Transradial access should be the access of choice in patients with acute coronary syndrome, while bivalirudin has not shown any benefit for this population.

The long-term follow-up from the MATRIX (Minimizing Adverse Hemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox) trial confirms the results at 30 days: transradial access is here to stay and all operators will have to adapt to this paradigm.

At 1 year, as well as at 30 days, there was no significant difference in terms of major cardiovascular events between both access sites compared (relative risk [RR]: 0.89; 95% confidence interval [CI]: 0.80-1.00). However, there was a statistically significant difference in net adverse clinical events (a 13% relative risk reduction), defined as a combination of non-surgery-related major bleeding and major cardiovascular events.

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This information obtained from the MATRIX trial, combined with a recently published large meta-analysis showing a reduction in 30-day mortality, turns transradial access into the first choice in patients with acute coronary syndrome.

Guidelines had already been updated in 2017 to give transradial access a class I indication for patients undergoing primary angioplasty.

The other point of focus in this study was the use of bivalirudin vs. heparin and glycoprotein IIb/IIIa inhibitors (the latter were not used systemically, being left to operator discretion). The analysis included 3603 patients and the results at 1 year confirmed the results at 30 days, showing that bivalirudin is not superior as regards the reduction of ischemic events or a combination of ischemic and bleeding events, regardless of the access site used. Bivalirudin did reduce bleeding by 16%, including a 32% reduction in Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding (non-surgery-related major bleeding).

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While definite thrombosis rates were consistently higher with bivalirudin (RR: 1.72; 95% CI: 1.02-2.91) across all studies, this risk is getting lower over time possibly due to the administration of new and more potent P2Y12 inhibitors as early as possible, and also due to efforts to prolong bivalirudin infusion after angioplasty.

Original title: Radial Versus Femoral Access and Bivalirudin Versus Unfractionated Heparin in Invasively Managed Patients with Acute Coronary Syndrome (MATRIX): Final 1-Year Results of a Multicenter, Randomized, Controlled Trial.

Reference: Presented by Marco Valgimigli at the European Society of Cardiology 2018 Congress in Munich and simultaneously published in The Lancet.

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