Usefulness of SYNTAX Score to Select Patients With Left Main Coronary Artery Disease to Be Treated With Coronary Artery Bypass Graft

Evaluate the Quality of Life in Patients With Percutaneous Coronary Intervention Versus Coronary Artery Bypass Graft

Introduction Globally, coronary heart disease is the most imperative cause of premature death. However, timely management with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) can improve the quality of life (QoL) and reduce mortality. The objective of this study was to evaluate the QoL between the patients who received PCI and CABG for the treatment of coronary heart disease. Materials and methods This was a retrospective observational study. Patients who underwent PCI or CABG at least three months before or more at enrollment were purposefully selected. Results A total of 156 patients were enrolled, 78 in each group. Health-related QoL was assessed by using the SF-36 scale for PCI or CABG procedures. The mean ± SD scores of QoL for PCI and CABG were 78.95 ±10.14 and 78.17 ± 10.92, respectively. Of the patients, 72.43% felt better after treatment, 17.95% felt the same as before treatment, and 9.62% felt worse than before treatment in both groups. Among CABG patients, 38.46% felt significantly better after treatment compared to PCI (33.97%) (p=0.048). Moreover, more CABG patients (6.41%) felt significantly worse than PCI patients (3.21%) after treatment (p=0.048). Male patients were significantly more in the CABG group (89.74%) compared to the PCI group (75.64%). In contrast, female patients had more PCI (24.36%) compared to CABG patients (10.26%) (p=0.020). Conclusion Subjective perceptions of physical and mental well-being improved significantly from before treatment to at least three months after treatment, and an enhanced health-related QoL was noticed for medical intervention (PCI) and surgical approach (CABG).

Developing a Clinical Decision Support System for Prediction Postoperative Coronary Artery Bypass Grafting Infection in Diabetic Patients

BACKGROUND

Postoperative infection in Coronary Artery Bypass Graft (CABG) is one of the most common complications for diabetic patients, due to an increase in the hospitalization and cost. To address these issues, it is necessary to apply some solutions.

OBJECTIVE

The study aimed to the development of a Clinical Decision Support System (CDSS) for predicting the CABG postoperative infection in diabetic patients.

MATERIAL AND METHODS

This developmental study is conducted on a private hospital in Tehran in 2016. From 1061 CABG surgery medical records, we selected 210 cases randomly. After data gathering, we used statistical tests for selecting related features. Then an Artificial Neural Network (ANN), which was a one-layer perceptron network model and a supervised training algorithm with gradient descent, was constructed using MATLAB software. The software was then developed and tested using the receiver operating characteristic (ROC) diagram and the confusion matrix.

RESULTS

Based on the correlation analysis, from 28 variables in the data, 20 variables had a significant relationship with infection after CABG (P<0.05). The results of the confusion matrix showed that the sensitivity of the system was 69%, and the specificity and the accuracy were 97% and 84%, respectively. The Receiver Operating Characteristic (ROC) diagram shows the appropriate performance of the CDSS.

CONCLUSION

The use of CDSS can play an important role in predicting infection after CABG in patients with diabetes. The designed software can be used as a supporting tool for physicians to predict infections caused by CABG in diabetic patients as a susceptible group. However, other factors affecting infection must also be considered for accurate prediction.

Predictors and clinical outcomes of post-coronary artery bypass grafting cerebrovascular strokes

Background

Despite the improved medical and surgical managements, still there is a significant risk of developing acute cerebrovascular strokes after coronary artery bypass grafting (CABG). Our objectives were to study the immediate and long-term outcomes after CABG and to identify the possible predictors of post-CABG strokes.

Results

Between January 2016 and August 2020, 410 adult patients, mostly males (82.2%), were retrospectively enrolled after CABG. Acute postoperative strokes occurred in 31 (7.5%) patients; of them, 30 (96.8%) patients had ischemic stroke, while 1 (3.2%) had hemorrhagic stroke. Mechanical thrombectomy was done in two cases. The patients who developed acute cerebral stroke had significantly higher admission (p = 0.02) and follow-up (p < 0.001) SOFA scores, higher arterial blood lactate level (p < 0.001), longer hospitalization (p < 0.001) and more hospital mortality (p < 0.001) compared with the patients who did not develop stroke. Kaplan–Meier curves for 5-year mortality showed increased risk in those patients with postoperative stroke (HR: 23.03; 95% CI: 6.10–86.92, p < 0.001). After multivariate regression, the predictors of early postoperative stroke were carotid artery stenosis (CAS), postoperative atrial fibrillation, cardiopulmonary bypass time, prior cerebral stroke, admission SOFA score and chronic kidney disease (CKD). The predictors of late cerebrovascular stroke were CAS, combined CABG and valve surgery, CKD, atrial fibrillation, prior stroke and HbA1c.

Conclusions

The development of post-CABG acute cerebrovascular stroke is associated with longer hospitalization, multiple morbidities and increased mortality. Careful assessment and management of risk factors especially atrial fibrillation and carotid artery stenosis should be implemented to decrease this substantial complication after CABG.

PCI or CABG for Left Main Disease: Does Disease Location Matter?

PURPOSE OF REVIEW

This review attempts to specifically assess impact of disease location in left main artery on mortality and cardiovascular outcomes in patients treated with percutaneous coronary intervention versus coronary artery bypass surgery.

RECENT FINDINGS

The management of left main disease, once thought to be the sole province of cardiothoracic surgeon, has recently undergone a reappraisal by the cardiovascular medicine community. For many years, societal guideline recommendations advised bypass surgery as the "de rigeur" method of revascularization for unprotected left main disease. However, recent studies suggest that coronary intervention, especially with advances in drug-eluting stent technology, has mounted a serious challenge to surgical bypass in treatment of this disease. Although overall mortality rates are comparable for percutaneous coronary intervention and bypass surgery, left main disease location does influence long-term outcomes for percutaneous coronary intervention more than bypass surgery. A patient- and lesion-centered approach to treatment of this disease may provide optimal outcomes.

Predictive Value of the Residual SYNTAX Score in Patients With Cardiogenic Shock

BACKGROUND

In hemodynamically stable patients, complete revascularization (CR) following percutaneous coronary intervention (PCI) is associated with a better prognosis in chronic and acute coronary syndromes.

OBJECTIVES

This study sought to assess the extent, severity, and prognostic value of remaining coronary stenoses following PCI, by using the residual SYNTAX score (rSS), in patients with cardiogenic shock (CS) related to myocardial infarction (MI).

METHODS

The CULPRIT-SHOCK (Culprit Lesion Only Percutaneous Coronary Intervention [PCI] Versus Multivessel PCI in Cardiogenic Shock) trial compared a multivessel PCI (MV-PCI) strategy with a culprit lesion-only PCI (CLO-PCI) strategy in patients with multivessel coronary artery disease who presented with MI-related CS. The rSS was assessed by a central core laboratory. The study group was divided in 4 subgroups according to tertiles of rSS of the participants, thereby isolating patients with an rSS of 0 (CR). The predictive value of rSS for the 30-day primary endpoint (mortality or severe renal failure) and for 30-day and 1-year mortality was assessed using multivariate logistic regression.

