Author + information
- Received July 17, 2017
- Revision received September 12, 2017
- Accepted September 14, 2017
- Published online January 1, 2018.
- Giuseppe Gargiulo, MDa,b,
- Sara Ariotti, MDa,
- Pascal Vranckx, MD, PhDc,d,
- Sergio Leonardi, MDe,
- Enrico Frigoli, MDa,
- Nestor Ciociano, PharmDf,
- Carlo Tumscitz, MDg,
- Francesco Tomassini, MDh,
- Paolo Calabrò, MDi,
- Stefano Garducci, MDj,
- Gabriele Crimi, MDe,k,
- Giuseppe Andò, MD, PhDl,
- Maurizio Ferrario, MDe,
- Ugo Limbruno, MDm,
- Bernardo Cortese, MDn,o,
- Paolo Sganzerla, MDp,
- Alessandro Lupi, MDq,
- Filippo Russo, MDr,
- Roberto Garbo, MDs,
- Arturo Ausiello, MDt,
- Dennis Zavalloni, MDu,
- Gennaro Sardella, MDv,
- Giovanni Esposito, MD, PhDb,
- Andrea Santarelli, MDw,
- Simone Tresoldi, MDx,
- Marco Stefano Nazzaro, MD, PhDy,
- Antonio Zingarelli, MDz,
- Anna Sonia Petronio, MDaa,
- Stephan Windecker, MDa,
- Bruno R. da Costa, PhDa,bb and
- Marco Valgimigli, MD, PhDa,∗ ()
- aDepartment of Cardiology, Bern University Hospital, Bern, Switzerland
- bDepartment of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
- cDepartment of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Hasselt, Belgium
- dFaculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- eUOC Cardiologia, Dipartimento CardioToracoVascolare, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- fEUSTRATEGY Association, Forlì, Italy
- gCardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Cona, Italy
- hCardiology Unit, Ospedali Riuniti di Rivoli, ASL Torino 3, Turin, Italy
- iDivision of Cardiology, Department of Cardiothoracic Sciences, University of Campania “Luigi Vanvitelli,” Naples, Italy
- jStruttura complessa di Cardiologia ASST di Vimercate, Desio, Italy
- kDepartment of Cardiology, ASL3 Ospedale Villa Scassi, Genoa, Italy
- lAzienda Ospedaliera Universitaria Policlinico “Gaetano Martino,” University of Messina, Messina, Italy
- mUO Cardiologia, Azienda USL Toscana Sudest, Grosseto, Italy
- nASST Fatebenefratelli-Sacco, Milan, Italy
- oFondazione Toscana Gabriele Monasterio, Pisa, Italy
- pASST Bergamo Ovest, Ospedale di Treviglio, Bergamo, Italy
- qCardiology Unit, University Hospital “Maggiore della Carità,” Novara, Italy
- rCardiovascular Interventional Unit, Cardiology Department, S.Anna Hospital, Como, Italy
- sInterventional Cardiology Unit, Ospedale San Giovanni Bosco, Turin, Italy
- tCasa di Cura Villa Verde, Taranto, Italy
- uHumanitas Research Hospital, IRCCS, Rozzano, Italy
- vDepartment of Cardiovascular, Respiratory, Nephrologic, Anesthesiologic and Geriatric Sciences, Policlinico Umberto I, “Sapienza” University of Rome, Rome, Italy
- wCardiovascular Department, Infermi Hospital, Rimini, Italy
- xCardiology Unit, A.O. Ospedale di Desio, Desio, Italy
- yInterventional Cardiology Unit, San Camillo-Forlanini, Rome, Italy
- zInterventional Cardiology Unit, IRCCS AOU San Martino, Genoa, Italy
- aaCatheterisation Laboratory, Cardiothoracic and Vascular Department, University of Pisa, Pisa, Italy
- bbInstitute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- ↵∗Address for correspondence:
Dr. Marco Valgimigli, Bern University Hospital, Freiburgstrasse 4, CH-3010, Bern, Switzerland.
Objectives This study sought to assess whether transradial access (TRA) compared with transfemoral access (TFA) is associated with consistent outcomes in male and female patients with acute coronary syndrome undergoing invasive management.
Background There are limited and contrasting data about sex disparities for the safety and efficacy of TRA versus TFA for coronary intervention.
