How to use the SYNTAX Score and other Anatomic
and Clinical Risk Scores
in day-to-day Practice ?
William WIJNS
Aalst, Belgium
http://cardio-aalst.be & William.Wijns@olvz-aalst.be
Global appraisal of the patient’s
condition & risk
• Use of a standard check list (adapted to each institution)
–
–
–
–
–
–
–
Clinical information, psychological profile and culture
Co-morbid factors
Possible interference with DAPT
Biochemical markers
LV and valvular function
Testing for ischemia/viability
Coronary angiography
• Use of risk scores
Global appraisal of the patient’s
condition & risk
• Why using Risk scores in day-to-day practice?
– Physicians are risk-averse and driven by personal
experience
– High-risk patients are denied the potentially large
benefit of invasive therapies, be it with increased risk
– Using risk scores helps reducing bias and targeting
treatment strategies to personnalized needs
– Adherences to guidelines increases, with subsequent
improvement in outcomes
How to use the SYNTAX Score and other Anatomic
and Clinical Risk Scores
in day-to-day Practice ?
STEMI
NSTEMI and NSTE-ACS
Stable CAD
http://cardio-aalst.be & William.Wijns@olvz-aalst.be
Joint ESC - EACTS Guidelines
on Myocardial Revascularisation
Joint Task Force on Myocardial Revascularisation of
the European Society of Cardiology (ESC) and
the European Association for Cardio-Thoracic Surgery (EACTS)
Developed with the special contribution of
the European Association for
Percutaneous Cardiovascular Interventions (EAPCI)
European Heart Journal (2010) 31, 2501-2555
European Journal of Cardio-thoracic Surgery 38, S1 (2010) S1-S52
www.escardio.org/guidelines
How to use the SYNTAX Score and other Anatomic
and Clinical Risk Scores
in day-to-day Practice ?
STEMI
- no recommendation,
except for cardiogenic shock
- practice driven by:
time delays
ECG
reperfusion
http://cardio-aalst.be & William.Wijns@olvz-aalst.be
How to use the SYNTAX Score and other Anatomic
and Clinical Risk Scores
in day-to-day Practice ?
NSTEMI and NSTE-ACS
http://cardio-aalst.be & William.Wijns@olvz-aalst.be
Intended Early Invasive vs. Conservative Strategy
Long term outcome by initial Risk Score
Meta-analysis of 3 major trials
50%
45%
Selective invasive
Routine invasive
40%
High
35%
30%
Cumulative
percentage
25%
20%
Intermediate
15%
10%
Low
5%
0%
0
Selective invasive
Routine invasive
2746
2721
Fox KA et al. JACC 2010;55(22):2435-45
www.escardio.org/guidelines
1
2452
2485
2
2351
2410
3
4
2178
2235
2077
2166
5 Follow-up time (years)
2005
2079
Calculating GRACE Risk Score
Killip
class
Points
Systolic
BP
Points
Age
Points
I
0
≤70
66
≤30
0
0-0.39
II
17
70-89
53
30-49
10
III
34
90-109
40
50-69
IV
51
110-129
27
≥130
19
Baseline risk factors
Creatinine Points
Heart
rate
Points
3
≤70
10
0.4-0.9
9
70-89
15
29
1.0-1.9
32
90-109
26
70-79
56
≥2
51
110-129
32
80-89
73
130-149
24
≥90
91
150-169
16
170-199
8
≥200
0
Points
Cardiac arrest at admission
38
ST-segment deviation
18
Positive cardiac markers
14
STEMI
14
Total from clinical evaluation
www.escardio.org/guidelines
Joint 2010 ESC - EACTS Guidelines
on Myocardial Revascularisation
Calculating GRACE Risk Score
http://www.outcomes-umassmed.org/grace
www.escardio.org/guidelines
Joint 2010 ESC - EACTS Guidelines
on Myocardial Revascularisation
Recommendations for
revascularisation in NSTE-ACS
Specification
Class
Level
An invasive strategy is indicated in patients with:
• GRACE score > 140 or at least one high-risk criterion,
• recurrent symptoms,
• inducible ischaemia at stress test.
I
A
An early invasive strategy (< 24 h) is indicated in patients with GRACE score > 140
or multiple other high-risk criteria.
I
A
A late invasive strategy (within 72 h) is indicated in patients with GRACE score <
140 or absence of multiple other high-risk criteria but with recurrent symptoms or
stress-inducible ischaemia.
I
A
Patients at very high ischaemic risk (refractory angina, with associated heart
failure, arrhythmias or haemodynamic instability) should be considered for
emergent coronary angiography (< 2 h).
IIa
C
An invasive strategy should not be performed in patients:
• at low overall risk,
• at a particularly high-risk for invasive diagnosis or intervention.
III
A
www.escardio.org/guidelines
How to use the SYNTAX Score and other Anatomic
and Clinical Risk Scores
in day-to-day Practice ?
