Comparison of the New Mayo Clinic
Risk Scores and Clinical SYNTAX
Score in Predicting Adverse
Cardiovascular Outcomes following
Percutaneous Coronary Intervention
at the Philippine Heart Center
Helenne Joie M. Brown, MD
Background
Risk Stratification
Management
Evaluation of
health economics
Quality Control
Ischemic Heart
Disease
Objective
New Mayo Clinic
Risk Scores
Clinical
Prognostic Value
In-hospital and 30-day
Mortality and MACCE
Study Design
Prospective Cohort Study
Inclusion Criteria
Exclusion Criteria
All patients who underwent
percutaneous coronary
intervention at the Philippine
Heart Center during the
period of April 1, 2011 to
September 30, 2011,
aged > 18 years were included.
Patients with no baseline
systolic function.
Study Design
Sample Size
The computed sample size was > 460 based on
95% confidence level and 80% power to detect
statistical significance at assumed difference in
area under the curve of 10%. The assumption was
based on the paper of Garg et al which presented
an AUC of 0.89 for MACE.
Garg S et al. A New Tool for the Risk Stratification of Patients with
Complex Coronary Artery Disease: The Clinical SYNTAX Score. Circ
Cardiovasc Interv. 2010;3:317-326.
Study Design
Study Maneuver
Ischemic Heart Disease
Cardiovascular history
and risk factors
2 Interventional
Cardiologists
Coronary Angiogram
PCI
Study Design
Study Maneuver
New Mayo Clinic
Risk Scores
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Age
Serum creatinine
LVEF
Preprocedural shock = 9 points
MI < 24 hours = 4 points
CHF on presentation = 3 points
PAD = 2 points
Clinical
CSS = [SYNTAX
Score] x [modified
ACEF score]
Study Design
Study Maneuver
New Mayo Clinic
Risk Scores
Clinical
Risk Stratification
Mortality Prediction MACCE Prediction
Very low risk: 0-5
Very low risk: 0-2
Low-risk: 6-7
Low-risk: 3-5
Moderate risk: 8-10 Moderate risk: 6-90
High risk: 11-12
High risk: 10-13
Very high risk: 13+ Very high risk: 14+
Outcomes
In-hospital and 30-day
all-cause mortality and
MACCE
Low-risk: < 15.6
Moderate risk: >15.6 <27.5
High risk: >27.5
Study
Results
Maneuver
New Mayo Clinic
Risk Scores
N = 482
Clinical
Risk Stratification
Mortality Prediction MACCE Prediction
Very low risk: 0-5
Very low risk: 0-2
Low-risk: 6-7
Low-risk: 3-5
Moderate risk: 8-10 Moderate risk: 6-90
High risk: 11-12
High risk: 10-13
Very high risk: 13+ Very high risk: 14+
Outcomes
In-hospital and 30-day
all-cause mortality and
MACCE
Low-risk: < 15.6
Moderate risk: >15.6 <27.5
High risk: >27.5
Results
Table 1. Baseline and Procedural Variables
Variable
n = 482
Mean
SD
Age, + SD, years
59.8
+ 11.4
Serum Creatinine, mg/dl
1.2
+ 0.9
Creatinine Clearance,
74.1
+ 29.6
55.3
+ 9.4
ml/min
LVEF, %
Results
Table 1. Baseline and Procedural Variables
Variable
n= 482
No.
%
Male
367
76.1
Female
115
23.9
Myocardial Infarction < 24 hours
98
20.3
Unstable Angina
176
36.5
Non-elective PCI
82
17.0
Diabetes mellitus
175
36.3
Current and previous smoker
253
52.5
Hypertension
373
77.4
Dyslipidemia
373
77.4
CHF on presentation
64
13.3
Gender
Results
Table 1. Baseline and Procedural Variables
Variable
n= 482
No.
%
NYHA Class III or IV
22
4.6
PAD
23
4.8
Previous PCI
40
8.3
Previous CABG
29
6.0
Previous MI
138
28.6
Previous CVA
20
4.1
Family History of IHD
86
17.8
Results
Table 1. Baseline and Procedural Variables
Variable
n= 482
No.
%
ASA
425
88.2
Clopidogrel
298
61.8
B-blockers
233
48.3
ACE inhibitors/ARBs
405
84.0
Statins
446
92.5
Meds at Screening
Results
New Mayo Clinic
Risk Scores
N = 482
Clinical
Risk Stratification
Mortality Prediction MACCE Prediction
Very low risk: 0-5
Very low risk: 0-2
Low-risk: 6-7
Low-risk: 3-5
Moderate risk: 8-10 Moderate risk: 6-90
High risk: 11-12
High risk: 10-13
Very high risk: 13+ Very high risk: 14+
Outcomes
In-hospital and 30-day
all-cause mortality and
MACCE
Low-risk: < 15.6
Moderate risk: >15.6 <27.5
High risk: >27.5
Results
Table 2. In-hospital Mortality and MACCE
following PCI
Event
n= 482
No.