RESULTS

Among the 587 patients with an rSS available, the median rSS was 9.0 (interquartile range: 3.0 to 17.0); 102 (17.4%), 100 (17.0%), 196 (33.4%), and 189 (32.2%) patients had rSS = 0, 0 < rSS ≤5, 5 < rSS ≤14, and rSS >14, respectively. CR was achieved in 75 (25.2%; 95% confidence interval [CI]: 20.3% to 30.5%) and 27 (9.3%; 95% CI: 6.2% to 13.3%) of patients treated using the MV-PCI and CLO-PCI strategies, respectively. After multiple adjustments, rSS was independently associated with 30-day mortality (adjusted odds ratio per 10 units: 1.49; 95% CI: 1.11 to 2.01) and 1-year mortality (adjusted odds ratio per 10 units: 1.52; 95% CI: 1.11 to 2.07).

CONCLUSIONS

Among patients with multivessel disease and MI-related CS, CR is achieved only in one-fourth of the patients treated using an MV-PCI strategy. and the residual SYNTAX score is independently associated with early and late mortality.

Comparison of the prognostic value of SYNTAX score and clinical SYNTAX score on outcomes of Chinese patients underwent percutaneous coronary intervention

Background

Previous studies have validated the capability of SYNTAX score (SS) and clinical SYNTAX score (CSS) in the prediction of clinical outcomes in patients who have undergone PCI; however, studies on comparison of these two scoring systems in Chinese population have been sparse.

Methods

To study the ability of SS and CSS in prediction of clinical outcomes of Chinese patients underwent percutaneous coronary intervention (PCI). We retrospectively calculated SS and CSS for 547 Chinese patients from a single center who underwent PCI. Patients were stratified into tertiles according to their SS and CSS. We compared the 2-year clinical outcomes in these patients stratified separately by SS and CSS tertiles.

Results

The incidence of major adverse cardiac and cerebro-vascular events (MACCE) was the highest in patients with SS_HIGH (13.5%), comparing to 6.8% in SS_MED and 0% in SS_LOW (p < 0.0001). The Cox multivariable analysis showed that the SS and CSS were both strong independent predictors for MACCE [1.100 (1.069–1.133), 1.017 (1.010–1.025), both p < 0.0001]. The receiver operating characteristic (ROC) curves showed the areas-under-the-curves for all-cause death by CSS was slightly larger comparing to SS but not significantly (AUC SS, 0.64; AUC CSS, 0.71; p = 0.23).

Conclusion

We concluded that both the SS and CSS were capable of risk stratification of clinical outcomes in all-comers population as well as in low and moderate risk Chinese patients undergoing PCI with CSS showing slightly better advantage.

Real-time coronary artery stenosis detection based on modern neural networks

Invasive coronary angiography remains the gold standard for diagnosing coronary artery disease, which may be complicated by both, patient-specific anatomy and image quality. Deep learning techniques aimed at detecting coronary artery stenoses may facilitate the diagnosis. However, previous studies have failed to achieve superior accuracy and performance for real-time labeling. Our study is aimed at confirming the feasibility of real-time coronary artery stenosis detection using deep learning methods. To reach this goal we trained and tested eight promising detectors based on different neural network architectures (MobileNet, ResNet-50, ResNet-101, Inception ResNet, NASNet) using clinical angiography data of 100 patients. Three neural networks have demonstrated superior results. The network based on Faster-RCNN Inception ResNet V2 is the most accurate and it achieved the mean Average Precision of 0.95, F1-score 0.96 and the slowest prediction rate of 3 fps on the validation subset. The relatively lightweight SSD MobileNet V2 network proved itself as the fastest one with a low mAP of 0.83, F1-score of 0.80 and a mean prediction rate of 38 fps. The model based on RFCN ResNet-101 V2 has demonstrated an optimal accuracy-to-speed ratio. Its mAP makes up 0.94, F1-score 0.96 while the prediction speed is 10 fps. The resultant performance-accuracy balance of the modern neural networks has confirmed the feasibility of real-time coronary artery stenosis detection supporting the decision-making process of the Heart Team interpreting coronary angiography findings.

Long-term clinical outcomes after a percutaneous coronary intervention with a drug-eluting stent in patients with unprotected left main coronary artery disease excluded from clinical trials

BACKGROUND

Major randomized clinical trials assessing clinical outcomes in patients who underwent a percutaneous coronary intervention (PCI) for left main coronary artery disease excluded some high-risk subsets. Whether the effectiveness and safety of a percutaneous approach in this group of patients are comparable with those observed in clinical trials is unclear. We aimed to explore the long-term outcomes of contemporary drug-eluting stent (DES)-based revascularization for left main coronary artery disease in patients presenting with one or more clinical or angiographic characteristics who would have precluded inclusion in randomized trials.

PATIENTS AND METHODS

Between April 2003 and December 2011, 340 consecutive patients with unprotected left main coronary artery stenosis of at least 50% who underwent successful PCI with DES at Sejong General Hospital (Bucheon, Republic of Korea) were included in this retrospective study. Patients were classified into the exclusion group (group E; n=120) and the inclusion group (group I; n=220) according to the prespecified inclusion and exclusion criteria utilized in clinical trials.

RESULTS

During the median follow-up of 86 (52-114) months, major adverse cardiac or cerebrovascular events occurred in 69 (31.4%) patients in group I and 46 (38.3%) patients in group E (P=0.155). In the propensity score-matched population, group E was not associated with a higher incidence of major adverse cardiac or cerebrovascular events (hazard ratio: 1.42, 95% confidence interval: 0.76-2.65, P=0.758). Definite or probable stent thrombosis occurred in five patients of group I, with no cases in group E.

CONCLUSION

In our real-world registry, about a third of patients who underwent PCI for unprotected left main coronary artery stenosis had one or more high-risk characteristics or comorbid conditions that represent exclusion criteria of previous randomized trials. PCI using DES is feasible in these patients.

Association of epicardial fat thickness assessed by echocardiography with the severity of coronary artery disease

Introduction: Epicardial fat thickness (EFT) can reflect risk of cardiovascular disease particularly coronary artery disease (CAD). The aim of this study was to investigate the association of EFT assessed by echocardiography and presence as well as severity of CAD.

Methods: Two hundred and twenty consecutive patients who candidate for coronary angiography because of possible CAD were studied. EFT was evaluated in standard parasternal long axis (PlAX) and parasternal short axis (PSAX) view from 3 cardiac cycles at the end of systole and diastole. The severity of CAD was defined in two ways: (1) SYNTAX score, (2) number of vessels with significant lesion.

Results: PLAX (EFT_S) (EFT in systole) and PLAX (EFT_d) (EFT in diastole) were significantly higher in patients with CAD in comparison with patients without CAD (P = 0.046, P = 0.041 respectively). There was a significant correlation between PLAX (EFT_S) (P = 0.05), PLAX (EFT_d) (P = 0.04) and SYNTAX score. There was no statistically significant relationship between EFT and number of diseased vessel (P > 0.05). Multivariate analysis was done for adjusting the effects of confounding factors and it showed that EFT (OR: 10.53, P = 0.004) was significantly correlated severe CAD as assessed by the SYNTAX score.

