Comparison of a vascular closure device versus the radial approach to reduce access site complications in non-ST-segment elevation acute coronary syndrome patients: The angio-seal versus the radial approach in acute coronary syndrome trial.

OBJECTIVES: To compare the radial versus femoral approach using Angio-Seal for the incidence of access site complications among non-ST-segment elevation acute coronary syndrome patients undergoing invasive strategy. BACKGROUND: Arterial access is a major site of complications after invasive coronary procedures. Vascular closure devices provide more comfort to patients decreasing time to hemostasis and need for bed rest. However, the inconsistency of data proving their safety limits their routine adoption as a strategy to prevent vascular complications. METHODS: Single-center non-inferiority trial where 240 patients were randomized to radial or femoral access using Angio-Seal. The primary objective was the occurrence of complications at the arterial puncture site until 30 days after the procedure. RESULTS: There were no baseline clinical differences between groups, except for a greater prevalence of female patients in the radial group (33.3 vs. 20.0%, P = 0.020). Hemostasis was achieved in the entire radial group with the use of TR Band and in 95% of the procedures in the femoral group with Angio-Seal (P = 0.029). Except for a higher incidence of asymptomatic arterial occlusion in the radial group, there were no differences among the other analyzed outcomes. According to the noninferiority test, the use of Angio-Seal was noninferior to the radial approach, considering the margin of 15% (12.5 vs. 13.3%, difference -0.83%, 95% CI -9.31 - 7.65, P for noninferiority <0.001). CONCLUSIONS: Angio-Seal seems noninferior in the incidence of access site complications at 30 days when compared with the radial approach. © 2016 Wiley Periodicals, Inc.

Three vs twelve months of dual antiplatelet therapy after zotarolimus-eluting stents: the OPTIMIZE randomized trial.

IMPORTANCE: The current recommendation is for at least 12 months of dual antiplatelet therapy after implantation of a drug-eluting stent. However, the optimal duration of dual antiplatelet therapy with specific types of drug-eluting stents remains unknown. OBJECTIVE: To assess the clinical noninferiority of 3 months (short-term) vs 12 months (long-term) of dual antiplatelet therapy in patients undergoing percutaneous coronary intervention (PCI) with zotarolimus-eluting stents. DESIGN, SETTING, AND PATIENTS: The OPTIMIZE trial was an open-label, active-controlled, 1:1 randomized noninferiority study including 3119 patients in 33 sites in Brazil between April 2010 and March 2012. Clinical follow-up was performed at 1, 3, 6, and 12 months. Eligible patients were those with stable coronary artery disease or history of low-risk acute coronary syndrome (ACS) undergoing PCI with zotarolimus-eluting stents. INTERVENTIONS: After PCI with zotarolimus-eluting stents, patients were prescribed aspirin (100-200 mg daily) and clopidogrel (75 mg daily) for 3 months (n = 1563) or 12 months (n = 1556), unless contraindicated because of occurrence of an end point. MAIN OUTCOMES AND MEASURES: The primary end point was net adverse clinical and cerebral events (NACCE; a composite of all-cause death, myocardial infarction [MI], stroke, or major bleeding); the expected event rate at 1 year was 9%, with a noninferiority margin of 2.7%. Secondary end points were major adverse cardiac events (MACE; a composite of all-cause death, MI, emergent coronary artery bypass graft surgery, or target lesion revascularization) and Academic Research Consortium definite or probable stent thrombosis. RESULTS: NACCE occurred in 93 patients receiving short-term and 90 patients receiving long-term therapy (6.0% vs 5.8%, respectively; risk difference, 0.17 [95% CI, -1.52 to 1.86]; P = .002 for noninferiority). Kaplan-Meier estimates demonstrated MACE rates at 1 year of 8.3% (128) in the short-term group and 7.4% (114) in the long-term group (HR, 1.12 [95% CI, 0.87-1.45]). Between 91 and 360 days, no statistically significant association was observed for NACCE (39 [2.6%] vs 38 [2.6%] for the short- and long-term groups, respectively; HR, 1.03 [95% CI, 0.66-1.60]), MACE (78 [5.3%] vs 64 [4.3%]; HR, 1.22 [95% CI, 0.88-1.70]), or stent thrombosis (4 [0.3%] vs 1 [0.1%]; HR, 3.97 [95% CI, 0.44-35.49]). CONCLUSIONS AND RELEVANCE: In patients with stable coronary artery disease or low-risk ACS treated with zotarolimus-eluting stents, 3 months of dual antiplatelet therapy was noninferior to 12 months for NACCE, without significantly increasing the risk of stent thrombosis. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01113372.