%
Mortality
22
4.6
Myocardial Infarction
5
1
Emergency CABG
1
0.2
CVA
9
1.9
Figure 1. ROC Curve for In-hospital Mortality for the New Mayo
Clinic Risk Score (NMCRS) for Predicting Mortality, the NMCRS
for Predicting MACE and the Clinical Syntax Score (CSS).
Figure 6. ROC Curve for In-hospital Composite Endpoints for the New Mayo
Clinic Risk Score (NMCRS) for Predicting Mortality, the NMCRS for Predicting
MACE and the Clinical Syntax Score (CSS).
Results
New Mayo Clinic
Risk Scores
N = 482
Clinical
Risk Stratification
Mortality Prediction MACCE Prediction
Very low risk: 0-5
Very low risk: 0-2
Low-risk: 6-7
Low-risk: 3-5
Moderate risk: 8-10 Moderate risk: 6-90
High risk: 11-12
High risk: 10-13
Very high risk: 13+ Very high risk: 14+
Outcomes
In-hospital and 30-day
all-cause mortality and
MACCE
Low-risk: < 15.6
Moderate risk: >15.6 <27.5
High risk: >27.5
Results
Table 2. 30-day Mortality and MACCE
following PCI
Event
n= 482
No.
%
Mortality
9
2
Myocardial Infarction
9
2
Emergency CABG
0
0
CVA
1
0.2
Figure 4. ROC Curve for 30-day Mortality for the New Mayo Clinic Risk Score
(NMCRS) for Predicting Mortality, the NMCRS for Predicting MACE and the
Clinical Syntax Score (CSS).
Figure 7. ROC Curve for 30-day Composite Endpoints for the New Mayo Clinic
Risk Score (NMCRS) for Predicting Mortality, the NMCRS for Predicting MACE
and the Clinical Syntax Score (CSS).
Figure 8. ROC Curve for In-hospital and 30-day Composite Endpoints for the
New Mayo Clinic Risk Score (NMCRS) for Predicting Mortality, the NMCRS for
Predicting MACE and the Clinical Syntax Score (CSS).
versus
Age
Serum creatinine
LVEF
 predictors of adverse outcomes after revascularization
Garg et al. A New Tool for the Risk Stratification of Patients with Complex
Coronary Artery Disease: The Clinical SYNTAX Score. Circ Cardiovasc Interv.
2010;3:317-326.
Ranucci et al. Risk of Assessing Mortality Risk in Elective Cardiac Operations:
Age, Creatinine, Ejection Fraction, and the Law of Parsimony. Circulation.
2009;119:3053-3061.
 not subject to interobserver variability
Results
Risk Stratification
Mortality Prediction
MACCE Prediction
Clinical variables
Outcomes
In-hospital and 30-day
all-cause mortality and
MACCE
Clinical +
angiographic
variables
versus
“… despite exclusion of angiographic variables, the
NMCRS can accurately estimate peri-procedural risk from
PCI.”
Singh et al. Bedside Estimation of Risk from Percutaneous Coronary
Intervention: The New Mayo Clinic Risk Scores. Mayo Clin Proc June
2007;82(6):701-708.
Our study demonstrated that the prognostic utility of the
NMCRS for predicting mortality and MACCE can be
extended to estimation of mortality and MACCE 30 days
after a patient undergoes PCI.
versus
all-comers study:
1-, 2- 3-vessel CAD
2- or 3-vessel CAD
Excluded:
Previous PTCA
Left Main CAD
Overt CHF
LVEF < 30%
Hx of TIA
Hx of transmural MI
Utility: long-term
outcomes
Conclusion
This study demonstrates the superior ability
of a risk stratification tool which uses purely
clinical variables, i.e. (1) the NMCRS for
Predicting Mortality to predict in-hospital
mortality and composite MACCE and (2)
the NMCRS for Predicting MACE to predict
30-day mortality and composite MACCE,
when compared with the CSS which uses
angiographic and clinical variables.
Recommendation
• We therefore recommend the use of the New Mayo
Clinic Risk Score for risk stratification of patients who
will undergo PCI.
simple bedside tool
expedient for both the physician and patient in
decision-making for revascularization
superior discriminative ability over the Clinical
Syntax Score for peri-procedural and 30-day
adverse outcomes
Good afternoon.