Conclusion: EFT assessed by transthoracic echocardiography was higher significantly in patients with CAD than in normal patients. EFT as an easily available and cost-effective echocardiographic feature might be useful to predict complexity of CAD.

Inter-observer variation of Syntax score among cardiac surgeons, clinical and interventional cardiologists

Background:

Despite the complexity of SYNTAX score (SS), guidelines recommend this tool to help choosing between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with left main of three-vessel coronary artery disease. The aim of this study was to compare the inter-observer variation in SS performed by clinical cardiologists (CC), interventional cardiologists (IC), and cardiac surgeons (CS).

Methods:

Seven coronary angiographies from patients with left main and/or three-vessel disease chosen by a heart team were analyzed by 10 CC, 10 IC and 10 CS. SS was calculated via SYNTAX website.

Results:

Kappa concordance was very low between CC and CS (k = 0.176), moderate between CS and IC (k = 0.563), and moderate between CC and IC (0.553). There was a statistically significant difference between CC, who classified more cases as low complexity (70%), and CS, who classified more cases as moderate complexity (80%) (p = 0.041).

Conclusion:

Concordance between SS analyzed by CC, CS and IC is low. The usefulness of SS in decision-making of revascularization strategy is undeniable and evidence supports its use. However, this study highlights the importance of well-trained professionals on calculating the SS. It could avoid misclassification of borderline cases.

Anterior Tragal Crease Is Associated With SYNTAX Score in Non-ST-Segment Elevation Myocardial Infarction

The main aim of this study was to investigate the relation between anterior tragal crease (ATC) and coronary artery lesion complexity and severity assessed using the SYNTAX score (SXscore) in patients with non-ST-segment elevation myocardial infarction (NSTEMI). A total of 121 patients with a first-time diagnosis of NSTEMI were consecutively enrolled. ATC was defined as ≥1 crease that was close to the tragus and descended anteriorly. SXscore was calculated using the SXscore algorithm. The SXscore was higher in the ATC-positive group than in the ATC-negative group (11.85 ± 8.20 vs 7.52 ± 6.38, P = .003). In the univariate analysis, hemoglobin (male: 11.7-17.4 g/dL, female: 11.7-16.1 g/dL; P = .006), diabetes mellitus (P = .031), current smoking (P = .022), and presence of ATC (P = .022) were significantly associated with increased SXscore. Multivariate analysis revealed ATC (95% confidence interval [CI]: 1.313-7.800, P = .011), current smoking (95% CI: 2.034-13.893, P = .001), and hemoglobin (95% CI: 0.433-0.822, P = .002) as independent determinants of increased SXscore. Anterior tragal crease is easily detected by physical examination. Presence of ATC in patients with NSTEMI may be a warning signal of complexity and severity of coronary artery disease (CAD).

Impact of non-respect of SYNTAX score II recommendation for surgery in patients with left main coronary artery disease treated by percutaneous coronary intervention: an EXCEL substudy

OBJECTIVES

The SYNTAX score II (SSII) was developed from the SYNTAX trial to predict the 4-year all-cause mortality after left main or multivessel disease revascularization and to facilitate the decision-making process. The SSII provides the following treatment recommendations: (i) coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) (equipoise risk), (ii) CABG preferred (excessive risk for PCI) or (iii) PCI preferred (excessive risk for CABG). We sought to externally validate SSII and to investigate the impact of not abiding by the SSII recommendations in the randomized EXCEL trial of PCI versus CABG for left main disease.

METHODS

The calibration plot of predicted versus observed 4-year mortality was constructed from individual values of SSII in EXCEL. To assess overestimation versus underestimation of predicted mortality risk, an optimal fit regression line with slope and intercept was determined. Prospective treatment recommendations based on SSII were compared with actual treatments and all-cause mortality at 4 years.

RESULTS

SSII variables were available from EXCEL trial in 1807/1905 (95%) patients. For the entire cohort, discrimination was possibly helpful (C statistic = 0.670). SSII-predicted all-cause mortality at 4 years overestimated the observed mortality, particularly in the highest-risk percentiles, as confirmed by the fit regression line [intercept 2.37 (1.51-3.24), P = 0.003; slope 0.67 (0.61-0.74), P < 0.001]. When the SSII-recommended treatment was CABG, randomized EXCEL patients treated with PCI had a trend towards higher mortality compared with those treated with CABG (14.1% vs 5.3%, P = 0.07) in the as-treat population. In the intention-to-treat population, patients randomized to PCI had higher mortality compared with those randomized to CABG (15.1% vs 4.1%, P = 0.02), when SSII recommended CABG.

CONCLUSIONS

In the EXCEL trial of patients with left main disease, the SSII-predicted 4-year mortality overestimated the 4-year observed mortality with a possibly helpful discrimination. Non-compliance with SSII CABG treatment recommendations (i.e. randomized to PCI) was associated with higher 4-year all-cause mortality.

The Mean Platelet Volume in the Prognosis of Coronary Artery Disease Severity and Risk Stratification of Acute Coronary Syndromes

Introduction:

Platelets play a crucial role in thrombotic episodes. Mean Platelet Volume (MPV) is the primary indicator of platelet’s activation; its measurement is easy and time-effective.

Aim:

We tested the hypothesis that MPV is correlated with SYNTAX score in patients that suffered from an Acute Coronary Syndrome (ACS).

Material and Methods:

One hundred and four (104) patients (79 male–25 female, mean age 64.2±11.1 years), who were hospitalized for an ACS and underwent coronary angiography, were included in the study. Syntax score, as an indicator of the severity of coronary artery disease (CAD), was calculated. We tried to investigate the correlation between the first measured MPV, CRP, Creatinine and high sensitivity Troponin with the Syntax score of the patient and the association of MPV and a possible Major Advanced Cardiac Event (MACE) during hospitalization.

Results:

The patients were divided into four groups according to the SYNTAX score: Group A (SYNTAX score: 0, n=12), group B: Mild CAD (SYNTAX score: 1–22, n=68), group C: Moderate CAD (SYNTAX score: 23–32, n=12), and group D: Severe CAD (SYNTAX score: ≥ 33, n=12). Four patients (3.8%) developed a MACE during their hospitalization. MPV was significantly correlated to Syntax score (r=0.658, p<0.001) and was found to be an independent predictor factor of MACE with HR=6.8 (95% Confidence Interval 1.46-33.36). The cut-off value of MPV was 7.5 with a sensitivity of 98% and a specificity of 30.8%.

Conclusion:

We determined a positive correlation between MPV and Syntax score, transforming this simple test in a possible factor of risk stratification in ACS.

Apolipoprotein A1 is associated with SYNTAX score in patients with a non-ST segment elevation myocardial infarction

BACKGROUND

The study was designed to investigate lipid profile and SYNTAX score in patients with non-ST segment elevation myocardial infarction (NSTEMI).

METHODS

311 patients with NSTEMI were enrolled. The demographic, clinical data, blood samples and SYNTAX score were documented. The Pearson linear correlation was used to detect confounding factors linearly correlated with SYNTAX score. The significantly correlated confounding factors were put into the multiple linear regressions.

