Transradial Intervention Around the Globe: Trends and Forecasts Sunil V. Rao MD Duke University Medical Center Duke Clinical Research Institute Durham VA Medical Center

Disclosures Consultant/Honoraria Research funding The Medicines Company, Medtronic, Astra Zeneca, ZOLL Research funding Ikaria Off-label uses of drugs/devices may be discussed

Transradial Trends and Forecasts Where have we been? Where are we going? What is driving the trends? Summary

Transradial Trends and Forecasts Where have we been? Where are we going? What is driving the trends? Summary

Worldwide Transradial PCI Utilization 2004-2007 National Database Estimates KEY POINTS This slide depicts worldwide transradial PCI utilization based on either 2008-2009 data from National Database Registries or 2009 estimates.1 It can be noted that, in comparison to other countries, the United States lags in the utilization of transradial PCI. Percentages represent data in figure: National Database1 Estimates1 REFERENCE Caputo RP, Tremmel JA, Rao S, et al. Transradial arterial access for coronary and peripheral procedures: executive summary by the Transradial Committee of the SCAI. Catheter Cardiovasc Interv. 2011;78:823-839. Data based on National Database Registries (2008 or 2008/9) or estimates (2009). Country % Radial France 55 UK 35 Poland 21.8 US 1.7 Country % Radial Germany 25 Spain 43 Italy Canada 50 Japan 60 India 32 China Caputo RP et al. Catheter Cardiovasc Interv. 2011;78:823-839.

Prevalence of radial approach in the US 2004-2007 N = 593,094 PCI procedures 2004-2007 606 sites 1.3% of all PCI procedures Rao SV, et. al. JACC: CI 2008

Radial volume at US Sites 2004-2007 Rao SV, et. al. JACC Intv 2008

Transradial Trends and Forecasts Where have we been? Where are we going? What is driving the trends? Summary

US Radial uptake 2007-2012; N=2.8 million procedures from 1381 sites Feldman D, et. al. Circ 2013

US Radial uptake 2007-2012; N=2.8 million procedures from 1381 sites Feldman D, et. al. Circ 2013

US Radial uptake 2007-2012; N=2.8 million procedures from 1381 sites Feldman D, et. al. Circ 2013

Radial approach in the United Kingdom Total Radial Femoral Transradial course

Transradial Trends and Forecasts Where have we been? Where are we going? What is driving the trends? Summary

Radial approach: Drivers of uptake Clinical evidence Guidelines Training courses Marketing Population trends

Radial mega-analysis N=76 studies (15 rand; 61 obs); 761,919 patients Bertrand OF, et. al. AHJ 2012

ACC/AHA/SCAI Recommendation COR LOE PCI Guidelines ACC/AHA/SCAI Recommendation COR LOE Radial artery access to decrease access site complications IIa A Hillis LD, et. al. JACC 2011

MARS 2012 AIM-RADIAL 2012 19th Annual Transradial Master Class Crewe, UK

These are my people…

Changing definition of “Outpatient” CMS Moves Benchmark to Stays Spanning At Least Two Midnights for Inpatient Admission – Began October 1, 2013 Patient stays spanning at least two midnights will be presumed to qualify for Inpatient admission Patient stays spanning fewer than two midnights will be presumed to qualify only for Outpatient payment. Admitting physician is required to document their expectation of the supposed need for at least a 48-hour stay (crossing the two midnights) and the evidence used to make said decision, to clearly and completely support their order for admission. CMS has now modified the criteria for Inpatient admission. These changes are effective starting Oct 1, 2013. However, CMS has recently announced that it will not allow RACs to enforce the new 2-midnight rule until Jan 1, 2014 in order to give hospitals some time to adjust to the new admission criteria. Source: FY 2014 IPPS Final Rule

Same-day discharge in the US N=107,018 elective PCI procedures from 903 sites Prevalence of same-day discharge 1.25% 30-day death or rehosp Rao SV, et. al. JAMA 2011

You can’t wake a person who is pretending to be asleep - Navajo proverb

Transradial trends and forecasts There has been a significant increase in the use of radial artery access in the USA and the UK Likely mirrored in other countries Change driven by evidence, guidelines, availability of training, market forces, and population trends The growth of radial will likely continue to increase Obsolescence of interventional cardiologists who refuse to adapt and adopt Policy changes that emphasize value over volume

Duke Univ. Medical Center Duke Clinical Research Institute “The practice of medicine should be based on science; “The ‘art’ of medicine is in how you interact with the patient. - Robert M. Califf MD Duke Clinical Research Institute