Cardiology Update Vol. 3

A collection of interview-based cardiology articles by leading experts.

Cardiology Update

Volume 3

Read some of our top articles on updated guidelines, CHF, and more. www.physiciansweekly.com/cardiology

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Table of Contents 14

uiding Evidence-Based G Percutaneous Coronary Intervention — Glenn N. Levine, MD

18

nalyzing Preventive A CRT in the Elderly — David T. Huang, MD

12 G uidelines for PAD: A Welcome Update — Thom W. Rooke, MD, FACC

16 K eys to Transradial Access for Percutaneous Revascularization — Ronald P. Caputo, MD, FACC, FSCAI

A Message From the Editor We at Physician’s Weekly are excited to present you with an eBook dedicated to feature stories we’ve covered on cardiology-related topics. In recent months, our publication has published a variety of news items in this field, focusing on clinical and evidence-based research. The content in these articles relies on the expertise of our contributing physician authors. Physician’s Weekly will continue to feature cardiology news in the coming months, and we hope that you find this information useful in your practice. Please let us know your thoughts at the Contact Us page here.

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Click here to view this article online.

Gu

E

Pe

4

Guiding

Evidence-Based

ercutaneous Coronary Intervention

Experts have unveiled a revised guideline for the management of patients with coronary artery disease undergoing PCI. The recommendations emphasize careful patient selection and feature a robust comparison of CABG and PCI. The Heart Team Concept Glenn N. Levine, MD Professor of Medicine Baylor College of Medicine Director, Cardiac Care Unit Michael E. DeBakey VA Medical Center

O

ver the last decade, significant advances and innovations have rapidly evolved in the use of PCI for patients with coronary artery disease (CAD). The American College of Cardiology (ACC)/American Heart Association (AHA), together with the Society for Cardiovascular Angiography and Interventions (SCAI), released a revised clinical guideline for the management of CAD patients undergoing PCI. Published in the December 6, 2011 Journal of the American College of Cardiology, the update emphasizes careful selection of CAD treatment and includes the most extensive section to date on revascularization.

“The heart team includes an interventional cardi­ologist and a cardiac surgeon who review patient history and anatomy, discuss whether PCI and/or CABG are appropriate, and explain these options in detail with patients before a treatment option is chosen,” says Glenn N. Levine, MD, who chaired the ACC/AHA/ SCAI guideline writing committee. The guidelines include a Class I recommendation for utilizing a heart team approach in patients with unprotected left main CAD and/or complex CAD in cases where the optimal revascularization strategy is not straightforward.

CAD Revascularization For the first time ever, the CAD revascularization section was developed through a collaboration that involved experts from the ACC, AHA, and SCAI on both PCI and CABG. According to the guidelines, CABG is recommended for improving survival in patients with significant left main coronary artery stenosis, as well as those with significant stenoses in visit www.physiciansweekly.com

5

Table 1

Preprocedural Considerations & Interventions COR

LOE

Patients should be assessed for risk of contrast-induced AKI before PCI.

I

C

Patients undergoing cardiac catheterization with contrast media should receive adequate preparatory hydration.

I

B

In patients with CKD (creatinine clearance <60 mL/min), the volume of contrast media should be minimized.

I

B

Administration of N-acetyl-L-cysteine is not useful for the prevention of contrast-induced AKI.

III: No benefit

A

I

B

III: No benefit

C

Aspirin

CKD

Bleeding Risk

Statins

Anaphylactoid reactions

Contrast-Induced AKI

Recommendations

Patients with prior evidence of an anaphylactoid reaction to contrast media should receive appropriate prophylaxis before repeat contrast administration.

In patients with a prior history of allergic reactions to shellfish or seafood, anaphylactoid prophylaxis for contrast reaction is not beneficial.

Administration of a high-dose statin is reasonable before PCI to reduce the risk of periprocedural MI.

A: Statin naïve IIa

B: Chronic statin therapy

All patients should be evaluated for risk of bleeding before PCI.

I

C

In patients undergoing PCI, the glomerular filtration rate should be estimated and the dosage of renally cleared medications should be adjusted.

I

B

Patients already on daily aspirin therapy should take 81 mg to 325 mg before PCI.

I

B

Patients not on aspirin therapy should be given nonenteric aspirin 325 mg before PCI.

