Radial versus femoral access in patients with acute coronary syndromes with or without ST-segment elevation.

Aims: To assess whether radial compared with femoral access is associated with consistent outcomes in patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Methods and results: In the Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and Systemic Implementation of angioX (MATRIX) programme patients were randomized to radial or femoral access, stratified by STEMI (2001 radial, 2009 femoral) and NSTE-ACS (2196 radial, 2198 femoral). The 30-day co-primary outcomes were major adverse cardiovascular events (MACE), defined as death, myocardial infarction, or stroke, and net adverse clinical events (NACE), defined as MACE or major bleeding In the overall study population, radial access reduced the NACE but not MACE endpoint at the prespecified 0.025 alpha. MACE occurred in 121 (6.1%) STEMI patients with radial access vs. 126 (6.3%) patients with femoral access [rate ratio (RR) = 0.96, 95% CI = 0.75-1.24; P = 0.76] and in 248 (11.3%) NSTE-ACS patients with radial access vs. 303 (13.9%) with femoral access (RR = 0.80, 95% CI = 0.67-0.96; P = 0.016) (Pint = 0.25). NACE occurred in 142 (7.2%) STEMI patients with radial access and in 165 (8.3%) patients with femoral access (RR = 0.86, 95% CI = 0.68-1.08; P = 0.18) and in 268 (12.2%) NSTE-ACS patients with radial access compared with 321 (14.7%) with femoral access (RR = 0.82, 95% CI = 0.69-0.97; P = 0.023) (Pint = 0.76). All-cause mortality and access site-actionable bleeding favoured radial access irrespective of ACS type (Pint = 0.11 and Pint = 0.36, respectively). Conclusion: Radial as compared with femoral access provided consistent benefit across the whole spectrum of patients with ACS, without evidence that type of presenting syndrome affected the results of the random access allocation.

Impact of sex on comparative outcomes of bivalirudin versus unfractionated heparin in patients with acute coronary syndromes undergoing invasive management: a pre-specified analysis of the MATRIX trial.

AIMS: Our aim was to assess whether bivalirudin compared with unfractionated heparin (UFH) is associated with consistent outcomes in males and females with acute coronary syndrome (ACS) undergoing invasive management. METHODS AND RESULTS: In the MATRIX programme, 7,213 patients were randomised to bivalirudin or UFH. Patients in the bivalirudin group were subsequently randomly assigned to receive or not a post-PCI bivalirudin infusion. The 30-day co-primary outcomes were major adverse cardiovascular events (MACE), defined as death, myocardial infarction, or stroke, and net adverse clinical events (NACE), defined as MACE or major bleeding. The primary outcome for the comparison of a post-PCI bivalirudin infusion with no post-PCI infusion was a composite of urgent target vessel revascularisation (TVR), definite stent thrombosis (ST), or NACE. The rate of MACE was not significantly lower with bivalirudin than with heparin in male (rate ratio [RR] 0.90, 95% confidence interval [CI]: 0.75-1.07; p=0.22) and female patients (RR 1.06, 95% CI: 0.80-1.40; p=0.67) without significant interaction (pint=0.31), nor was the rate of NACE (males: RR 0.85, 95% CI: 0.72-1.01; p=0.07; females: RR 0.98, 95% CI: 0.76-1.28; p=0.91; pint=0.38). Post-PCI bivalirudin infusion, as compared with no infusion, did not significantly decrease the rate of urgent TVR, definite ST, or NACE (males: RR 0.84, 95% CI: 0.66-1.07; p=0.15; females: RR 1.06, 95% CI: 0.74-1.53; p=0.74; pint=0.28). CONCLUSIONS: In ACS patients, the rates of MACE and NACE were not significantly lower with bivalirudin than with UFH in both sexes. The rate of the composite of urgent TVR, definite ST, or NACE was not significantly lower with a post-PCI bivalirudin infusion than with no post-PCI infusion in both sexes.

[Cardiogenic shock following mantlefield radiotherapy for Hodgkin's lymphoma: emergency treatment with coronary stent and follow-up at 6 months. Report of a case and review of the literature]. / Shock cardiogeno successivo a radioterapia mantellare per linfoma di Hodgkin: stenting coronarico di emergenza e follow-up a sei mesi. Descrizione di un caso e revisione della letteratura.

Radiation therapy is an effective and common treatment modality for Hodgkin's lymphoma, with proven long-term high survival rates and freedom from recurrences. However, the development of radiation-induced coronary artery disease, characterized by severe and widespread coronary involvement and by a high mortality secondary to acute ischemic events, is one of the most feared complications of this treatment modality. Furthermore, in such patients the optimal approach to revascularization remains to be determined, owing to some specific technical surgical difficulties and, as reported in the literature, to the limited experience available to date with percutaneous intervention, especially in case of acute ischemic syndromes. We report on a case of acute anterior myocardial infarction with cardiogenic shock in a 29-year-old male who had undergone radiation therapy to the chest for Hodgkin's lymphoma 10 years previously. He was immediately transferred to the catheterization laboratory: intra-aortic balloon counterpulsation was followed by coronary angiography which revealed severe, widespread triple-vessel disease and an acutely suboccluded very large left anterior descending coronary artery providing collaterals to large segments of the right and circumflex coronary territories. Primary angioplasty and stenting of the left anterior descending coronary artery was performed successfully, with a gradual amelioration of the hemodynamic and clinical parameters. Angiographic follow-up at 6 months demonstrated a widely patent stent, with minimal neointimal hyperplasia but no evidence of restenosis. The patient remained asymptomatic. We discuss our therapeutic strategy and review the relevant literature on the subject.