Wimmer N - AIMRADIAL 2014 - Door-to-balloon
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Radial PCI and door-to-balloon time in STEMI: Is there an acceptable delay to reperfusion
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Wimmer N - AIMRADIAL 2014 - Door-to-balloon
- 1. Radial PCI and door-to-balloon time in STEMI: Is there an acceptable delay to reperfusion? Neil J. Wimmer, MD, MSc AIM-RADIAL 2014 October 24, 2014
- 2. Disclosure Statement of Financial Interest I, Neil Wimmer, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.
- 3. Weighing Benefits and Risks of Transradial Access in STEMI Benefits • Less access site bleeding • Ability to anticoagulate more aggressively? • Earlier ambulation • Patient comfort Risks • Longer door-to-balloon times • Longer procedures • More contrast • Longer fluoro times
- 4. Transradial use for STEMI in US Baklanov et al. JACC. 2013.
- 5. Concern about door-to-balloon time Nallamothu et al. Am Heart J. 2003. Rathore et al. BMJ. 2009.
- 7. Policy Responses Bradley et al. JACC. 2009.
- 8. RCT data for Transradial in STEMI - Mortality Karrowni et al. JACC Cardiovascular Int. 2013.
- 9. Are Door-to-Balloon Times Different? STEMI subset in RIVAL Mehta et al. JACC. 2012
- 10. Does reducing door-to-balloon time still improve outcomes? •No significant association between annual decreases in DTB time and in-hospital mortality (odds ratio for 10 min reduction in DTB time: 1.04, 95% CI: 0.99 – 1.14). Menees et al. N Engl J Med. 2013.
- 11. Thought Experiment If radial PCI is associated with a delay in door-to-balloon time in STEMI, how much of a delay would be acceptable for patients to still benefit from transradial PCI? Wimmer et al. Am Heart J. 2014.
- 12. How much delay in DTB time would offset the mortality benefit of transradial PCI in RCTs? Wimmer et al. Am Heart J. 2014.
- 13. It may be worth the extra time 83 minutes of delay in DTB time offsets the RCT mortality benefit of transradial PCI Wimmer et al. Am Heart J. 2014.
- 14. 83 minutes of delay in DTB time offsets the RCT mortality benefit of transradial PCI 21 minutes of delay Wimmer et al. Am Heart J. 2014. RR cut to 1/4 It may be worth the extra time
- 15. Not strongly influenced by crossover Wimmer et al. Am Heart J. 2014.
- 16. Conclusions • A transradial delay of 83.0 minutes was needed to offset the mortality benefit of transradial PCI. • When the mortality benefit of transradial PCI was one-quarter that observed in RCTs, the delay associated with equivalent mortality was 20.9 minutes. • Results were robust to changing multiple assumptions and have implications for operators reluctant to transition to transradial PCI in STEMI
- 17. Proposed Algorithm Rao et al. CCI. 2013
- 18. Conclusions • If the mortality benefit (or even a fraction of this benefit) of transradial intervention observed in RCTs is true, it would be the preferred approach even if this led to delays in DTB time. • Integrating the ability to comfortably perform transradial PCI for STEMI should be a goal for all interventionalists, as this is the population that will derive the greatest benefit from the approach. • Our goal should be to integrate multiple effective interventions in the care of our patients at the same time.