February 22nd, 2013
SYNTAX After 5 Years: Any Change in Results (or Your Practice)?
The 5 year results of the SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery) trial are now published. SYNTAX assessed the optimal revascularization strategy for patients with left main and/or 3-vessel disease by randomly assigning such patients to CABG or PCI (with a first-generation paclitaxel-eluting stent) and then determining the rate of major adverse cardiac and cerebrovascular events (MACCE, defined as all-cause mortality, stroke, myocardial infarction, and repeat revascularization).
1) CABG should remain the standard of care for patients with complex lesions (i.e., SYNTAX scores that are intermediate [score, 23-32) or high [score, > 33].
2) For patients with 3-vessel disease considered to be less complex (i.e., a SYNTAX score < 22) or left main disease with a SYNTAX score considered to have a low or intermediate score (i.e., < 32), PCI is an acceptable alternative.
3) All the data from patients with complex multivessel CAD should be reviewed and discussed by a cardiac surgeon and an interventional cardiologist, after which consensus on optimal treatment can be reached.
The fine points…
1) In patients with a high SYNTAX score (> 33), the CABG group had lower mortality than the PCI group.
2) In subjects with an intermediate SYNTAX score (23-32), mortality rates were similar in the 2 treatment groups, but MACCE was higher with PCI than CABG (due to increased rates of MI and repeat revascularization).
3) In patients with low (0-22) SYNTAX scores, MACCE rates did not differ between CABG and PCI.
4) About two-thirds of those with complex CAD are best treated with CABG.
SYNTAX II….the nomogram that may bring you to tears….
Vasim Farooq and colleagues describe the SYNTAX score II, which quantifies the risks and probable outcomes of CABG or PCI in individual subjects by combining the purely anatomical SYNTAX score with clinical variables. The SYNTAX II score — based on 2 anatomical variables (SYNTAX score and presence of left main disease) and 6 clinical variables (age, gender, creatinine clearance, LV ejection fraction, chronic obstructive pulmonary disease, and peripheral vascular disease) — provides a more accurate prediction of early and long-term outcomes with PCI or CABG than the SYNTAX score….unless you are “nomographically challenged” (to see what I’m talking about, look at the nomogram shown in Figure 4).
Okay, let’s be honest….
1. In your hospital, in what percentage of patients with left main or 3 vessel CAD are all the data systematically reviewed and discussed by a “Heart Team”?
2. Do you calculate SYNTAX on all patients with left main or 3 vessel disease, or do you usually just “guestimate” lesion complexity?