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Residual SYNTAX Score After Revascularization in ACS
Study Questions:
Does a residual SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score (RSS) predict outcomes among acute coronary syndrome (ACS) patients undergoing functionally complete revascularization?
Methods:
This was a post-hoc, pooled, patient-level analysis of 547 ACS patients who underwent functionally complete revascularization from three randomized controlled trials: DANAMI-3-PRIMULTI (Primary PCI in Patients With ST-elevation Myocardial Infarction and Multivessel Disease: Treatment of Culprit Lesion Only or Complete Revascularization), FAME (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation), and FAMOUS-NSTEMI (Fractional Flow Reserve Versus Angiographically Guided Management to Optimise Outcomes in Unstable Coronary Syndromes). RSS was based on post–percutaneous coronary intervention (PCI) SYNTAX score. Major adverse cardiac events (MACE) were defined as the composite endpoint of all-cause death, nonfatal myocardial infarction, and any repeat revascularization, and were compared at 2 years stratified by RSS subgroups: 0, 1 to <5, 5 to <10, >10 (RSS = 0 represents angiographically complete revascularization).
Results:
Approximately one half of the patients presented with unstable angina/non–ST-segment elevation myocardial infarction (n = 271) and 276 with ST-segment elevation myocardial infarction. MACE at 2 years occurred in 69 patients (12.6%), and there was no difference in RSS after PCI among those with or without MACE (RSS: 7.2 ± 5.5 vs. 6.6 ± 5.9; p = 0.23). Kaplan-Meier curve analysis showed a similar incidence of MACE regardless of the RSS subgroups (p = 0.54). After adjusting for differences, RSS did not predict MACE.
Conclusions:
Residual angiographic disease as measured by the residual SYNTAX score does not predict 2-year outcomes among patients with ACS who undergo complete revascularization of functionally significant stenoses by fractional flow reserve (FFR). These results lend support to using functional assessment to guide complete revascularization in ACS patients.
Perspective:
The accuracy of FFR in ACS patients has been questioned in the past. Concerns regarding acute microvascular ischemia in nonculprit territories and its impact on FFR results in the setting of an infarct have been raised. Although the study is limited by design (post-hoc analysis involving three different studies), it does lend support to the idea that after FFR-guided complete revascularization, extent of residual angiographic disease does not predict subsequent ischemic events in patients with ACS.
Keywords: Acute Coronary Syndrome, Angina, Unstable, Angiography, Constriction, Pathologic, Fractional Flow Reserve, Myocardial, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention
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