RESULTS

The Pearson linear correlation showed that high-density lipoprotein- cholesterol (HDL-C) and apolipoprotein A1 (ApoA1) were significantly correlated with Syntax Score (r = - 0.119, P = 0.044 and r = - 0.182, P = 0.002, respectively). The multiple linear regressions for Syntax Score were built using HDL-C and ApoA1, respectively. After the adjustment of other significantly correlated confounding factors such as white blood cell count (WBC), myohemoglobin (MB), glutamic-oxalacetic transaminase (AST) and creatinine, the ApoA1 still showed significant association with Syntax Score (β = - 0.151, P = 0.028). The area under curve was (AUC) 0.624 and the optimal cutoff value is 1.07 g/L when using ApoA1 to predict moderate and severe coronary artery lesions. The patients with ApoA1 ≥ 1.07 g/L and < 1.07 g/L have the Syntax Scores of 12.21 ± 11.58 and 16.33 ± 11.53, respectively (P = 0.001).

CONCLUSIONS

The ApoA1 is the only lipid factor significantly associated with complexity of coronary artery lesion in patients with NSTEMI, the patients with ApoA1 < 1.07 g/L may have more complex coronary artery lesions.

Trials Comparing Percutaneous And Surgical Myocardial Revascularization: A Review

INTRODUCTION

Ischemic heart diseases are the major leading cause of death worldwide. Revascularization procedures dramatically reduced the overall risk for death related to acute coronary syndromes. Two kinds of myocardial revascularization can grossly be outlined: percutaneous coronary intervention (PCI) and surgical coronary artery bypass graft intervention (CABG). The net clinical benefit coming from these two kinds of procedures is still under debate.

METHODS

We have traced the state-of-the-art background about myocardial revascularization procedures by comparing the most important trials dealing with the evaluation of percutaneous interventions versus a surgical approach to coronary artery diseases.

RESULTS

Both PCI and CABG have become effective treatments for revascularization of patients suffering from advanced CAD. The advance in technology and procedural techniques made PCI an attractive and, to some extent, more reliable procedure in the context of CAD. However, there are still patients that cannot undergo PCI and have to be rather directed towards CABG.

CONCLUSION

CABG still remains the best strategy for the treatment of multiple vessel CAD due to improved results in term of survival and freedom from reintervention. Anyway, a systematic, multidisciplinary approach to revascularization is the fundamental behaviour to be chased in order to effectively help the patients in overcoming its diseases. The creation of the "heart team" seems to be a good option for the correct treatment of patients suffering from stable and unstable CAD.

Impact of angiographic coronary artery disease complexity on ischemic and bleeding risks and on the comparative effectiveness of zotarolimus-eluting vs. bare-metal stents in uncertain drug-eluting stent candidates

BACKGROUND

The impact of coronary artery disease (CAD) extension/complexity on outcomes and on the comparative benefits/risks of zotarolimus-eluting stent (ZES) versus bare-metal stents (BMS) remains unclear in patients at high risk of bleeding or thrombosis or at low restenosis risk.

METHODS

We performed a post-hoc analysis of the ZEUS trial. The impact of coronary anatomic complexity measured by the SYNTAX score on the differences in outcomes following ZES and BMS was assessed at 1 year.

RESULTS

The mean SYNTAX score was 16.3 ± 13.1 with a median of 12 (IQR: 7 to 22). We stratified patients according to SYNTAX tertiles (0-8: n = 563; >8-19 n = 532; >19: n = 511), and observed that the higher the score, the correspondingly higher was the rate of the primary endpoint of major adverse cardiovascular events (MACE) and other ischemic events, but not bleeding after adjustment. The superior efficacy of ZES versus BMS for MACE was consistent across SYNTAX tertiles (tertile 1: HR 0.71, 95% CI 0.44-1.13; tertile 2: HR 0.71, 95% CI 0.46-1.09; tertile 3: HR 0.83, 95% CI 0.61-1.10) without significant heterogeneity (p for trend = 0.55). This between-groups difference mainly reflected a reduction in MI and TVR without effect on mortality. There was no significant interaction between the SYNTAX score and allocated stent type with respect to ischemic and bleeding endpoints.

CONCLUSIONS

The SYNTAX score was predictor of major adverse cardiovascular events but not bleeding and ZES provided superior efficacy and safety than BMS across the whole spectrum of CAD complexity. SYNTAX score may be routinely used for the assessment of the ischemic risk (but not bleeding) after PCI and should not guide the decision-making for DES versus BMS in patients undergoing PCI.

Prognostic Value of SYNTAX Score II in Patients with Acute Coronary Syndromes Referred for Invasive Management: A Subanalysis from the SPUM and COMFORTABLE AMI Cohorts

Aims

To assess the incremental prognostic value of SYNTAX score II (SxSII) as compared to anatomical SYNTAX Score (SxS) and GRACE risk score in patients with acute coronary syndromes who underwent percutaneous coronary intervention.

Methods and results

SxSII and SxS were determined in 734 ACS patients. Patients were enrolled in the prospective Special Program University Medicine ACS and the COMFORTABLE AMI cohorts and later on stratified according to tertiles of SxSII (SxSII_Low ≤21.5 (n=245), SxSII_Mid 21.5–30.6 (n=245), and SxSII_High ≥30.6 (n=244). The primary endpoint of adjudicated all-cause mortality and secondary endpoints of MACE (cardiac death, repeat revascularization, and myocardial infarction) and MACCE (all-cause mortality, cerebrovascular events, MI, and repeat revascularization) were determined at 1-year follow-up. SxSII provided incremental predictive information for risk stratification when compared to SxS and GRACE risk score (AUC 0.804, 95% CI 0.77–0.84, p < 0.001 versus 0.67, 95% CI 0.63–0.72, p=0.007 versus 0.69, 95% CI 0.6–0.8, p=0.002), respectively. In a multivariable Cox regression analysis, we found that unlike SxS (adjusted HR 1.013, 95% CI (0.96–1.07), p=0.654), SxSII was significantly associated with all-cause mortality (HR = 1.095, 95% CI (1.06–1.11), p < 0.001). This was also true for the prediction of both secondary outcomes MACE (n=60) and MACCE (n=70) with an adjusted HR = 1.055, 95% CI (1.03–1.08), p < 0.001, and HR = 1.065, 95% CI (1.04–1.09), p < 0.001.

Conclusion

In patients with ACS who underwent PCI, SxSII is an independent predictor of mortality during 1-year follow-up. SxSII shows superiority in discriminating risk compared to conventional SxS and GRACE for all-cause mortality.

Dietary Supplements and Cardiovascular Diseases

The market of nutritional supplements is expected to expand over 6%/year through 2018 due to growing interest in personal health, aging population, and promising personalized care products. The most used dietary supplements are fish oil, multivitamins, Vitamin D, and coenzyme Q10 (CoQ10) in this order, while probiotics is the fastest growing supplement. In the U.S., over 68% of the population use dietary supplements regularly. On the other hand, in the developed countries, cardiovascular diseases (CVDs) are the main cause of death and morbidity from the 1900s. The effects of most dietary supplements on cardiovascular risk and CVD have been studied for a long time. However, despite several studies explored the association of the various supplements to the cardiovascular risk, there is still a lack of consensus. Multivitamin supplementation has been advocated to reduce cardiovascular events; Vitamin D levels have been associated with the occurrence of coronary artery disease, heart failure, and atrial fibrillation; CoQ10 deficiency has been associated with myocardial dysfunction and with statin myopathy; probiotoics has been suggested to lower both blood pressure and circulating lipids. However, the study of the effects of dietary supplementations is not straightforward, since people assuming dietary supplements generally have a healthier diet and lifestyle, and randomized studies are rarely performed. In this review, we will summarize the findings linking dietary supplements to CVD with a special focus on novel insights.

