Transfemoral access in non-ST-segment elevation myocardial infarction (NSTEMI) did not significantly increase TIMI (thrombolysis in myocardial infarction) major bleeding, according to results of the ACCOAST access substudy, published in JACC: Cardiovascular Interventions.

Transradial access, on the other hand, was associated with a reduction in TIMI major or minor bleeding.

The original ACCOAST (A Comparison of prasgurel at the time of percutaneous Coronary intervention Or as pre-treatment At the time of diagnosis in patients with NSTEMI) study explored outcomes between a prasugrel loading dose of 60 mg given at the start of percutaneous coronary intervention (PCI) vs a split loading dose (30 mg at time of NSTE-ACS [acute coronary syndrome] diagnosis and then 30 mg given at the start of PCI). Researchers compared bleeding and ischemic outcomes of both access points using propensity score correction.


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Of the 4033 patients in the ACCOAST trial, 3987 had valid access site data and were included in the substudy. Transradial access was used in 1711 patients. Those patients were younger, less often hypertensive, and less often from Eastern Europe vs Western Europe, Israel, or Canada. Previous MI, coronary artery bypass graft (CABG), or PCI procedures were lower in this patient group. In addition, multiple antithrombin drugs were used more often as the anticoagulant regimen.

In both the transradial and transfemoral groups, 69% underwent PCI, 6% had CABG, and 25% received only medical management. A closure device was used in approximately 40% of transfemoral access procedures. PCI duration was slightly shorter in the transradial group vs the transfemoral group.

Transfemoral access was not associated with increased non-CABG-related TIMI (hazard ratio [HR] for transfemoral access: 1.46; 95% confidence interval [CI]: 0.59-3.62; P=.42). It did however, increase combined non-CABG TIMI major or minor bleeding (HR: 2.34; 95% CI: 1.17-4.69; P=.017).

“Patients treated with TRA [transradial access] had primary ischemic end point rates similar to those of patients treated using TFA [transfemoral access], in both the entire population and the patients who underwent PCI,” researchers wrote.

The reduced risk for stroke in transfemoral access seemed to be limited to patients who did not have PCI. In those patients who did have PCI however, transfemoral access was actually associated with an increased risk of MI and demonstrated a trend for increased risk of urgent revascularization. After propensity score correction, these associations were not significantly changed, with the exception of the increased risk of MI associated with transfemoral access, which became nonsignficant.

Researchers conducted a post hoc subanalysis of patients who had a stroke within 1 week from randomization to better understand the relationship between access site and stroke incidence. Strokes occurred in 16 patients who received either transradial or transfemoral access through 7 days; 12 patients in the transradial group (0.7%) and 4 (0.2%) in the transfemoral group (P=.009). Six patients underwent PCI (transradial=4; transfemoral=2), 6 had medical management (transradial=5; transfemoral=1), and 4 underwent CABG (transradial=3; transfemoral=1).

“Access site was not associated with different rates of primary ischemic end point, although subtler differences were evident in associations between access site and individual components of this end point, including a disturbing signal associating TRA with a higher incidence of stroke,” researchers noted.

Since transradial access was associated with lower non-CABG TIMI major or minor bleeding, it should be considered in patients with NSTE-ACS at an increased risk of bleeding. However, the increased stroke risk and reduced risk for urgent revascularization observed with the transradial approach warrant further study.

Reference

Porto I, Bolognese L, Dudek D, et al; for the ACCOAST Investigators. Impact of access site on bleeding and ischemic events in patients with non-ST-segment elevation myocardial infarction treated with prasugrel. The ACCOAST access substudy. JACC Cardiovasc Interv. 2016;9(9):897-907. doi: 10.1016/j.jcin.2016.01.041.