Methods In the MATRIX (Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and Systemic Implementation of angioX) program, 8,404 patients were randomized to TRA or TFA. The 30-day coprimary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE), defined as death, myocardial infarction, or stroke, and net adverse clinical events (NACE), defined as MACCE or major bleeding.
Results Among 8,404 patients, 2,232 (26.6%) were women and 6,172 (73.4%) were men. MACCE and NACE were not significantly different between men and women after adjustment, but women had higher risk of access site bleeding (male vs. female rate ratio [RR]: 0.64; p = 0.0016), severe bleeding (RR: 0.17; p = 0.0012), and transfusion (RR: 0.56; p = 0.0089). When comparing radial versus femoral, there was no significant interaction for MACCE and NACE stratified by sex (pint = 0.15 and 0.18, respectively), although for both coprimary endpoints the benefit with TRA was relatively greater in women (RR: 0.73; p = 0.019; and RR: 0.73; p = 0.012, respectively). Similarly, there was no significant interaction between male and female patients for the individual endpoints of all-cause death (pint = 0.79), myocardial infarction (pint = 0.25), stroke (pint = 0.18), and Bleeding Academic Research Consortium type 3 or 5 (pint = 0.45).
Conclusions Women showed a higher risk of severe bleeding and access site complications, and radial access was an effective method to reduce these complications as well as composite ischemic and ischemic or bleeding endpoints.
The advent of combined antithrombotic therapies and early invasive management has reduced the ischemic burden but increased bleeding risk in patients with acute coronary syndrome (ACS) (1–3). The use of radial instead of femoral access mitigates bleeding while preserving ischemic risks, thereby providing consistent mortality benefit across trials (4).
Female patients have increased periprocedural bleeding risk as compared with men (1,5). However, female patients have smaller radial arteries that are more prone to spasm as well as shorter aortic roots than men, which adds to the operative difficulty and may undermine the efficacy of radial access in this population. Previous studies have shown contrasting evidence about potential sex disparities for the safety and efficacy of transradial access (TRA) versus transfemoral access (TFA) (6,7).
We sought to investigate the comparative efficacy and safety outcomes across sex of radial versus femoral access in ACS patients participating in the MATRIX-Access (Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and Systemic Implementation of angioX) trial.
The MATRIX-Access was a randomized, multicenter, superiority trial comparing radial with femoral access in patients with ACS with or without ST-segment elevation undergoing coronary angiography and percutaneous coronary intervention (PCI), if indicated (4,8). This was the first of 3 trials of the MATRIX program (ClinicalTrials.gov; NCT01433627) and was performed in all patients with an ACS consenting to participate in the program. The institutional review board at each participating center approved the trial, and all patients gave written informed consent to participate.
Patients were eligible if they had an ACS with or without ST-segment elevation, were scheduled to undergo an invasive approach, and the interventional cardiologist was willing to proceed with either radial or femoral access with expertise for both, including at least 75 coronary interventions performed and at least 50% of interventions in ACS via the radial route during the previous year. Patients presenting with non–ST-segment elevation ACS (NSTE-ACS) were eligible if they had a history consistent with new or worsening ischemia, occurring at rest or with minimal activity within 7 days before randomization, and fulfilled at least 2 high-risk criteria (4,8). Patients with ST-segment elevation myocardial infarction were eligible if they presented within 12 h of the onset of symptoms or between 12 and 24 h after symptom onset if there was evidence of continued ischemia or previous fibrinolytic treatment and if they had ST-segment elevation of at least 1 mm in 2 or more contiguous leads, new left bundle branch block, or true posterior MI. The main inclusion and exclusion criteria were previously reported (4,8).
