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717 Radial vs. femoral access in patients referred for primary percutaneous coronary intervention: Characteristics and clinical outcomes
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cantly reduced total DCS when compared to the control (14.8 versus 19.5, P ⫽ 0.04). Patients in the PtDA group were also significantly more knowledgeable regarding the risks and benefits associated with each vascular access (mean knowledge score of 3.0/5 (95% confidence intervals (CI) 2.6-3.3) versus 2.0 (95% CI 1.7-2.3, P ⬍ 0.01). Despite 76.3 % of patients actively selecting their vascular access route of choice in the PtDA group as compared to 39.2% in the control group (P ⬍ 0.01), there were no significant differences in safety outcomes. CONCLUSION: A vascular access PtDA for eligible patients undergoing coronary angiography procedures significantly improves the patient’s knowledge of their health care options and reduces decisional conflict, without affecting safety outcomes. This study demonstrates the significant benefits of involving eligible patients in the decision process regarding vascular access for coronary angiography procedures. McMaster University, Dept of Medicine Internal Career Research Award and Division of Cardiology, AFP research competition grant
717 RADIAL VS. FEMORAL ACCESS IN PATIENTS REFERRED FOR PRIMARY PERCUTANEOUS CORONARY INTERVENTION: CHARACTERISTICS AND CLINICAL OUTCOMES S Mansour, MJ Bertrand, LM Stevens, N Noiseux, A Kokis, JB Masson, F Gobeil Montréal, Québec BACKGROUND: Although a recent randomised clinical trial compar-
ing radial vs. femoral approach did not show any difference in clinical outcome in patients with acute coronary syndrome, a subgroup analysis of patients with ST-elevation myocardial infarction (STEMI) showed a superiority of the radial access to reduce serious adverse events. Therefore, we aim to determine in a real-life cohort the characteristics and outcomes of STEMI patients referred for primary percutaneous coronary intervention (PCI) according to arterial access. METHODS AND RESULTS: Five-hundred-and-fifty-three consecutive patients with STEMI treated with primary PCI from January 2008 to December 2009 were prospectively followed. The mean age was 61 ⫾ 13 years with a predominance of male (75%), 16% diabetics, 42% anterior MI and 88% Killip class 1. The median door-to-balloon (DtB) was 97 [interquartile range:80,125] minutes. The arterial access was femoral in 24% (n ⫽ 132) and radial in 76% (n ⫽ 420). The femoral group had more females (34% vs. 23% P ⫽ 0.017), previous CABG (7% vs. 0%; P ⬍ .001), chronic renal failure (11% vs. 2%; P ⬍ .001), anterior MI (50% vs. 39%; P ⫽ 0.033) and high (⬎1) killip class (30% vs. 6%; P ⬍ .001) compared to radial group. Of note, 38% (n ⫽ 50) of patients in the femoral group had a radial access attempt. Usage of GIIb/ IIIa glycoprotein inhibitors was lower in the femoral group (49% vs. 60%; P ⫽ 0.034). No difference was found in the median DtB time 100 [85,120] vs. 95 [78, 126]; P ⫽ 0.260) or the final TIMI 3 flow between the two groups (93% vs. 95%; P ⫽ 0.158). During the inhospital follow-up, the femoral group had a higher incidence of
Canadian Journal of Cardiology Volume 27 2011
death (14% vs. 1%; P ⬍ .001) and major bleeding (12% vs. 2%, P ⬍ .001). CONCLUSION: In centers where the radial approach is usually privileged, patients treated with trans-femoral primary PCI had a high rate of co-morbidities and therefore had a higher rate of in-hospital adverse events. In STEMI patients, using the radial approach significantly decrease the risk of bleeding and serious events. Further randomized studies are warranted to compare between both approaches in this high risk population.
