Experienced operators could abolish prophylactic nitroglycerin use in transradial access
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Among experienced operators, prophylactic nitroglycerin did not prevent radial artery spasm during transradial access compared with placebo, though it was associated with fewer incidences among inexperienced operators, data show.
“The use of prophylactic nitroglycerin reduces the incidence of spasms in transradial access (TRA) procedures performed by inexperienced operators, and therefore should be incorporated into the routine of training centers,” Roberto Léo da Silva, MD, PhD, director of the interventional cardiology department at Instituto de Cardiologia de Santa Catarina, Brazil, told Healio.
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“But the most important fact to incorporate in clinical practice is that among more experienced operators, nitroglycerin did not show to be beneficial in radial artery spasm (RAS) prevention. To quit its administration might reduce cost, procedure duration and occurrence of complications, such as hypotension.”
In a prespecified subanalysis of the PATENS trial, da Silva and colleagues analyzed data from 2,040 patients who underwent PCI or diagnostic angiography with TRA at three high-volume centers in Brazil between August 2017 and October 2021. Researchers randomly assigned patients to 500 g preventive nitroglycerin or placebo at two time points, shortly after gaining access and sheath placement and before sheath removal. The mean age of patients was 62 years; 40% were women.
“For spasm evaluation, we considered only the first intervention: nitroglycerin, at a dose of 500 g, diluted in 10 mL of saline solution through the sheath shortly after gaining access vs. a control placebo (saline solution) in the same volume,” the researchers wrote.
Operator’s expertise was classified as inexperienced (< 100 transradial procedures), intermediate (100-1,000 procedures) and experienced (> 1,000 procedures).
The findings were published in Catheterization and Cardiovascular Interventions.
“The incidence of the RAS, defined by the forearm pain referred by the patient, had a trend toward less spasm in the group that received prophylactic nitroglycerin [compared with placebo] (10.8% vs. 13.4%; P = .07),” the researchers wrote. “The same trend was observed using operator’s RAS assessment [for nitroglycerin vs. placebo] (2.5% vs. 3.9%; P = .08).”
RAS incidence was 14.5% for inexperienced operators, 12.5% for intermediate experienced operators and 9.7% for experienced operators (P = .01). However, among patients who had procedures with inexperienced operators, nitroglycerin reduced RAS compared with placebo (17.4% vs. 11.1%; P = .04), which was not observed in other groups.
“Overall, nitroglycerin does not prevent RAS, which is more common among inexperienced operators,” the researchers wrote. “More experienced operators could abolish preventive nitroglycerin use.”
Da Silva said future studies might test verapamil, other vasodilators or different combinations for preventing radial spasm.
“As animal studies have even hinted that nitric oxide-eluting sheaths can decrease spasm and inflammation, maybe this is a better way to deliver drugs that could minimize spasm or occlusion, with less systemic effects,” da Silva told Healio.
For more information:
Roberto Léo da Silva, MD, PhD, can be reached at roberto.leo@ufsc.br; Twitter: @drrobertoleo.
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