Jonathan Frazier, PharmD Candidate 2015, Mercer University College of Pharmacy
Acute coronary syndrome (ACS), more commonly known as heart attack or unstable angina, is an umbrella term for any situation in which blood flow to the heart is suddenly blocked. The sudden blockage is often due to a build up of plaque in the arteries, causing them to narrow and making it more difficult for blood to flow through them. The treatment for ACS includes a procedure called angioplasty in which the goal is to inflate a small balloon in the blocked artery to the heart in order to insert a stent to hold it open. There are two major arteries that are used in this procedure, the femoral and radial artery.1
Radial artery access is increasing in common practice due to trials showing a reduction in access site complications compared to femoral assess. The only downfall so far is that radial access has been associated with longer procedure times, greater radiation doses and higher likelihood of access failure then the femoral approach.2 The following, RIVAL, trial took a look at this increase in radial access and tried to compare its effectiveness to femoral access.
Primary Outcome MeasureThe occurrence of death, myocardial infarction (MI), stroke, or non-coronary artery bypass graft (non-CABG)-related major bleeding within 30 days.
|Title: Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomized, parallel group, multicenter trial3|
|Design||Randomized, multicenter, parallel group trial; 7,021 participants|
|Objective||To assess whether radial access was superior to femoral access in patients undergoing coronary angiography with acute coronary syndrome (ACS).|
|Study groups||Two study groups; radial access (N=3,507) and femoral access (N=3,514)|
|Methods||Patients were included if they had ACS with or without ST segment elevation. After an invasive approach was planned the interventional cardiologist was would be willing to proceed with either radial or femoral access.|
|Duration||June 6, 2006 through November 3, 2010|
|Baseline Characteristics||Radial: age>75 years 506 (14%), men 2599 (74.1%), diagnosis at admission: unstable angina 1554 (44.3%), NTSTEMI 998 (28.5%), STEMI 995 (27.2%), present smoker 1083 (30.9%), hypertension 2118 (60.4%) history of MI 658 (18.8%)
Femoral: age>75 years 529 (15.1%), men 2561 (72.9%), diagnosis at admission: unstable angina 1606 (45.7%), NTSTEMI 905 (25.8%), STEMI 1003 (28.5%), present smoker 1097 (31.2%), hypertension 2076 (59.1%) history of MI 622 (17.7%)
|Results||Death, MI, stroke, or non-CABG bleeding at 30 days: radial 128 (3.7%) femoral 139 (4.0%); hazard ratio 0.92 (95% CI, 0.72-1.17) P=0.50|
|Adverse Events||Common Adverse Events:N/A|
|Serious Adverse Events:N/A|
|Percentage that Discontinued due to Adverse Evens:N/A|
|Study Author Conclusions||Based on the results of this study, the authors concluded that radial access for angiography and intervention resulted in similar rates of the composite of death, MI, stroke, or non-CABG-related bleeding as femoral access. However radial access resulted in less vascular complications.|
For patients with ACS undergoing angioplasty, the most important factor for them at that point is time. There is a saying “time is tissue” and for every minute, or even second, that goes by that the interventional cardiologist is taking to try and get either radial or femoral access, more cardiac muscle is dying. Since the results of this study show no benefit in one type of access over the other, it appears that safest thing at this point is for the interventional cardiologist to proceed with what they know best and are the most comfortable with.
1. Heart.org. Heart Attack. 2015. Available at http://www.heart.org/HEARTORG/Conditions/HeartAttack/AboutHeartAttacks/Acute-Coronary-Syndrome_UCM_428752_Article.jsp. Accessed March 19, 2015
2. Yuan DZ, Brooks M, Dabin B, Higgs E, Hyun K, Brieger D. Radial versus femoral access for cardiac catheterisation: impact on quality of life. Int J Cardiol. 2015;178:91-2.
3. Jolly SS, Yusuf S, Cairns J, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet. 2011;377(9775):1409-20.