I

B

Abbreviations: AKI, acute kidney injury; CKD, chronic kidney disease; COR, class of recommendation; LOE, level of evidence; MI, myocardial infarction; PCI, percutaneous coronary intervention.

Source: Adapted from Levine G, et al. J Am Coll Cardiol. December 6, 2011.

three major coronary arteries or in the proximal left anterior descending artery and one other major coronary artery. CABG or PCI is recommended for survivors of sudden cardiac death with presumed ischemia-mediated ventricular tachycardia caused by significant ste­nosis in a major coronary artery.

Dr. Levine says “CABG or PCI can improve symptoms in patients with one or more significant coronary artery stenoses that are amenable to revascularization and in whom angina persists despite guideline-adherent care.”

Preprocedural Considerations Contrast-induced acute kidney injury (AKI) is one of the most common causes of hospital-acquired AKI, according to Dr. Levine. “Clinicians should be aware of this risk in patients undergoing PCI and 6

proper preprocedural precautions should be taken [Table 1]. Saline hydration and minimizing contrast media are the only methods shown to clearly reduce risk of contrast-induced AKI.” Some data show that patients with a history of anaphylactoid reaction have a recurrence rate of 16% to 44%. Research, however, has shown that adequate pretreatment can reduce recurrence rates dramatically. When administered within 7 days of PCI, statins seem to reduce the risk of periprocedural myocardial infarction in patients with CAD and acute coronary syndrome (ACS). Because periprocedural bleeding is widely recognized as a major risk factor for subsequent mortality, measures to minimize bleeding complication risks are recommended in the ACC/AHA/SCAI guidelines. “We now have data showing that PCI can be performed success-

• Present to a hospital with PCI capability or can be rapidly transported to a hospital that performs PCI.

fully at hospitals without on-site cardiac surgical backup when properly planned using strict criteria for the performance of PCI in such situations,” adds Dr. Levine.

• Develop severe heart failure or cardio-genic shock.

•H ave STEMI and contraindications to fibrinolytic therapy with ischemic symptoms for <12 hours.

Special Populations Among patients with unstable angina/NSTEMI, an early invasive strategy is indicated for those with refractory hemodynamic or electrical instability or for those at high risk for clinical events. “The choice between PCI or CABG in patients with ACS should be based on the same considerations as those without ACS,” Dr. Levine says. In patients with STEMI, immediate coronary angiography with intent to perform PCI is recommended for those who are candidates for primary PCI or have severe heart failure or cardiogenic shock and are suitable for revascularization. The guidelines recommend primary PCI for patients within 12 hours of onset who:

Table 2

For patients with cardiogenic shock, PCI is recommended (Table 2). A hemodynamic support device is recommended after STEMI for those who do not quickly stabilize with pharmacologic therapy.

Stay Tuned “We still have insufficient data to form recom­ mendations for many other aspects of care for these patients, including intracoronary stem cell infusions, designer drugs, optical coherence tomography, virtual histology, and drug-eluting balloons,” says Dr. Levine.

“Future PCI guidelines will need to address these and other emerging technologies and treatments.”

Indications for PCI in STEMI

Indications

COR

LOE

STEMI symptoms within 12 h

I

A

Severe heart failure or cardiogenic shock

I

B

Contraindications to fibrinolytic therapy with ischemic symptoms <12 h

I

B

Clinical and/or electrocardiographic evidence of ongoing ischemia between 12 and 24 h after symptom onset

IIa

B

Asymptomatic patients presenting between 12 and 24 h after symptom onset and higher risk

IIb

C

III: Harm

B

Clinical evidence for fibrinolytic failure or infarct artery reocclusion

IIa

B

Patent infarct artery 3 to 24 h after fibrinolytic therapy

IIa

B

Ischemia on noninvasive testing

IIa

B

Hemodynamically significant stenosis in a patent infarct artery >24 h after STEMI

IIb

B

III: No benefit

B

Primary PCI*

Noninfarct artery PCI at the time of primary PCI in patients without hemodynamic compromise Delayed or elective PCI in patients with STEMI

Totally occluded infarct artery >24 h after STEMI in a hemodynamically stable asymptomatic patient without evidence of severe ischemia

* Systems goal of performing primary PCI within 90 min of first medical contact when the patient presents to a hospital with PCI capability ( 394,395 ) ( Class I; LOE: B ) and within 120 min when the patient presents to a hospital without PCI capability ( 396–398 ) ( Class I; LOE: B ).