Long-term outcomes following left main bifurcation stenting in Indian population-Analysis based on SYNTAX I and II scores

Background

Syntax 1 and recently Syntax 2 (SS2) scores are validated risk prediction models in coronary disease.

Objectives

To find out the long term outcomes following stenting for unprotected left main bifurcation disease (LMD) and to validate and compare the performance of the SYNTAX scores 1 and 2 (SS1 and SS2 PCI) for predicting major adverse cardiac events (MACE) in Indian population.

Methods

Single-center, retrospective, observational study involving patients who underwent percutaneous coronary intervention (PCI) with at least one stent implanted for the LMD. Discrimination and calibration models were assessed by ROC curve and the Hosmer-Lemeshow test.

Results

Data of 103 patients were analyzed. The mean SS1 and SS2 scores were 27.9 and 30.7 and MACE was 16.5% at 4 years. The target lesion revascularization (TLR) rate at 4 years was 11(10.7%). There were 4 deaths (3.8%). The mean left ventricular ejection fraction (LVEF) was the only variable in SS2, which predicted cardiac events. ROC curve analysis showed both models to be accurate in predicting TLR and mortality following LM PCI. SS2 score showed a better risk prediction than SSI with AUC for TLR (SSI 0.560 and SS2PCI 0.625) and AUC for mortality (SS1 0.674 and SS2PCI 0.833). Hosmer-Lemeshow test validated the accuracy of both the risk models in predicting the events.

Conclusions

Both risk models were applicable for Indian patients. The SS2 score was a better predictor for mortality and TLR. In the SS2 score, the LVEF was the most useful predictor of events after LM PCI.

Association Between Serum LDL-C and ApoB and SYNTAX Score in Patients With Stable Coronary Artery Disease

The aim of this study was to examine the relationship between low-density lipoprotein cholesterol (LDL-C) and apolipoprotein (Apo) B levels and the SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) score (SS) in patients with stable angina pectoris. We enrolled 594 patients who were suspected to have coronary heart disease (CHD) and who underwent coronary angiography. Patients were divided into 4 groups based on the SS: normal (SS = 0, n = 154), low SS (SS ≤ 22, n = 210), intermediate SS (22 < SS < 32, n = 122), and high SS (SS ≥ 33, n = 63). Positive correlations between lipoprotein (a), LDL-C, ApoB, total cholesterol, and SS were significant ( r = 0.132, 0.632, 0.599, and 0.313, respectively; P < .01), whereas high-density lipoprotein cholesterol (HDL-C), ApoA1, and ApoA1/ApoB levels showed a significant negative correlation ( r = -0.29, -0.344, and -0.561, respectively; P < .01). Multivariate linear regression analysis revealed that LDL-C, ApoB, ApoA1/ApoB, fibrinogen (Fg), and HDL-C levels had an effect on SS (standardized regression coefficients were 0.41, 0.29, -0.12, 0.08, and -0.09, respectively; P < .05). In conclusion, LDL-C, ApoB, ApoA1/ApoB, Fg, and HDL-C levels affected the SS and were predictors of CHD complexity.

Percutaneous coronary intervention with drug-eluting stent versus coronary artery bypass grafting: A meta-analysis of patients with left main coronary artery disease

BACKGROUND

The relative efficacy and safety of percutaneous coronary intervention (PCI) with drug-eluting stents (DES), in comparison to coronary artery bypass grafting (CABG) for left main coronary artery disease (LMCAD) remains controversial.

METHODS

We performed a meta-analysis of randomised studies comparing patients with LMCAD treated with PCI with DES versus those treated with CABG, with respect to clinical outcomes at 1, 3 and 5years. A secondary meta-analysis was performed according to low (<32), or high (≥33) SYNTAX score.

RESULTS

Five studies comprising 4595 patients were included. There was no significant difference in all-cause death at all time points or when stratified with respect to SYNTAX score. The need for repeat revascularization was significantly higher with PCI at all time-points, and regardless of SYNTAX score. There was significant association between need for repeat revascularization with PCI and diabetics (p=0.04). At 5years, non-fatal MI was higher with PCI owing to increased non-procedural events (OR 3.00; CI 1.45-6.21; p=0.003). CABG showed higher rate of stroke at 1year (OR 0.21; CI 0.07-0.63; p=0.005). There was no difference in non-fatal MI or stroke at other time points, nor according to SYNTAX score.

CONCLUSIONS

PCI with DES or CABG are equivalent strategies for LMCAD up to 5years with respect to death, regardless of SYNTAX score. PCI increases the rate of non-procedural MI at 5years. CABG avoids the need for repeat revascularization, especially in diabetics, but this benefit is offset by higher rate of stroke in the first year of follow up.

Application of the SYNTAX score in interventional cardiology: A systematic review and meta-analysis

BACKGROUND

Should the SYNTAX score be integrated in Interventional Cardiology? Should it really be considered as a vital decision-making tool in percutaneous coronary intervention (PCI)? To confirm the importance of this score, we aimed to systematically compare the postinterventional adverse cardiovascular outcomes which were observed in patients who were allotted a low versus a high SYNTAX score.

METHODS

Randomized controlled trials and observational studies which were published from January 2007 to January 2017 were identified from MEDLINE, EMBASE, and the Cochrane databases using the searched terms 'SYNTAX score and percutaneous coronary intervention.' Adverse cardiovascular outcomes were considered as the major endpoints. Risk ratios (RRs) with 95% confidence intervals (CIs) were used as the statistical parameters, and the main analysis was carried out by the RevMan 5.3 software.

RESULTS

Sixteen studies with a total number of 19,751 participants (8589 participants with a low versus 11,162 participants with a high SYNTAX score) were included. Current results showed mortality to be significantly higher with a higher SYNTAX score (RR 2.09, 95% CI 1.78-2.46, P = .00001). Cardiac death also significantly favored a low SYNTAX score (RR 2.08, 95% CI 1.66-2.61, P = .00001. Similarly, myocardial infarction, major adverse cardiac events, repeated revascularization, and stent thrombosis were significantly higher following a high SYNTAX score (RR 1.71, 95% CI 1.45-2.03, P = .00001; RR 2.03, 95% CI 1.81-2.26, P = .00001; RR 1.96, 95% CI 1.69-2.28, P = .00001; and RR 3.16, 95% CI 2.17-4.59, P = .00001, respectively). Even when patients with ST-segment elevation myocardial infarction were separately analyzed, a low SYNTAX score was still significantly associated with lower adverse outcomes.

