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Radial artery approach was safe in patients with cardiogenic shock undergoing percutaneous coronary intervention (PCI), and was associated with a reduced mortality compared with transfemoral access, a single-center study found.

In-hospital mortality in patients with cardiogenic shock was significantly lower in transradial cases than transfemoral ones (32% and 64%, P=0.001), according to Oriol Rodriguez-Leor, MD, and colleagues from Hospital Universitari Germans Trias i Pujol in Barcelona.

In the multivariate analysis, those undergoing radial access had a 61% reduced risk of death compared with access through the groin (OR 0.39, 95% CI 0.15 to 0.97), they wrote in the March issue of the American Heart Journal.

Age over 75 and previous treatment with diuretics were also predictive of death.

Cardiogenic shock in the setting of PCI is associated with a 50% in-hospital death rate. However, several studies have indicated that chances of survival are improved with revascularization.

Many interventionalists rely on hemodynamic support with intra-aortic balloon counterpulsation (IAPB) in shock patients undergoing PCI, but this technique failed to show a benefit in the IAPB-SHOCK II trial.

When results from the SHOCK II study were published last August, Mariell Jessup, MD, told 乌鸦传媒 that the current American Heart Association/American College of Cardiology guidelines for treatment of ST-segment elevation myocardial infarction (STEMI) support the use of IABP. But the recommendation was based on the first SHOCK trial, which evaluated IAPB in the setting of , added Jessup, who is from the University of Pennsylvania Perelman School of Medicine in Philadelphia.

The buzz was that IAPB-SHOCK II could influence practice in a major way. That doesn't seem likely, though, as interventionalists are in shock themselves over the outcomes of the trial and will willingly recall the many times IAPB was of benefit in shock patients.

Nevertheless, evidence has emerged showing a clear benefit of radial access over femoral access in patients with STEMI. One of the problems, however, is that "few randomized trials of STEMI have included shock patients," noted Ian Gilchrist, MD, from Penn State Heart and Vascular Institute in Hershey, Pa., and Sunil Rao, MD, from The Duke Clinical Research Institute in Durham, N.C., in an editorial accompanying the current study.

Gilchrist and Rao pointed out that slightly more than half of the patients in this study did not have a radial pulse -- the main factor that prevented the use of a transradial approach in the study -- and were relegated to femoral access.

Hypotension is one of the reasons why "even some experienced radial operator may avoid radial access in patients with shock," they wrote.

Nevertheless, "given the amount of published evidence supporting the safety of the radial approach over femoral approach, a 'radial first' strategy likely still applies in most patients, even those with large STEMI and shock," the editorialists concluded.

To bolster the evidence for the safety and effectiveness of PCI in shock patients, Rodriguez-Leor and colleagues prospectively analyzed outcomes of consecutive patients with STEMI undergoing primary angioplasty or rescue angioplasty or patients with non-STEMI. The data were from a registry that spanned from February 2007 to January 2012.

Researchers included 1,400 emergency PCI cases and of those, 80 had cardiogenic shock. Sixty-six percent underwent radial access and 34% underwent femoral.

The mean age of patients was 67, about 31% were older than 75, three-quarters were men, and the mean body mass index was 27 kg/m². There were significantly more women in the femoral versus radial group -- 26% versus 11% (P=0.03).

There also were some significant differences between the two groups that indicated transfemoral patients were at a higher risk. Specifically, the transfemoral group had more patients with:

• Insulin-treated diabetes: 36% versus 7% (P<0.0001)
• Previous myocardial infarction (MI): 42% versus 27% (P=0.04)
• Glomerular filtration: 53 versus 66 mL/min/1.73m² -- (P=0.03)
• Prior coronary artery surgery: 12% versus 0% (P=0.002)
• Mechanical ventilation before PCI: 67% versus 41% (P=0.008)
• Inotropic treatment prior to PCI: 88% versus 64% ( P=0.004)

The femoral group also had significantly more patients with three-vessel disease, incomplete revascularization, higher blood pressure, and a lower left ventricular ejection fraction. As well, they had fewer patients with glycoprotein IIb/IIIa inhibitor use and a lower procedural success rate.

If patients did not have a radial pulse, their PCI would proceed via the femoral approach. This was the main reason for choosing femoral access (55%). Another common reason was logistical: if the interventionalist had to insert an intra-aortic balloon pump or a provisional pacemaker, the procedure was completed transfemorally. That occurred in 27% of cases.

Significantly more access site complications occurred in the femoral group along with significantly more access site complications that required blood transfusion.

Femoral site access was associated with significantly more major adverse cardiovascular events (MACE) than the radial approach (74% versus 44%, P=0.001). MACE included death, MI, stroke, serious bleeding, and delayed coma after hypoxia.

"To our knowledge, this is the first study describing PCI using the transradial approach in a population of consecutive, unselected patients with cardiogenic shock," researchers concluded.

In fact, they said, the choice of access site "may influence mortality in these patients."

The study had some limitations including the diagnosis of shock that was defined by medical records and not hemodynamic monitoring. Also, some factors relevant to prognosis may not have been captured in the uni- and multivariate analyses. Finally, access site approach was left to the discretion of the operator.

From the American Heart Association:

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