Prognostic Value of SYNTAX Score II | Journal Scan

Study Questions:

Can the SYNTAX Score II be validated, and outcomes be forecasted, for the randomized EXCEL (Evaluation of the Xience Everolimus-Eluting Stent Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial?


The authors applied the SYNTAX II score to patients enrolled in the EXCEL trial. This study is a prospective, randomized multicenter trial designed to establish the efficacy and safety of percutaneous coronary intervention (PCI) with the everolimus-eluting stent compared with coronary artery bypass graft (CABG) surgery in patients with unprotected left-main coronary artery (ULMCA) disease and low-intermediate anatomical SYNTAX scores (<33). The 95% prediction intervals (PIs) for mortality were computed using simulation with bootstrap resampling (10,000 times).


For the entire study cohort, the 4-year predicted mortalities were 8.5% and 10.5% in the PCI and CABG arms, respectively (odds ratios [OR], 0.79; 95% PI, 0.43-1.50). In subjects with low (≤22) anatomical SYNTAX scores, the predicted OR was 0.69 (95% PI, 0.34-1.45); in intermediate anatomical SYNTAX scores (23-32), the predicted OR was 0.93 (95% PI, 0.53-1.62). Based on 4-year mortality predictions in EXCEL, clinical characteristics shifted long-term mortality predictions either in favor of PCI (older age, male gender, and chronic obstructive pulmonary disease) or CABG (younger age, lower creatinine clearance, female gender, reduced left ventricular ejection fraction).


The SYNTAX Score II predicts an equipoise for long-term mortality between CABG and PCI in subjects with ULMCA disease up to an intermediate anatomical complexity. Both anatomical and clinical characteristics impact long-term mortality predictions and decision making between CABG and PCI.


The authors are to be commended for using the SYNTAX score to predict the outcomes of PCI and CABG among patients undergoing revascularization for ULMCA disease, given that the accuracy of their prediction can only be verified once the final results of the EXCEL trial are available. It is reassuring that based on the best available data, there is true equipoise on the subject and either therapy may be equally efficacious among patients with a low or intermediate SYNTAX score.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery

Keywords: Coronary Artery Bypass, Coronary Vessels, Drug-Eluting Stents, Stents, Percutaneous Coronary Intervention, Prospective Studies, Decision Making

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