Radial access reduces mortality in patients with acute coronary syndromes. Results from an updated trial sequential analysis of randomized trials

OBJECTIVES The authors sought to investigate whether the cumulative evidence coming from randomized studies has reached the necessary power to consider radial access as a bleeding avoidance strategy that reduces mortality and ischemic endpoints in patients with acute coronary syndromes (ACS). BACKGROUND Studies in ACS patients have reached conflicting conclusions about the impact of radial access in improving ischemic outcomes in addition to the established bleeding benefit. METHODS English-language publications and abstracts of major cardiovascular meetings until October 2015 were scrutinized. Study quality, patient characteristics, procedural data, and outcomes were extracted. Data were pooled in random effects meta-analyses with classic and trial sequential techniques. Trial sequential analysis combines the a priori information size calculation needed to allow for clinically meaningful statistical inference with the adjustment of thresholds for which results are considered significant. RESULTS Seventeen studies, encompassing data from 19,328 patients, were pooled. Radial access was found to reduce mortality (relative risk [RR]: 0.73; 95% confidence interval [CI]: 0.60 to 0.88; p ¼ 0.001), major adverse cardiovascular events (RR: 0.86; 95% CI: 0.77 to 0.95; p ¼ 0.005), and major bleeding (RR: 0.60; 95% CI: 0.48 to 0.76; p < 0.001). Multiple sensitivity analyses showed consistent results, and trial sequential analysis suggested firm evidence for a meaningful reduction in mortality with radial access. CONCLUSIONS Radial access reduces mortality compared with femoral access in ACS patients undergoing invasive management. This benefit is paralleled by consistent reductions in major adverse cardiovascular events and major bleeding, supporting radial access as the default strategy for cardiac catheterization in patients with ACS. (J Am Coll Cardiol Intv 2016;9:660–70) © 2016 by the American College of Cardiology Foundation.