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Ninomiya K, Kageyama S, Shiomi H, Kotoku N, Masuda S, Revaiah PC, Garg S, O'Leary N, van Klaveren D, Kimura T, Onuma Y, Serruys PW. Can Machine Learning Aid the Selection of Percutaneous vs Surgical Revascularization? J Am Coll Cardiol 2023; 82:2113-2124. [PMID: 37993203 DOI: 10.1016/j.jacc.2023.09.818] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/15/2023] [Accepted: 09/20/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND In patients with 3-vessel coronary artery disease (CAD) and/or left main CAD, individual risk prediction plays a key role in deciding between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). OBJECTIVES The aim of this study was to assess whether these individualized revascularization decisions can be improved by applying machine learning (ML) algorithms and integrating clinical, biological, and anatomical factors. METHODS In the SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) study, ML algorithms (Lasso regression, gradient boosting) were used to develop a prognostic index for 5-year death, which was combined, in the second stage, with assigned treatment (PCI or CABG) and prespecified effect-modifiers: disease type (3-vessel or left main CAD) and anatomical SYNTAX score. The model's discriminative ability to predict the risk of 5-year death and treatment benefit between PCI and CABG was cross-validated in the SYNTAX trial (n = 1,800) and externally validated in the CREDO-Kyoto (Coronary REvascularization Demonstrating Outcome Study in Kyoto) registry (n = 7,362), and then compared with the original SYNTAX score II 2020 (SSII-2020). RESULTS The hybrid gradient boosting model performed best for predicting 5-year all-cause death with C-indexes of 0.78 (95% CI: 0.75-0.81) in cross-validation and 0.77 (95% CI: 0.76-0.79) in external validation. The ML models discriminated 5-year mortality better than the SSII-2020 in the external validation cohort and identified heterogeneity in the treatment benefit of CABG vs PCI. CONCLUSIONS An ML-based approach for identifying individuals who benefit from CABG or PCI is feasible and effective. Implementation of this model in health care systems-trained to collect large numbers of parameters-may harmonize decision making globally. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES]; NCT03417050; SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries; NCT00114972).
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Affiliation(s)
- Kai Ninomiya
- Department of Cardiology, University of Galway, Galway, Ireland
| | | | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Nozomi Kotoku
- Department of Cardiology, University of Galway, Galway, Ireland
| | | | | | - Scot Garg
- Department of Cardiology, Royal Blackburn Hospital, Blackburn, United Kingdom
| | - Neil O'Leary
- Department of Cardiology, University of Galway, Galway, Ireland
| | - David van Klaveren
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshinobu Onuma
- Department of Cardiology, University of Galway, Galway, Ireland
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Serruys PW, Revaiah PC, Ninomiya K, Masuda S, Kotoku N, Kageyama S, Onuma Y, Morel MA, Garg S, Feldman T, Kappetein AP, Holmes DR, Mack MJ, Mohr FW. 10 Years of SYNTAX: Closing an Era of Clinical Research After Identifying New Outcome Determinants. JACC. ASIA 2023; 3:409-430. [PMID: 37396431 PMCID: PMC10308124 DOI: 10.1016/j.jacasi.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/21/2023] [Accepted: 03/24/2023] [Indexed: 07/04/2023]
Abstract
The SYNTAX trial randomized patients equally eligible for coronary artery bypass grafting or percutaneous coronary intervention using the Heart Team approach. The SYNTAXES study achieved a follow-up rate of 93.8% and reported the 10-year vital status. Factors associated with increased mortality at 10 years were pharmacologically treated diabetes mellitus, increased waist circumference, reduced left ventricular function, prior cerebrovascular and peripheral vascular disease, western Europe and North American descent, current smoking, chronic obstructive pulmonary disease, elevated C-reactive protein, anemia, and an increase in HbA1c. Procedural factors associated with higher 10 years mortality include periprocedural myocardial infarction, extensive stenting, small stents, ≥1 heavily calcified lesion, ≥1 bifurcation lesion, residual SYNTAX score >8, and staged percutaneous coronary intervention. Optimal medical therapy at 5 years, use of statins, on-pump coronary artery bypass grafting, multiple arterial grafts, and higher physical component score and mental component score were associated with lower mortality at 10 years. Numerous scores and prediction models were developed to help individualize risk assessment. Machine learning has emerged as a novel approach for developing risk models.
