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
Ischemic Heart
Disease
Quality Control

Objective
New Mayo Clinic
Risk Scores
Prognostic Value
Clinical
In-hospital and 30-day
Mortality and MACCE

Study Design
Prospective Cohort Study
Inclusion 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.
Exclusion Criteria
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
New Mayo Clinic
Risk Scores
Study Maneuver
Clinical
• Age
• Serum creatinine
• LVEF
• Preprocedural shock = 9 points
• MI < 24 hours = 4 points
• CHF on presentation = 3 points
• PAD = 2 points
CSS = [SYNTAX
Score] x [modified
ACEF score]

Study Design
New Mayo Clinic
Risk Scores
Study Maneuver
Clinical
Risk Stratification
Mortality Prediction
Very low risk: 0-5
Low-risk: 6-7
Moderate risk: 8-10
High risk: 11-12
Very high risk: 13+
MACCE Prediction
Very low risk: 0-2
Low-risk: 3-5
Moderate risk: 6-90
High risk: 10-13
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

New Mayo Clinic
Risk Scores
N = 482
Clinical
Risk Stratification
Mortality Prediction
Very low risk: 0-5
Low-risk: 6-7
Moderate risk: 8-10
High risk: 11-12
Very high risk: 13+
MACCE Prediction
Very low risk: 0-2
Low-risk: 3-5
Moderate risk: 6-90
High risk: 10-13
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
Age, + SD, years
Serum Creatinine, mg/dl
Creatinine Clearance, ml/min
LVEF, %
Mean
59.8
1.2
74.1
n = 482
SD
+ 11.4
+ 0.9
+ 29.6
55.3
+ 9.4

Results
Table 1. Baseline and Procedural Variables
Variable n= 482
No. %
Gender
Male
Female
Myocardial Infarction < 24 hours
Unstable Angina
Non-elective PCI
Diabetes mellitus
Current and previous smoker
Hypertension
Dyslipidemia
CHF on presentation
367
115
98
176
82
175
253
373
373
64
52.5
77.4
77.4
13.3
76.1
23.9
20.3
36.5
17.0
36.3

Results
Table 1. Baseline and Procedural Variables
Variable
NYHA Class III or IV
PAD
Previous PCI
Previous CABG
Previous MI
Previous CVA
Family History of IHD
29
138
20
86
No.
22
23
40 n= 482
6.0
28.6
4.1
17.8
%
4.6
4.8
8.3

Results
Table 1. Baseline and Procedural Variables
Variable
Meds at Screening
ASA
Clopidogrel
B-blockers
ACE inhibitors/ARBs
Statins
No. n= 482
%
425
298
233
405
446
88.2
61.8
48.3
84.0
92.5

New Mayo Clinic
Risk Scores
Results
N = 482
Clinical
Risk Stratification
Mortality Prediction
Very low risk: 0-5
Low-risk: 6-7
Moderate risk: 8-10
High risk: 11-12
Very high risk: 13+
MACCE Prediction
Very low risk: 0-2
Low-risk: 3-5
Moderate risk: 6-90
High risk: 10-13
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
Mortality
Myocardial Infarction
Emergency CABG
CVA
No.
22
5
1
9 n= 482
%
4.6
1
0.2
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).

New Mayo Clinic
Risk Scores
Results
N = 482
Clinical
Risk Stratification
Mortality Prediction
Very low risk: 0-5
Low-risk: 6-7
Moderate risk: 8-10
High risk: 11-12
Very high risk: 13+
MACCE Prediction
Very low risk: 0-2
Low-risk: 3-5
Moderate risk: 6-90
High risk: 10-13
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
Event
Mortality
Myocardial Infarction
Emergency CABG
CVA
Table 2. 30-day Mortality and MACCE following PCI
No.
9
9
0
1 n= 482
%
2
2
0
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 .

all-comers study:
1-, 2- 3-vessel CAD versus
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