Advertisement

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

      The Syntax score (SXscore) was recently developed as a comprehensive angiographic scoring system aiming to assist in patient selection and risk stratification of patients with extensive coronary artery disease undergoing contemporary revascularization. A validation of this angiographic classification scheme is lacking. We assessed its predictive value in patients who underwent percutaneous intervention (PCI) for 3-vessel disease and explored its performance in comparison with the modified lesion classification system of the American Heart Association/American College of Cardiology. The SXscore, applied to 1,292 lesions in 306 patients who underwent PCI for 3-vessel disease in the Arterial Revascularization Therapies Study Part II, was 4 to 54.5, and after a median of 370 days (range 274 to 400) predicted the rate of major adverse cardiac and cerebrovascular events (hazard ratio 1.08/U increase, 95% confidence interval 1.05 to 1.11, p <0.0001), with patients in the highest SXscore tertile having a significantly higher event rate (27.9%) than patients in the lowest tertile (8.7%, hazard ratio 3.5, 95% confidence interval 1.7 to 7.4, p = 0.001). By multivariable analyses, SXscore independently predicted outcome with an almost fourfold adjusted increase in the risk of major adverse cardiac and cerebrovascular events in patients with high versus low values based on the discrimination level provided by classification and regression tree analysis. Compared with the modified lesion classification scheme of the American Heart Association/American College of Cardiology, SXscore showed a greater discrimination ability (c-index 0.58 ± 0.08 vs 0.67 ± 0.08, respectively, p <0.001) and a better goodness of fit with the Hosmer-Lemeshow statistic. In conclusion, the SXscore is a promising tool to risk stratify outcome in patients with extensive coronary artery disease undergoing contemporary PCI.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Teirstein P.S.
        A chicken in every pot and a drug-eluting stent in every lesion.
        Circulation. 2004; 109: 1906-1910
        • Moliterno D.J.
        • Steinhubl S.R.
        Clopidogrel for percutaneous coronary revascularization: time for more pretreatment, retreatment, or both?.
        JAMA. 2005; 294: 1271-1273
        • Kastrati A.
        • von Beckerath N.
        • Joost A.
        • Pogatsa-Murray G.
        • Gorchakova O.
        • Schomig A.
        Loading with 600 mg clopidogrel in patients with coronary artery disease with and without chronic clopidogrel therapy.
        Circulation. 2004; 110: 1916-1919
        • van Domburg R.T.
        • Lemos P.A.
        • Takkenberg J.J.
        • Liu T.K.
        • van Herwerden L.A.
        • Arampatzis C.A.
        • Smits P.C.
        • Daemen J.
        • Venema A.C.
        • Serruys P.W.
        • Bogers A.J.
        The impact of the introduction of drug-eluting stents on the clinical practice of surgical and percutaneous treatment of coronary artery disease.
        Eur Heart J. 2005; 26: 675-681
        • Loscalzo J.
        Clinical trials in cardiovascular medicine in an era of marginal benefit, bias, and hyperbole.
        Circulation. 2005; 112: 3026-3029
        • Sianos G.
        • Morel M.A.
        • Kappetein A.P.
        • Morice M.C.
        • Colombo A.
        • Dawkins K.
        • van den Brand M.
        • van Dick N.
        • Russell M.E.
        • Mohr F.W.
        • Serruys P.W.
        The Syntax score: an angiographic tool grading the complexity of coronary artery disease.
        Eurointervention. 2005; 1: 219-227
        • Serruys P.W.
        • Lemos P.A.
        • van Hout B.A.
        Sirolimus eluting stent implantation for patients with multivessel disease: rationale for the Arterial Revascularisation Therapies Study part II (ARTS II).
        Heart. 2004; 90: 995-998
        • Serruys P.W.
        • Ong A.T.
        • Morice M.C.
        • De Bruyne B.
        • Colombo A.
        • Macaya C.
        • Richardt G.
        • Fajadet J.
        • Hamm C.
        • Dawkins K.
        • et al.
        Arterial Revascularisation Therapies study part II—sirolimus-eluting stents for the treatment of patients with multivessel de novo coronary lesions.
        Eurointervention. 2005; 1: 147-156
        • Leaman D.M.
        • Brower R.W.
        • Meester G.T.
        • Serruys P.
        • van den Brand M.
        Coronary artery atherosclerosis: severity of the disease, severity of angina pectoris and compromised left ventricular function.
        Circulation. 1981; 63: 285-299
        • Ellis S.G.
        • Vandormael M.G.
        • Cowley M.J.
        • DiSciascio G.
        • Deligonul U.
        • Topol E.J.
        • Bulle T.M.
        • Multivessel Angioplasty Prognosis Study Group
        Coronary morphologic and clinical determinants of procedural outcome with angioplasty for multivessel coronary disease.
        Circulation. 1990; 82: 1193-1202
        • Smith Jr, S.C.
        • Dove J.T.
        • Jacobs A.K.
        • Kennedy J.W.
        • Kereiakes D.
        • Kern M.J.
