title: Arterial access site and outcomes in patients undergoing percutaneous coronary intervention with and without vorapaxar.
abstract: OBJECTIVE
  We evaluated outcomes associated with transradial vs. transfemoral approaches and vorapaxar in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) in the TRACER trial.
  
  
  BACKGROUND
  Vorapaxar reduces ischemic events but increases the risk of major bleeding.
  
  
  METHODS
  We compared 30-day and 2-year major adverse cardiac events (MACE: cardiovascular death, myocardial infarction, stroke, recurrent ischemia with rehospitalization, and urgent coronary revascularization) and noncoronary artery bypass graft (CABG)-related bleedings in 2,192 transradial and 4,880 transfemoral patients undergoing PCI after adjusting for confounding variables, including propensity for transradial access.
  
  
  RESULTS
  Overall, 30-day GUSTO moderate/severe and non-CABG TIMI major/minor bleeding occurred less frequently in transradial (0.9% vs. 2.0%, P = 0.001) vs. transfemoral (1.1% vs. 2.5%, P = 0.005) patients. A similar reduction was seen at 2 years (3.3% vs. 4.7%, P = 0.008; 3.3% vs. 4.9%, P < 0.001, respectively). Transradial was associated with an increased risk of ischemic events at 30 days (OR 1.38, 95% CI 1.11-1.72; P = 0.004), driven primarily by increased periprocedural myocardial infarctions. At 2 years, rates of MACE were comparable (HR 1.14, 95% CI 0.98-1.33; P = 0.096). Although bleeding rates were higher with vorapaxar in transfemoral vs. transradial patients, there was no significant treatment interaction. Also, the access site did not modulate the association between vorapaxar and MACE.
  
  
  CONCLUSIONS
  Transradial access was associated with lower bleeding rates and similar long-term ischemic outcomes, suggesting transradial access is safer than transfemoral access among ACS patients receiving potent antiplatelet therapies. Because of the nonrandomized allocation of arterial access, these results should be considered exploratory. © 2015 Wiley Periodicals, Inc.
authors.affiliation: Department of Cardiology and Cardiovascular Surgery, Institut Universitaire De Cardiologie Et De Pneumologie De Québec, Laval University, Quebec City, Canada.
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Déry
authors.affiliation: Department of Medicine, Department of Medicine, Stanford University, Stanford, California.
authors.forename: Kenneth W
authors.initials: KW
authors.lastname: Mahaffey
authors.affiliation: Department of Medicine, Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Pierluigi
authors.initials: P
authors.lastname: Tricoci
authors.affiliation: Department of Cardiology, Green Lane Cardiovascular Service, Auckland, New Zealand.
authors.forename: Harvey D
authors.initials: HD
authors.lastname: White
authors.affiliation: Department of Economics, Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Mohua
authors.initials: M
authors.lastname: Podder
authors.affiliation: Department of Economics, Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Cynthia M
authors.initials: CM
authors.lastname: Westerhout
authors.affiliation: Department of Internal Medicine, Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky.
authors.forename: David J
authors.initials: DJ
authors.lastname: Moliterno
authors.affiliation: Department of Medicine, Department of Medicine, Stanford University, Stanford, California.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Harrington
authors.affiliation: Bayer HealthCare Pharmaceuticals, Department of Internal Medicine, Bayer HealthCare Pharmaceuticals, Whippany, New Jersey.
authors.forename: Edmond
authors.initials: E
authors.lastname: Chen
authors.affiliation: Merck, Whitehouse Station, New Jersey.
authors.forename: John
authors.initials: J
authors.lastname: Strony
authors.affiliation: Department of Cardiovascular Sciences, University Hospitals Leuven, Belgium.
authors.forename: Frans
authors.initials: F
authors.lastname: Van de Werf
authors.affiliation: Department of Internal Medicine, Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky.
authors.forename: Khaled M
authors.initials: KM
authors.lastname: Ziada
authors.affiliation: Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Sweden.
authors.forename: Claes
authors.initials: C
authors.lastname: Held
authors.affiliation: Division of Medicine, SAHMRI, Flinders University and Medical Center, Adelaide, Australia.
authors.forename: Philip E
authors.initials: PE
authors.lastname: Aylward
authors.affiliation: Department of Economics, Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Paul W
authors.initials: PW
authors.lastname: Armstrong
authors.affiliation: Department of Medicine, Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Sunil V
authors.initials: SV
authors.lastname: Rao
mesh_terms: D054058:Acute Coronary Syndrome / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D000368:Aged; D002406:Catheterization, Peripheral / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D005260:Female; D005263:Femoral Artery; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D007783:Lactones / Q000009:adverse effects / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology / Q000628:therapy; D010359:Patient Readmission; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D011677:Punctures; D011725:Pyridines / Q000009:adverse effects / Q000627:therapeutic use*; D017534:Radial Artery; D012008:Recurrence; D019233:Retreatment; D012307:Risk Factors; D020521:Stroke / Q000209:etiology / Q000628:therapy; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D007783:Lactones; D010975:Platelet Aggregation Inhibitors; D011725:Pyridines; C530299:vorapaxar
keywords: angioplasty; coronary disease; hemorrhage; inhibitors; myocardial infarction; thrombin