Transulnar approach as an alternative access site for coronary invasive procedures after transradial approach failure.

BACKGROUND: Unsuccessful radial artery puncture, inability to advance the guide catheter to the ascending aorta, and inadequate guide catheter support represent mechanisms of transradial approach failure. With the rationale of sharing the same efficacy and safety promoted by radial access, the transulnar approach represents an alternative access site for percutaneous coronary procedures. METHODS: Between May 2007 and May 2012, 11,059 coronary invasive procedures were performed in a single institution: 10,108 by transradial approach (91.4%), 541 by transfemoral approach (4.9%), and 410 by transulnar approach (3.7%). Patients who underwent coronary procedures through transulnar access were included in a prospective registry of effectiveness and safety. RESULTS: Diagnostic procedures accounted for 71.8% of cases, and the right ulnar access was the most common route (88.9%). Procedure success was high (98.5%), with a crossover rate of 1.5% (6 cases), of which 5 were achieved through the contralateral radial access and 1 through femoral approach. Complications related to access site were low (3.9%), consisting mostly of minor bleeding due to subcutaneous hematomas. There were no cases of major bleeding, nerve injury, pseudoaneurysm, arteriovenous fistula, or necessity of vascular surgical repair. CONCLUSIONS: The transulnar approach represents an alternative to the transradial approach in selected cases when performed by radial-trained operators, sharing a high success rate and extremely low incidence of access-site complications.

Drug-eluting stents during ST-segment elevation acute myocardial infarction: a critical analysis.

Primary percutaneous coronary intervention is the preferred reperfusion therapy for ST-segment elevation acute myocardial infarction patients within 12 hours of symptom-onset. Routine stent implantation during the procedure significantly reduces the rate of target vessel revascularization, although restenosis still represents a current limitation of the technique. Drug-eluting stents were developed to treat and prevent coronary restenosis. Randomized trials, meta-analysis, and registries proved their efficacy and safety in different clinical situations, including acute myocardial infarction. However, the increased risk of late stent thrombosis associated with drug-eluting stents during primary percutaneous coronary interventions encourages a careful analysis to identify which patients most benefit from them, as well as those where a prolonged dual antiplatelet therapy does not represent a limiting factor.

Transulnar approach: the rationale from the radialist's view.

BACKGROUND: Radial access, besides providing greater comfort to the patient and reduction of hospital costs, promotes unequivocal reduction of vascular complications, with possible prognosis implication. A series of cases has shown that when its use is not suitable, ulnar access presents itself as a viable and effective alternative. OBJECTIVE: To evaluate the safety and effectiveness of ulnar approach in the performance of coronary procedures after failed attempt in obtaining radial access. METHODS AND RESULTS: From May 2007 to February 2009, 115 patients underwent 122 coronary procedures via ulnar access and were included in a prospective registry. The average age was 61.3 +/- 11.1 years, 67 (58%) were female and 36 (31%) were diabetic. Procedure success was achieved in 116 (95%) cases. There were no cases of major bleeding, transfusions or vascular repair surgery among the complications. There were hematomas in 4.9% of the cases, though mostly superficial, light to moderate spasms in 4% and asymptomatic ulnar artery occlusion, with no evidence of ischemia in 1.6%. CONCLUSIONS: The ulnar artery is a feasible and effective alternative approach to perform coronary procedures. When radial access is not available, it presents a similar safety profile with virtually no occurrence of hemorrhagic complications.

Vascular Closure Devices Attenuate Femoral Access Complications of Primary Percutaneous Coronary Intervention.

