How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ?...

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How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium http://cardio- aalst.be & [email protected]
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Transcript of How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ?...

Page 1: How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium ://cardio-aalst.be.

How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ?

William WIJNS Aalst, Belgium

http://cardio-aalst.be & [email protected]

Page 2: How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium ://cardio-aalst.be.

Global appraisal of the patient’s condition & risk

• Use of a standard check list (adapted to each institution)– Clinical information, psychological profile and culture– Co-morbid factors– Possible interference with DAPT– Biochemical markers– LV and valvular function– Testing for ischemia/viability– Coronary angiography

• Use of risk scores

Page 3: How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium ://cardio-aalst.be.

Global appraisal of the patient’s condition & risk

• Why using Risk scores in day-to-day practice?– Physicians are risk-averse and driven by personal

experience– High-risk patients are denied the potentially large benefit

of invasive therapies, be it with increased risk– Using risk scores helps reducing bias and targeting

treatment strategies to personnalized needs– Adherences to guidelines increases, with subsequent

improvement in outcomes

Page 4: How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium ://cardio-aalst.be.

How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ?

STEMINSTEMI and NSTE-ACSStable CAD

http://cardio-aalst.be & [email protected]

Page 5: How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium ://cardio-aalst.be.

www.escardio.org/guidelines

Joint ESC - EACTS Guidelineson Myocardial Revascularisation

Joint Task Force on Myocardial Revascularisation ofthe European Society of Cardiology (ESC) and

the European Association for Cardio-Thoracic Surgery (EACTS)

Developed with the special contribution ofthe European Association for

Percutaneous Cardiovascular Interventions (EAPCI)

European Heart Journal (2010) 31, 2501-2555European Journal of Cardio-thoracic Surgery 38, S1 (2010) S1-S52

Page 6: How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium ://cardio-aalst.be.

How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ?

STEMI - no recommendation, except for cardiogenic shock- practice driven by:

time delaysECGreperfusion

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Page 7: How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium ://cardio-aalst.be.

How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ?

NSTEMI and NSTE-ACS

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Page 8: How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium ://cardio-aalst.be.

www.escardio.org/guidelines

Intended Early Invasive vs. Conservative Strategy

Fox KA et al. JACC 2010;55(22):2435-45

Long term outcome by initial Risk ScoreMeta-analysis of 3 major trials

Selective invasive 2746 2452 2351 2178 2077 2005

Routine invasive 2721 2485 2410 2235 2166 2079

Selective invasiveRoutine invasive High

Intermediate

Low

50%

45%

40%

35%

30%

25%

20%

15%

10%

5%

0%

0 1 2 3 4 5

Cumulativepercentage

Follow-up time (years)

Page 9: How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium ://cardio-aalst.be.

www.escardio.org/guidelinesJoint 2010 ESC - EACTS Guidelineson Myocardial Revascularisation

Calculating GRACE Risk ScoreKillip Pointsclass

I 0

II 17

III 34

IV 51

Systolic PointsBP

≤70 66

70-89 53

90-109 40

110-129 27

≥130 19

Heart Pointsrate

≤70 10

70-89 15

90-109 26

110-129 32

130-149 24

150-169 16

170-199 8

≥200 0

Age Points

≤30 0

30-49 10

50-69 29

70-79 56

80-89 73

≥90 91

Creatinine Points

0-0.39 3

0.4-0.9 9

1.0-1.9 32

≥2 51

Baseline risk factors Points

Cardiac arrest at admission 38

ST-segment deviation 18

Positive cardiac markers 14

STEMI 14

Total from clinical evaluation

Page 10: How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium ://cardio-aalst.be.

www.escardio.org/guidelinesJoint 2010 ESC - EACTS Guidelineson Myocardial Revascularisation

Calculating GRACE Risk Score

http://www.outcomes-umassmed.org/grace

Page 11: How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium ://cardio-aalst.be.

www.escardio.org/guidelines

Specification Class Level

An invasive strategy is indicated in patients with:• GRACE score > 140 or at least one high-risk criterion,• recurrent symptoms,• inducible ischaemia at stress test.

I A

An early invasive strategy (< 24 h) is indicated in patients with GRACE score > 140 or multiple other high-risk criteria.

I A

A late invasive strategy (within 72 h) is indicated in patients with GRACE score < 140 or absence of multiple other high-risk criteria but with recurrent symptoms or stress-inducible ischaemia.

I A

Patients at very high ischaemic risk (refractory angina, with associated heart failure, arrhythmias or haemodynamic instability) should be considered for emergent coronary angiography (< 2 h).

IIa C

An invasive strategy should not be performed in patients:• at low overall risk,• at a particularly high-risk for invasive diagnosis or intervention.

III A

Recommendations forrevascularisation in NSTE-ACS

Page 12: How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium ://cardio-aalst.be.

How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ?

Stable CAD

http://cardio-aalst.be & [email protected]

Page 13: How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium ://cardio-aalst.be.

www.escardio.org/guidelines

ACEF score = [Age/Ejection Fraction (%)] + 1 (if Creatinine > 2 mg/dL).