718 RADIAL VERSUS FEMORAL ACCESS FOR PERCUTANEOUS CORONARY INTERVENTION IN ST-ELEVATION MYOCARDIAL INFARCTION PATIENTS TREATED WITH FIBRINOLYSIS: A PATIENT-LEVEL META-ANALYSIS OF THE RANDOMIZED EARLY ROUTINE INVASIVE CLINICAL TRIALS JJ Graham, WJ Cantor, M Tan, AT Yan, MR Le May, S Jolly, F Piscione, C Di Mario, B Scheller, PW Armstrong, M Madan, S Halvorsen, F Fernandez-Aviles, S Goodman Toronto, Ontario BACKGROUND: Bleeding following percutaneous coronary intervention (PCI) is associated with adverse short and long-term outcomes. Radial access as compared to femoral access has been associated with reduced vascular access site complications and bleeding. The choice of vascular access site and associated outcomes in fibrinolytic-treated ST-elevation myocardial infarction (STEMI) patients who are undergoing routine early angiography and PCI vs. standard care (including rescue PCI) is unknown. METHODS: Patient-level data from trials (6 of 7 where arterial access site was recorded) of STEMI patients receiving fibrinolysis and randomized to an early invasive approach vs. standard care were included as part of a collaborative meta-analysis (SIAM III, GRACIA-1, CAPITAL AMI, WEST, CARESS-inAMI, TRANSFER-AMI, and NORDISTEMI). The primary endpoint was 30-day major bleeding; secondary endpoints included 30-day death and re-infarction. The association between major bleeding and access site was evaluated in multivariable models with propensity score adjustment since vascular access site choice was not randomized. RESULTS: Of 2789 patients (median age 59 years, 20% female, BMI 27 kg/m2), 1900 underwent PCI (radial 342, femoral 1558). Patients undergoing radial PCI were less likely to be randomized to the routine early invasive strategy (54% vs. 65%), be older than 75 years (2% vs. 8%), diabetic (8% vs. 17%), heavier (median weight 82 [72,91] vs. 80 [70,90] kg), and more likely in Killip class I at presentation (87% vs. 82%); initial estimated creatinine clearance was higher in radial PCI patients (99 [78,122] vs. 87 [68,109])(all P ⱕ 0.02). Unfractionated heparin (vs. enoxaparin) with fibrinolysis (19% vs. 81%) and glycoprotein IIb/IIIa inhibitor use (39% vs. 66%) were less frequent in the radial PCI patients (P ⬍ 0.0001). Unadjusted and adjusted* 30-day outcomes are listed in the
cantly reduced total DCS when compared to the control (14.8 versus 19.5, P ⫽ 0.04). Patients in the PtDA group were also significantly more knowledgeable regarding the risks and benefits associated with each vascular access (mean knowledge score of 3.0/5 (95% confidence intervals (CI) 2.6-3.3) versus 2.0 (95% CI 1.7-2.3, P ⬍ 0.01). Despite 76.3 % of patients actively selecting their vascular access route of choice in the PtDA group as compared to 39.2% in the control group (P ⬍ 0.01), there were no significant differences in safety outcomes. CONCLUSION: A vascular access PtDA for eligible patients undergoing coronary angiography procedures significantly improves the patient’s knowledge of their health care options and reduces decisional conflict, without affecting safety outcomes. This study demonstrates the significant benefits of involving eligible patients in the decision process regarding vascular access for coronary angiography procedures. McMaster University, Dept of Medicine Internal Career Research Award and Division of Cardiology, AFP research competition grant
717 RADIAL VS. FEMORAL ACCESS IN PATIENTS REFERRED FOR PRIMARY PERCUTANEOUS CORONARY INTERVENTION: CHARACTERISTICS AND CLINICAL OUTCOMES S Mansour, MJ Bertrand, LM Stevens, N Noiseux, A Kokis, JB Masson, F Gobeil Montréal, Québec BACKGROUND: Although a recent randomised clinical trial compar-
