The Clinical SYNTAX score predicts survival better than the SYNTAX score in coronary revascularization

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 167; no. 1; pp. 164 - 173.e4
• Main Authors: Barac, Yaron D, Witberg, Guy, Assali, Abid, Klempfner, Robert, Krutzwald-Josefson, Efrat, Rubchevsky, Victor, Abergel, Eytan, Kornowski, Ran, Aravot, Dan
• Format: Journal Article
• Language: English
• Published: United States 01-01-2024
• Subjects: Coronary Angiography; Coronary Artery Disease - diagnostic imaging; Coronary Artery Disease - surgery; Humans; Percutaneous Coronary Intervention; Risk Factors; Treatment Outcome; CSS; revascularization; MULTICAD
• ISSN: 0022-5223; 1097-685X
• DOI: 10.1016/j.jtcvs.2022.02.030

The Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) trial showed that the SYNTAX score (SS) is a useful tool for customizing revascularization treatment for patients with multivessel coronary disease. In the past decade, the Clinical SS (CSS) has emerged as a comprehensive tool. This novel tool considers the SS as well as patient clinical parameters such as age, creatinine clearance, and ejection fraction, which were shown to be relevant for patient prognosis. Thus, in the current work we set out to compare the survival predictive values of the SS versus the CSS and their future application in real-world implementation of the revascularization guidelines.
This study was a subanalysis of data collected in a prospective national registry in Israel that enrolled consecutive patients with left main and/or 2- to 3-vessel coronary artery disease involving the proximal or mid-left anterior descending artery; the MULTI-vessel Coronary Artery Disease (MULTICAD). The revascularization method was chosen by the physicians taking care of the patients at each hospital and the patients were followed for 5 years. Patients were categorized according to their SS, the CSS, and their revascularization method (primary coronary intervention [PCI] vs coronary artery bypass grafting [CABG]) and patient survival were compared.
A total of 585 patients were enrolled in the study and were followed for 5 years. The median CSS was 27, with 288 patients showing a CSS ≥27, with a mean CSS of 47.85 and a mean SS of 29.05. At 3 and 5 years post-treatment, the CSS ≥27 group had a lower survival probability, CSS ≥27 was associated with a lower survival probability among patients who underwent PCI compared with those who underwent CABG. More specifically, the high-CSS CABG group had a 5-year mortality rate of 16.8%, whereas the high-CSS PCI group had a 5-year mortality rate of 32.2%. In a comparison of SS with CSS for the 5-year mortality outcome prediction, CSS was superior to SS with a higher area under the curve.
This prospective registry of real-world revascularization strategies in patients with multivessel disease showed that CSS is a better predictive tool of postrevascularization survival than SS. Moreover, it showed that surgical revascularization in patients with CSS ≥27 is associated with better all-cause mortality outcome after CABG as compared with after PCI. This attests to the need for a score that considers clinical parameters in a real-world scenario.