Abbreviations: AKI, acute kidney injury; CKD, chronic kidney disease; COR, class of recommendation; LOE, level of evidence; MI, myocardial infarction; PCI, percutaneous coronary intervention.

Source: Adapted from Levine G, et al. J Am Coll Cardiol. December 6, 2011.

Glenn N. Levine, MD, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

For more information on this article, including references, visit www.physiciansweekly.com. visit www.physiciansweekly.com

7

Analyzing

Preventive CR

in the Elder

Research indicates that cardiac resynchronization therapy, or CRT, is of significant benefit for elderly patients with congestive heart failure, suggesting that many of these individuals should be considered viable candidates for these procedures.

David T. Huang, MD Associate Professor, Department of Medicine, Cardiology Director, Electrophysiology Section University of Rochester Medical Center

P

ublished studies have shown that the prevalence of congestive heart failure (CHF) increases as people age, rising from 2% to 3% in the total population to 10% to 20% after patients reach age 75. When compared with younger patients, CHF in the elderly has been associated with higher mortality rates. “Even when medical management is optimized, elderly patients with CHF still require frequent healthcare

8

utilization, including those with the early stages of disease,” says David T. Huang, MD. “While medical therapy can sometimes help, there are concerns about disease recurrence.”

Cardiac resynchronization therapy (CRT) can be used in conjunction with implantable cardioverter defibrillators (ICDs), an approach that has been shown to reduce hospitalizations and mortality relative to CHF. “CRT and ICDs

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RT

rly

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9

have become important components for qualified patients with class III or IV heart failure,” adds Dr. Huang. “CRT has been used in patients of many age ranges in the past, but mostly in the most severe late-stage cases. Symptoms can improve with this therapy, but questions have been raised about whether or not CRT should be used in earlier stages of CHF in order to better prevent symptoms.”

The Effect of Age on Outcomes The Multicenter Automatic Defibrillator Implantation Trial with CRT (MADIT-CRT) recently found that CRT utilizing defibrillators (CRT-D) was associated with a 34% reduction in the risk of heart failure or death when compared with ICD-only

Table 1

Efficacy of CRT-D by Age Groups

Hazard Ratio

All patients

CHF or death

0.60

CHF

0.54

Death

0.91

Age ≥ 75

CHF or death

0.57

CHF

0.46

Death

1.14

Age 60–74

CHF or death

0.55

CHF

0.51

Death

0.73

Age < 60

CHF or death

0.80

CHF

0.73

Death

1.30

Notes: Adjusted for treatment, age group, gender, diabetes, QRS ≥ 150, ejection fraction ≤ 25%, left bundle branch block, ischemic etiology, NYHA functional class, GFR < 60 mL/min/1.73 m2. History of atrial arrhythmias and atrial fibrillation/flutter during the study follow-up.

Abbreviations: CRT-D, cardiac resynchronization therapy with defibrillator; CHF, congestive heart failure.

Source: Adapted from: Penn J, et al.

J Cardiovasc Electrophysiol. 2011;22:892-897.

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therapy in asymptomatic or mildly symptomatic patients. However, limited data are available on the benefits and complications of using preventive CRT-D therapy in older age groups.

In the August 2011 Journal of Cardiovascular Electrophysiology, Dr. Huang and colleagues conducted a study to evaluate the effect of age on outcomes in the MADIT-CRT trial. “Our study showed that CRT-D reduced the number of exacerbations associated with CHF when compared with ICD-only therapy,” says Dr. Huang (Table 1). “In patients aged 75 and older, CRT-D dramatically reduced the primary endpoints of CHF or death. These clinical response rates were similar for patients aged 60 to 74.” Dr. Huang added that risk reduction with CRT-D therapy was less pronounced in patients younger than 60, possibly because of lower event rates in this patient subset.

The investigation by Dr. Huang and colleagues also revealed that there was no evidence of increased adverse events relating to CRT-D in patients aged 75 and older when compared with younger patients (Table 2). There was no significant difference in the rate of device-related adverse events within 90 days following CRT-D implantation among agesubgroups.

