Trans-radial approach for catheterisation in non-ST segment elevation acute coronary syndrome: an analysis of major bleeding complications in the ABOARD Study G Cayla, 1,2 J Silvain, 1 O Barthelemy, 1 S ’O Connor, 1 L Payot, 3 A Bellemain-Appaix, 1 F Beygui, 1 M Aout, 4 J-P Collet, 1 E Vicaut, 4 G Montalescot, 1 for the ABOARD investigators ABSTRACT Aim To determine the incidence, type and possible association with mortality of major bleeding in patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) treated with an invasive strategy using predominantly the radial approach and triple antiplatelet therapy. Methods In the multicentre randomised ABOARD Study, 352 patients with NSTE-ACS were randomised to an ‘immediate percutaneous coronary intervention (PCI)’ strategy or a strategy of PCI on the ‘next working day’. Radial access was predominantly used in this study population. The present subanalysis evaluated the occurrence of major bleeding complications and their association with mortality at 1 month. Results Patients were treated with a triple antiplatelet therapy using high loading and maintenance doses of clopidogrel and abciximab in 99% of patients receiving PCI. The trans-radial approach was used in the vast majority of patients (84%). During the first 30 days, major bleeding complications (STEEPLE definition) occurred in 5.4% of patients (n¼19), with no difference between immediate and delayed intervention. The most common bleeding complications were occult bleeding (36.8% of bleeding, n¼7/19) and overt gastrointestinal bleeding (21% of bleeding, n¼4/19). Patients with major bleeding had a higher peak concentration of creatinine during hospitalisation (mean6SD, 1706169 vs 97657 mmol/l; p¼0.005) and a 1-month mortality of 26.3%, much higher than patients without bleeding (0.6%, p<0.0001). Major bleeding was strongly associated with 30-day mortality (OR 50.3; 95% CI 10.1 to 249.7; p<0.0001). Conclusion Despite the predominant use of the radial approach, major bleeding (essentially occult and gastrointestinal) remains a common complication, which is highly associated with mortality in patients with NSTE-ACS treated with optimal antithrombotic therapy. In acute coronary syndrome (ACS) treated by percutaneous coronary intervention (PCI), aggres- sive antithrombotic regimens have significantly enhanced the prognosis of patients through a reduction of ischaemic events. 1e3 However, these treatments have been constantly associated with an increased risk of bleeding complications. A body of evidence suggests that major bleeding complications are linked to recurrent ischaemic complications and mortality. 4 Therefore, mini- mising bleeding complications in the setting of ACS has become a critical issue. The potential benefits of trans-radial access have been reported to be prevention of bleeding complications and other adverse events, 5 and it is now the preferred approach in several countries for reducing puncture-related bleeding complications. Nevertheless, in these PCI centres that specialise in the trans-radial approach, data are lacking on the rate and types of bleeding complications and their effect on patients’ prognosis. The ABOARD (angioplasty to blunt the rise of troponin in acute coronary syndromes randomised for an immediate or delayed intervention) Study was a multicentre randomised study that enrolled 352 patients with moderate-to-high-risk non-ST segment elevation ACS (NSTE-ACS) to undergo immediate or delayed PCI. In this study, which is unique in its predominant use of radial access in patients also treated with triple antiplatelet therapy, we analysed the incidence and type of acute major bleeding complications and their potential effect on 1-month survival. METHODS Study population and randomisation The ABOARD Study has been published. 6 Briefly, 352 patients with NSTE-ACS were randomised to a ‘primary PCI’ strategy or a strategy of interven- tion deferred to the ‘ next working day ’. The mean delays between randomisation and PCI were 70 min in the ‘primary PCI’ strategy and 21 h in the ‘ next working day ’ strategy. NSTE-ACS was defined by the presence of at least two of the following criteria: symptoms of myocardial ischaemia; electrocardiographic ST-segment abnor- malities (depression or transient elevation of at least 0.1 mV) or T-wave inversion in at least two contiguous leads; or an elevated cardiac troponin I concentration (above the upper limit of normal). Only patients with a thrombolysis in myocardial infarction (TIMI) score of 3 or greater and an indication for catheterisation were eligible for randomisation. Medical therapy Patients received aspirin at an initial high loading dose of up to 500 mg, followed by low-dose aspirin 1 Institut de Cardiologie, Centre Hospitalier Universitaire Pitie ´-Salpe ˆtrie `re, Paris, France 2 Service de Cardiologie, Centre Hospitalier Universitaire Care ´meau, Nı ˆmes, France 3 Centre Hospitalier Intercommunal A Gre ´goire, Montreuil-sous-Bois, France 4 Unite ´ de Recherche Clinique, Centre Hospitalier Universitaire Lariboisie `re, Paris, France Correspondence to Gilles Montalescot, Bureau 236, Institut de Cardiologie, Pitie ´-Salpe ˆtrie `re University Hospital, 47-83 bld de l’Ho ˆpital, 75013 Paris, France; gilles.montalescot@psl.aphp.fr Accepted 22 February 2011 Cayla G, Silvain J, Barthelemy O, et al. Heart (2011). doi:10.1136/hrt.2010.220137 1 of 5 Original article Heart Online First, published on March 18, 2011 as 10.1136/hrt.2010.220137 Copyright Article author (or their employer) 2011. 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