Radial versus femoral access is associated with reduced complications and mortality in patients with non-ST-segment-elevation myocardial infarction: an observational cohort study of 10,095 patients

M Bilal Iqbal, Aruna Arujuna, Charles Ilsley, Andrew Archbold, Tom Crake, Sam Firoozi, Sundeep Kalra, Charles Knight, Pitt Lim, Iqbal S Malik, Anthony Mathur, Pascal Meier, Roby D Rakhit, Simon Redwood, Mark Whitbread, Dan Bromage, Krishna Rathod, Andrew Wragg, Philip MacCarthy, Miles Dalby
Circulation. Cardiovascular Interventions 2014, 7 (4): 456-64

BACKGROUND: Compared with transfemoral access, transradial access (TRA) for percutaneous coronary intervention is associated with reduced risk of bleeding and vascular complications. Studies suggest that TRA may reduce mortality in patients with ST-segment-elevation myocardial infarction. However, there are few data on the effect of TRA on mortality, specifically, in patients with non-ST-segment-elevation myocardial infarction.

METHODS AND RESULTS: We analyzed 10 095 consecutive patients with non-ST-segment-elevation myocardial infarction treated with percutaneous coronary intervention between 2005 and 2011 in all 8 tertiary cardiac centers in London, United Kingdom. TRA was a predictor for reduced bleeding (odds ratio=0.21; 95% confidence interval [CI]: 0.08-0.57; P=0.002), access-site complications (odds ratio=0.47; 95% CI: 0.23-0.95; P=0.034), and 1-year mortality (hazard ratio [HR]=0.72; 95% CI: 0.54-0.94; P=0.017). Between 2005 and 2007, TRA did not appear to reduce mortality at 1 year (HR=0.81; 95% CI: 0.51-1.28; P=0.376), whereas between 2008 and 2011, TRA conferred survival benefit at 1 year (HR=0.65; 95% CI: 0.46-0.92; P=0.015). The mortality benefit with TRA at 1 year was not seen at the low-volume centers (HR=0.80; 95% CI: 0.47-1.38; P=0.428) but specifically seen in the high volume radial centers (HR=0.70; 95% CI: 0.51-0.97; P=0.031). In propensity-matched analyses, TRA remained a predictor for survival at 1 year (HR=0.60; 95% CI: 0.42-0.85; P=0.005). Instrumental variable analysis demonstrated that TRA conferred mortality benefit at 1-year with an absolute mortality reduction of 5.8% (P=0.039).

CONCLUSIONS: In this analysis of patients with non-ST-segment-elevation myocardial infarction, TRA appears to be a predictor for survival. Furthermore, the evolving learning curve, experience, and expertise may be important factors contributing to the prognostic benefit conferred with TRA.

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