Variation in Adoption of Transradial Access for STEMI

Study Questions:

What are the patient, operator, and institutional factors associated with transradial access (TRA) in ST-segment elevation myocardial infarction (STEMI) percutaneous coronary intervention (PCI), the variation in use across operators and institutions, and the relationship with mortality and bleeding?

Methods:

The investigators used hierarchical logistic regression to identify patient, operator, and institutional characteristics associated with TRA use as well as to determine the variation in TRA for STEMI PCI from 2009 to 2015. They also described the relationship between operator- and institution-level use and risk-adjusted bleeding and mortality. Risk-adjusted mortality rates were calculated using analogous methods. The Spearman correlation coefficient for both percent TRA use and risk-adjusted bleeding rate, and percent TRA use and risk-adjusted mortality rate were calculated to determine the relationships between TRA for STEMI and in-hospital bleeding and mortality for operators and institutions within the National Cardiovascular Data Registry (NCDR) CathPCI Registry.

Results:

Among 692,433 patients undergoing STEMI PCI, 12% (n = 82,618) utilized TRA. TRA increased from 2% to 23% from 2009 to 2015, but with significant geographic variation. Age, sex, cardiogenic shock, cardiac arrest, operators entering practice before 2012, and nonacademically affiliated institutions were associated with lower rates of TRA. There was significant operator and institutional variation, wherein identical patients would have >8-fold difference in odds of TRA for STEMI PCI by changing operators (median odds ratio, 8.7), and >5-fold difference by changing institutions (median odds ratio, 5.1). Greater TRA use across operators was associated with reduced bleeding (rho = −0.053), whereas TRA use across institutions was associated with reduced mortality (rho = −0.077).

Conclusions:

The authors concluded that TRA for STEMI PCI is increasing, but remains underutilized with significant geographic, operator, and institutional variation.

Perspective:

This NCDR CathPCI Registry study reports that the TRA for PCI is increasing in the United States, but with significant geographic variation and ongoing opportunities for adoption. Furthermore, operator and institutional characteristics appear to be associated with a significant proportion of the variability of transradial adoption, independent of patient factors. This heterogeneity in practice patterns may afford an opportunity for overall quality improvement in the management of STEMI beyond access site.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Implantable Devices, SCD/Ventricular Arrhythmias, Acute Heart Failure, Interventions and ACS

Keywords: Acute Coronary Syndrome, CathPCI Registry, Heart Arrest, Hospital Mortality, Hemorrhage, Myocardial Infarction, Percutaneous Coronary Intervention, Quality Improvement, Shock, Cardiogenic


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