Study protocol and randomization
Before the start of angiography, patients were randomly assigned 1:1 to radial or femoral access for diagnostic angiography and PCI, if indicated, using a web-based system to ensure adequate concealment of allocation. The randomization sequence was computer generated, blocked, and stratified by site, intended new or ongoing use of ticagrelor or prasugrel, type of ACS (ST-segment elevation myocardial infarction or troponin-positive or troponin-negative NSTE-ACS), and anticipated use of immediate PCI. Access site management during and after the diagnostic or therapeutic procedure was left to the discretion of the treating physician, and closure devices were allowed as per local practice. The use of anticoagulant agents outside the protocol of the MATRIX program was not allowed. Bivalirudin administration was consistent with the approved product labeling, whereas unfractionated heparin was dosed at 70 to 100 U/kg in patients not receiving glycoprotein IIb or IIIa inhibitors and at 50 to 70 U/kg in patients receiving glycoprotein IIb or IIIa inhibitors. Use of all other antithrombotic medications, including oral antiplatelet agents and nonantithrombotic medications, such as beta-blockers, angiotensin-converting enzyme inhibitors, and other antihypertensive agents, were allowed as per guidelines (9).
Two coprimary 30-day composite outcomes were pre-specified: major adverse cardiovascular and cerebrovascular events (MACCE), defined as the composite of all-cause mortality, MI, or stroke; and net adverse clinical events (NACE), defined as the composite of MACCE or noncoronary artery bypass grafting–related major bleeding (Bleeding Academic Research Consortium [BARC] type 3 or 5) (10). Secondary outcomes included each component of the composite outcomes, cardiovascular mortality, and stent thrombosis. Bleeding was also assessed and adjudicated on the basis of the Thrombolysis In Myocardial Infarction and GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) scales (11,12). Stent thrombosis was defined as the definite or probable occurrence of a stent-related thrombotic event according to the Academic Research Consortium classification (13). All outcomes were pre-specified (4,8). An independent clinical events committee blinded to treatment allocation adjudicated all suspected outcome events by reviewing relevant medical records after site monitoring by Trial Form Support (Lund, Sweden) in Italy and the Netherlands, FLS-Research Support (Barcelona, Spain) in Spain, and Gothia Forum (Västra Götaland) in Sweden.
Statistical analyses were performed by an academic statistical group led by 1 of the authors (B.R.d.C.), who had access to the full deidentified data set.
The trial was powered for superiority on the 2 coprimary composite outcomes at 30 days expecting a rate reduction of 30%, corresponding to rate ratio (RR) of 0.70.
All analyses were performed per intention-to-treat principle, including all patients in the analysis based on the allocated access. Events up to 30 days post-randomization were considered. We analyzed primary and secondary outcomes separately for male and female patients as time to first event using the Mantel-Cox method, accompanied by log-rank tests to calculate corresponding 2-sided p values. We did not perform any adjustments for multiple comparisons but set the alpha error at 2.5% to correct for the 2 coprimary outcomes. We analyzed secondary outcomes with a 2-sided alpha value set at 5% to allow conventional interpretation of results. Survival curves were constructed using Kaplan-Meier estimates. We performed stratified analyses according to the pre-specified subgroup of randomization to heparin or bivalirudin, and estimated possible interaction terms across ordered groups separately for the male and female study populations. We also analyzed clinical outcomes in the overall population irrespective of randomized access to compare male and female patients, but due to the significant differences in baseline and procedural characteristics, multivariable adjustment was performed including the following variables: age, type of ACS, body mass index, diabetes, smoking, hypercholesterolemia, hypertension, previous MI, previous CABG, previous stroke or transient ischemic attack, Killip class, renal function, crossover, glycoprotein IIb or IIIa, and intra-aortic balloon pump. All analyses were performed using the statistical package Stata 13.1 (StataCorp, College Station, Texas).
The MATRIX-Access trial enrolled 8,404 patients with ACS from 78 centers in Italy, the Netherlands, Spain, and Sweden between October 2011 and November 2014. Of these patients, 6,172 (73.4%) were men, of whom 3,126 (37.2%) were allocated to radial and 3,046 (36.2%) to femoral access; and 2,232 (26.6%) were women, of whom 1,071 (12.8%) were assigned to radial and 1,161 (13.8%) to femoral access.
Baseline and procedural characteristics were largely imbalanced between sexes (Tables 1 and 2). Compared with men, women were older; had lower body weight and body mass index; presented more frequently with NSTE-ACS and advanced Killip class; and had a higher prevalence of diabetes, hypercholesterolemia, hypertension, renal dysfunction, and prior cerebrovascular events. However, women less frequently were smokers or had prior MI, PCI, or CABG. Crossover rates, use of intra-aortic balloon pump, left main treatment, and bare-metal stent implantation occurred more often in women, while attempted PCI, use of glycoprotein IIb/IIIa inhibitors, and bypass graft treatment were less frequent in women and stent diameter and length were lower (Table 1). Before arrival in the catheterization laboratory, female patients received aspirin and new P2Y12 inhibitors less frequently as compared with men (Table 1).