Recommended risk stratification scoresto be used in candidates for PCI or CABG

● For PCI, SYNTAX scoreemerges as preferred scoreto quantify complexity ofCAD, but needs to be testedin other trials.

● For CABG, both EuroSCOREand STS score are wellvalidated, mostly based onclinical variables.

● STS score is undergoingperiodic adjustment whichmakes longitudinalcomparisons difficult.

Score Validated outcomesClass/Level

PCI CABG

EuroSCORE Short and long-term mortality IIb B I B

SYNTAX score Quantify coronary artery disease complexity IIa B III B

Mayo Clinic Risk Score MACE and procedural death IIb C III C

NCDR CathPCI In-hospital mortality IIb B -

Parsonnet score 30-day mortality - III B

STS score

Operative mortality, stroke, renal failure, prolonged ventilation, deep sternal infection, re-operation, morbidity, length of stay < 6 or > 14 days

- I B

ACEF score Mortality in elective CABG - IIb C

Page 14: How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium ://cardio-aalst.be.

www.escardio.org/guidelinesJoint 2010 ESC - EACTS Guidelineson Myocardial Revascularisation

www.syntaxscore.com

Page 15: How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium ://cardio-aalst.be.

www.escardio.org/guidelinesJoint 2010 ESC - EACTS Guidelineson Myocardial Revascularisation

Page 16: How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium ://cardio-aalst.be.

www.escardio.org/guidelines

Indications for CABG versus PCI in stablepatients with lesions suitable for both procedures and

low predicted surgical mortality

In the most severe patterns of CAD, CABG appears to offer a survival advantageas well as a marked reduction in the need for repeat revascularisation

Subset of CAD by anatomy Favours CABG Favours PCI

1VD or 2VD - non-proximal LAD IIb C I C

1VD or 2VD - proximal LAD I A IIa B

3VD simple lesions, full functional revascularisation achievable with PCI, SYNTAX score ≤ 22

I A IIa B

3VD complex lesions, incomplete revascularisation achievable with PCI, SYNTAX score > 22

I A III A

Left main (isolated or 1VD, ostium/shaft) I A IIa B

Left main (isolated or 1VD, distal bifurcation) I A IIb B

Left main + 2VD or 3VD, SYNTAX score ≤ 32 I A IIb B

Left main + 2VD or 3VD, SYNTAX score ≥ 33 I A III B

Page 17: How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium ://cardio-aalst.be.

Further validation of SYNTAX Score

- SYNTAX Score works for non SYNTAX trial populationTested on all-comers population from Resolute trialC-index 0.62

Garg S et al, JACC Cardiovasc Interv. 2011 Apr;4(4):432-41

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Page 18: How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium ://cardio-aalst.be.

New scores to be further validated

- EuroHeart Score (based on EuroHeart Survey) for PCILarge dataset of 46.064 pts, 1:1 training:validation set16 clinical and angiographic variables predict mortalityC-index 0.91

De Mulder M et al, Eur Heart J. 2011 Jun;32(11):1398-408. Epub 2011 Feb 22.

http://cardio-aalst.be & [email protected]

Page 19: How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium ://cardio-aalst.be.

Currently used clinical and angiographic scores

Score

Number of variables used to calculate risk

Validated OutcomesRecommendation/

Level of evidenceClinical Angiographic PCI CABG

EuroSCORE 17 0 Short and long-term mortality IIb B I B

SYNTAX score 0 11 (per lesion)Quantify coronary artery

disease complexityIIa B III B

Why not combine EuroSCORE and SYNTAX score?

Global Risk Classification

Page 20: How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium ://cardio-aalst.be.

Risk scores

Global Risk Classification

EuroSCORE

SYNTAX score

<22 23-32 >33

0-2 low low mid

3-5 low low mid

>6 mid mid high

low, mid and high

Presented by P. W. Serruys

Page 21: How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium ://cardio-aalst.be.

5.3%

P=0.004

14.8%

6.5%

0 12 24Months Since Allocation

Cum

ula

tive E

vent

Rate

(%

)

30

60

0

36

P<0.00130.0%

13.1%

2.7%

0 12 24Months Since Allocation

Cum

ula

tive E

vent

Rate

(%

)

30

60

0

36

All-cause mortality to 3 yearsLM Patients (randomized + registry)

ITT populationCumulative KM Event Rate ± 1.5 SE; log-rank P value

EuroSCORE

SYNTAX Score

<22 23-32 >33

0-2 low low mid

3-5 low low mid

>6 mid mid high

Intermediate GRC (N=294)

High GRC (N=118)

Low GRC (N=185)

Intermediate GRC (N=177)

High GRC (N=70)

Low GRC (N=235)

N=1079

GABG PCI

Page 22: How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium ://cardio-aalst.be.

How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ?

Just use them routinely

http://cardio-aalst.be & [email protected]