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Baseline Bleeding Risk and Arterial Access Site Practice in Relation to Procedural Outcomes After Percutaneous Coronary Intervention
Study Questions:
Is transradial access (TRA) during percutaneous coronary intervention (PCI) related to better procedural outcomes, and how is this relationship influenced by baseline bleeding risk?
Methods:
TRA is associated with reduced access site–related bleeding complications and lower mortality after PCI. It is unknown whether these benefits are influenced by baseline bleeding risk. Using data from the British Cardiovascular Intervention Society database, baseline bleeding risk was calculated by using modified Mehran bleeding risk scores (MMRS) in 348,689 PCI procedures performed between 2006 and 2011. The association between TRA and 30-day mortality was assessed, and stratified by baseline bleeding risk. Use of TRA by baseline bleeding risk was also evaluated.
Results:
TRA was independently associated with a 35% reduction in 30-day mortality risk (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.59-0.72; p < 0.0001), with the magnitude of mortality reduction increasing according to baseline bleeding risk (MMRS <10; OR, 0.73; 95% CI, 0.62-0.86; MMRS ≥20; OR, 0.53; 95% CI, 0.47-0.61). In patients with an MMRS <10, TRA was used in 71,771 (43.2%) of 166,083 PCI procedures; TRA was used in 8,655 (40.1%) of 21,559 PCI procedures in patients with an MMRS ≥20, showing that TRA was used less in those at highest risk from bleeding complications (p < 0.0001).
Conclusions:
The authors concluded that TRA is linked to reduced 30-day mortality, and the magnitude of this effect is related to baseline bleeding risk, with those at highest risk of bleeding complications gaining the greatest benefit from adoption of TRA during PCI in both relative and absolute terms.
Perspective:
This is a neat study, tying together baseline bleeding risk and TRA use for the first time. As might have been expected, the benefits of TRA tended to be largest in those patients who were at the highest risk for bleeding complications. Methodological limitations to this report exist, as a large number of patients were excluded due to an inability to calculate baseline bleeding risk and the requirement of modifying the Mehran bleeding risk scores. Despite these limitations, however, the observations reported will be used to further push more cath labs to adopt TRA as a default strategy in routine cases. The additional finding of ‘risk-treatment’ paradox with the highest risk patients actually receiving TRA less often will also be used to develop better approaches for overcoming the challenges of using TRA in high-risk groups such as the elderly, women, and unstable patients.
Keywords: Hemorrhage, Percutaneous Coronary Intervention
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