On the contrary, female and male subgroups allocated to radial versus femoral access were generally well matched in terms of demographics, medical history, clinical presentation, and procedural aspects (Tables 1 and 2). Medications at discharge are shown in Online Table 1. Crossover rate from radial to femoral was numerically higher in women as compared with men (Table 2), however interaction testing did not confirm heterogeneity across sexes (interaction p = 0.051).
Clinical outcomes of male versus female patients
MACCE and NACE were significantly lower in men compared with women at unadjusted analysis but they no longer differed after adjustment for the multiple imbalances identified across patients’ characteristics (Table 3). Similarly, after adjustment, neither of the single components of both coprimary endpoints differed significantly in male compared with female patients (Table 3). There was however a trend toward higher risk of BARC type 3 or 5 access site bleeding and a 36% increase of BARC type 2, 3, or 5 access site bleeding rates in women compared with men after adjustment (Table 3). The need for transfusion and the composite of surgical access site repair and blood transfusion were also increased after adjustment in female compared with male patients (Table 3).
Clinical outcomes of radial versus femoral access according to sex
Overall crossover rates were higher in women as compared with men (4.7% vs. 3.8%; p = 0.037), however this difference disappeared after adjustment (p = 0.42).
No significant interaction was noted between access site and sex with respect to both coprimary endpoints of 30-day MACCE and NACE (interaction p = 0.15 and 0.18, respectively) (Figures 1 and 2, Table 4). MACCE and NACE were significantly reduced with radial as compared with femoral in female patients (MACCE: 9.1% vs. 12.2%; RR: 0.73; 95% confidence interval [CI]: 0.56 to 0.95; p = 0.019; NACE: 10.4% vs. 13.9%; RR: 0.73; 95% CI: 0.56 to 0.93; p = 0.012) (Figure 1, Table 4) and trended in favor of radial, albeit nonsignificantly in men (MACCE: 8.7% vs. 9.5%; RR: 0.92; 95% CI: 0.77 to 1.09; p = 0.31; NACE: 9.6% vs. 10.8%; RR: 0.89; 95% CI: 0.76 to 1.05; p = 0.16) (Figure 1, Table 4). Radial access was consistently (interaction p = 0.79) associated to lower all-cause fatalities in both sex groups (women: 2.4% vs. 3.5%; RR: 0.70; 95% CI: 0.43 to 1.15; men: 1.3% vs. 1.7%; RR: 0.76; 95% CI: 0.50 to 1.15) (Figure 3, Table 4). At further analysis, no signal of interaction was noted between access site and sex for stroke (interaction p = 0.18), myocardial infarction (interaction p = 0.25) and for other secondary endpoints including cardiovascular mortality (interaction p = 0.92), stent thrombosis (interaction p = 0.18), target vessel revascularization (interaction p = 0.18), or the composite of access site surgery or blood transfusion (interaction p = 0.18) (Figure 3, Table 4).
The key safety endpoint of BARC type 3 or 5 bleeding was similarly reduced (interaction p = 0.45) in the radial groups across sex, even if formal statistical significance was achieved in female (2.0% vs. 3.4%; RR: 0.58; 95% CI: 0.34 to 0.98; p = 0.040) but not in male patients (1.4% vs. 1.9%; RR: 0.74; 95% CI: 0.50 to 1.11; p = 0.14) (Table 4). Access site BARC type 3 or 5 bleeding was consistently (interaction p = 0.45) reduced in both female and male patients whereas non–access site BARC type 3 or 5 bleeding did not differ with radial in both sexes (Table 4). Results remained consistent across any BARC, TIMI, or GUSTO bleeding scales.
We assessed the role of sex disparities on clinical outcomes in largely unselected ACS patients recruited in the MATRIX-Access trial and undergoing invasive management via either radial or femoral access. The main findings are the following.
