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Mortality According to Residual SYNTAX Score
Quick Takes
- The present study reports that incomplete revascularization was more frequently observed in patients with PCI when compared with CABG.
- Patients with PCI and complete revascularization had no significant difference in the adjusted risk of all-cause death at 10 years compared with those with CABG, but PCI with incomplete revascularization had a significantly higher risk of all-cause death at 10 years.
- Anticipated completeness of revascularization should be factored in for decision making between CABG and PCI, and if it is unlikely that complete or nearly complete revascularization is achievable with PCI, CABG should be considered.
Study Questions:
What is the survival prognosis at 10 years in all-comers patients with de novo three-vessel disease or left main coronary artery disease randomized to percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) who were originally enrolled in the SYNTAX trial?
Methods:
The investigators of the SYNTAX Extended Survival Study evaluated vital status up to 10 years in patients who were originally enrolled in the SYNTAX trial. The outcomes of the CABG complete revascularization (CR) group were compared with the CABG incomplete revascularization (IR), PCI CR, and PCI IR groups. In addition, in the PCI cohort, the residual SYNTAX score (rSS) was used to quantify the extent of IR and to assess its association with fatal late outcome. The rSS of 0 suggests CR, whereas a rSS >0 identifies degree of IR.
Results:
IR was more frequently observed in patients with PCI versus CABG (56.6% vs. 36.8%) and more common in those with three-vessel disease than left main coronary artery disease in both the PCI (58.5% vs. 53.8%) and CABG arm (42.8% vs. 27.5%). Patients undergoing PCI with CR had no significant difference in 10-year all-cause death compared with those undergoing CABG (22.2% for PCI with CR vs. 24.3% for CABG with IR vs. 23.8% for CABG with CR). In contrast, those with PCI and IR had a significantly higher risk of all-cause death at 10 years compared with CABG and CR (33.5% vs. 23.7%; adjusted hazard ratio [aHR], 1.48; 95% confidence interval [CI], 1.15-1.91). When patients with PCI were stratified according to the rSS, those with a rSS ≤8 had no significant difference in all-cause death at 10 years as the other terciles (22.2% for rSS = 0 vs. 23.9% for rSS >0-4 vs. 28.9% for rSS >4-8), whereas a rSS >8 had a significantly higher risk of 10-year all-cause death as compared with those undergoing PCI with CR (50.1% vs. 22.2%; aHR, 3.40; 95% CI, 2.13-5.43).
Conclusions:
The authors concluded that IR is common after PCI, and the degree of incompleteness was associated with 10-year mortality.
Perspective:
The present study reports that IR was more frequently observed in patients with PCI when compared with CABG, and while patients with PCI and CR had no significant difference in the adjusted risk of all-cause death at 10 years compared with those with CABG, PCI with IR had a significantly higher risk of all-cause death at 10 years. Furthermore, a residual SYNTAX score >8 was associated with a significantly higher risk of all-cause death. Anticipated completeness of revascularization should be factored in for decision making between CABG and PCI, and if it is unlikely that CR or nearly CR is achievable with PCI in patients with three-vessel disease, CABG should be considered.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Coronary Artery Disease
Keywords: Cardiac Surgical Procedures, Coronary Artery Bypass, Coronary Artery Disease, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Risk Assessment, Secondary Prevention
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