Important Caveats “Elderly patients differ substantially from younger individuals with CHF, even at early stages of the disease,” explains Dr. Huang. “The elderly are more likely to have comorbidities. These can lead to increased rates of overall medical resource utilization, urgent care visits, hospitalization, and mortality. The increasing prevalence of heart failure, in conjunction with age-associated differences relating to CHF, underscore the need to further evaluate efficacy and safety of CRT in various age groups.”

He notes that the MADIT-CRT trial was designed with no upper age limit as an exclusion criterion.

This facilitated the analysis of younger and older aged group outcomes in the Journal of Cardiovascular Electrophysiology study.

When patients with CHF are properly selected, age should not be used as a sole discriminator to exclude device therapy.

—David T. Huang, MD

Table 2

Adverse Events in the Elderly Relating to CRT-D Age

Device-Related Adverse Events (Event Rates)

Device-Related Severe Adverse Events (Event Rates)

≥ 75 years

11.7%

1.5%

60–74 years

15.7%

1.1%

< 60 years

16.7%

2.2%

Abbreviation: CRT-D, cardiac resynchronization therapy with defibrillator.

There is currently ongoing debate about whether or not older patients should endure CRT procedures because of their invasiveness, Dr. Huang says. “Our study suggests that there is a benefit, but it’s important to remember that patients from the MADIT-CRT trial were carefully selected. These individuals had few comorbidities and may not reflect ‘real-world’ elderly patients. Proper selection of appropriate patients for any device therapy is always warranted. When patients with CHF are properly selected, age should not be used as a sole discriminator to exclude device therapy.”

Dr. Huang’s study team plans to reassess findings from their investigation to further explore the use of

Source: Adapted from: Penn J, et al. J Cardiovasc Electrophysiol. 2011;22:892-897.

CRT-D in younger patients who experienced little or no change in the primary endpoint. “The lack of statistically significant results in these individuals may be explained in part by their overall low clinical risk with ICD-only therapy during the MADITCRT trial period. With longer term follow-up, it’s possible that CRT-D will be associated with a significant clinical benefit in these younger patients too. Meanwhile, it behooves us to continue striving to improve and optimize techniques and to reduce implant times for patients being considered for CRT-D. As these enhancements come, there is hope that we can further reduce the risk of adverse events and complications for these patients.”

David T. Huang, MD, has indicated to Physician’s Weekly that he worked as a consultant for St. Jude Medical, and as a paid speaker for Boston Scientific, and has received grants/research aid from Boston Scientific, Medtronic, St. Jude Medical, and Biotronik. For more information on this article, including references, visit www.physiciansweekly.com.

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12

Guidelines for PAD: A Welcome Update

Updated guidelines for the diagnosis and management of peripheral arterial disease (PAD) include expanded criteria for an earlier PAD diagnosis, increased efforts for smoking cessation, and improved use of clot-preventing medications and other interventions.

Thom W. Rooke, MD, FACC Krehbiel Professor of Vascular Medicine Mayo Clinic School of Medicine

P

eripheral arterial disease (PAD) is a common and dangerous condition that affects millions of Americans, especially those with a history of diabetes or smoking. Despite efforts to increase awareness in the medical community, the disease remains largely underdiagnosed. For many patients, PAD is asymptomatic and may not lead to recognizable symptoms. In turn, a diagnosis may be delayed.

If left untreated, PAD has been shown in published research to be predictive of heart attack, stroke, leg amputations, and death.

In 2005, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA), along with collaborating societies, released guidelines for the management of PAD. In 2011, the ACCF/AHA updated these guidelines to reflect new data in the diagnosis and treatment of the condition. “The 2011 guideline includes new information for diagnosing PAD, smoking cessation, the use of antiplatelet therapy, and interventions for treating severely ischemic limbs and abdominal aortic aneurysms (AAAs),” says Thom W. Rooke, MD, FACC, who chaired the committee that developed the 2011 guidelines. “The update can assist primary care clinicians, cardiologists, pulmonologists, interventional radiologists, vascular surgeons, and vascular medicine specialists in improving patient care.”

Diagnosing PAD The 2011 ACCF/AHA guideline includes a recommendation to lower the age at which ankle-brachial visit www.physiciansweekly.com

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Table 1

Smoking Cessation Level of Evidence

Recommendation Patients who are smokers or former smokers should be asked about status of tobacco use at every visit.

