ECG-guided culprit-first vs. angiography-based revascularization in STEMI: a real-world retrospective study

The single transradial guiding catheter (STGC) technique has emerged as a promising approach to minimize catheter exchanges and optimize reperfusion timelines in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). This study aimed to compare the procedural efficiency and clinical outcomes of two STGC-based strategies: electrocardiogram (ECG)-guided culprit-first intervention and angiography-based group.

A retrospective cohort study was conducted on 494 STEMI patients who underwent transradial PCI using a 6Fr IL3.5 (Terumo) STGC at Jiading District Central Hospital between January 2022 and December 2024. Patients were stratified into two groups based on procedural workflow: the ECG-guided group (n = 128) underwent immediate culprit vessel PCI guided by preoperative ECG followed by contralateral angiography, while the angiography-based group (n = 366) received bilateral diagnostic angiography prior to culprit vessel intervention. Primary endpoints included door-to-balloon (D2B), catheterization lab-to-balloon (C2B), and puncture-to-balloon (P2B) times. Secondary endpoints encompassed procedural success rate, 30-day major adverse cardiac events (MACE), and operator preference.

The ECG-guided group demonstrated significantly shorter median C2B (20.96 vs. 23.55 min, p = 0.01) and P2B times (13.89 vs. 16.06 min, p < 0.01) compared to the angiography-based group. However, there was no statistically significant difference in D2B time between the two groups (50.46 vs. 56.44 min, p = 0.36). Both groups achieved high procedural success rates (98.43% vs. 99.18%, p = 0.68) and comparable post-PCI Thrombolysis In Myocardial Infarction flow grade(TIMI)-3 flow rates (98.44% vs. 99.18%). Culprit vessel distribution differed significantly (p < 0.001), with left anterior descending artery (LAD) predominance in the ECG-guided group (71.88%) and a more balanced distribution between right coronary artery (RCA) and LAD in the angiography-based group. Operator preference strongly influenced strategy selection (p = 0.002), with four operators showing varying inclinations towards angiography-based group (66.67∽87.18%). No significant differences were observed in 30-day MACE (cardiac death, reinfarction, target vessel revascularization) or stroke rates (all p > 0.05).

In STEMI patients undergoing transradial PCI with an IL3.5 single transradial guiding catheter, the ECG-guided culprit-first strategy was associated with significantly shorter C2B and P2B times compared with the angiography-based approach. However, no significant difference was observed in total D2B time between the two strategies.