First, male and female patients differed considerably for multiple baseline characteristics, procedural features, and choice of medications. Although unadjusted analyses apparently yielded greater risk of main efficacy and safety endpoints in female patients as compared with men, they no longer differed after adjustment. Only access site bleeding, but not overall bleeding, along with transfusion rates alone or in combination with surgical repair for the instrumented access site, remained higher in female as compared with male patients.
Second, there was no clear signal of heterogeneity across sex with respect to any of the investigated outcome measures, including the 2 coprimary composite endpoints or each of the individual components. Women but not men showed a significant reduction of both coprimary endpoints (fulfilling the pre-specified level of significance at an alpha error of 2.5%) with radial access, indicating that the well-known sex-specific procedural challenges of transradial coronary catheterization and intervention do not mitigate the expected benefits in female patients.
Advances in PCI procedures and optimization of concomitant antithrombotic agents have improved outcomes of patients with ACS by reducing ischemic events, but at the cost of greater bleeding risk. The latter remains a matter of concerns especially for patients at increased procedural hemorrhagic risk such as female patients. Although the spontaneous (i.e., out of hospital) bleeding risk appears not to differ among sexes (14–17), female patients have been consistently shown to suffer the greatest from access site hemorrhagic complications as compared with male counterparts (1,5) Access site bleeds represent a large part of periprocedural bleeding and TRA has emerged as the most appealing and cost-saving treatment strategy to mitigate those complications. However, sex-specific procedural challenges of transradial coronary catheterization and intervention, possibly leading to a delayed or less effective percutaneous treatment especially in ACS female patients, remain a matter of concern. Previous studies have reported that female sex is an independent predictor of failure of transradial PCI (18) and an independent predictor of radial spasm (19), limiting the success of the transradial procedure.
The MATRIX-Access trial is the largest (n = 8,404) randomized trial to compare radial and femoral access, including unselected patients at high baseline and procedural risk. Our current findings are in agreement with those of previous observational studies (20,21), and those reported in the RIVAL (Radial Vs femorAL access for coronary intervention) trial. A pre-specified subgroup analysis of RIVAL compared outcomes in women (n = 1,861) and men (n = 5,160) who were randomized to radial versus femoral access and showed that women undergoing coronary angiography and PCI had a higher risk of vascular access site complications compared with men, but radial access was an effective method to reduce these complications (7). In the RIVAL trial the type of antithrombotic medications during coronary intervention was not protocol-mandated. As a result, the majority of patients were treated with heparin rather than bivalirudin (approximately 2.6%). Therefore, it was not possible to exclude that using bivalirudin would have reduced the benefits of radial access especially in female patients (22). In the MATRIX-Access trial, heparin and bivalirudin were randomly and evenly assigned to patients at the time of coronary intervention. No signal of heterogeneity was noted for type of anticoagulant agent and access site for both men and women across the coprimary endpoints, mortality, or the key safety bleeding endpoint. This novel and unique observation that the benefits of radial access remain consistent in both sexes irrespective of the choice of parenteral anticoagulation during PCI has notable implications for current practice. Against the widespread belief that radial access and use of bivalirudin represent competing treatment strategies to minimize bleeding risks, our findings support their complementary role to mitigate both access site and non–access site bleeding risks, both in male and female patients.
The SAFE-PCI for Women (Study of Access Site for Enhancement of PCI for Women) trial was unique for selecting exquisitely women to undergo radial or femoral access (6). The trial was stopped prematurely due to lower than expected event rate and no significant difference was found in the primary efficacy endpoint (BARC 2, 3, or 5 bleeding or vascular complications requiring intervention) between TRA and TFA in patients undergoing PCI (n = 691; primary endpoint cohort). However, in a secondary analysis also including female patients who underwent cardiac catheterization (n = 1,787), radial access significantly reduced bleeding and vascular complications (6). Hence, the apparent lack of benefit of radial over femoral access in this study likely reflects limited study power more than lack of treatment effect in women.
We observed that women randomized to TRA more frequently needed crossovers to TFA compared with men (7.6% vs. 5.2%). This likely reflects greater challenges in women to obtain vascular access when attempting TRA, likely because of smaller and more prone to spasm radial arteries. Yet, the duration of the procedure was overall shorter in women as compared with men, and in the former group TRA did not require longer procedural or fluoroscopic time as compared with TFA. This observation suggests that female patients who are intervened upon via the radial access do not pose specific further technical challenges once vascular access has been established.
