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MATRIX: Radial access lowers net events vs. femoral access at 1 year
MUNICH — At 1 year, a strategy of transradial access for coronary angiography, followed by PCI if indicated, conferred lower net adverse clinical events compared with transfemoral access among patients with ACS undergoing invasive management in the MATRIX trial.
The trial also compared anticoagulation with bivalirudin (Angiomax, The Medicines Company) vs. heparin, and researchers reported no significant differences in outcomes between the two at 1 year, Marco Valgimigli, MD, from Inselspital, Bern University Hospital, Bern, Switzerland, said during a presentation at the European Society of Cardiology Congress.
The 2x2 multifactorial trial enrolled 8,404 patients with ACS. All patients were randomly assigned to coronary angiography with transradial or transfemoral access, followed by PCI, if indicated. Of those, 7,213 were randomly assigned to receive heparin or bivalirudin during the procedure. In addition, those assigned bivalirudin were assigned to post-procedure infusion of bivalirudin, with dose at the discretion of the treating physician, or no post-procedure infusion.
Access comparison
Valgimigli presented 1-year results, showing that major adverse CV events — defined as all-cause mortality, MI or stroke — numerically, but not significantly, favored the transradial group over the transfemoral group (14.2% vs. 15.7%; rate ratio = 0.89; 95% CI, 0.8-1).
Net adverse clinical events — defined as all-cause mortality, MI, stroke or non-CABG-related BARC 3 or 5 major bleeding — were lower in the transradial group (15.2% vs. 17.2%; rate ratio = 0.87; 95% CI, 0.78-0.97), Valgimigli said.
The results were partially driven by a reduction in access-site bleeding, he said.
“The long-term benefit for net adverse clinical events, driven by a reduction in major bleeding and cardiovascular mortality, ought to change practice so that radial access should be the default approach in invasively managed patients with acute coronary syndrome,” Dominick J. Angiolillo, MD, PhD, professor of medicine at University of Florida College of Medicine, Jacksonville, and Cardiology Today’s Intervention Editorial Board Member, wrote in an editorial in The Lancet.
Treatment comparison
Also presented here, there was no difference in bivalirudin vs. heparin for 1-year major adverse CV events (15.8% vs. 16.8%, respectively; rate ratio = 0.94; 95% CI, 0.83-1.05) or net adverse clinical events (17% vs. 18.4%, respectively; rate ratio = 0.91; 95% CI, 0.81-1.02), according to the researchers.
In the bivalirudin group, the rate of 1-year urgent target vessel revascularization, stent thrombosis or net adverse clinical events was 17.4% in both those who had post-PCI bivalirudin infusion and those who did not.
“Radial access reduced 1-year [net adverse clinical events] rates owing to a dual effect of cardiovascular death and bleeding complications,” Valgimigli said during the presentation. “The use of bivalirudin did not reduce [major adverse CV events] or [net adverse clinical events]. However, its effect on mortality and bleeding may persist at 1 year, as compared to unfractionated heparin plus, in about 20% of patients, [glycoprotein IIb/IIIa inhibitors].”
He noted that in an exploratory analysis, the full recommended post-PCI bivalirudin infusion was associated with better outcomes than no infusion, but a reduced dose was associated with worse outcomes than no infusion.
As Cardiology Today’s Intervention previously reported, at 30 days, transradial access was associated with better outcomes than transfemoral access, while bivalirudin compared to heparin did not improve major adverse CV events or net clinical adverse events but did improve all-cause, CV and cardiac mortality. – by Erik Swain
References:
Valgimigli M, et al. Late-Breaking Science in Interventional Cardiology 1. Presented at: European Society of Cardiology Congress; Aug. 25-29, 2018; Munich.
Valgimigli M, et al. Lancet. 2018;doi:10.1016/S0140-6736(18)31714-8.
Disclosures: The study was supported in part by grants from Terumo and The Medicines Company. Valgimigli reports he received grants from Terumo and The Medicines Company during the conduct of the study; grants and personal fees from AstraZeneca; personal fees and nonfinancial support from The Medicines Company; and personal fees from Abbott Vascular, Alvimedica, Correvio, St. Jude Vascular and The Medicines Company outside the context of the study. Please see the full study for a list of the other authors’ relevant financial disclosures.
Perspective
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The most exciting result from MATRIX is the radial vs. femoral portion of the trial.
While total major adverse CV events were no different with either approach, the net adverse clinical events over the course of 1 year were higher with the femoral approach.
Since there are fewer events with the radial approach, that leads us to favor it. By following a large number of patients for a year, we were able to see that the benefits of the radial approach were confirmed in practice. Furthermore, the anticoagulation arm of the study tells us solidly that heparin and bivalirudin appear to have equal results and outcomes. It dispels the previous notion that bivalirudin is superior due to less bleeding.