CONCLUSIONS

This analysis is a confirmatory piece of evidence to show that the application of the SYNTAX score in Interventional Cardiology is apparently relevant. The use of this scoring system to grade patients with coronary artery disease and to further guide for revascularization should be encouraged.

The Predictive Value of the Syntax Score in Patients With Chronic Coronary Artery Disease Undergoing Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting: A Pilot Study

Objectives:

To evaluate the usefulness of the SYNTAX score (SS) in predicting 1-year clinical outcomes in a population of patients with chronic coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).

Background:

Despite the proven prognostic value of the SS in patients with multivessel and/or left main (LM) CAD, its usefulness in other patient subsets remains uncertain.

Methods:

This was a prospective single centre cohort study conducted from September 2012 to November 2014 at the Nicosia General Hospital, Cyprus. Patients (n=140; 94% men and 6% women) with chronic CAD undergoing revascularization with either PCI or CABG were evaluated.

Results:

At 1-year, angina occurred in 20 patients (14.3%), myocardial infarction (MI) in 3 patients (2.1%), repeat revascularization procedures in 9 patients (6.4%) and death in 12 patients (8.6%). The SS independently predicted angina (p=0.024) but was not predictive of MI (p=0.964), death (p=0.292) or repeat revascularization (p=0.069).

Conclusion:

In this patient population, the SS predicted angina in the year following revascularization but was not predictive of MI, death or repeat revascularization.

Percutaneous coronary intervention vs coronary artery bypass grafting for left main coronary artery disease? A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

It is not clear whether percutaneous coronary intervention (PCI) is as effective and safe as coronary artery bypass grafting (CABG) for left main coronary artery disease. We aimed to perform a systematic review and meta-analysis of all randomized controlled trials (RCTs) that compared PCI and CABG in left main coronary disease.

METHODS

We searched PubMed, EMBASE, Cochrane, Scopus and relevant references for RCTs (inception through, November 20, 2016 without language restrictions) and performed meta-analysis using random-effects model. All-cause mortality, myocardial infarction, revascularization rate, stroke, and major adverse cardiac and cerebrovascular events (MACCE) were the measured outcomes.

RESULTS

Six RCTs with a total population of 4700 were analyzed. There was no difference in all-cause mortality at 30-day, one-year, and five-year (1.8% vs 1.1%; OR 0.60; 95% CI: 0.26-1.39; P=.23; I² =9%) follow-up between PCI and CABG. CABG group had less myocardial infarction (MI) at five-year follow-up than PCI (5% vs 2.5%; OR 2.04; CI: 1.30-3.19; P=.002; I² =1%). Revascularization rate favored CABG in one-year (8.6% vs 4.5%; OR 2; CI: 1.46-2.73; P<.0001; I² =45%) and five-year (15.9% vs 9.9%; OR 1.73; CI: 1.36-2.20; P<.0001; I² =0%) follow-up. Although stroke rate was lower in PCI group at 1 year, there was no difference in longer follow-up. MACCE at 5 years favored CABG (24% vs 18%; OR 1.45; CI: 1.19-1.76; P=.0001; I² =0%). On subgroup analysis, MACCE were not different between two groups in low-to-intermediate SYNTAX group while it was higher for PCI group with high SYNTAX group.

CONCLUSION

Percutaneous coronary intervention could be as safe and effective as CABG in a select group of left main coronary artery disease patients.

Usefulness of the SYNTAX score II to predict 1-year outcome in patients with primary percutaneous coronary intervention

OBJECTIVE

This study aimed to investigate the predictive effect of SYNTAX score II (SS-II) for the 1-year outcome in patients with ST-segment elevation myocardial infarction undergoing a primary percutaneous coronary intervention and whether SS-II improves the ability of anatomical and Logistic Clinical SYNTAX score and Global Registry of Acute Coronary Events to predict major adverse cardiac events (MACE).

BACKGROUND

SS-II can predict 1-year outcomes in patients with complex coronary artery disease. However, the prognostic value of SS-II for patients undergoing primary percutaneous coronary intervention remains unclear.

MATERIALS AND METHODS

A total of 477 patients were divided into three groups on the basis of SS-II [SS-II low tertile <20 (n=161), 20 ≤SS-II intermediate tertile ≤26 (n=145), and SS-II high tertile >26 (n=171)]. Kaplan-Meier methods were used to compare the MACE at the 1-year follow-up.

RESULTS

MACE was highest in the SS-II high tertile (21.1 vs. 10.3 vs. 5.5%, P<0.001), including all-cause mortality (11.7 vs. 4.1 vs. 2.5%, P=0.001), target vessel revascularization (7.6 vs. 4.1 vs. 1.8%, P=0.037), and recurrent MI (5.8 vs. 2.1 vs. 1.2%, P=0.035), compared with SS-II intermediate and low tertiles. In Cox multivariable analysis, SS-II was an independent predictor for MACE at 1 year. The receiver operating characteristic curve showed that SS-II had 60% sensitivity and 78% specificity for predicting 1-year MACE as a cut-off value of 27.5. The respective C-statistics of SS-II, anatomical, and Logistic Clinical SYNTAX score and Global Registry of Acute Coronary Events for MACE were 0.726, 0.587, 0.684, and 0.628 (P<0.05).

CONCLUSION

SS-II can predict 1-year clinical outcomes in patients with ST-segment elevation myocardial infarction and has an improved ability to predict MACE.

Percutaneous Coronary Intervention, Coronary Artery Bypass Surgery and the SYNTAX score: A systematic review and meta-analysis

The SYNTAX [Synergy Between percutaneous coronary intervention (PCI) With Taxus and coronary artery bypass surgery (CABG)] score is a decision-making tool in interventional cardiology. However, several facts still remain to be addressed: What about PCI or CABG with a low versus a high score respectively? And what about PCI with a low score versus CABG with a high score? Electronic databases were carefully searched for relevant publications. Odds ratios (OR) with 95% confidence intervals (CIs) were calculated and the analysis was carried out by RevMan 5.3. Eleven studies with a total number of 11,037 patients were included. In terms of clinical outcomes, this analysis showed PCI to have significantly favored patients with a low versus a high SYNTAX score. In patients who were re-vascularized by CABG, mortality and major adverse cardiac events were significantly lower with a low SYNTAX score. However, when PCI with a low SYNTAX score was compared with CABG with a high SYNTAX score, no significant difference in mortality and combined death/stroke/myocardial infarction were observed. In conclusion, the SYNTAX score might be considered useful in interventional cardiology. Nevertheless, the fact that it has limitations when compared to newer tools should also not be ignored.

Predictive value of SYNTAX score II for clinical outcomes in octogenarian undergoing percutaneous coronary intervention

OBJECTIVE

To evaluate the predictive value of SYNTAX Score II (SS-II) for percutaneous coronary intervention (PCI) in octogenarian (≥ 80 years old) undergoing PCI.

