THE PREVALENCE AND OUTCOMES OF TRANSRADIAL PERCUTANEOUS CORONARY

INTERVENTION FOR ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION:

Analysis from the NCDR® (2007-2011)

Dmitri V. Baklanov MD,Lisa A. Kaltenbach MS, Steven P. Marso MD, Sumeet Subherwal MD,

Dmitriy N. Feldman MD, Kirk Garratt MD, Jeptha Curtis MD, John Messenger MD, Sunil V. Rao MD

Funding Support and Disclaimer This research was supported by the American College of Cardiology Foundation’s National Cardiovascular Data Registry (NCDR). The views expressed in this presentation represent those of the author(s), and do not necessarily represent the official views of the NCDR or its associated professional societies identified at www.ncdr.com.

Disclosure None

Background• Transradial PCI is associated with reduced risk

of bleeding and vascular complications, as compared with femoral access PCI

• Studies have suggested that TRI may reduce mortality among patients with STEMI

• The rate of use of radial access for STEMI PCI in the U.S. is unknown

ObjectiveTo examine use and describe outcomes of radial access for percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI)

• 294,769 patients undergoing PCI for STEMI at 1204 hospitals in the CathPCI Registry®

• Patients were grouped according to access site used for PCI

• To minimize confounding, an inverse probability weighting analysis incorporating propensity scores was used

Methods

Statistical AnalysisTemporal Trends• Quarterly proportion of

TRI cases out of all PCI for STEMI

Outcomes• Logistic regression with

generalized estimating equations to account for within hospital clustering• Propensity score to adjust

for confounding by inverse probability of treatment weighting method

2,673,218 PCI admissions at 1315 sites performed between 1/2007 and 10/2011CONSORT

DIAGRAM

356,425 admissions

354,865 admissions

350,019 admissions

313,838 admissions

295,999 admissions

295,892 admissions

294,769 admissions at 1204 sites used for temporal trends analysis

158,547 admissions

Final study population 90,879 admissions at 541 sites

Exclude if non STEMI PCI and PCI with >24 hrs of symptom onset

Exclude if brachial access

Exclude if non-acute PCI

Exclude if cardiogenic shock

Exclude if multiple PCI per hospital stay

Exclude if missing data to calculate bleeding risk

Exclude if a site has fewer than 10 PCI per year

Exclude v.3 of CathPCI Registry

Exclude sites with no TRI

Patient CharacteristicsVariable Radial

(N=6159)Femoral

(N=84720) P-value

Age, mean 59.37± 12.51 60.61± 12.95 <.0001Gender, male 75.27 72.38 <.0001Race - white 89.24 88.09 0.0074Body Mass Index (kg/m2) 30.11 ± 6.88 29.12 ±6.04 <.0001Previous MI 16.97 19.70 <.0001Diabetes 22.83 22.81 0.9833Cerebrovascular Disease 6.90 6.77 0.6848Peripheral Vascular Disease 6.95 5.69 <.0001Chronic Lung Disease 9.34 9.44 0.7761Hypertension 64.56 65.62 0.0914Current/Recent Smoker 45.30 43.93 0.0379Dyslipidemia 61.81 63.45 0.0096Family History CAD 25.05 20.73 <.0001Previous PCI 17.92 21.19 <.0001Previous CABG 1.93 5.87 <.0001Currently on Dialysis 0.54 0.89 0.0035Heart Failure within 2 weeks 6.59 5.97 0.0491

Endpoints

• Primary – In-hospital mortality

• Secondary–Procedural success–Bleeding

Results

Procedure CharacteristicsVariable Radial

(N=6159)Femoral

(N=84720) P-value

Fluoroscopy time (minutes) 12.80 10.40 <.0001Contrast Volume 180.00 185.00 <.0001Left Heart Catheterization 85.87 85.17 0.5367IABP 1.69 5.21 <.0001DES 51.97 52.46 0.0699No Stent Used 9.09 9.80 0.0699Bivalirudin 30.00 34.65 <.0001Low Molecular Weight Heparin 7.85 5.83 <.0001GP IIb/IIIa (any) 58.14 61.09 <.0001High/C Lesion Risk 63.99 66.08 0.0007Bifurcation Lesion 12.71 12.37 0.4254Single lesion treated 80.55 78.90 0.0542Lesion successfully dilated 94.82 94.04 0.0254Door-to-Device Time 78.00 74.00 <.0001

Temporal Trends in TRI for STEMI

0%

1%

2%

3%

4%

5%

6%

7%% Radial, 6.36%

Q1 Q2 Q3Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4Q1 Q2 Q3 Q4

2007 2008 2009 2010 2011

Variability of TRI Use in STEMI

Pre- and Post- IPTW Balance of the Covariates

Pre- and Post- IPTW Balance of the Covariates

Association Between Radial vs. Femoral Access and Outcomes

Study Limitations

• Association with outcomes cannot prove causality

• Unmeasured confounding can be present• Events could be underreported• Outcomes are not adjudicated

• Use of radial access for PCI in STEMI has increased over the study period

• Despite longer door-to-balloon times, radial approach was associated with reduced in-hospital bleeding and mortality

• These data support a need for an adequately powered randomized trial of TRI in STEMI

Conclusions