ing radial vs. femoral approach did not show any difference in clinical outcome in patients with acute coronary syndrome, a subgroup analysis of patients with ST-elevation myocardial infarction (STEMI) showed a superiority of the radial access to reduce serious adverse events. Therefore, we aim to determine in a real-life cohort the characteristics and outcomes of STEMI patients referred for primary percutaneous coronary intervention (PCI) according to arterial access. METHODS AND RESULTS: Five-hundred-and-fifty-three consecutive patients with STEMI treated with primary PCI from January 2008 to December 2009 were prospectively followed. The mean age was 61 ⫾ 13 years with a predominance of male (75%), 16% diabetics, 42% anterior MI and 88% Killip class 1. The median door-to-balloon (DtB) was 97 [interquartile range:80,125] minutes. The arterial access was femoral in 24% (n ⫽ 132) and radial in 76% (n ⫽ 420). The femoral group had more females (34% vs. 23% P ⫽ 0.017), previous CABG (7% vs. 0%; P ⬍ .001), chronic renal failure (11% vs. 2%; P ⬍ .001), anterior MI (50% vs. 39%; P ⫽ 0.033) and high (⬎1) killip class (30% vs. 6%; P ⬍ .001) compared to radial group. Of note, 38% (n ⫽ 50) of patients in the femoral group had a radial access attempt. Usage of GIIb/ IIIa glycoprotein inhibitors was lower in the femoral group (49% vs. 60%; P ⫽ 0.034). No difference was found in the median DtB time 100 [85,120] vs. 95 [78, 126]; P ⫽ 0.260) or the final TIMI 3 flow between the two groups (93% vs. 95%; P ⫽ 0.158). During the inhospital follow-up, the femoral group had a higher incidence of
Canadian Journal of Cardiology Volume 27 2011
death (14% vs. 1%; P ⬍ .001) and major bleeding (12% vs. 2%, P ⬍ .001). CONCLUSION: In centers where the radial approach is usually privileged, patients treated with trans-femoral primary PCI had a high rate of co-morbidities and therefore had a higher rate of in-hospital adverse events. In STEMI patients, using the radial approach significantly decrease the risk of bleeding and serious events. Further randomized studies are warranted to compare between both approaches in this high risk population.
718 RADIAL VERSUS FEMORAL ACCESS FOR PERCUTANEOUS CORONARY INTERVENTION IN ST-ELEVATION MYOCARDIAL INFARCTION PATIENTS TREATED WITH FIBRINOLYSIS: A PATIENT-LEVEL META-ANALYSIS OF THE RANDOMIZED EARLY ROUTINE INVASIVE CLINICAL TRIALS JJ Graham, WJ Cantor, M Tan, AT Yan, MR Le May, S Jolly, F Piscione, C Di Mario, B Scheller, PW Armstrong, M Madan, S Halvorsen, F Fernandez-Aviles, S Goodman Toronto, Ontario BACKGROUND: Bleeding following percutaneous coronary intervention (PCI) is associated with adverse short and long-term outcomes. Radial access as compared to femoral access has been associated with reduced vascular access site complications and bleeding. The choice of vascular access site and associated outcomes in fibrinolytic-treated ST-elevation myocardial infarction (STEMI) patients who are undergoing routine early angiography and PCI vs. standard care (including rescue PCI) is unknown. METHODS: Patient-level data from trials (6 of 7 where arterial access site was recorded) of STEMI patients receiving fibrinolysis and randomized to an early invasive approach vs. standard care were included as part of a collaborative meta-analysis (SIAM III, GRACIA-1, CAPITAL AMI, WEST, CARESS-inAMI, TRANSFER-AMI, and NORDISTEMI). The primary endpoint was 30-day major bleeding; secondary endpoints included 30-day death and re-infarction. The association between major bleeding and access site was evaluated in multivariable models with propensity score adjustment since vascular access site choice was not randomized. RESULTS: Of 2789 patients (median age 59 years, 20% female, BMI 27 kg/m2), 1900 underwent PCI (radial 342, femoral 1558). Patients undergoing radial PCI were less likely to be randomized to the routine early invasive strategy (54% vs. 65%), be older than 75 years (2% vs. 8%), diabetic (8% vs. 17%), heavier (median weight 82 [72,91] vs. 80 [70,90] kg), and more likely in Killip class I at presentation (87% vs. 82%); initial estimated creatinine clearance was higher in radial PCI patients (99 [78,122] vs. 87 [68,109])(all P ⱕ 0.02). Unfractionated heparin (vs. enoxaparin) with fibrinolysis (19% vs. 81%) and glycoprotein IIb/IIIa inhibitor use (39% vs. 66%) were less frequent in the radial PCI patients (P ⬍ 0.0001). Unadjusted and adjusted* 30-day outcomes are listed in the