Wimmer N - AIMRADIAL 2014 - Door-to-balloon
This document discusses radial PCI and door-to-balloon time for STEMI patients. It notes that while radial PCI is associated with less bleeding and faster recovery, it can also lead to longer procedure times. The document summarizes several studies that have looked at the mortality benefits of radial PCI for STEMI. A key study found that even with an 83 minute delay in door-to-balloon time, radial PCI was still associated with lower mortality based on results from randomized controlled trials. The conclusion is that the benefits of radial PCI outweigh the risks associated with potential delays, and radial PCI should be the preferred approach.
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Wimmer N - AIMRADIAL 2014 - Door-to-balloon
- 1. Radial PCI anddoor-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 ofFinancial 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 andRisks 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 forSTEMI in US Baklanov et al. JACC. 2013.
- 5. Concern about door-to-balloontime Nallamothu et al. Am Heart J. 2003. Rathore et al. BMJ. 2009.
- 6.
- 7. Policy Responses Bradleyet al. JACC. 2009.
- 8. RCT data forTransradial in STEMI - Mortality Karrowni et al. JACC Cardiovascular Int. 2013.
- 9. Are Door-to-Balloon TimesDifferent? STEMI subset in RIVAL Mehta et al. JACC. 2012
- 10. Does reducing door-to-balloontime 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 Ifradial 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 delayin DTB time would offset the mortality benefit of transradial PCI in RCTs? Wimmer et al. Am Heart J. 2014.
- 13. It may beworth 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 ofdelay 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 influencedby crossover Wimmer et al. Am Heart J. 2014.
- 16. Conclusions • Atransradial 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 Raoet al. CCI. 2013
- 18. Conclusions • Ifthe 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.