Elsevier

International Journal of Cardiology

Volume 227, 15 January 2017, Pages 478-484
International Journal of Cardiology

ApPropriateness of myocaRdial RevascularizatiOn assessed by the SYNTAX score II in a coUntry without cardiac Surgery faciliTies; PROUST study,☆☆

https://doi.org/10.1016/j.ijcard.2016.11.001Get rights and content

Abstract

Background/objectives

The SYNTAX Score II (SSII) was proposed as a novel approach for objective individualized decision-making for optimal myocardial revascularization i.e. percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery. We sought to investigate how many lives may be saved by SSII use.

Methods

A total number of 651 consecutive SSII-naive-patients with complex coronary artery disease who were treated with PCI (n = 409) or referred to other institutions for CABG (n = 242) were included. All-cause mortality was ascertained in 96% of patients. The SSII was calculated for each patient.

Results

Based on the SSII treatment recommendation, CABG would have been the treatment of choice in 257/651 (39.5%) patients, PCI in 7/651 (1.1%) patients and CABG or PCI in 387/651 (59.4%) patients. Out of 257 patients in whom the treatment recommendation by SSII was CABG, 113/257 (44.0%) patients had actually CABG, while the remaining 144/257 (56.0%) underwent PCI. It was shown that 144/257 patients with treatment recommendations in favour of CABG who were treated with PCI had significantly higher mortality at 4 years when compared with patients with SSII treatment recommendation for PCI or equally favouring CABG and PCI (12.5% vs. 0.0% vs. 6.9%, respectively, P = 0.04).

Conclusion

The intuitive decision-making for choosing the optimal myocardial revascularization method differed predominantly from the SSII recommendation for CABG. The discordance between the SSII recommended revascularization strategy and the clinical decision was associated with a higher 4-year mortality i.e. one life may be saved if SSII would be calculated and followed consequently in 18 patients.

Introduction

Over the last few decades the optimal revascularization modality of patients with complex coronary artery disease (CAD) has been coronary artery bypass graft (CABG) surgery. However, percutaneous coronary intervention (PCI) has experienced a large number of technical and technological improvements, and hence, has challenged the superiority of CABG. Recent studies have shown that in certain groups of patients, PCI may be a safe and effective alternative and it was reflected in the newest guidelines on myocardial revascularization [1], [2], [3], [4].

The widespread adoption of PCI has led to the need for evidence-based clinical tools to aid decision-making on the most optimal revascularization modality in patients with complex CAD. One of the first clinical tools to objectively determine which patients with complex CAD were suitable for CABG or PCI was the anatomical SYNTAX Score [5], [6]. This score was created and tested before improved modern stent designs, better PCI techniques, and improved pharmacologic strategies were available, a situation that frequently led to discussions whether PCI might take over more originally surgical indications.

Recently, the SYNTAX Score II (SSII) has been developed in the landmark, all-comers, randomized SYNTAX trial [7] and externally validated in a total number of 8405 patients from three large multicenter registries [7], [8], [9]. Moreover, the most recent ESC/EACTS guidelines on myocardial revascularization [4] have endorsed the implementation of the SSII (Class IIa; Level of evidence B) in decision-making process between CABG and PCI. This score unifies the anatomical SYNTAX Score with six clinical variables to form a single score for CABG and PCI, and gives 4-year mortality predictions for individual patient following CABG or PCI to aid decision-making by the Heart Team [7]. The SSII does not apply for patients with ST segment elevation myocardial infarction, as these patients were not studied in the SYNTAX trial. Currently the on-going EXCEL trial [10] and SYNTAX II trial [11], [12] will better quantify the performance of the SSII.

Every cardiologist being interventional and/or clinical has dilemmas if CABG or PCI was the right decision, especially in case of complications that may strike his or her self-confidence on the knowledge and clinical skills. Very often asked by the patients: “Doctor, what would you do if you were in my feet?”, cardiologists today are struggling to find out the best myocardial revascularization modality for their patients. The need for applying SSII in “real world” populations including patients with complex CAD (anatomical SYNTAX > 33) and poor left ventricular ejection fraction (LVEF) has recently been summarized by Parissis [13]. The purpose of the present study was to investigate whether indications for CABG or PCI based on the most educated intuitive judgement of PCI-operators without cardiac surgery on-site in routine clinical practice in the era before the SSII (SSII-naive patients) approximate to the treatment recommendation of the recently published SSII. Our working hypothesis was that the SSII could help in better guiding myocardial revascularization if it would have existed at the time of treatment, and is superior to the approach based on decision-making solely by interventional cardiologists, which might be corrected by using a unique and organized system that SSII proposes.