A

Patients should be assisted with counseling and developing a plan for quitting that may include pharmacotherapy and/or referral to a smoking cessation program.

A

Individuals with lower extremity PAD who smoke cigarettes or use other forms of tobacco should be advised by each of their clinicians to stop smoking and offered behavioral and pharmacologic treatment.

C

In the absence of contraindication or other compelling clinical indication, one or more of the following pharmacologic therapies should be offered: varenicline, bupropion, or nicotine replacement therapy.

A

Abbreviations: PAD, peripheral artery disease.

index (ABI) diagnostic testing should be performed in the practice setting. “Previously, the recommendation was for patients aged 70 or older to receive an ABI,” says Dr. Rooke. “That threshold has been lowered to age 65 or older based on mounting evidence demonstrating that people in this age range have a 20% chance of having either symptomatic or asymptomatic PAD.” Furthermore, ABI diagnostic testing is now recommended for patients aged 50 and older if they have a history of diabetes or smoking because they are considered at especially high risk for PAD.

Quitting Smoking Recommendations for physicians to help people with PAD quit smoking are strengthened in the 2011 ACCF/AHA guideline update (Table 1). Doctors are now recommended to consistently ask current and former smokers about tobacco use at each visit. In addition, physicians should be proactive about offering support through counseling, pharmacologic therapies, and formal smoking cessation programs. “In addition to other health benefits, getting patients to quit smoking can have a significant impact on outcomes in PAD,” says Dr. Rooke.

“Smoking cessation can lower risks of disease-related comorbidities, including heart attack, stroke, and lower limb amputation.”

Other Important Recommendations In addition to changes in diagnosing PAD and increasing smoking cessation efforts, the 2011 14

Source: Adapted from: Rooke TW, et al. J Am Coll Cardiol. 2011;58:2020-2045.

guideline update broadens the indications for using antiplatelet therapies and antithrombotic drugs (Table 2). “The use of therapies that prevent clotting is important when treating patients with PAD,” Dr. Rooke says. Several new Class IIa and IIb recommendations were made in the update, while other recommendations from the 2005 guidelines were modified to reflect new evidence that has emerged in recent years.

Leg artery angioplasty is indicated as a first-line treatment for certain individuals with severe PAD who may require amputation. Balloon angioplasty, however, is not an ideal treatment for all patients with PAD. The guidelines now recommend angioplasty as the initial procedure to improve distal blood flow for patients with limb-threatening lower extremity ischemia and an estimated life expectancy of 2 years or less. Bypass surgery is recommended for these patients if they have an estimated life expectancy of more than 2 years.

New recommendations were also added for managing AAAs. Open or endovascular repair of infrarenal AAAs and common iliac aneurysms is now indicated in patients who are good surgical candidates. Open aneurysm repair can be used in good surgical candidates who cannot comply with the periodic longterm surveillance that is required after endovascular repair. However, it is unknown whether or not patients with infrarenal aortic aneurysms who are at high surgical or anesthetic risk will benefit from endovascular repair.

Looking Forward When PAD is undetected and poorly managed, it is among the most costly cardiovascular diseases.

“We still have a long way to go in order to improve the management of PAD,” says Dr. Rooke. “The 2011 ACCF/AHA guideline update can serve as a roadmap to the most appropriate practices and

Table 2

interventions based on evidence-based science, but opportunities remain to further our knowledge and efforts for prevention and earlier, life-saving interventions. Until more data emerge, promoting use of these guidelines in hospitals and healthcare systems may reduce the burden of PAD and improve clinical outcomes associated with the disease.”

Antiplatelet & Antithrombotic Drugs

Recommendation

Level of Evidence

Class I Antiplatelet therapy is indicated to reduce the risk of MI, stroke, and vascular death in individuals with symptomatic atherosclerotic lower extremity PAD, including those with intermittent claudication or critical limb ischemia, prior lower extremity revascularization (endovascular or surgical), or prior amputation for lower extremity ischemia.

A

Aspirin, typically in daily doses of 75 to 325 mg, is recommended as safe and effective antiplatelet therapy to reduce the risk of MI, stroke, or vascular death in individuals with symptomatic atherosclerotic lower extremity PAD, including those with intermittent claudication or critical limb ischemia, prior lower extremity revascularization (endovascular or surgical), or prior amputation for lower extremity ischemia).