        • Kuntz R.E.
        • Popma J.J.
        • Schaff H.V.
        • Williams D.O.
        • et al.
        ACC/AHA guidelines for percutaneous coronary intervention (revision of the 1993 PTCA guidelines)—executive summary: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty) endorsed by the Society for Cardiac Angiography and Interventions.
        Circulation. 2001; 103: 3019-3041
        • Silber S.
        • Albertsson P.
        • Aviles F.F.
        • Camici P.G.
        • Colombo A.
        • Hamm C.
        • Jorgensen E.
        • Marco J.
        • Nordrehaug J.E.
        • Ruzyllo W.
        • et al.
        • The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology
        Guidelines for percutaneous coronary interventions.
        Eur Heart J. 2005; 26: 804-847
        • Serruys P.W.
        • Unger F.
        • Sousa J.E.
        • Jatene A.
        • Bonnier H.J.
        • Schonberger J.P.
        • Buller N.
        • Bonser R.
        • van den Brand M.J.
        • van Herwerden L.A.
        • Morel M.A.
        • van Hout B.A.
        Comparison of coronary-artery bypass surgery and stenting for the treatment of multivessel disease.
        N Engl J Med. 2001; 344: 1117-1124
        • Sauerbrei W.
        • Schumacher M.
        A bootstrap resampling procedure for model building: application to the Cox regression model.
        Stat Med. 1992; 11: 2093-2109
        • Ambler G.
        • Brady A.R.
        • Royston P.
        Simplifying a prognostic model: a simulation study based on clinical data.
        Stat Med. 2002; 21: 3803-3822
        • Zhang D.D.
        • Zhou X.H.
        • Freeman Jr, D.H.
        • Freeman J.L.
        A non-parametric method for the comparison of partial areas under ROC curves and its application to large health care data sets.
        Stat Med. 2002; 21: 701-715
        • Fonarow G.C.
        • Adams Jr, K.F.
        • Abraham W.T.
        • Yancy C.W.
        • Boscardin W.J.
        Risk stratification for in-hospital mortality in acutely decompensated heart failure: classification and regression tree analysis.
        JAMA. 2005; 293: 572-580
        • Ellis S.G.
        • Roubin G.S.
        • King III, S.B.
        • Douglas Jr, J.S.
        • Weintraub W.S.
        • Thomas R.G.
        • Cox W.R.
        Angiographic and clinical predictors of acute closure after native vessel coronary angioplasty.
        Circulation. 1988; 77: 372-379
        • Holmes Jr, D.R.
        • Holubkov R.
        • Vlietstra R.E.
        • Kelsey S.F.
        • Reeder G.S.
        • Dorros G.
        • Williams D.O.
        • Cowley M.J.
        • Faxon D.P.
        • Kent K.M.
        • et al.
        Comparison of complications during percutaneous transluminal coronary angioplasty from 1977 to 1981 and from 1985 to 1986: the National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry.
        J Am Coll Cardiol. 1988; 12: 1149-1155
        • Ischinger T.
        • Gruentzig A.R.
        • Meier B.
        • Galan K.
        Coronary dissection and total coronary occlusion associated with percutaneous transluminal coronary angioplasty: significance of initial angiographic morphology of coronary stenoses.
        Circulation. 1986; 74: 1371-1378
        • Meier B.
        • Gruentzig A.R.
        • Hollman J.
        • Ischinger T.
        • Bradford J.M.
        Does length or eccentricity of coronary stenoses influence the outcome of transluminal dilatation?.
        Circulation. 1983; 67: 497-499
        • Ross M.J.
        • Herrmann H.C.
        • Moliterno D.J.
        • Blankenship J.C.
        • Demopoulos L.
        • DiBattiste P.M.
        • Ellis S.G.
        • Ghazzal Z.
        • Martin J.L.
        • White J.
        • Topol E.J.
        Angiographic variables predict increased risk for adverse ischemic events after coronary stenting with glycoprotein IIb/IIIa inhibition: results from the TARGET trial.
        J Am Coll Cardiol. 2003; 42: 981-988
        • Ryan T.J.
        • Faxon D.P.
        • Gunnar R.M.
        • Kennedy J.W.
        • King III, S.B.
        • Loop F.D.
        • Peterson K.L.
        • Reeves T.J.
        • Williams D.O.
        • Winters Jr, W.L.
        • et al.
        Guidelines for percutaneous transluminal coronary angioplasty.
        Circulation. 1988; 78: 486-502
        • Antman E.M.
        • Cohen M.
        • Bernink P.J.
        • McCabe C.H.
        • Horacek T.
        • Papuchis G.
        • Mautner B.
        • Corbalan R.
        • Radley D.
        • Braunwald E.
        The TIMI risk score for unstable angina/non–ST elevation MI: a method for prognostication and therapeutic decision making.
        JAMA. 2000; 284: 835-842
        • Altman D.G.
        • Royston P.
        What do we mean by validating a prognostic model?.
        Stat Med. 2000; 19: 453-473