Transradial Access vs. Transfemoral Access for Primary PCI in ST-Elevation Myocardial Infarction Complicated by Cardiogenic Shock: Findings from a National, Multicenter Registry and Meta-Analysis

BACKGROUND AND OBJECTIVES: Transradial access (TRA) is recommended for percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) due to lower mortality and bleeding risk, but evidence in STEMI with cardiogenic shock (STEMI-CS) remains limited. To evaluate the efficacy and safety of TRA versus transfemoral access (TFA) for primary PCI in STEMI-CS. METHODS: Using data from a nationwide, multicenter registry, we compared TRA and TFA with multivariable-adjusted Cox regression, propensity score matching, and inverse probability treatment weighting. The primary outcome was in-hospital all-cause mortality. Other outcomes included major bleeding and major adverse cardiovascular events (MACE), defined as a composite of all-cause mortality, cardiac arrest, reinfarction, stroke, or in-stent thrombosis. A meta-analysis was conducted to compare short-term outcomes of interest during hospitalization or within 30 days of hospital discharge. RESULTS: Among 837 eligible patients, 669 underwent TRA. Multivariable Cox regression showed that TRA was associated with a lower risk of in-hospital mortality (adjusted hazard ratio [HR], 0.62; 95% confidence interval [CI], 0.42-0.91), MACE (adjusted HR, 0.63; 95% CI, 0.43-0.91), but a non-significantly lower risk of major bleeding (adjusted HR, 0.72; 95% CI, 0.35-1.49) compared to TFA. Meta-analysis of 65,943 patients from 17 studies confirmed lower short-term mortality (odds ratio [OR], 0.50; 95% CI, 0.43-0.57), major bleeding (OR, 0.58; 95% CI, 0.48-0.71), and MACE (OR, 0.65; 95% CI, 0.53-0.80) with TRA. CONCLUSIONS: Our findings indicate that, in STEMI-CS, TRA is associated with lower short-term all-cause mortality compared with TFA, supporting the potential advantages of TRA in this population. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02306616.