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Transradial access may reduce bleeding in non-ST-elevation ACS
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In patients with medium- to high-risk NSTE-ACS, angiography access site does not appear to affect major adverse cardiac ischemic events, but transradial access may yield lower rates of TIMI major or minor bleeding vs. a transfemoral route, according to results from a subanalysis of the ACCOAST trial.
The ACCOAST trial was a prospective, randomized trial of 4,033 patients diagnosed with NSTE-ACS and elevated troponin levels. Patients were randomly allocated a loading dose of 60 mg prasugrel (Effient, Daiichi Sankyo/Eli Lilly) given after angiography at the time of PCI or a 30-mg pretreatment loading dose of prasugrel and additional 30-mg dose of prasugrel at the time of PCI, after angiography had verified the indication for PCI.
For the subanalysis, researchers evaluated 3,987 patients from ACCOAST for whom data on coronary angiography access site was available. This analysis focused on patients who underwent coronary angiography through a transfemoral access (n = 2,276) or transradial access (n = 1,711) route. The researchers defined the primary safety endpoint as TIMI major bleeding not related to CABG surgery.
Roughly 69% of the patients in both the transfemoral access and transradial access groups underwent PCI, whereas 6% had CABG and 25% were treated with medical management only.
The researchers found the rates of ischemic endpoints were similar between patients treated with transradial access vs. those treated with transfemoral access, both in the overall population and in patients who underwent PCI. Stroke risk appeared to be reduced with transfemoral access, although this finding was restricted to patients who did not undergo PCI; among those who underwent PCI, transfemoral access was linked to increased MI risk and trended toward increased risk for urgent revascularization. In the entire study population, transfemoral access appeared to increase the risk for urgent revascularization.
After propensity-score correction, transfemoral access was not significantly associated with non-CABG TIMI major bleeding in the overall population (HR = 1.46; 95% CI, 0.59-3.62). After propensity-score correction, transfemoral access also was not significantly associated with the following categories of major bleeding: GUSTO (HR = 1.09; 95% CI, 0.51-2.33) or STEEPLE (HR = 0.84; 95% CI, 0.52-1.34).
However, combined non-CABG TIMI major or minor bleeding was increased with transfemoral access (HR for transfemoral access = 2.34; 95% CI, 1.17-4.69).
“Modern treatment of NSTE-ACS is based on rapid coronary angiography and on the administration of powerful antiplatelet and anticoagulant drugs. [Transradial access] may provide improved outcomes compared with transfemoral access in this patient group,” the researchers wrote. “[Transradial access] should be considered in NSTE-ACS patients at increased risk of bleeding while the reduced risk of urgent revascularization and the increased risk of stroke seen with [Transradial access] approach deserve further study.” – by Jennifer Byrne
Disclosure: The trial was sponsored by Daiichi-Sankyo and Eli Lilly. Please see the full study for a list of the researchers’ relevant financial disclosures.
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