicine and Primary Care, University of Keele, Stoke on Trent, UK
cles and challenges for more widespread adoption of the radial access site as the default access site in PPCI. Keywords Access site . Radial . STEMI . Bleeding . Outcomes
Introduction Primary percutaneous coronary intervention (PPCI) in ST elevation myocardial infarction (STEMI) represents the current gold standard reperfusion therapy in contemporary practice. Whilst recent advances in antiplatelet and anticoagulant therapy have reduced the risk of ischemic complications and mortality in PPCI, this has been at the expense of major bleeding complications [1]. Despite the lower rates of adverse events associated with the newer antithrombotic such as bivalirudin, the rates of major bleeding in STEMI remain significant with 30-day major bleeding event rates reported at 4.9 % (INFUSE-AMI and Horizons-AMI) [2, 3]. Major bleeding complications are associated with adverse outcomes, and a recent meta-analysis of 42 trials involving 533,333 patients has shown that major bleeding is independently associated with a threefold increase in mortality and major adverse cadiovascular events (MACEs) outcomes after adjustment for confounding variables [4••]. Access site-related bleeding continues to be an important source for major bleeding and contributes up to 50 % of reported major bleeding [5]. Transradial intervention (TRI) has recently been shown to reduce access site bleeding and mortality outcomes in selected cohorts of patients [6••, 7••] which has fuelled the interest in its adoption as the access site of choice in STEMI, in which patients are at highest risk of bleeding complications [8, 9••]. The radial artery is now recommended by SCAI and ESC guidelines as the primary access site for PCI when performed
30 Page 2 of 6
by experienced radial operators [10, 11]. This review will present the evidence in support for TRI in STEMI and highlight the challenges that remain after exploring this evidence.
Registry Data National registry data from North American and European databases have reported changes in access site selection from a national perspective and how these have influenced major bleeding and mortality outcomes [7••, 9••, 12]. One of the important findings from these registry data derived from national cohorts is the growth of the radial artery as the primary access site adopted during PPCI. For example, the percentage of STEMI patients undergoing PCI with a radial access site more than doubled (from 4.9 to 11.9 %) in New York over a period of 12 months between January 2009 and December 2010 [12]. The British Cardiovascular Intervention Society (BCIS) registry similarly reported an increase in transradial intervention (TRI) from 12.5 % in 2006 to 49.5 % in 2010. The growing trends in TRI in the setting of STEMI reflect the recent evidence in favour of TRI and the appearance of dedicated radial equipment. National registry data has consistently demonstrated that the reported increase in transradial access site utilisation is independently associated with a lower risk of in-hospital and 30-day mortality, major bleeding complications and vascular complications. For example, data from the National Cardiovascular Data Registry (NCDR) looking at 90,979 patients presenting for primary or rescue PCI, TRI (n=6159, 6.8 %) was associated with a lower risk of in-hospital mortality (odds ratio (OR): 0.76 95 % confidence interval (CI): 0.57 to 0.99), bleeding (OR: 0.62 95 % CI: 0.53 to 0.72) and vascular complications requiring procedural care (0.13 vs. 0.49 % p