METHODS & RESULTS

Data from three consecutive years of octogenarian undergoing PCI from Ruijin Hospital (Shanghai, China) was retrospectively collected (n = 308). Follow up clinical data at one year including all cause mortality, cardiac mortality and main adverse cardiovascular and cerebrovascular events (MACCE) were collected. Patients were stratified according to tertiles of SS-II for PCI: SS-II ≤ 26 (n = 104), SS-II: 27-31 (n = 102), SS-II > 31 (n = 102). After adjustment for confounding factors, SS-II for PCI was an independent risk factors for all cause mortality (odds ratio: 2.77, 95% CI: 1.13-8.06; P = 0.04). Kaplan-Meier curves showed higher event rates for all cause mortality and cardiac mortality in higher tertile of SS-II for PCI (Log-Rank test P = 0.002 and P = 0.001, respectively). SS-II for PCI predicted one year mortality in octogenarian population undergoing PCI.

CONCLUSIONS

In octogenarian, SS-II which incorporated clinical variables with angiographic anatomy variable was suitable in risk stratifying and predicting clinical outcomes at one year.

Association of syntax score with short-term outcomes among acute ST-elevation myocardial infarction patients undergoing primary PCI

Objective

Syntax score (SX) has emerged as a reproducible angiographic tool to quantify the extent of coronary artery disease based on location and complexity of each lesion. It has been shown to predict long-term clinical outcomes in patients with left main or multi-vessel disease and recently also in ST-segment elevation myocardial infarction undergoing primary PCI. The aim of this study was to evaluate whether the syntax score is associated with short-term cardiovascular outcomes in patients treated with primary percutaneous coronary intervention (PCI) for acute ST-segment elevation myocardial infarction (STEMI).

Methods

Syntax score was determined in 90 consecutive patients (mean age 54.2 ± 11.6) of STEMI undergoing primary PCI. Outcomes were stratified according to syntax score groups: SX low ≤15 (n = 33), SX mid 16–22 (n = 30), and SX high ≥23 (n = 27). The primary endpoint was all-cause mortality at 30 days. Secondary endpoints were nonfatal major adverse cardiac and cerebrovascular events (MACE) defined as a composite of any repeat revascularization, acute coronary syndrome, and stroke at 30 days in patients discharged alive.

Results

Mortality at 30 days was higher in the SX high group compared to the SX mid and SX low group (18.5% vs 3.3% p = 0.011), MACE at 30 days was higher in SX high group compared to SX mid and SX low group (48.1% vs 16.6% vs 9.1%, p = 0.001).

Conclusions

The syntax score is associated with 30-day mortality in patients with STEMI undergoing primary PCI. In those discharged, it is associated with risk of MACE at 30 days.

Effect of Serum Growth Differentiation Factor-15 and the Syntax Score on 2-Year Outcomes in Patients With Acute Coronary Syndrome

Growth differentiation factor-15 (GDF-15) is produced by cardiomyocytes and atherosclerotic lesions under stress conditions, but little is known about its relation with severity and complexity of coronary lesions. The aim of this study was to investigate the association between GDF-15 and the syntax score for risk prediction of major adverse cardiovascular events (MACE) at 2-year follow-up in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). This is a prospective cohort study of 502 patients with NSTEACS. The syntax score was calculated from baseline coronary angiography. Blood samples were obtained at study entry for the assessment of GDF-15 and high-sensitivity C reactive protein. One hundred and three patients (20.5%) showed MACE at 2-year follow-up. Patients who developed MACE had greater GDF-15 concentrations and syntax score (p <0.001) compared to patients who did not. There was a positive, but moderate, correlation between GDF-15 and syntax score (ρ = 0.45, p <0.0001). On Cox regression analysis, only GDF-15 levels (p <0.001), body mass index (p = 0.04), and syntax score (p <0.001) remained independent predictors of the MACE. The area under the curve of GDF-15 (0.912, 95% confidence interval 0.894 to 0.944) was significantly greater compared to high-sensitivity C reactive protein and syntax score. In conclusion, in patients with NSTEACS, levels of GDF-15 at admission were correlated with the syntax score and independently associated with an increased risk of MACE during 2-year follow-up.

Risk Stratification for Percutaneous Coronary Intervention

The Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score is a semiquantitative angiographic score developed to prospectively characterize the disease complexity of the coronary vasculature. With more than 50 validation studies, the SYNTAX score is the most-studied risk model in the setting of percutaneous coronary intervention. In this article, the evolutionary journey of the SYNTAX score is reviewed, with emphasis on its sequential modifications and adaptations, now culminating in the development and validation of the SYNTAX score II.

Percutaneous Coronary Intervention for Bifurcation Lesions

This article summarizes treatment alternatives for coronary bifurcation lesions. It also reviews current definitions and classifications pertaining to bifurcation lesions and provides an overview of the impact of bifurcation lesions on clinical outcomes.

Potential Utility of the SYNTAX Score 2 in Patients Undergoing Left Main Angioplasty

Background

The revascularization strategy of the left main disease is determinant for clinical outcomes.

Objective

We sought to 1) validate and compare the performance of the SYNTAX Score 1 and 2 for predicting major cardiovascular events at 4 years in patients who underwent unprotected left main angioplasty and 2) evaluate the long-term outcome according to the SYNTAX score 2-recommended revascularization strategy.

Methods

We retrospectively studied 132 patients from a single-centre registry who underwent unprotected left main angioplasty between March 1999 and December 2010. Discrimination and calibration of both models were assessed by ROC curve analysis, calibration curves and the Hosmer-Lemeshow test.

Results

Total event rate was 26.5% at 4 years.The AUC for the SYNTAX Score 1 and SYNTAX Score 2 for percutaneous coronary intervention, was 0.61 (95% CI: 0.49-0.73) and 0.67 (95% CI: 0.57-0.78), respectively. Despite a good overall adjustment for both models, the SYNTAX Score 2 tended to underpredict risk. In the 47 patients (36%) who should have undergone surgery according to the SYNTAX Score 2, event rate was numerically higher (30% vs. 25%; p=0.54), and for those with a higher difference between the two SYNTAX Score 2 scores (Percutaneous coronary intervention vs. Coronary artery by-pass graft risk estimation greater than 5.7%), event rate was almost double (40% vs. 22%; p=0.2).

Conclusion

The SYNTAX Score 2 may allow a better and individualized risk stratification of patients who need revascularization of an unprotected left main coronary artery. Prospective studies are needed for further validation.

Predictors of Peak Troponin Level in Acute Coronary Syndromes: Prior Aspirin Use and SYNTAX Score

The peak troponin level has been associated with cardiovascular (CV) mortality and adverse CV events. The association of peak troponin with CV risk factors and severity and complexity of coronary artery disease remains unknown. We assessed the predictors of peak troponin in patients with acute coronary syndrome (ACS). This study aims to determine the predictors of peak troponin in ACS. Cardiac catheterization (CC) reports and electronic medical records from 2010 to 2013 were retrospectively reviewed. A total of 219 patients were eligible for the study. All major CV risk factors, comorbidities, laboratory data, CC indications, and coronary lesion characteristics were included. Univariate and multivariate regression analyses were done. On multivariate linear regression analysis, ST-elevation myocardial infarction (p = 0.001, β = 65.16) and increasing synergy between percutaneous coronary intervention with Taxus and cardiac surgery (SYNTAX) score (p = 0.002, β = 1.15) were associated with higher peak troponin. The Pearson correlation between SYNTAX score and peak troponin was r = 0.257, p = 0.001. History of daily aspirin use was associated with lower peak troponin (p = 0.002, β = -24.32). Prior statin use (p = 0.321, β = -8.98) and the presence of CV risk factors were not associated with peak troponin. Coronary artery disease severity and complexity, urgency of CC, and prior aspirin use are associated with peak troponin levels in ACS. Our findings may help predict patient population with ACS who would be at a greater risk for short- and long-term CV morbidity and mortality due to elevated peak troponin.

