Relationship Between Arterial Access and Outcomes in ST-Elevation Myocardial Infarction With a Pharmacoinvasive Versus Primary Percutaneous Coronary Intervention Strategy: Insights From the STrategic Reperfusion Early After Myocardial Infarction (STREAM) Study.

Abstract

BACKGROUND: The effectiveness of radial access (RA) in ST-elevation myocardial infarction (STEMI) has been predominantly established in primary percutaneous coronary intervention (pPCI) with limited exploration of this issue in the early postfibrinolytic patient. The purpose of this study was to compare the effectiveness and safety of RA versus femoral (FA) access in STEMI undergoing either a pharmacoinvasive (PI) strategy or pPCI. METHODS AND RESULTS: Within STrategic Reperfusion Early After Myocardial Infarction (STREAM), we evaluated the relationship between arterial access site and primary outcome (30-day composite of death, shock, congestive heart failure, or reinfarction) and major bleeding according to the treatment strategy received. A total of 1820 STEMI patients were included: 895 PI (49.2%; rescue PCI [n=379; 42.3%], scheduled PCI [n=516; 57.7%]) and 925 pPCI (50.8%). Irrespective of treatment strategy, there was comparable utilization of either access site (FA: PI 53.4% and pPCI 57.6%). FA STEMI patients were younger, had lower presenting systolic blood pressure, lesser Thrombolysis In Myocardial Infarction risk, and more ∑ST-elevation at baseline. The primary composite endpoint occurred in 8.9% RA versus 15.7% FA patients (P<0.001). On multivariable analysis, this benefit on the primary composite outcome favoring RA persisted (adjusted odds ratio [OR], 0.59; 95% CI, 0.44-0.78; P<0.001) and was evident in both pPCI (adjusted OR, 0.63; 95% CI, 0.43-0.92) and PI cohorts (adjusted OR, 0.57 95% CI, 0.37-0.86; P interaction=0.730). There was no difference in nonintracranial major bleeding with either access group (RA vs FA, 5.2% vs 6.0%; P=0.489). CONCLUSIONS: Regardless of the application of a PI or pPCI strategy, RA was associated with improved clinical outcomes, supporting current STEMI evidence in favor of RA in PCI. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00623623.