Perspective:

The SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) Score has established itself as an anatomical-based tool for objectively determining the complexity of coronary artery disease and guiding decision-making between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), and is now advocated in both the European and US revascularization guidelines for decision-making. Since the SYNTAX Score was developed, limitations of this scoring system in aiding decision-making between CABG and PCI have become evident—namely, the lack of clinical variables and lack of a personalized approach to decision-making. The SYNTAX Score II was therefore built on the ACEF (age, creatinine, ejection fraction) ‘skeleton,’ with the addition of risk factors that were shown to directly affect decision-making between CABG and PCI—that is, interaction effects, namely a risk factor being more predictive of mortality in patients undergoing PCI compared with CABG, or vice versa. Additional SYNTAX-based tools (residual and post-CABG SYNTAX Scores), as measures of completeness of revascularization, show significant promise, and may aid the heart team in determining a reasonable level of revascularization.