OBJECTIVES: To compare severe complications related to radial access and those related to femoral access using vascular closure devices for patients undergoing primary percutaneous coronary intervention (PCI). BACKGROUND: Femoral artery access is still used for acute myocardial infarction management; studies comparing state-of-the-art radial and femoral techniques are required to minimize bias regarding the outcomes associated with operator preferences. METHODS: We performed a randomized study comparing radial access with a compression device and anatomic landmark-guided femoral access with a hemostatic vascular closure device. The severe complication rates related to the access site were assessed until hospital discharge. A meta- analysis including studies with comparable populations reporting severe bleeding and major adverse cardiovascular event rates was performed. RESULTS: A total of 250 patients were included who underwent PCI between January 2016 and February 2019. Mean age was 61.5 ± 12.2 years, 73.2% were men, and 28.4% had diabetes. There were no differences between groups or in vascular access-related severe complication rates (8.0% for femoral group vs 5.6% for radial group; P=.45). Although radial access was associated with decreased vascular complications related to the access site when compared with the femoral approach (relative risk [RR], 0.64; 95% confidence interval [CI], 0.43-0.95), the meta-analysis did not show an impact on severe bleeding (RR, 0.74; 95% CI, 0.37-1.46) or severe cardiovascular adverse events (RR, 0.69; 95% CI, 0.30-1.58). CONCLUSIONS: Compliance with femoral artery puncture techniques and routine use of a vascular closure device promoted low severe complication rates.

Performance of coronary procedures through the transulnar access without assessment of the integrity of the deep palmar arch.

Occurrence of ischemic complications after transulnar coronary procedures is virtually absent. The presence of a complete deep palmar arch in approximately 95% of the population as well as the great capacity of the collateral circulation of the hand might justify these findings. We report the occurrence of complications in 62 patients submitted to coronary procedures through the transulnar approach, without assessment of the integrity of the deep palmar arch by the inverse Allen's test. The rate of asymptomatic occlusion of the ulnar artery was 3%, without any ischemic complication. We believe the performance of Allen's test is not necessary when using transulnar access.

Primary coronary angioplasty in 9,434 patients during acute myocardial infarction: predictors of major in- hospital adverse events from 1996 to 2000 in Brazil.

OBJECTIVE: To verify the results after the performance of primary coronary angioplasty in Brazil in the last 4 years. METHODS: During the first 24 hours of acute myocardial infarction onset, 9,434 (12.2%) patients underwent primary PTCA. We analyzed the success and occurrence of major in-hospital events, comparing them over the 4-year period. RESULTS: Primary PTCA use increased compared with that of all percutaneous interventions (1996=10.6% vs. 2000=13.1%; p<0.001). Coronary stent implantation increased (1996=20% vs. 2000=71.9%; p<0.001). Success was greater (1998=89.5% vs. 1999=92.5%; p<0.001). Reinfarction decreased (1998=3.9% vs. 99=2.4% vs. 2000=1.5%; p<0.001) as did emergency bypass surgery (1996=0.5% vs. 2000=0.2%; p=0.01). In-hospital deaths remained unchanged (1996=5.7% vs. 2000=5.1%, p=0.53). Balloon PTCA was one of the independent predictors of a higher rate of unsuccessful procedures (odds ratio 12.01 [CI=95%] 1.58-22.94), and stent implantation of lower mortality rates (odds ratio 4.62 [CI=95%] 3.19-6.08). CONCLUSION: The success rate has become progressively higher with a significant reduction in reinfarction and urgent bypass surgery, but in-hospital death remains nearly unchanged. Coronary stenting was a predictor of a lower death rate, and balloon PTCA was associated with greater procedural failure.

Femoral versus radial access in primary angioplasty. Analysis of the ACCEPT registry.

BACKGROUND: The radial access provides a lower risk of bleeding and vascular complications related to the puncture site in comparison to the femoral access. Recent studies have suggested a reduction in mortality associated with the radial access in patients with acute myocardial infarction undergoing percutaneous coronary intervention. OBJECTIVE: To compare the occurrence of adverse cardiovascular ischemic and hemorrhagic events in patients undergoing primary angioplasty according to the type of arterial access route. METHODS: From August 2010 to December 2011, 588 patients undergoing primary percutaneous coronary intervention during acute ST-segment elevation myocardial infarction were assessed; they were recruited from 47 centers participating in the ACCEPT registry. Patients were grouped and compared according to the arterial access used for the procedure. RESULTS: The mean age was 61.8 years; 75% were males and 24% had diabetes mellitus. There was no difference between groups as regards the procedure success rate, as well as regards the occurrence of death, reinfarction, or stroke at six months of follow-up. Severe bleeding was reported in 1.1% of the sample analyzed, with no statistical difference related to the access used. CONCLUSIONS: The femoral and radial accesses are equally safe and effective for the performance of primary percutaneous coronary intervention. The low rate of cardiovascular events and of hemorrhagic complications reflects the quality of the participating centers and the operators expertise with the use of both techniques.