Stable CAD
http://cardio-aalst.be & William.Wijns@olvz-aalst.be
Recommended risk stratification scores
to be used in candidates for PCI or CABG
Score
Validated outcomes
Class/Level
PCI
CABG
EuroSCORE
Short and long-term mortality
IIb B
IB
SYNTAX score
Quantify coronary artery disease
complexity
IIa B
III B
Mayo Clinic Risk
Score
MACE and procedural death
IIb C
III C
NCDR CathPCI
In-hospital mortality
IIb B
-
Parsonnet score
30-day mortality
-
III B
STS score
Operative mortality, stroke, renal failure,
prolonged ventilation, deep sternal
infection, re-operation, morbidity, length
of stay < 6 or > 14 days
-
IB
ACEF score
Mortality in elective CABG
-
IIb C
ACEF score = [Age/Ejection Fraction (%)] + 1 (if Creatinine > 2 mg/dL).
www.escardio.org/guidelines
● For PCI, SYNTAX score
emerges as preferred score
to quantify complexity of
CAD, but needs to be tested
in other trials.
● For CABG, both EuroSCORE
and STS score are well
validated, mostly based on
clinical variables.
● STS score is undergoing
periodic adjustment which
makes longitudinal
comparisons difficult.
www.syntaxscore.com
www.escardio.org/guidelines
Joint 2010 ESC - EACTS Guidelines
on Myocardial Revascularisation
www.escardio.org/guidelines
Joint 2010 ESC - EACTS Guidelines
on Myocardial Revascularisation
Indications for CABG versus PCI in stable
patients with lesions suitable for both procedures and
low predicted surgical mortality
Subset of CAD by anatomy
Favours CABG
Favours PCI
IIb C
IC
1VD or 2VD - proximal LAD
IA
IIa B
3VD simple lesions, full functional revascularisation achievable
with PCI, SYNTAX score ≤ 22
IA
IIa B
3VD complex lesions, incomplete revascularisation achievable
with PCI, SYNTAX score > 22
IA
III A
Left main (isolated or 1VD, ostium/shaft)
IA
IIa B
Left main (isolated or 1VD, distal bifurcation)
IA
IIb B
Left main + 2VD or 3VD, SYNTAX score ≤ 32
IA
IIb B
Left main + 2VD or 3VD, SYNTAX score ≥ 33
IA
III B
1VD or 2VD - non-proximal LAD
 In the most severe patterns of CAD, CABG appears to offer a survival advantage
as well as a marked reduction in the need for repeat revascularisation
www.escardio.org/guidelines
Further validation of SYNTAX Score
- SYNTAX Score works for non SYNTAX trial population
Tested on all-comers population from Resolute trial
C-index 0.62
Garg S et al, JACC Cardiovasc Interv. 2011 Apr;4(4):432-41
http://cardio-aalst.be & William.Wijns@olvz-aalst.be
New scores to be further validated
- EuroHeart Score (based on EuroHeart Survey) for PCI
Large dataset of 46.064 pts, 1:1 training:validation set
16 clinical and angiographic variables predict mortality
C-index 0.91
De Mulder M et al, Eur Heart J. 2011 Jun;32(11):1398-408. Epub 2011 Feb 22.
http://cardio-aalst.be & William.Wijns@olvz-aalst.be
Currently used clinical and angiographic scores
Score
Number of variables used to
calculate risk
Validated Outcomes
Recommendation/
Level of evidence
PCI
CABG
Clinical
Angiographic
EuroSCORE
17
0
Short and long-term mortality
IIb B
IB
SYNTAX score
0
11 (per lesion)
Quantify coronary artery disease
complexity
IIa B
III B
Why not combine EuroSCORE and SYNTAX score?
Global Risk Classification
Risk scores
Global Risk Classification
low, mid and high
Presented by P. W. Serruys
SYNTAX score
Euro
SCORE
<22
23-32
>33
0-2
low
low
mid
3-5
low
low
mid
>6
mid
mid
high
All-cause mortality to 3 years
LM Patients (randomized + registry)
60
>33
0-2
low
low
mid
3-5
low
low
mid
>6
mid
mid
high
Intermediate GRC (N=294)
Intermediate GRC (N=177)
High GRC (N=118)
P=0.004
14.8%
6.5%
5.3%
0
0
23-32
Low GRC (N=185)
GABG
30
<22
Low GRC (N=235)
36
12
24
Months Since Allocation
Cumulative KM Event Rate ± 1.5 SE; log-rank P value
Cumulative Event Rate (%)
Cumulative Event Rate (%)
N=1079
SYNTAX Score
Euro
SCORE
60
High GRC (N=70)
PCI
30
P<0.001
30.0%
13.1%
2.7%
0
0
36
12
24
Months Since Allocation
ITT population
How to use the SYNTAX Score and other Anatomic
and Clinical Risk Scores
in day-to-day Practice ?
Just use them routinely
http://cardio-aalst.be & William.Wijns@olvz-aalst.be