Section snippets

Database and study population

Between January 1, 2008, and December 31, 2010 patients from the University Clinical Centre of the Republic of Srpska, Banja Luka, Bosnia and Herzegovina were recruited using the hospital information system. The study group comprised consecutive patients with angiographically proven 3-vessel CAD (≥ 50% diameter stenosis) and/or significant unprotected left main coronary artery (ULMCA) disease (≥ 50% diameter stenosis) without major hemodynamic instability, who were treated in our institution with

Patients characteristics

Using the hospital information system, 3456 consecutive patients were screened and 2805 elected not to follow the inclusion criteria. Out of 651 patients included in this study, 409 (62.8%) patients underwent PCI and 242 (37.2%) patients were referred to other institutions abroad for CABG (Fig. 1). The mean age was 60.6 ± 9.2 years, 72.8% were men, 80.5% had 3-vessel CAD, 10.5% had ULMCA and 9.0% had both 3-vessel CAD and ULMCA disease. Baseline characteristics of the study population classified

Discussion

The main findings of the present study are as follows: 1. Our mortality data in comparison to the SYNTAX trial indicate that the population investigated is similar thus enabling us to calculate SSII in our patient cohort treated with CABG or PCI; 2. In the total population, the clinical judgement of PCI-operators deviated in 1/4 (148/651) patients from the revascularization modality recommended by the SSII; 3. In the sub-population in which the SSII recommended CABG as optimal revascularization

Conclusion

The present study demonstrates that an intuitive decision-making process by experienced interventional cardiologists for choosing the optimal myocardial revascularization method for the individual patient depends on local availability of cardiac surgery but also other reasons that are in contrast to guideline-recommendations and lead to a discordance of the definitely chosen methods vs. the recommended method based on the SSII, which mainly led to more PCI procedures for patients that would

Conflict of interest

All authors have no conflict of interest to disclose.

References (23)

  • G. Sianos et al.

    The SYNTAX score: an angiographic tool grading the complexity of coronary artery disease

    EuroIntervention

    (2005)
  • Cited by (16)

    • Geographic disparity in 10-year mortality after coronary artery revascularization in the SYNTAXES trial

      2022, International Journal of Cardiology
      Citation Excerpt :

      Regional variation in morbidity and cardiovascular mortality exists, and this has been attributed to factors such as household income, medical insurance, provision and availability of healthcare services and medical equipment, density of doctors and hospitals, and other less well-identified factors such as diet and regional epigenetics [2]. Notably, the individual preference of patients and healthcare professionals regarding the modality of coronary revascularization, and the availability and costs of percutaneous and surgical treatments, are also heterogeneous between countries [3]. Previous studies show that patient characteristics and clinical patterns differ significantly between countries, impacting 5-year health care outcomes [4–6], with geographic variation also seen in the rate of atheroma progression and cardiac events [7].

    • Relevance of SYNTAX score for assessment of saphenous vein graft failure after coronary artery bypass grafting

      2020, Chronic Diseases and Translational Medicine
      Citation Excerpt :

      Likewise, if the difference in mortality risk prediction was in favor of PCI with 95% CI, PCI was recommended. If there was no significant difference in mortality rates with 95% CI, equipoise between PCI and CABG was recommended.7 Both anatomical SS and SS-II in our study were calculated with the SYNTAX score online calculator (www.syntaxscore.com).

    • PCI and CABG for Treating Stable Coronary Artery Disease: JACC Review Topic of the Week

      2019, Journal of the American College of Cardiology
      Citation Excerpt :

      For the conduct of PCI, restenosis and stent thrombosis would need to be solved before less stenotic lesions can be addressed, hoping for an impact of elective PCI on new myocardial infarctions and possibly survival. Our current practice, however, suggests that treatment decisions are not always consistent with the currently available evidence (65) and recommendations (1). One potential solution may have arrived with the noninvasive imaging of even severe coronary artery disease using CT, potentially including functional flow assessments (33,67), allowing the objective discussion of risk-benefit tradeoffs (68) for CABG or PCI, independent of the need for a potential second intervention.

    View all citing articles on Scopus

    The acronym of our study was chosen to be PROUST as famous novelist, critic, and essayist Marcel Proust wrote his monumental novel À la recherche du temps perdu (In Search of Lost Time) published in seven parts between 1913 and 1927. Similarly we have been trying during our carrier to search for lost lives in order to save lives in the future.

    ☆☆

    There was no grant support about this article.

    1

    This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. The author have made substantial contribution to the intellectual content of the paper in: conceived and designed the research, performed statistical analysis, drafted the manuscript, made critical revision of the manuscript for key intellectual content.

    View full text