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Transradial intervention as the first choice of treatment for ST elevation myocardial infarction patients: editorial comment

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Copyright © 2018 The Korean Association of Internal Medicine

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

pISSN 1226-3303 eISSN 2005-6648 http://www.kjim.org

EDITORIAL

Transradial intervention as the first choice of

treatment for ST elevation myocardial infarction

patients: editorial comment

Byoung Kwon Lee

Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea

Received : June 14, 2018 Accepted : June 20, 2018 Correspondence to Byoung Kwon Lee, M.D. Department of Internal Medicine, Cardiovascular Center, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eon-ju-ro, Gangnam-gu, Seoul 06273, Korea

Tel: +82-2-2019-3307 Fax: +82-2-3463-3882 E-mail: cardiobk@yuhs.ac

Recently, transradial intervention (TRI) has been widely used for percutane-ous coronary intervention (PCI). Over the past decades, TRI has become very efficacious even during complex proce-dures, given the remarkable advances in interventional devices. ST elevation myocardial infarction (STEMI) is high-ly thrombotic, associated with a high bleeding risk if antiplatelet and anti-coagulation agents are given; bleeding complications compromise clinical outcomes. Several studies have demon-strated the efficacy and safety of TRI compared to transfemoral intervention (TFI) in STEMI patients [1-4]. These studies include the Radial Versus Femo-ral Access for Coronary Angiography or Intervention (RIVAL) study, the ST-Seg-ment Elevation Myocardial Infarction Treated by Radial or Femoral Approach in a Multicenter Ran domized Clinical (STEMI-RADIAL) trial, and the Radial versus Femoral Randomized Investi-gation in ST-segment Elevation Acute Coronary Syndrome (RIFLE-STEACS) study. All reported significant reduc-tions in access site-related complica-tions, lower mortality, and fewer net clinical adverse events (NACE) in acute coronary syndrome (ACS) patients

in-cluding STEMI patients, attributable principally to significant reductions in bleeding and all-cause mortality. The Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and Systemic Implementation of AngioX (MATRIX) trial confirmed that TRI improved outcomes compared to TFI, affording consistent benefits across the entire spectrum of ACS patients including STEMI patients [4]. A 2018 meta-analysis of 31 studies reported in the Cochrane database [5] found that TRI reduced 30-day short-term NACE, cardiac death, all-cause mortality, bleed-ing, and access site complications; but insufficient evidence was available in terms of long-term clinical outcomes.

In the current issue, Li et al. [6] de-scribe the outcomes of TRI, including relatively long-term NACE, in STEMI patients. TRI for STEMI patients undergoing primary PCI featuring drug-eluting stents was associated with lower incidences of access site hematoma, 12-month repeat revascu-larization, and NACE compared to TFI, as has been found in previous studies. Interestingly, the repeat revasculariza-tion rate was significantly lower in the TRI group. The authors consider that this is explained by the complex le-sional subset; complex patients might See Article on Page 716-726

Korean J Intern Med 2018;33:691-692 https://doi.org/10.3904/kjim.2018.206

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The Korean Journal of Internal Medicine Vol. 33, No. 4, July 2018

https://doi.org/10.3904/kjim.2018.206 692

not be adequately handled in statistical terms because data were not randomized. Also, image-guided PCI was more frequent in the TRI group. This finding should be confirmed in a large-scale, long-term, prospective randomized study. No significant differences in the revascularization rates associated with either approach were apparent in previous short-term studies.

Additionally, upon subgroup analysis of MATRIX data, the effects of radial versus femoral access were consistent across most subgroups including those de-fined by age, sex, body mass index, planned or actual prescription of prasugrel or ticagrelor versus clopi-dogrel, diabetes status, renal function, or a history of peripheral vascular disease. However, TRI afforded significantly better outcomes in high-volume centers (where over 80% of patients underwent TRI) [4], but TRI was associated with more operator and patient ra-diation exposure [7].

Conclusively, the evidence (including the findings of this study) suggests that TRI should be the first-line approach for patients, including STEMI patients who are hemodynamically stable, especially in high-volume TRI centers, with care taken to provide appropriate ra-diation shielding.

Conflict of interest

No potential conflict of interest relevant to this article was reported.

REFERENCES

1. Jolly SS, Yusuf S, Cairns J, et al. Radial versus femo-ral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet 2011;377:1409-1420.

2. Romagnoli E, Biondi-Zoccai G, Sciahbasi A, 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;60:2481-2489.

3. Bernat I, Horak D, Stasek J, et al. ST-segment elevation myocardial infarction treated by radial or femoral ap-proach in a multicenter randomized clinical trial: the STEMI-RADIAL trial. J Am Coll Cardiol 2014;63:964-972. 4. Vranckx P, Frigoli E, Rothenbuhler M, et al. Radial

ver-sus femoral access in patients with acute coronary syn-dromes with or without ST-segment elevation. Eur Heart J 2017;38:1069-1080.

5. Kolkailah AA, Alreshq RS, Muhammed AM, Zahran ME, Anas El-Wegoud M, Nabhan AF. Transradial versus trans-femoral approach for diagnostic coronary angiography and percutaneous coronary intervention in people with coronary artery disease. Cochrane Database Syst Rev 2018;4:CD012318.

6. Li H, Rha SW, Choi BG, et al. Transradial versus trans-femoral intervention in ST-segment elevation myocardial infarction patients in Korean population. Korean J Intern Med 2018;33:716-726.

7. Sciahbasi A, Frigoli E, Sarandrea A, et al. Radiation expo-sure and vascular access in acute coronary syndromes: the RAD-matrix trial. J Am Coll Cardiol 2017;69:2530-2537.

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