Design and rationale of the AngioSeal versus the Radial approach In acute coronary SyndromE (ARISE) trial: a randomized comparison of a vascular closure device versus the radial approach to prevent vascular access site complications in non-ST-segment elevation acute coronary syndrome patients.

BACKGROUND: Arterial access is a major site of bleeding complications after invasive coronary procedures. Among strategies to decrease vascular complications, the radial approach is an established one. Vascular closure devices provide more comfort to patients and decrease hemostasis and need for bed rest. However, the inconsistency of data proving their safety limits their routine adoption as a strategy to prevent vascular complications, requiring evidence through adequately designed randomized trials. The aim of this study is to compare the radial versus femoral approach using a vascular closure device for the incidence of arterial puncture site vascular complications among non-ST-segment elevation acute coronary syndrome patients submitted to an early invasive strategy. METHODS: ARISE is a national, multicenter, non-inferiority randomized clinical trial. Two hundred patients with non-ST-segment elevation acute coronary syndrome will be randomized to either radial or femoral access using a vascular closure device. The primary outcome is the occurrence of vascular complications at an arterial puncture site 30 days after the procedure, including major bleeding, retroperitoneal hematoma, compartment syndrome, hematoma ≥ 5 cm, pseudoaneurysm, arterio-venous fistula, infection, limb ischemia, arterial occlusion, adjacent nerve injury or the need for vascular surgical repair. RESULTS: Enrollment was initiated in September 2012, and until October 2013 91 patients were included. The inclusion phase is expected to last until the second half of 2014. CONCLUSIONS: The ARISE trial will help define the role of a vascular closure device as a bleeding avoidance strategy in patients with NSTEACS. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01653587.

Radial approach in percutaneous coronary interventions: current status in Brazil.

BACKGROUND: Although the radial approach offers an unquestionable result in terms of reduction of vascular complications and occurrence of severe bleeding in comparison to the femoral approach, so far it has only been used in few centers which elected it as the preferential access. OBJECTIVE: To evaluate the current status of percutaneous coronary interventions in Brazil, as regards the use of the radial approach. METHODS: Analysis of data spontaneously recorded in Central Nacional de Intervenções Cardiovasculares - CENIC (National Center for Cardiovascular Interventions) from 2005 to 2008, in a total of 83,376 procedures. RESULTS: The radial approach was used in 12.6% of the procedures performed, and the femoral approach, in 84.3%. The remaining 3.1% corresponded to brachial artery dissection or puncture. With a success rate of 97.5%, the choice of the radial approach was associated with a significant reduction of vascular complications in comparison to the femoral approach (2.5% versus 3.6 %, p < 0.0001). CONCLUSION: The radial approach remains uncommonly used in Brazil, and this is possibly explained by the lack of training programs, uncertainties regarding the learning curve, and the lack of large-scale studies corroborating the benefits demonstrated to date.

Major bleeding in acute coronary syndromes.

Treatment of acute coronary syndrome has been based on the prevention of ischemic complications by means of antithrombotic therapy and invasive strategies. The desired reduction reached in the recurrence of ischemic events reveals its price, an increase in the occurrence of major bleeding. Initially tolerated as a benign complication, it is now shown to be an important predictor of mortality. Greater attention dedicated to the prognostic impact of bleeding is recent, motivated by the development of new antithrombotic agents. Detailed analysis of the risk factors for myocardial infarction or bleeding is an important issue and allows institution of individualized approach.

