Comparación de seguridad y efectividad entre los accesos radiales derecho e izquierdo en la intervención coronaria percutánea / Comparison of safety and effectiveness between the right and left radial artery approach in percutaneous coronary intervention

Introducción y objetivos: Existen pocos estudios que comparen los accesos por la radial izquierda (ARI) y por la radial derecha en intervenciones coronarias percutáneas (ICP) en población general y practicadas por cirujanos con diferentes grados de experiencia en intervencionismo. El objetivo de nuestro estudio es comparar la seguridad y el beneficio clínico con cada acceso en pacientes no seleccionados con síndrome coronario agudo (SCA) y angina estable (AE). Métodos: Para evitar los posibles sesgos de un estudio no aleatorizado, se usó la puntuación de propensión para comparar ambos accesos radiales. Se recogieron datos de 18.716 pares con AE y 46.241 con SCA sometidos a ICP con implante de stent entre 2014 y 2017, en 151 centros terciarios con cardiología intervencionista en Polonia (registro nacional de Polonia [ORPKI]). Resultados: No se encontraron diferencias en cuanto a mortalidad y complicaciones periprocedimiento en AE. El ARI se asoció con mayores dosis de radiación independientemente de la presentación clínica (AE, 1.067,0±947,10 frente a 1.007,4±983,5 mGy; p=0,001; SCA, 1.212,7±1.005,5 frente a 1.053,5±1.029,7 mGy; p=0,001). En los pacientes con SCA, el ARI se asoció con mayor cantidad de contraste (174,2±75,4 frente a 167,2±72,1ml; p=0,001). Además, en los pacientes con SCA y ARI, las complicaciones periprocedimiento como disección coronaria (el 0,16 frente al 0,09%; p=0,008), fenómeno de no reflow (el 0,65 frente al 0,49%; p=0,005) y hemorragia en el sitio de punción (el 0,09 frente al 0,05%; p=0,04) resultaron más frecuentes. No hubo diferencias en la mortalidad entre los 2 grupos (p=0,90). Conclusiones: Los resultados que se presentan podrían estar en relación con una menor experiencia en el ARI. Ambos accesos son seguros en los pacientes con AE, pero el ARI se asoció con una mayor frecuencia de complicaciones periprocedimiento de ICP en el SCA (AU)

Introduction and objectives: There is a paucity of data comparing the left radial approach (LRA) and right radial approach (RRA) for percutaneous coronary intervention (PCI) in all-comers populations and performed by operators with different experience levels. Thus, we sought to compare the safety and clinical outcomes of the RRA and LRA during PCI in “real-world” patients with either stable angina or acute coronary syndrome (ACS). Methods: To overcome the possible impact of the nonrandomized design, a propensity score was calculated to compare the 2 radial approaches. The study group comprised 18 716 matched pairs with stable angina and 46 241 with ACS treated with PCI and stent implantation between 2014 and 2017 in 151 tertiary invasive cardiology centers in Poland (the ORPKI Polish National Registry). Results: The rates of death and periprocedural complications were similar for the RRA and LRA in stable angina patients. A higher radiation dose was observed with PCI via the LRA in both clinical presentations (stable angina: 1067.0±947.1 mGy vs 1007.4±983.5 mGy, P=.001; ACS: 1212.7±1005.5 mGy vs 1053.5±1029.7 mGy, P=.001). More contrast was used in LRA procedures but only in ACS patients (174.2±75.4mL vs 167.2±72.1mL, P=.001). Furthermore, periprocedural complications such as coronary artery dissection (0.16% vs 0.09%, P=.008), no-reflow phenomenon (0.65% vs 0.49%, P=.005), and puncture site bleeding (0.09% vs 0.05%, P=.04) were more frequently observed with the LRA in ACS patients. There was no difference in mortality between the 2 groups (P=.90). Conclusions: Our finding of poorer outcomes with the LRA may be related to lower operator experience with this approach. While both the LRA and RRA are safe in the setting of stable angina, the LRA was associated with a higher rate of periprocedural complications during PCI in ACS patients (AU)

Simple point-of-care risk stratification in acute coronary syndromes: the AMIS model.

BACKGROUND: Early risk stratification is important in the management of patients with acute coronary syndromes (ACS). OBJECTIVE: To develop a rapidly available risk stratification tool for use in all ACS. DESIGN AND METHODS: Application of modern data mining and machine learning algorithms to a derivation cohort of 7520 ACS patients included in the AMIS (Acute Myocardial Infarction in Switzerland)-Plus registry between 2001 and 2005; prospective model testing in two validation cohorts. RESULTS: The most accurate prediction of in-hospital mortality was achieved with the "Averaged One-Dependence Estimators" (AODE) algorithm, with input of seven variables available at first patient contact: age, Killip class, systolic blood pressure, heart rate, pre-hospital cardiopulmonary resuscitation, history of heart failure, history of cerebrovascular disease. The c-statistic for the derivation cohort (0.875) was essentially maintained in important subgroups, and calibration over five risk categories, ranging from <1% to >30% predicted mortality, was accurate. Results were validated prospectively against an independent AMIS-Plus cohort (n = 2854, c-statistic 0.868) and the Krakow-Region ACS Registry (n = 2635, c-statistic 0.842). The AMIS model significantly outperformed established "point-of-care" risk-prediction tools in both validation cohorts. In comparison to a logistic regression-based model, the AODE-based model proved to be more robust when tested on the Krakow validation cohort (c-statistic 0.842 vs 0.746). Accuracy of the AMIS model prediction was maintained at 12-month follow-up in an independent cohort (n = 1972, c-statistic 0.877). CONCLUSIONS: The AMIS model is a reproducibly accurate point-of-care risk stratification tool for the complete range of ACS, based on variables available at first patient contact.