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Chulalongkorn Medical Journal

Abstract

Background: According to recent global data, transradial primary PCI in ST-elevation myocardial infarction (STEMI) patients has demonstrated better procedural outcomes compared to transfemoral PCI.

Objective: To compare the clinical outcomes between transradial and transfemoral primary PCI in STEMI patients at Chonburi Hospital.

Methods: Patients diagnosed with STEMI who underwent PCI at Chonburi Hospital between October 1, 2016, and September 30, 2023, were enrolled. Clinical data were obtained through a retrospective review of medical records and the Chonburi Hospital STEMI registry database.

Results:A total of 913 patients were eligible for statistical analysis, with 532 and 381 patients undergoing PCI via radial and femoral access, respectively. Most patients were male (81.2% in the radial group and 68.5% in the femoral group) (P=0.006). The mean age was 58.25±12.2 years in the radial group and 64.04±14 years in the femoral group (P=0.001). Diabetes prevalence was 27.6% and 35.7% (P=0.006), cardiac arrest incidence was 11.1% and 19.7% (P=0.001), Killip class IV was observed in 9.7% and 24.2% (P

During the hospital stay, all-cause mortality occurred in 11 patients in the radial group and 49 patients in the femoral group (2.07% and 12.86%, respectively; P

Factors affecting mortality in STEMI patients, identified through multivariate regression analysis, included Killip class (odds ratio (95% CI) of 3.15 (2.21-4.49); P

Conclusion: In this study, the radial approach was associated with significantly reduced all-cause mortality, major bleeding events, and length of stay in STEMI patients who underwent primary PCI.

DOI

10.56808/2673-060X.5755

First Page

Globally, over 7 million people are diagnosed with acute coronary syndrome (ACS) each year, with more than 1 million in the United States alone requiring hospitalization annually. ST-segment elevation myocardial infarction (STEMI) is the most severe form of ACS, a life-threatening emergency. It accounts for approximately 30% of all ACS cases and is a leading cause of death worldwide. (1) In Thailand, a 2004 report (2) showed a 16.2% mortality rate for STEMI patients, which decreased to 8.85% according to the 2020 Thai ACS registry, making STEMI the third leading cause of death nationwide. Many studies have aimed to reduce mortality in STEMI by re-establishing blood flow through coronary arteries as quickly as possible. Current evidence and updated guidelines (3) (4) suggest that primary percutaneous coronary intervention (PCI) is more effective than thrombolytic therapy, reducing mortality, recurrence of coronary artery occlusion, and complications related to intracranial hemorrhage. Additionally, patients undergoing PCI experience shorter hospital stays and incur lower in-hospital costs. (5) (6) A meta-analysis (5), including a 2003 prospective, randomized controlled trial published in The Lancet, compared PCI with thrombolytic therapy. Results showed a reduction in short-term mortality (7% vs. 9%, p=0.0002), overall mortality (5% vs. 7%, p=0.0003), recurrence of acute coronary syndrome (3% vs. 7%, p<0.0001), and stroke (1% vs. 2%, p=0.0004). There are two primary arterial access routes for PCI: 1. Femoral Artery Access: This traditional approach provides a larger vessel diameter, making it easier to maneuver devices through the artery. However, femoral access is located deeper beneath the skin, making hemostasis more challenging and increasing the risk of bleeding complications. 2. Radial Artery Access: Studies, including a meta-analysis by Jolly et al. (7), have shown that radial access can significantly reduce bleeding and mortality compared to femoral access. Further research, such as the RIVAL study (8), indicated that although the primary outcomes between radial and femoral access were similar (3.7% vs. 4%, p=0.5), radial access resulted in significantly lower bleeding rates at the catheter insertion site (1.4% vs. 3.7%, p<0.0001) and overall bleeding events (1.0% vs. 4.5%, p<0.0001). In the RIFLE-STEACS study (9), researchers found that radial access reduced mortality (2.7% vs. 4.7%; OR=0.55, 95% CI: 0.40 to 0.76, p<0.001), major bleeding (1.4% vs. 2.9%; OR=0.51, 95% CI: 0.31 to 0.85, p=0.01), and access-site-specific bleeding (2.1% vs. 5.6%; OR=0.35, 95% CI: 0.25 to 0.50, p<0.001) in STEMI patients undergoing PCI. In 2015, the European Society of Cardiology (ESC) guidelines classified radial access as a Class I, Level A

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1. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined--a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol. 2000;36(3):959-69. 2. จาดศรี ประจวบเหมาะ กัมปนาท วีรกุล. ทะเบียนผู้ป่วยกล้ามเนื้อหัวใจขาดเลือดเฉียบพลัน. 2547. 3. Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023;44(38):3720-826. 4. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145(3):e18-e114. 5. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet. 2003;361(9351):13-20. 6. Andersen HR, Nielsen TT, Rasmussen K, Thuesen L, Kelbaek H, Thayssen P, et al. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med. 2003;349(8):733-42. 7. Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials. Am Heart J. 2009;157(1):132-40. 8. Jolly SS, Yusuf S, Cairns J, Niemelä K, Xavier D, Widimsky P, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet. 2011;377(9775):1409-20. 9. Romagnoli E, Biondi-Zoccai G, Sciahbasi A, Politi L, Rigattieri S, Pendenza G, et al. Radial versus femoral randomized investigation in ST-segment elevation acute coronary syndrome: the RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) study. J Am Coll Cardiol. 2012;60(24):2481-9. 10. Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016;37(3):267-315. 11. Valgimigli M, Gagnor A, Calabró P, Frigoli E, Leonardi S, Zaro T, et al. Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial. Lancet. 2015;385(9986):2465-76. 12. Cantor WJ, Mehta SR, Yuan F, Džavík V, Worthley M, Niemelä K, et al. Radial versus femoral access for elderly patients with acute coronary syndrome undergoing coronary angiography and intervention: insights from the RIVAL trial. Am Heart J. 2015;170(5):880-6. 13. Guo L, Lv HC, Huang RC. Percutaneous Coronary Intervention in Elderly Patients with Coronary Chronic Total Occlusions: Current Evidence and Future Perspectives. Clin Interv Aging. 2020;15:771-81. 14. Koltowski L, Koltowska-Haggstrom M, Filipiak KJ, Kochman J, Golicki D, Pietrasik A, et al. Quality of life in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention--radial versus femoral access (from the OCEAN RACE Trial). Am J Cardiol. 2014;114(4):516-21. 15. Mamas MA, Ratib K, Routledge H, Neyses L, Fraser DG, de Belder M, et al. Influence of arterial access site selection on outcomes in primary percutaneous coronary intervention: are the results of randomized trials achievable in clinical practice? JACC Cardiovasc Interv. 2013;6(7):698-706. 16. Kołtowski L, Filipiak KJ, Kochman J, Pietrasik A, Rdzanek A, Huczek Z, et al. Access for percutaneous coronary intervention in ST segment elevation myocardial infarction: radial vs. femoral--a prospective, randomised clinical trial (OCEAN RACE). Kardiol Pol. 2014;72(7):604-11.

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