Overall, present findings contribute to support the concept that radial access should be preferred over the femoral access, adding to the current knowledge firm evidence that this approach is applicable to both male and female patients, and that probably it is even more beneficial in women who are characterized by increased risk of bleeding and access site related complications. Therefore, efforts should be done to increase the adoption of radial access, but at the same time improving the operators’ training, which is fundamental to reach the most appropriate skills, particularly in women where radial access might be more challenging due to anatomical reasons.
Although a sex subgroup analysis was pre-specified, the MATRIX-Access trial was not powered to explore differences between sexes, and randomization was not stratified by sex. As such, the current analyses may be subject to type II error. As expected in an exploratory analysis of effect modification, an ad hoc power analysis indicates a 30% power for the analysis of our primary outcome. Female study population was smaller compared with the male group, as observed in most trials investigating patients with CAD. Yet, the benefits of TRA over TFA were consistent across sexes and if anything seemed to be slightly more pronounced among women. We did not adjust for multiple comparisons, increasing the risk of type I error. Radial artery occlusion was not systematically looked for in the context of the MATRIX study. Results apply to the context of this trial in which most centers participating were highly experienced in the radial technique; therefore, similar outcomes may not apply in centers performing lower volumes of radial access.
This sex-specific analysis of the largest trial comparing radial versus femoral access in ACS patients invasively managed suggests that women experienced a higher risk of severe bleeding and access site complications, and radial access was an effective method to reduce these complications, as well as composite ischemic and ischemic or bleeding endpoints.
WHAT IS KNOWN? There are limited and contrasting data about sex disparities for the safety and efficacy of TRA versus TFA for coronary intervention.
WHAT IS NEW? The MATRIX-Access trial results showing superiority of TRA versus TFA were consistent across sexes. Women experienced a higher risk of severe bleeding and access site complications, and radial access was an effective method to reduce these complications, as well as composite ischemic and ischemic or bleeding endpoints.
WHAT IS NEXT? Radial access should become the default access for patients with ACS undergoing invasive management, irrespective of sex.
The trial was sponsored by the Società Italiana di Cardiologia Inasiva (a nonprofit organization), which received grant support from The Medicines Company and Terumo. This substudy did not receive any direct or indirect funding. Dr. Gargiulo has received research grant support from the Cardiopath PhD program and from the Società Italiana di Cardiologia supported by MSD Italia-Merck Sharp and Dohme Corporation. Dr. Vranckx has received personal fees from Daiichi-Sankyo and Bayer Healthcare. Dr. Leonardi has received personal fees from The Medicines Company, AstraZeneca, Chiesi, outside the submitted work; and grant support from AstraZeneca outside the submitted work. Dr. Andò has received nonfinancial support from Terumo and Volcano-Phillips; and personal fees from Abbott, Bayer Healthcare Pharmaceuticals, AstraZeneca, and Daiichi-Sankyo. Dr. Cortese has received research grants from AB Medica, Abbott, St. Jude Medical, and Stentys; and personal fees from Abbott, AstraZeneca, Daiichi-Sankyo and Eli-Lilly, Stentys, all outside the submitted work. Dr. Petronio is consultant for Medtronic, Boston Scientific, and Abbott. Dr Windecker has received research grants to the institution from Bracco, Boston Scientific, and Terumo. Dr. Valgimigli has received research grant support from The Medicines Company, Terumo, and AstraZeneca; and personal fees from Terumo, St. Jude Vascular, and Abbott Vascular. Dr. Sonia has served as a consultant for Medtronic, Boston Scientific, and Abbott. Dr. Windecker has received institutional research grants from Abbott, Boston Scientific, Biotronik, Medtronic, Edwards Lifesciences, and St. Jude Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- acute coronary syndrome(s)
- Bleeding Academic Research Consortium
- coronary artery bypass grafting
- major adverse cardiovascular and cerebrovascular event(s)
- myocardial infarction
- net adverse clinical event(s)
- non–ST-segment elevation acute coronary syndrome(s)
- percutaneous coronary intervention
- rate ratio
- transfemoral access
- transradial access
- Received July 17, 2017.
- Revision received September 12, 2017.
- Accepted September 14, 2017.
- 2018 American College of Cardiology Foundation
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