The full report is titled “Comparative Effectiveness of Multivessel Coronary Bypass Surgery and
Multivessel Percutaneous Coronary Intervention. A Cohort Study.” It is in the 21 May 2013 issue
of Annals of Internal Medicine (volume 158, pages 727-734). The authors are M.A.
Hlatky, D.B. Boothroyd, L. Baker, D.S. Kazi, M.D. Solomon, T.I. Chang, D. Shilane, and A.S. Go.
This article was published at www.annals.org on 23 April 2013.
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Hualien-Armed Forces General Hospital
April 27, 2013
Functional SYNTAX score for reclassifying risk of patients with complex coronary artery disease for coronary bypass grafting
To the Editor:
Current concept for coronary artery bypass grafting surgery (CABG) is indicated for patients with left main or triple-vessel coronary artery disease (CAD), diffuse lesions not amenable to percutaneous coronary intervention (PCI) and high-risk patients with severe left ventricular dysfunction or diabetes. Recently, the severity of coronary anatomy by the SYNTAX score in addition to the functional status was emphasized for patients with multi-vessel coronary artery disease undergoing CABG or PCI. In summary, the SYNTAX trials showed that CABG should remain the standard of care for patients with high or intermediate SYNTAX scores (23-32) in a 5 year follow-up. For patients with low SYNTAX scores (0-21), PCI was an acceptable alternative.1 Furthermore, patients with complex CAD who had more benefits from CABG could be evaluated by a combination of anatomical and clinical factors in SYNTAX score II system as well.2 These reports reclassified the “high-risk” patients with complex CAD by not only concomitant status with impaired ventricular function or diabetes but also systemically review for coronary severity and multi- risk factors estimation.
In the community-based cohort study by Hlatky et al, the results expanded the evidence that those with complex CAD and risk factors of diabetes, tobacco use, heart failure, or peripheral arterial disease were in great favor of CABG.3 As is known, these factors were highly associated with severe coronary anatomy with high SYNTAX score, resulting in similar post-procedural prediction effectiveness. To further improve the SYNTAX score for reclassifying patients at high risk for PCI , the FAME (Fractional Flow Reserve Versus Angiography in Multivessel Evaluation) study demonstrated that the functional SYNTAX score (FSS) by only incorporating ischemia-producing lesions as determined by fractional flow reserve (FFR) decreased the number of higher-risk patients (32%) and better discriminates risk for the major cardiac adverse events in patients with multi-vessel CAD undergoing PCI.4
Obviously, near half of the FAME cohort with high SYNTAX score (mean: 21.7) were classified to the group with intermediate SYNTAX score (23-32) in the SYNTAX registry. In addition, the net reclassification rate from high to medium or low SYNTAX score was estimated to 38% by FSS in the FAME study. Accordingly, FSS may be more sensitive to select patients with intermediate SYNTAX score preferably to receive PCI or CABG. In our opinion, a cohort study is required to see patients with intermediate FSS and coexisting risk factors to follow up the subsequent cardiac events by treatments.
1. Mohr FW, Morice MC, Kappetein AP, Feldman TE, Ståhle E, Colombo A, Mack MJ, Holmes DR, Morel MA, Dyck NV, Houle VM, Dawkins KD, Serruys PW. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet 2013; 381: 629-638
2. Farooq V, van Klaveren D, Steyerberg EW, Meliga E, Vergouwe Y, Chieffo A, Kappetein AP, Colombo A, Holmes DR, Mack M, Feldman T, Morice MC, Ståhle E, Onuma Y, Morel MA, Garcia-Garcia HM, van Es GA, Dawkins KD, Mohr FW, Serruys PW. Anatomical and clinical characteristics to guide decision making between coronary artery bypass surgery and percutaneous coronary intervention for individual patients: development and validation of SYNTAX score II. Lancet 2013; 381: 639-650
3. Hlatky MA, Boothroyd DB, Baker L, Kazi DS, Solomon MD, Chang TI, Shilane D, Go AS. Comparative Effectiveness of Multivessel Coronary Bypass Surgery and Multivessel Percutaneous Coronary Intervention: A Cohort Study. Ann Intern Med. 2013 Apr 23. doi: 10.7326-0003-4819-158-10-201305210-00639. [Epub ahead of print]
4. Nam CW, Mangiacapra F, Entjes R, Chung IS, Sels JW, Tonino PA, De Bruyne B, Pijls NH, Fearon WF; FAME Study Investigators. Functional SYNTAX score for risk assessment in multivessel coronary artery disease. J Am Coll Cardiol. 2011;58: 1211-1218.
Comparing the Effectiveness of Coronary Artery Bypass Graft Surgery and Nonsurgical
Catheter-Based Interventions for Coronary Artery Disease. Ann Intern Med. ;158:I–24. doi: 10.7326/0003-4819-158-10-201305210-00641
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Published: Ann Intern Med. 2013;158(10):I-24.
Cardiology, Coronary Heart Disease.
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