How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium &

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

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

How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? STEMI NSTEMI and NSTE-ACS Stable CAD &

Joint ESC - EACTS Guidelines on Myocardial Revascularisation Joint Task Force on Myocardial Revascularisation of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Developed with the special contribution of the European Association for Percutaneous Cardiovascular Interventions (EAPCI) European Heart Journal (2010) 31, European Journal of Cardio-thoracic Surgery 38, S1 (2010) S1-S52

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 delays ECG reperfusion &

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

Intended Early Invasive vs. Conservative Strategy Fox KA et al. JACC 2010;55(22): Long term outcome by initial Risk Score Meta-analysis of 3 major trials Selective invasive Routine invasive Selective invasive Routine invasive High Intermediate Low 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Cumulative percentage Follow-up time (years)

Joint 2010 ESC - EACTS Guidelines on Myocardial Revascularisation Calculating GRACE Risk Score KillipPoints class I0 II17 III34 IV51 SystolicPoints BP ≤ ≥13019 HeartPoints rate ≤ ≥2000 AgePoints ≤ ≥9091 CreatininePoints ≥251 Baseline risk factorsPoints Cardiac arrest at admission38 ST-segment deviation18 Positive cardiac markers14 STEMI14 Total from clinical evaluation

Joint 2010 ESC - EACTS Guidelines on Myocardial Revascularisation Calculating GRACE Risk Score

SpecificationClassLevel 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. IA An early invasive strategy ( 140 or multiple other high-risk criteria. IA 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. IA 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). IIaC An invasive strategy should not be performed in patients: at low overall risk, at a particularly high-risk for invasive diagnosis or intervention. IIIA Recommendations for revascularisation in NSTE-ACS

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

ACEF score = [Age/Ejection Fraction (%)] + 1 (if Creatinine > 2 mg/dL). Recommended risk stratification scores to be used in candidates for PCI or CABG ●For PCI, SYNTAX score emerges as preferred score to quantify complexity of CAD, but needs to be tested in other trials. ●For CABG, both EuroSCORE and STS score are well validated, mostly based on clinical variables. ●STS score is undergoing periodic adjustment which makes longitudinal comparisons difficult. ScoreValidated outcomes Class/Level PCICABG EuroSCOREShort and long-term mortality IIb BI B SYNTAX score Quantify coronary artery disease complexity IIa BIII B Mayo Clinic Risk Score MACE and procedural death IIb CIII C NCDR CathPCIIn-hospital mortality IIb B- Parsonnet score30-day mortality -III B STS score Operative mortality, stroke, renal failure, prolonged ventilation, deep sternal infection, re-operation, morbidity, length of stay 14 days -I B ACEF scoreMortality in elective CABG -IIb C

Joint 2010 ESC - EACTS Guidelines on Myocardial Revascularisation

Joint 2010 ESC - EACTS Guidelines on Myocardial Revascularisation

Indications for CABG versus PCI in stable patients with lesions suitable for both procedures and low predicted surgical mortality In the most severe patterns of CAD, CABG appears to offer a survival advantage as well as a marked reduction in the need for repeat revascularisation Subset of CAD by anatomyFavours CABGFavours PCI 1VD or 2VD - non-proximal LADIIb CI C 1VD or 2VD - proximal LADI AIIa B 3VD simple lesions, full functional revascularisation achievable with PCI, SYNTAX score ≤ 22 I AIIa B 3VD complex lesions, incomplete revascularisation achievable with PCI, SYNTAX score > 22 I AIII A Left main (isolated or 1VD, ostium/shaft)I AIIa B Left main (isolated or 1VD, distal bifurcation)I AIIb B Left main + 2VD or 3VD, SYNTAX score ≤ 32I AIIb B Left main + 2VD or 3VD, SYNTAX score ≥ 33I AIII B

Further validation of SYNTAX Score - SYNTAX Score works for non SYNTAX trial population Tested on all-comers population from Resolute trial C-index 0.62 Garg S et al, JACC Cardiovasc Interv Apr;4(4): &

New scores to be further validated - EuroHeart Score (based on EuroHeart Survey) for PCI Large dataset of pts, 1:1 training:validation set 16 clinical and angiographic variables predict mortality C-index 0.91 De Mulder M et al, Eur Heart J Jun;32(11): Epub 2011 Feb &

Currently used clinical and angiographic scores Score Number of variables used to calculate risk Validated Outcomes Recommendation/ Level of evidence ClinicalAngiographicPCICABG EuroSCORE170Short and long-term mortalityIIb BI B SYNTAX score011 (per lesion) Quantify coronary artery disease complexity IIa BIII B Why not combine EuroSCORE and SYNTAX score? Global Risk Classification

Risk scores Global Risk Classification Euro SCORE SYNTAX score < >33 0-2low mid 3-5low mid >6>6 high low, mid and high Presented by P. W. Serruys

5.3% P= % 6.5% Months Since Allocation Cumulative Event Rate (%) P< % 13.1% 2.7% Months Since Allocation Cumulative Event Rate (%) All-cause mortality to 3 years LM Patients (randomized + registry) ITT population Cumulative KM Event Rate ± 1.5 SE; log-rank P value Euro SCORE SYNTAX Score < >33 0-2low mid 3-5low mid >6mid 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

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