B

Clopidogrel (75 mg per day) is recommended as a safe and effective alternative antiplatelet therapy to aspirin to reduce the risk of MI, ischemic stroke, or vascular death in individuals with symptomatic atherosclerotic lower extremity PAD, including those with intermittent claudication or critical limb ischemia, prior lower extremity revascularization (endovascular or surgical), or prior amputation for lower extremity ischemia.

B

Class IIa Antiplatelet therapy can be useful to reduce the risk of MI, stroke, or vascular death in asymptomatic individuals with an ABI less than or equal to 0.90.

C

Class IIb The usefulness of antiplatelet therapy to reduce the risk of MI, stroke, or vascular death in asymptomatic individuals with borderline abnormal ABI, defined as 0.91 to 0.99, is not well established.

A

The combination of aspirin and clopidogrel may be considered to reduce the risk of cardiovascular events in patients with symptomatic atherosclerotic lower extremity PAD, including those with intermittent claudication or critical limb ischemia, prior lower extremity revascularization (endovascular or surgical), or prior amputation for lower extremity ischemia, and those who are not at increased risk of bleeding and who are at high perceived cardiovascular risk.

B

Class III: No benefit In the absence of any other proven indication for warfarin, its addition to antiplatelet therapy to reduce the risk of adverse cardiovascular ischemic events in individuals with atherosclerotic lower extremity PAD is of no benefit and is potentially harmful due to increased risk of major bleeding.

Abbreviations: ABI, ankle-brachial index; MI, myocardial infarction; PAD, peripheral artery disease.

B

Source: Adapted from: Rooke TW, et al. J Am Coll Cardiol. 2011;58:2020-2045.

Thom W. Rooke, MD, FACC, has indicated to Physician’s Weekly that he has or has had no financial interests to report. For more information on this article, including references, visit www.physiciansweekly.com. visit www.physiciansweekly.com

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Tr

for

Re

16

Keys to

ransradial Access r Percutaneous

evascularization

The use of transradial access for percutaneous revascularization has grown steadily because it reduces complications, increases patient satisfaction, and is less invasive than transfemoral access.

As adoption continues to grow, increased efforts are needed to guide clinicians on training and proper patient selection.

Ronald P. Caputo, MD, FACC, FSCAI Invasive/Interventional Cardiologist St. Joseph’s Hospital SUNY Upstate Medical School

A

lthough the adoption of radial coronary angiography and radial PCI in the United States lags behind that of other countries, particularly those in Europe and Asia, transradial coronary interventions has seen an 8% to 10% increased utilization in the U.S., a trend that is expected to con-

tinue. The Society for Cardiovascular Angiography and Interventions (SCAI) published an executive summary on transradial access (TRA) for coronary and peripheral procedures in the November 2011 issue of Catheterization and Cardiovascular Interventions. The overview examined utility, utilization, and training aspects to consider when performing angioplasty via the radial artery.

“Historically, the traditional route to access blocked coronary arteries has been through the larger femoral artery,” says Ronald P. Caputo, MD, FACC, FSCAI, lead author of the SCAI paper. “TRA is advantageous to transfemoral access because it’s less invasive visit www.physiciansweekly.com

17

Vascular Complications Associated With Transradial Catheterization

Table 1

• Catheterization • Spasm • Bleeding • Hematoma • Compartment syndrome • Perforation, laceration, dissection • Avulsion of artery • Arteriovenous fistula

arteriovenous shunt for dialysis, and absence of a radial pulse. Future use of the radial artery for an arterial conduit for bypass may also be a relative contraindication.

While appropriate patient selection helps avoid complications of TRA for coronary interventions, Dr. Caputo says it is important to note that the radial artery can be damaged by puncture, sheath insertion, and catheter manipulation, as with any artery. Vascular complications specific to TRA include spasm, compartment syndrome, and radial artery occlusion (RAO; Table 1).

