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Published on: May 28, 2019
Delay in reperfusion with transradial percutaneous coronary intervention for ST-elevation myocardial infarction:
Neil J Wimmer1, David J Cohen2, Jason H Wasfy3
1Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
Insights
A significant delay in transradial percutaneous coronary intervention (PCI) is needed to negate its mortality benefits for ST-elevation myocardial infarction (STEMI). Even a 30-minute delay is unlikely to offset the advantages of the transradial approach over transfemoral PCI.
Area of Science:
- Cardiology
- Interventional Cardiology
- Health Outcomes Research
Background:
- Randomized clinical trials (RCTs) indicate benefits of transradial percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI).
- Concerns exist that transradial PCI may cause reperfusion delays, potentially limiting its adoption.
- Quantifying the acceptable reperfusion delay is crucial for evaluating transradial PCI's net benefit.
Purpose of the Study:
- To determine the threshold of transradial delay that would offset the observed mortality benefit of transradial PCI compared to transfemoral PCI in STEMI patients.
- To assess the impact of varying levels of transradial delay on mortality outcomes.
Main Methods:
- A decision-analytic model was developed to compare transfemoral and transradial PCI strategies in STEMI.
- Thirty-day mortality rates were estimated by pooling data from two RCTs comparing the two approaches.
- The impact of transradial delay on mortality was projected using established relationships between door-to-balloon time and mortality.
Main Results:
- A transradial delay of 83 minutes was required to offset the mortality benefit in the base case analysis.
- Even when the mortality benefit of transradial PCI was reduced to one-quarter of that observed in RCTs, a delay of 20.9 minutes was needed to equalize mortality.
- Probabilistic sensitivity analyses showed transradial PCI was favored in 97.5% of simulations with a 30-minute delay and 79.0% with a 60-minute delay.
Conclusions:
- A substantial delay in transradial PCI is necessary to counteract its mortality benefits in STEMI.
- The findings suggest that concerns about reperfusion delays should not deter the adoption of transradial PCI, as its benefits generally outweigh potential delays.
- Results remained robust across various assumptions, supporting the continued use of transradial PCI in STEMI management.
Background:
Randomized clinical trials (RCTs) suggest benefits for the transradial approach to percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). However, transradial PCI may delay reperfusion, leading to its avoidance. We sought to quantify the delay in reperfusion from transradial PCI ("transradial delay") that would need to be introduced to offset the potential mortality benefit of transradial PCI, compared with transfemoral, observed in RCTs.
Methods:
We developed a decision-analytic model to compare transfemoral and transradial PCI in STEMI. Thirty-day mortality rates were estimated by pooling STEMI patients from 2 RCTs comparing transfemoral and transradial PCI. We projected the impact of transradial delay using estimates of the increase in mortality associated with door-to-balloon time delays. Sensitivity analyses were performed to understand the impact of uncertainty in assumptions.
Results:
In the base case, a transradial delay of 83.0 minutes was needed to offset the mortality benefit of transradial PCI. When the mortality benefit of transradial PCI was one-quarter that observed in RCTs, the delay associated with equivalent mortality was 20.9 minutes. In probabilistic sensitivity analyses, transradial PCI was preferred over transfemoral PCI in 97.5% of simulations when transradial delay was 30 minutes and in 79.0% of simulations when delay was 60 minutes.
Conclusions:
A substantial transradial delay is required to eliminate even a fraction of the mortality benefit observed with transradial PCI in RCTs. Results were robust to changing multiple assumptions and have implications for operators reluctant to transition to transradial PCI in STEMI because of concern for delaying reperfusion.
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