Transição entre ticagrelor e duas diferentes doses de clopidogrel na alta hospitalar de pacientes submetidos à intervenção coronária percutânea na vigência de síndrome coronariana aguda / Transition between ticagrelor and two different doses of clopidogrel at hospital discharge in patients with acute coronary syndrome submitted to percutaneous coronary intervention

Introdução: A transição do ticagrelor para o clopidogrel não está fundamentada em estudos farmacodinâmicos ou clínicos, mas é uma prática comum. O objetivo do presente estudo foi testar, de forma exploratória, em pacientes com diagnóstico de síndrome coronariana aguda submetidos à intervenção coronariana percutânea, inicialmente tratados com ticagrelor, a transição para duas diferentes doses de clopidogrel no momento da alta hospitalar. Métodos: Pacientes previamente tratados com ticagrelor foram randomizados para receber uma dose de ataque de 300 mg de clopidogrel no momento da alta hospitalar, ou 75 mg, omitindo-se a dose de ataque. O objetivo primário foi a incidência de eventos adversos cardiovasculares ou sangramento aos 30 dias. Resultados: Dentre 348 pacientes selecionados, 132 foram incluídos e completaram o estudo. A incidência de eventos isquêmicos e hemorrágicos aos 30 dias foi similar entre os grupos, traduzindo-se em uma taxa de eventos cardíacos e cerebrovasculares de 6,1% vs. 9,1% (RR: 0,787; IC 95%: 0,361-1,715; p = 0,74). Conclusões: A transição para clopidogrel com a dose de 75 mg no momento da alta, omitindo-se uma dose de ataque, aparenta ser uma estratégia possível. Estudos com maior poder estatístico são necessários para confirmar estes achados

Background: The transition from ticagrelor to clopidogrel is not based on pharmacodynamic or clinical studies, but it is a common practice. The aim of the present study was to test, in an exploratory way, the transition to two different doses of clopidogrel at the time of hospital discharge in patients diagnosed with acute coronary syndrome submitted to percutaneous coronary intervention who were initially treated with ticagrelor. Methods: Patients previously treated with ticagrelor were randomized to receive a loading dose of 300 mg clopidogrel at hospital discharge, or 75 mg without the loading dose. The primary endpoint was the incidence of cardiovascular adverse events or bleeding at 30 days. Results: Of 348 selected patients, 132 were enrolled and completed the study. The incidence of ischemic and hemorrhagic events at 30 days was similar between the groups, resulting in a rate of cardiac and cerebrovascular events of 6.1% vs. 9.1% (RR: 0.787; 95% CI: 0.361-1.715; p = 0.74). Conclusions: The transition to clopidogrel with a dose of 75 mg at discharge, without a loading dose, appears to be a possible strategy. Studies with greater statistical power are needed to confirm these findings

Femoral versus Radial Access in Primary Angioplasty. Analysis of the ACCEPT Registry / Via de Acesso Femoral versus Radial na Angioplastia Primária. Análise do Registro ACCEPT

Background: The radial access provides a lower risk of bleeding and vascular complications related to the puncture site in comparison to the femoral access. Recent studies have suggested a reduction in mortality associated with the radial access in patients with acute myocardial infarction undergoing percutaneous coronary intervention. Objective: To compare the occurrence of adverse cardiovascular ischemic and hemorrhagic events in patients undergoing primary angioplasty according to the type of arterial access route. Methods: From August 2010 to December 2011, 588 patients undergoing primary percutaneous coronary intervention during acute ST-segment elevation myocardial infarction were assessed; they were recruited from 47 centers participating in the ACCEPT registry. Patients were grouped and compared according to the arterial access used for the procedure. Results: The mean age was 61.8 years; 75% were males and 24% had diabetes mellitus. There was no difference between groups as regards the procedure success rate, as well as regards the occurrence of death, reinfarction, or stroke at six months of follow-up. Severe bleeding was reported in 1.1% of the sample analyzed, with no statistical difference related to the access used. Conclusions: The femoral and radial accesses are equally safe and effective for the performance of primary percutaneous coronary intervention. The low rate of cardiovascular events and of hemorrhagic complications reflects the quality of the participating centers and the operators expertise with the use of both techniques. .

