The RIVAL trial was performed in 32 countries and included 7,021 patients with acute coronary syndromes from 2006 to 2010 (6). RIVAL remains the largest trial comparing the radial versus femoral approach to date. Of note, only 122 patients were recruited in the United States. Initially, the RIVAL study was a substudy of the CURRENT (Clopidogrel Optimal Loading Dose Usage to Reduce Recurrent Events) trial (no STEMI), which recruited approximately one-half of its patients before the study continued on its own. Patients with STEMI began to be enrolled after the protocol was amended, and 1,958 patients (28% of the total trial) were included. Results were reported in 2011, and more recently the authors provided a detailed analysis comparing results in patients presenting with STEMI versus those presenting with unstable angina or non-STEMI. Comparison between the characteristics of the 2 trials is provided in (Table 1). It is important to mention that the primary outcome for the overall RIVAL trial was not significantly reduced with the radial approach compared with the femoral approach (3.7% vs. 4.0%; hazard ratio [HR]: 0.92; 95% CI: 0.72 to 1.17; p = 0.50). The rate of TIMI (Thrombolysis In Myocardial Infarction) major non–coronary artery bypass graft (CABG)-related bleeding was low and identical in both groups at 0.5%. Yet using the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) major bleeding definition, the researchers found a significant benefit with the radial approach compared with the femoral approach (1.9% vs. 4.5%; HR: 0.43; 95% CI: 0.32 to 0.57; p < 0.0001). In accordance with recently published meta-analyses, they also found a significant reduction in vascular complications with the radial approach (1.4% vs. 3.7%; HR: 0.37; 95% CI: 0.27 to 0.52; p < 0.0001) (7). Two findings in pre-specified subgroups, however, have generated much discussion. First, the primary outcome was lower among patients assigned to the radial approach at high-volume radial centers (HR: 0.49; 95% CI: 0.28 to 0.87; p = 0.015). Second, among patients with STEMI (the subject of the article under discussion), the radial approach significantly reduced the primary outcome (3.1% vs. 5.2%; HR: 0.60; 95% CI: 0.38 to 0.94; p = 0.026), as well as all-cause mortality (1.3% vs. 3.2%; HR: 0.39; 95% CI: 0.20 to 0.76; p = 0.006). In the primary PCI population, the radial approach produced a 54% relative reduction in mortality at 30 days compared with the standard femoral approach. No such benefits were found in patients without STEMI. Importantly, using the OASIS-5 (Fifth Organization to Assess Strategies in Acute Ischemic Syndromes)–derived major bleeding definition (main definition), neither access site–related nor non–access site–related bleeding were reduced by the radial approach in patients with and without STEMI, whereas access site bleeding was reduced in patients both with and without STEMI with the ACUITY definitions. Conversely, non–access site–bleeding was similar with the radial and femoral approaches in both clinical scenarios.