Relation of Angiographic Thrombus Burden with Severity of Coronary Artery Disease in Patients with ST Segment Elevation Myocardial Infarction

Background

We planned to investigate the relationship of thrombus burden with SYNTAX score in patients with ST elevation myocardial infarction (STEMI).

Material/Methods

We retrospectively enrolled 780 patients who underwent PPCI in our clinic due to STEMI. Clinical, laboratory, and demographic properties of the patients were recorded. Angiographic coronary thrombus burden was classified using thrombolysis in myocardial infarction (TIMI) thrombus grades.

Results

Patients with high thrombus burden were older, with higher diabetes prevalence longer pain to balloon time, higher leukocyte count, higher admission troponin, and admission CK-MB concentrations. SYNTAX score was higher and myocardial perfusion grades were lower in patients with high thrombus burden. Multivariate logistic regression analysis revealed SYNTAX score as the strongest predictor of thrombus burden. ROC analysis demonstrated a sensitivity of 75.5%, specificity of 61.2%, and cut-off value of >14 (area under the curve (AUC): 0.702; 95% confidence interval [CI]: 0.773–0.874;P<0.001) for high thrombus burden.

Conclusions

SYNTAX score may have additional value in predicting higher thrombus burden besides being a marker of coronary artery disease severity and complexity.

Validation of the SYNTAX revascularization index to quantify reasonable level of incomplete revascularization after percutaneous coronary intervention

Incomplete revascularization is common after percutaneous coronary intervention (PCI). Whether a "reasonable" degree of incomplete revascularization is associated with a similar favorable long-term prognosis compared with complete revascularization remains unknown. We sought to quantify the proportion of coronary artery disease burden treated by PCI and evaluate its impact on outcomes using a new prognostic instrument-the Synergy Between PCI with Taxus and Cardiac Surgery (SYNTAX) Revascularization Index (SRI). The baseline SYNTAX score (bSS), the residual SYNTAX score, and the delta SYNTAX score (ΔSS) were determined from 888 angiograms of patients enrolled in the prospective SYNTAX trial. The SRI was then calculated for each patient using the following formula: SRI = (ΔSS/bSS]) × 100. Outcomes were examined according to the proportion of revascularized myocardium (SRI = 100% [complete revascularization], 50% to <100%, and <50%). The Youden index for the SRI was computed to identify the best cutoff for 5-year all-cause mortality. The mean bSS was 28.4 ± 11.5, and after PCI, the mean ΔSS was 23.8 ± 10.9 and the mean residual SYNTAX score was 4.5 ± 6.9. The mean SRI was 85.3 ± 21.2% and was 100% in 385 patients (43.5%), <100% to 50% in 454 patients (51.1%), and <50% in 48 patients (5.4%). Five-year adverse outcomes, including death, were inversely proportional to the SRI. An SRI cutoff of <70% (present in 142 patients [16.0%] after PCI) had the best prognostic accuracy for prediction of death and, by multivariable analysis, was an independent predictor of 5-year mortality (hazard ratio [HR] 4.13, 95% confidence interval [CI] 2.79 to 6.11, p <0.0001). In conclusion, the SRI is a newly described method for quantifying the proportion of coronary artery disease burden treated by PCI. The SRI is a useful tool in assessing the degree of revascularization after PCI, with SRI ≥70% representing a "reasonable" goal for patients with complex coronary artery disease.

Continued expansion of the Heart Team concept

ABSTRACT 

The concept of a multidisciplinary Heart Team approach to treating cardiovascular disease has garnered increasing interest in recent years. This team-based approach has been a cornerstone of practice in other medical fields, such as oncology and solid organ transplantation. Advances in technology and new therapeutic strategies now offer multiple treatment options to patients with complex coronary artery or valvular heart disease, making therapeutic decision-making more challenging. There is a growing literature that use of a Heart Team for management of these complex cardiovascular diseases has demonstrated great merit. While the composition and implementation of Heart Team will vary, this multidisciplinary team-based approach will become the standard of care in cardiovascular medicine in the future.

Do Cardiovascular Risk Factors and Coronary SYNTAX Score Predict Contrast Volume Use During Cardiac Catheterization?

The association of cardiovascular risk factors and complexity and severity of coronary artery disease with contrast volume (CV) remains unknown. We assessed the predictive factors of CV use during elective and emergent cardiac catheterization (CC). Electronic medical records from 2010 to 2013 were retrospectively reviewed. A total of 708 patients were eligible. On multivariable regression analysis, the presence of obstructed coronary arteries was associated with CV ( P = .01, β = −14.17), with greater CV used in patients with single or double vessel disease compared to those with triple vessel disease. The presence of lesions with >70% stenosis in major epicardial arteries ( P = .019, β = 24.39) and ST-segment elevation myocardial infarction ( P = .001, β = 36.14) was associated with increased CV use. Elevated B-type natriuretic peptide ( P = .036, β = −17.23) and increase in Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery score ( P = .024, β = −29.06) were associated with decreased CV use. These aforementioned associations were attenuated after adjusting for percutaneous coronary intervention. Our findings may help predict patient populations who could be exposed to increased CV during CC, thereby possibly increasing their risk of contrast-induced nephropathy.

Relationship between extent and complexity of coronary artery disease and different left ventricular geometric patterns in patients with coronary artery disease and hypertension

OBJECTIVE

The relationship between severity of coronary artery disease (CAD) and left ventricler (LV) hypertrophy in hypertensive patients is well known. However, the association between the extent and complexity of CAD assessed with SYNTAX score (SS) and different LV geometric patterns has not been investigated. We aimed to investigate the association between SYNTAX score and different LV geometric patterns in hypertensive patients.

METHODS

The study had been made in our clinic between January 2013 and August 2013. We studied 251 CAD patients who had hypertension and who underwent coronary angiography (147 males, 104 females; mean age 61.61±9.9 years). Coronary angiography was performed based on clinical indications. SS was determined in all patients. Echocardiographic examination was performed in all subjects. Four different geometric patterns were determined in patients according to LV mass index (LVMI) and relative wall thickness (RWT) (Groups: NG- normal geometry, CR- concentric remodeling, EH- eccentric hypertrophy, and CH- concentric hypertrophy). Biochemical markers were measured in all participants.

RESULTS

The highest SS values were observed in the CH group compared with the NG, CR, and EH groups (p<0.05 for all). Also, the SS values of the EH group were higher than in the NG and CR groups (p<0.05 for all). Multivariate linear regression analysis showed that SS was independently associated with LV geometry (β=0.316, p=0.001), as well as age (β=0.163, p=0.007) and diabetes (β=-0.134, p=0.022).

CONCLUSION

SYNTAX score is independently related with LV geometry in hypertensive patients. This result shows that LV remodeling is parallel to the increase in the extent and complexity of CAD in our study patients.