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Affiliation(s)
- Patrick W. Serruys
- Department of Cardiology, National University of Ireland, Galway (NUIG), and CORRIB Research Centre for Advanced Imaging and Core Laboratory, Galway, Ireland
| | - Pruthvi C. Revaiah
- Department of Cardiology, National University of Ireland, Galway (NUIG), and CORRIB Research Centre for Advanced Imaging and Core Laboratory, Galway, Ireland
| | - Kai Ninomiya
- Department of Cardiology, National University of Ireland, Galway (NUIG), and CORRIB Research Centre for Advanced Imaging and Core Laboratory, Galway, Ireland
| | - Shinichiro Masuda
- Department of Cardiology, National University of Ireland, Galway (NUIG), and CORRIB Research Centre for Advanced Imaging and Core Laboratory, Galway, Ireland
| | - Nozomi Kotoku
- Department of Cardiology, National University of Ireland, Galway (NUIG), and CORRIB Research Centre for Advanced Imaging and Core Laboratory, Galway, Ireland
| | - Shigetaka Kageyama
- Department of Cardiology, National University of Ireland, Galway (NUIG), and CORRIB Research Centre for Advanced Imaging and Core Laboratory, Galway, Ireland
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway (NUIG), and CORRIB Research Centre for Advanced Imaging and Core Laboratory, Galway, Ireland
| | - Marie Angele Morel
- Department of Cardiology, National University of Ireland, Galway (NUIG), and CORRIB Research Centre for Advanced Imaging and Core Laboratory, Galway, Ireland
| | - Scot Garg
- Department of Cardiology, Royal Blackburn Hospital, Blackburn, United Kingdom
| | - Ted Feldman
- Edwards Lifesciences, Irvine, California, USA
| | - Arie Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - David R. Holmes
- Department of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J. Mack
- Department of Cardiothoracic Surgery, Baylor Scott & White Health, Dallas, Texas, USA
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Kotoku N, Serruys PW, Ninomiya K, Soo A, Masuda S, Kageyama S, Revaiah PC, Mack MJ, Holmes DR, Morice MC, Davierwala PM, Mohr FW, Milojevic M, Kappetein AP, Garg S, Onuma Y. Impact of periprocedural major adverse events on 10-year mortality after revascularisation. EUROINTERVENTION 2023; 18:1272-1283. [PMID: 36632743 PMCID: PMC10018290 DOI: 10.4244/eij-d-22-00681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/18/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND The long-term prognostic impact of a composite of periprocedural major adverse events (PMAE) following revascularisation for patients with complex coronary artery disease (CAD) has not yet been established. AIMS This study aimed to assess the impact on 10-year mortality of non-fatal PMAE following percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Other objectives were to evaluate 1) whether PMAE affect mortality predicted by the SYNTAX score II 2020 (SSII-2020) and 2) whether optimal medical therapy (OMT) positively affects the prognosis of patients with non-fatal PMAE. METHODS The association between 10-year mortality and non-fatal PMAE occurring within 30 days of PCI or CABG in patients with three-vessel disease and/or left main disease enrolled in the SYNTAXES study was investigated. RESULTS The main findings are that non-fatal PMAE occurred less frequently following PCI than CABG (11.2% vs 28.2%; p<0.001) and that non-fatal PMAE were an independent predictor of all-cause mortality in the first year post-procedure, but not at 5 or 10 years, in both treatment modalities. PMAE substantially alter the individual predictions of 10-year mortality by the SSII-2020. In patients with non-fatal PMAE, OMT may provide survival benefits during the first year post-procedure as well as in the long term. CONCLUSIONS In patients with complex CAD, non-fatal PMAE were more common following CABG than PCI, but their prognostic impact was similar, being significant in the first year and then diminishing out to 10 years. Patients with non-fatal PMAE may therefore require more careful follow-up and additional preventive treatment in the first year post-procedure.
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Affiliation(s)
- Nozomi Kotoku
- Department of Cardiology, University of Galway, Galway, Ireland
| | | | - Kai Ninomiya
- Department of Cardiology, University of Galway, Galway, Ireland
| | - Alan Soo
- Department of Cardiothoracic Surgery, University Hospital Galway, Galway, Ireland
| | | | | | | | - Michael J Mack
- Department of Cardiothoracic Surgery, Baylor Scott & White Health, Dallas, TX, USA
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Marie-Claude Morice
- Unité de Cardiologie, Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France
| | - Piroze M Davierwala
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, ON, Canada
| | - Friedrich W Mohr
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Milan Milojevic
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Arie Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Scot Garg
- Department of Cardiology, Royal Blackburn Hospital, Blackburn, UK
| | - Yoshinobu Onuma
- Department of Cardiology, University of Galway, Galway, Ireland
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Burgess SN, Mamas MA. Narrowing disparities in PCI outcomes in women; From risk assessment, to referral pathways and outcomes. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 24:100225. [PMID: 38560635 PMCID: PMC10978432 DOI: 10.1016/j.ahjo.2022.100225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/23/2022] [Accepted: 10/26/2022] [Indexed: 04/04/2024]
Abstract
This review evaluates published data regarding outcomes for women with ACS undergoing PCI. Data is discussed from a patient centred perspective and timeline, beginning with sex-based differences in perception of risk, time to presentation, time to treatment, access to angiography, access to angioplasty, the impact of incomplete revascularization, prescribing practices, under-representation of women in randomized controlled trials and in cardiology physician workforces. The objective of the review is to identify factors contributing to outcome disparities for women with ACS, and to discuss potential solutions to close this outcome gap.
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Affiliation(s)
- Sonya N. Burgess
- Department of Cardiology, Nepean Hospital, Sydney, Australia
- University of Sydney, NSW, Australia
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke on Trent, UK
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Kageyama S, Serruys PW, Garg S, Ninomiya K, Masuda S, Kotoku N, Colombo A, Mack MJ, Banning AP, Morice MC, Witkowski A, Curzen N, Burzotta F, James S, van Geuns RJ, Davierwala PM, Holmes DR, Wood DA, McEvoy JW, Onuma Y. Geographic disparity in 10-year mortality after coronary artery revascularization in the SYNTAXES trial. Int J Cardiol 2022; 368:28-38. [DOI: 10.1016/j.ijcard.2022.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 07/24/2022] [Accepted: 08/04/2022] [Indexed: 11/24/2022]
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Gulati M, Burgess S. SYNTAXES, biomarkers and survival in complex coronary artery disease: the intervention of secondary prevention. EUROINTERVENTION 2022; 17:1460-1462. [PMID: 35446258 PMCID: PMC9896389 DOI: 10.4244/eij-e-22-00008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
| | - Sonya Burgess
- University of Sydney, Nepean Hospital, Sydney, Australia,Division of Cardiology, Sydney Southwest Hospital, Sydney, Australia
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