Reaching the heart through the wrist rather than the groin improves patient outcomes for heart procedures like angioplasty, but the United States lags behind in adopting the safer method
Doctors around the world are opening clogged arteries in the heart by
going through blood vessels in the wrist rather than the femoral artery
in the groin when performing angioplasties and related procedures, but
U.S. cardiologists have been slower to adopt the safer treatment method.
That's one finding of a review of more 2.8 million of these procedures — called percutaneous coronary interventions (PCIs) — from the largest U.S. registry ever studied. The big data analysis uncovered a 13-fold increase over six years in the proportion of PCI procedures done through the radial artery in the wrist, yet today only one in six proceedures uses this newer method because of a lag in physician training, says a new paper in the journal Circulation by Dmitriy Feldman, MD and other investigators at Weill Cornell Medical College and New York Presbyterian Hospital in New York.
According to Samin Sharma, MD, a cardiologist and Director of Clinical & Interventional Cardiology at Mount Sinai in New York, “This is a hot topic. At Mount Sinai we do about 12 to 13 percent radial, which is increasing, just as in the paper.” Radial PCI refers to access through the radial artery in the wrist; groin access is usually through the femoral artery.
The proportion of U.S. procedures in which a patient’s heart was accessed through the wrist went up from only 1 percent in 2007 at the study start, to just over 16 percent in the last quarter of 2012, when the study concluded.
Sharma puts the report into perspective with experiences from around the world, “It’s purely education," he said. "Radial in the U.S. has never taken off in the way it has internationally. In France they do 75 percent radial and in India 68 percent radial.” The United States rate is 16 percent.
Why the Wrist Is Safer Than the Groin for Angioplasty
During a PCI procedure, a narrow area of a heart artery is widened by angioplasty or a related procedure. Wrist access for PCI is safer for patients than groin access because the risk of bleeding is cut in half and there are fewer complications after the procedure, according to the new report.
Radial PCI also provides the greatest benefit over groin access for patients who are at highest risk for complications. This includes patients with acute coronary syndrome (ACS), patients who are 75 or older, and women.
“I don’t think we know the answer to why women are more at risk, but they are more likely to bleed than men, particularly women who are older and with lower BMI [body mass index], said study author Dr. Feldman.
"Many trials have shown that radial procedures saves lives, particularly in the cases of heart attack," noted Dr. Sharma.
Training Doctors in Safer Methods
The transition to the new method for heart procedures is a slow one, because many physicians first learned to access the heart through the groin and are not familiar with the wrist method.
“Many centers perform radial PCI, but not all operators perform them," said Feldman. "About 13 percent of centers don’t perform any radial PCI.” The new review found geographic variation in the uptake of radial PCI procedures, which are used more often in the Northeast than in other regions of the United States.
For the doctors in these centers, training is particularly important.
According to Sharma, the procedure “is very simple and the younger generation is learning more radials.” American College of Cardiology physician training programs aim to speed adoption of radial PCI.
Choosing the Safest Heart Procedure
How do patients and healthcare teams decide whether to go in through the wrist or groin to reach the heart? “You have to choose an institution and individual doctors who are performing radial procedures,” recommended Feldman.
At his institution, Sharma noted that the radial procedure is done as the default strategy when the patient is obese, for those who have blocked arteries in a leg, and for those with a higher risk of bleeding. “Any patient is a candidate. We compress the wrist with the thumb and see whether there is any decrease in sensation in the hand. In 95 percent of patients, you still have good blood flow to the hand, and you can do the radial procedure,” Sharma said.
If you or a loved one need a heart procedure, discuss it with your physician. “I think when patients undergo this procedure and are given an explanation of risks and benefits is the time to have this conversation. The risks include bleeding and complications. Discussion should include what route and what the safest procedure is,” Feldman said.
Sharma agreed, “Ask the doctor, ‘why don’t you do the procedure by the radial approach?’”
Weigh your options, because electing to have a radial procedure over a femoral one just might save your life.
sources: http://www.everydayhealth.com/heart-health/best-access-for-heart-procedures-is-the-wrist-1508.aspx
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