Fundamentos: O acesso radial promove menor risco de sangramento e complicações vasculares relacionadas ao sítio de punção quando comparado ao acesso femoral. Estudos recentes sugerem redução de mortalidade favorável ao primeiro em pacientes com infarto agudo do miocárdio submetidos à intervenção coronária percutânea. Objetivo: Comparar a ocorrência de eventos cardiovasculares adversos isquêmicos e hemorrágicos em pacientes submetidos à angioplastia primária conforme a via de acesso arterial. Métodos: No período de agosto de 2010 a dezembro de 2011, foram avaliados 588 pacientes que realizaram intervenção coronária percutânea primária na vigência de um infarto agudo do miocárdio com supradesnivelamento de ST, incluídos em 47 centros participantes do registro ACCEPT. Os pacientes foram agrupados e comparados de acordo com a via de acesso arterial utilizada para a efetivação do procedimento. Resultados: A média de idade foi de 61,8 anos, sendo 75% pertencentes ao sexo masculino e 24% portadores de diabetes melito. Não houve diferença entre os grupos na taxa de sucesso do procedimento, bem como na ocorrência de óbito, reinfarto ou acidente vascular encefálico aos seis meses de seguimento. Sangramento grave foi relatado em 1,1% da amostra analisada, sem diferença estatística conforme a via de acesso utilizada. Conclusões: As vias de acesso femoral e radial são igualmente seguras e eficazes para a realização de intervenção coronária percutânea primária. A baixa taxa de eventos cardiovasculares, bem como de complicações hemorrágicas, reflete a qualidade dos centros participantes e a experiência dos operadores com a utilização de ambas as técnicas. .

Primary percutaneous coronary intervention through transulnar approach: safety and effectiveness.

The transradial approach is safe and effective for coronary procedures. However, its use may be compromised in cases of variations in radial artery anatomy, spasms, and negative Allen's test. The transulnar approach emerges as a viable alternative to transradial approach. We report on a patient who underwent primary angioplasty via ulnar artery without ischemic hand complications despite prior occlusion of the ipsilateral radial artery.

Resolução do segmento ST após intervenção coronária percutânea primária: características, preditores de insucesso e impacto na mortalidade / ST-Segment resolution after primary percutaneous coronary intervention: characteristics, predictors of failure and impact on mortality

INTRODUÇÃO: A resolução do segmento ST é um importante preditor de patência da artéria relacionada ao infarto e de perfusão efetiva da microcirculação. O objetivo deste trabalho foi comparar pacientes com e sem resolução do segmento ST e identificar variáveis que se associam à não resolução do ST. MÉTODOS: Entre março de 2012 e julho de 2013, 61 pacientes com infarto agudo do miocárdio com elevação do segmento ST foram submetidos à intervenção coronária percutânea (ICP) primária e incluídos em um registro prospectivo. Para comparar os grupos com e sem resolução do segmento ST, foi utilizado o teste qui-quadrado ou exato de Fisher, para as variáveis qualitativas, e o teste t de Student ou de Mann-Whitney, para variáveis quantitativas. Para identificar variáveis associadas à não resolução do ST, foram ajustados modelos de regressão logística simples e múltipla. RESULTADOS: O grupo de pacientes sem resolução do segmento ST apresentou maior frequência cardíaca, maior prevalência de diabetes mellitus, de insuficiência renal crônica e tendência a maior tempo de isquemia. Observou-se maior mortalidade hospitalar entre pacientes que não obtiveram resolução do ST. Pela análise univariada, as variáveis frequência cardíaca, diabetes mellitus, insuficiência renal crônica e tempo de isquemia associaram-se à maior chance de não resolução do ST, perdendo significância no modelo multivariado. CONCLUSÕES: A não resolução do segmento ST pode ocorrer em até um terço dos pacientes submetidos à ICP primária, requerendo o advento de novas estratégias farmacológicas ou de intervenção capazes de minimizá-la.

BACKGROUND: ST-segment resolution is an important predictor of infarct-related artery patency and effective microcirculatory perfusion. The aim of this study was to compare patients with and without ST-segment elevation resolution and identify variables that are associated with failure of ST-segment resolution. METHODS: Between March 2012 and July 2013, 61 patients with ST-segment elevation acute myocardial infarction underwent primary percutaneous coronary intervention (PCI) and were included in a prospective registry. To compare the groups with and without ST-segment resolution, the chi-square test or Fisher's exact test were used for qualitative variables and Student's t test or Mann-Whitney's test for quantitative variables. Simple and multiple logistic regression models were used to identify variables associated with failure of ST-segment resolution. RESULTS: The group of patients without ST-segment resolution had higher heart rate, higher prevalence of diabetes mellitus, chronic renal failure and a trend towards longer ischemia time. There was a higher mortality rate in patients who did not achieve ST-segment elevation resolution. In the univariate analysis, heart rate, diabetes mellitus, chronic renal failure and ischemia time were associated with increased odds of not obtaining ST-segment resolution, losing significance in the multivariate model. CONCLUSIONS: Failure of ST-segment resolution is observed in up to one-third of patients undergoing primary PCI and requires new pharmacologic strategies or interventions to minimize it.