• Pseudoaneurysm • Subcutaneous granulomatous reaction (hydrophilic coating) • Cutaneous infection • Subacute and delayed occlusion • Digital ischemia • Accelerated atherosclerosis • Transient vocal cord paralysis • Mediastinal hematoma • Delayed reflex sympathetic dystrophy

The SCAI executive summary suggests that generous patient sedation, spasmolytic cocktails, and hydrophilic sheaths of the smallest possible diameter can be used as possible methods for preventing spasms. Routine heparin therapy to reduce risk of RAO is also suggested in the SCAI paper. “When they occur, hematomas tend to be small and controlled well with manual pressure,” adds Dr. Caputo. “As soon as local bleeding is suspected, severe complications can be limited by discontinuing

Source: Adapted from: Caputo R, et al. Cath Card Intervene. 2011;78:823-839.

and has been shown to decrease the risk of access site complications and bleeding.” TRA also is preferred by the vast majority of patients because, unlike the transfemoral approach, it causes less discomfort and allows them to stand up and ambulate immediately following the procedure. In addition, some patients undergoing TRA procedures can be discharged the same day. “These advantages ultimately can decrease length of stay and reduce hospitalization costs while still improving clinical outcomes,” adds Dr. Caputo.

Avoiding Complications Appropriate patient selection for TRA is the first important step in a successful procedure, says Dr. Caputo. Ideal patients for TRA include those with a palpably large radial artery with a strong pulse and a normal Allen’s test with no history of an ipsilateral brachial procedure. Contraindications include abnormal Allen’s test, a severe vasospastic condition (eg, Raynaud’s), a planned or present 18

Key Objectives for Transradial Access Training

Table 2

• Basic anatomy related to the upper extremity vasculature.

• Patient evaluation and selection for TRA. • Selection of right or left TRA. • Patient preparation and room set-up.

• Specific methods and equipment designed to optimize TRA. • Pharmacologic considerations related to TRA. • Obtaining radial artery access.

• Catheter selection and manipulation from the upper extremity.

• Basic trouble-shooting during TRA. • Recognizing and managing complications related to TRA. • Sheath removal and access site management.

Abbreviation: TRA, transradial access.

Source: Adapted from: Caputo R, et al. Cath Card Intervene. 2011;78:823-839.

TRA is advantageous to transfemoral access because it’s less invasive and has been shown to decrease the risk of access site complications and bleeding.

IV anticoagulant therapy, controlling pain and blood pressure, and using a blood pressure cuff for compression.” The most serious complication is compartment syndrome, which is rare but must be considered.

Optimizing Training “Optimal training in TRA is recommended because there are nuances to consider when navigating smaller arteries,” Dr. Caputo says. “Unfortunately, the number of invasive and interventional cardiologists who can adequately train others remains low, and guidelines on TRA training programs are vague.” Currently, most training is acquired at 1- to 2-day programs that consist of formal, in-person interactive teaching and proctorship, and/or informal, didactic lectures, readings, instructional videos, and simulations. “Clinicians can also gain training by visiting the practices of those who have expertise in TRA and shadowing them for a day or two,” adds Dr. Caputo.

The objectives of TRA training include the acquisition of knowledge and competence in several areas (Table 2). The learning curve for TRA tends to be longer than that associated with transfemoral approaches, and no standard definitions or guide-

— Ronald P. Caputo, MD, FACC, FSCAI

lines exist for competency. The SCAI proposes the following levels of competency: Level 1 competency: Able to perform simple diagnostic cases on patients with favorable upper limb anatomy (eg, larger men).

Level 2 competency: Able to perform simple diagnostic and interventional procedures on patients with more challenging upper limb anatomy (eg, elective single vessel PCI or bypass grafts, smaller women, and radial and subclavian loops).

Level 3 competency: Able to perform complex interventional procedures even with challenging limb anatomy (eg, chronic total occlusions, multivessel PCI, and acute myocardial infarction).

Looking Into the Future As more TRA procedures are completed success-fully and patient and physician interest grows, so too will advancements in the technology, says Dr. Caputo.

“The development of smaller catheters specifically meant for TRA will be beneficial for physicians in the future. As adoption of TRA procedures continues to increase, it’s important that guidelines on training and com­petency are created to ensure the safest and most effective outcomes.”

Ronald P. Caputo, MD, FACC, FSCAI, has indicated to Physician’s Weekly that he has worked as a consultant for Terumo and Medtronic. For more information on this article, including references, visit www.physiciansweekly.com.

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