Identify Unsuitable Patients with Left Main Coronary Artery Disease in Intermediate SYNTAX Scores Treated by Percutaneous Coronary Intervention
DOI:
https://doi.org/10.1532/hsf.1741Keywords:
intermediate SYNTAX score, percutaneous coronary intervention (PCI), left main (LM), repeat revascularization, major adverse cerebro-cardiovascular events (MACCE)Abstract
Background: With the follow-up extending to 5 years, the outcomes of SYNTAX (Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) trial were comparable between coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) in left-main (LM) patients with intermediate SYNTAX scores of 23–32. A subdivision depending on SYNTAX score will help to identify unsuitable LM patients with intermediate SYNTAX scores to receive PCI treatment.
Methods: Between January 2011 and June 2013, 104 patients with LM Coronary Artery Disease (CAD) undergoing PCI were selected retrospectively. We compared clinical outcomes in patients with SYNTAX score <27 and ≥27. The follow-up time was 25.23 ± 7.92 months. Kaplan-Meier survival analyses and Cox proportional hazards models were used to compare various outcomes between two groups.
Results: Higher rates of repeated revascularization (18.2% versus 4.2%, P = .027) and major adverse cerebro-cardiovascular events (MACCE) (24.2% versus 7.0%,
P = .014) were shown in patients with SYNTAX score ≥ 27. After multivariate adjustment, a significant higher risk of repeated revascularization (hazard ratio: 6.25, 95% confidence interval: 1.48 to 26.37, P = .013) and MACCE (hazard ratio: 4.49, 95% confidence interval: 1.41 to 14.35, P = .011) were also found in patients with SYNTAX score ≥ 27.
Conclusions: Based on the higher rate of repeated revascularization and MACCE, patients with LM CAD and intermediate SYNTAX scores will need a subdivision to identity the one not benefit from PCI. CABG is still the standard treatment method for patients of LM CAD with a SYNTAX score of ≥ 27.
References
Ben-Gal Y, Moses JW, Mehran R, et al. 2010. Surgical versus percutaneous revascularization for multivessel disease in patients with acute coronary syndromes: analysis from the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial. JACC Cardiovasc Interv 3:1059-1067.
Birim O, van Gameren M, Bogers AJ, et al. 2009. Complexity of coronary vasculature predicts outcome of surgery for left main disease. Ann Thorac Surg 87:1097-1104; discussion 1104-1095.
Capodanno D, Di Salvo ME, Cincotta G, et al. 2009. Usefulness of the SYNTAX score for predicting clinical outcome after percutaneous coronary intervention of unprotected left main coronary artery disease. Circ Cardiovasc Interv 2:302-308.
Cutlip DE, Windecker S, Mehran R, et al. 2007. Clinical end points in coronary stent trials: a case for standardized definitions. Circulation 115:2344-2351.
Farkouh ME DM, Sleeper LA, Siami FS, et al. 2012. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med 367:2375-2384.
Head SJ, Farooq V, Serruys PW, Kappetein AP. 2014. The SYNTAX score and its clinical implications. Heart 100:169-177.
Hillis LD, Smith PK, Anderson JL, et al. 2011. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol 58:e123-210.
Holzhey DM, Luduena MM, Rastan A, et al. 2010. Is the SYNTAX score a predictor of long-term outcome after coronary artery bypass surgery? Heart Surg Forum13:E143-148.
Kappetein AP1 FT, Mack MJ, Morice MC, et al. 2011. Comparison of coronary bypass surgery with drug-eluting stenting for the treatment of left main and/or three-vessel disease: 3-year follow-up of the SYNTAX trial. Eur Heart J 32:2125-2134.
Kip KE, Hollabaugh K, Marroquin OC, Williams DO. 2008. The problem with composite end points in cardiovascular studies: the story of major adverse cardiac events and percutaneous coronary intervention. J Am Coll Cardiol 51:701-707.
Lemesle G, Bonello L, de Labriolle A, et al. 2009. Prognostic value of the Syntax score in patients undergoing coronary artery bypass grafting for three-vessel coronary artery disease. Catheter Cardiovasc Interv 73:612-617.
Li Y, Torguson R, Syed AI, et al. 2009. Effect of drug-eluting stents on frequency of repeat revascularization in patients with unstable angina pectoris or non-ST-elevation myocardial infarction. Am J Cardiol 104:1654-1659.
Morice MC SP, Kappetein AP, Feldman TE, et al. 2014. Five-Year Outcomes in Patients With Left Main Disease Treated With Either Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting in the Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery Trial. Circulation 129:2388-2394.
Park DW, Kim YH, Yun SC, et al. 2010. Long-term outcomes after stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: 10-year results of bare-metal stents and 5-year results of drug-eluting stents from the ASAN-MAIN (ASAN Medical Center-Left MAIN Revascularization) Registry. J Am Coll Cardiol 56:1366-1375.
Park SJ, Kim YH, Park DW, et al. 2011. Randomized trial of stents versus bypass surgery for left main coronary artery disease. N Engl J Med 364:1718-1727.
Serruys PW, Morice MC, Kappetein AP, et al. 2009. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 360:961-972.
Sianos G, Morel MA, Kappetein AP, et al. 2005. The SYNTAX Score: an angiographic tool grading the complexity of coronary artery disease. EuroIntervention 1:219-227.
Takayama T, Hiro T, Hirayama A. 2010. Is angioplasty able to become the gold standard of treatment beyond bypass surgery for patients with multivessel coronary artery disease? Circ J 74:2744-2749.
Valgimigli M SP, Tsuchida K, Vaina S, et al. 2007. Cyphering the complexity of coronary artery disease using the syntax score to predict clinical outcome in patients with three-vessel lumen obstruction undergoing percutaneous coronary intervention. Am J Cardiol 99:1072-1081.
Venkitachalam L, Kip KE, Selzer F, et al. 2009. Twenty-year evolution of percutaneous coronary intervention and its impact on clinical outcomes: a report from the National Heart, Lung, and Blood Institute-sponsored, multicenter 1985-1986 PTCA and 1997-2006 Dynamic Registries. Circ Cardiovasc Interv 2:6-13.
