ApPropriateness of myocaRdial RevascularizatiOn assessed by the SYNTAX score II in a coUntry without cardiac Surgery faciliTies; PROUST study

Abstract

Background/objectives: The SYNTAX Score II (SSII) was proposed as a novel approach for objective individualized decision-making for optimal myocardial revascularization i.e. percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery. We sought to investigate how many lives may be saved by SSII use.

Methods: A total number of 651 consecutive SSII-naive-patients with complex coronary artery disease who were treated with PCI (n=409) or referred to other institutions for CABG (n=242) were included. All-cause mortality was ascertained in 96% of patients. The SSII was calculated for each patient.

Results: Based on the SSII treatment recommendation, CABG would have been the treatment of choice in 257/651 (39.5%) patients, PCI in 7/651 (1.1%) patients and CABG or PCI in 387/651 (59.4%) patients. Out of 257 patients in whom the treatment recommendation by SSII was CABG, 113/257 (44.0%) patients had actually CABG, while the remaining 144/257 (56.0%) underwent PCI. It was shown that 144/257 patients with treatment recommendations in favour of CABG who were treated with PCI had significantly higher mortality at 4years when compared with patients with SSII treatment recommendation for PCI or equally favouring CABG and PCI (12.5% vs. 0.0% vs. 6.9%, respectively, P=0.04).

Conclusion: The intuitive decision-making for choosing the optimal myocardial revascularization method differed predominantly from the SSII recommendation for CABG. The discordance between the SSII recommended revascularization strategy and the clinical decision was associated with a higher 4-year mortality i.e. one life may be saved if SSII would be calculated and followed consequently in 18 patients.

Keywords: All-cause mortality; Clinical judgement; Heart team; Myocardial revascularization; SYNTAX score II.