Adding clinical factors to the anatomical SYNTAX model improved prediction of 4-year mortality with surgery versus stenting for complex coronary artery disease.
The SYNTAX score provides an anatomically based measure of coronary artery disease to help physicians and patients choose an appropriate revascularization strategy. However, other patient characteristics are often important factors in clinical decisions.
To improve the SYNTAX scoring system, investigators used SYNTAX trial data to identify six clinical factors — age, creatinine clearance, left ventricular ejection fraction [LVEF], peripheral vascular disease, female sex, and chronic obstructive pulmonary disease [COPD]) — that independently predicted 4-year mortality or showed an interaction effect between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for long-term mortality (notably, diabetes did not meet either of these criteria and was excluded from the model). These variables were combined with two anatomic measures: SYNTAX score and presence of left main disease.
Compared with the original SYNTAX model, the SYNTAX score II predicted similar 4-year mortality with CABG and PCI at lower scores with some clinical factors (female sex, lower LVEF) and at higher scores with others (older age, COPD, left main disease). The new model discriminated well between CABG and PCI, both in the SYNTAX population and in a validation cohort of 2900 participants in an international registry.
Comment: The inclusion of clinical variables improves the SYNTAX score by allowing clinicians to identify lower-risk patients in high categories of anatomic risk, and vice versa. Although externally validated, the new score requires further validation in randomized studies. In the meantime, clinicians should consider taking this common-sense approach to making revascularization decisions.
Source: Journal Watch Cardiology