Acesso radial em intervenções coronarianas percutâneas: panorama atual brasileiro / Radial approach in percutaneous coronary interventions: current status in Brazil / Acceso radial en intervenciones coronarias percutáneas: panorama actual brasileño

FUNDAMENTO: Embora a técnica radial exiba resultados incontestáveis na redução de complicações vasculares e ocorrência de sangramento grave quando comparada à técnica femoral, seu emprego permanece restrito a poucos centros que a elegeram como via de acesso preferencial. OBJETIVO: Avaliar o cenário atual das intervenções coronarianas percutâneas no Brasil quanto à utilização da via de acesso radial. MÉTODOS: Análise dos dados cadastrados de forma espontânea na Central Nacional de Intervenções Cardiovasculares (CENIC) durante o quadriênio de 2005-2008, o que totaliza 83.376 procedimentos. RESULTADOS: A técnica radial foi utilizada em 12,6 por cento dos procedimentos efetivados, e a técnica femoral, em 84,3 por cento. Os 3,1 por cento restantes foram representados pela dissecção ou punção braquial. Com uma taxa de sucesso de 97,5 por cento, a opção pelo acesso radial associou-se à redução significativa de complicações vasculares quando comparado ao femoral (2,5 por cento versus 3,6 por cento, p < 0,0001). CONCLUSÃO: A utilização da técnica radial permanece baixa no Brasil. Ausência de programas de treinamento, incertezas quanto à curva de aprendizagem e carência de estudos em larga escala, que corroboram os benefícios demonstrados até o momento, são possíveis justificativas para esses achados.

BACKGROUND: Although the radial approach offers an unquestionable result in terms of reduction of vascular complications and occurrence of severe bleeding in comparison to the femoral approach, so far it has only been used in few centers which elected it as the preferential access. OBJECTIVE: To evaluate the current status of percutaneous coronary interventions in Brazil, as regards the use of the radial approach. METHODS: Analysis of data spontaneously recorded in Central Nacional de Intervenções Cardiovasculares - CENIC (National Center for Cardiovascular Interventions) from 2005 to 2008, in a total of 83,376 procedures. RESULTS: The radial approach was used in 12.6 percent of the procedures performed, and the femoral approach, in 84.3 percent. The remaining 3.1 percent corresponded to brachial artery dissection or puncture. With a success rate of 97.5 percent, the choice of the radial approach was associated with a significant reduction of vascular complications in comparison to the femoral approach (2.5 percent versus 3.6 percent, p < 0.0001). CONCLUSION: The radial approach remains uncommonly used in Brazil, and this is possibly explained by the lack of training programs, uncertainties regarding the learning curve, and the lack of large-scale studies corroborating the benefits demonstrated to date.

FUNDAMENTO: Aunque la técnica radial exhiba resultados incontestables en la reducción de complicaciones vasculares y ocurrencia de sangrado grave cuando es comparada a la técnica femoral, su empleo permanece restringido a pocos centros que la eligieron como vía de acceso preferencial. OBJETIVO:Evaluar el escenario actual de las intervenciones coronarias percutáneas en el Brasil en cuanto a la utilización de la vía de acceso radial. MÉTODOS:Análisis de los datos registrados de forma espontánea en la Central Nacional de Intervenciones Cardiovasculares (CENIC) durante el cuatrienio de 2005-2008, lo que totaliza 83.376 procedimientos. RESULTADOS:La técnica radial fue utilizada en 12,6 por ciento de los procedimientos efectuados, y la técnica femoral, en 84,3 por ciento. Los 3,1 por ciento restantes fueron representados por la disección o punción braquial. Con una tasa de éxito de 97,5 por ciento, la opción por el acceso radial se asoció a la reducción significativa de complicaciones vasculares cuando fue comparado al femoral (2,5 por ciento versus 3,6 por ciento, p < 0,0001). CONCLUSIÓN:La utilización de la técnica radial permanece baja en el Brasil. Ausencia de programas de entrenamiento, dudas en cuanto a la curva de aprendizaje y carencia de estudios en gran escala, que corroboren los beneficios demostrados hasta el momento, son posibles justificativas para esos hallazgos.