title: Anatomical and clinical characteristics to guide decision making between coronary artery bypass surgery and percutaneous coronary intervention for individual patients: development and validation of SYNTAX score II.
abstract: BACKGROUND
  The anatomical SYNTAX score is advocated in European and US guidelines as an instrument to help clinicians decide the optimum revascularisation method in patients with complex coronary artery disease. The absence of an individualised approach and of clinical variables to guide decision making between coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) are limitations of the SYNTAX score. SYNTAX score II aimed to overcome these limitations.
  
  
  METHODS
  SYNTAX score II was developed by applying a Cox proportional hazards model to results of the randomised all comers SYNTAX trial (n=1800). Baseline features with strong associations to 4-year mortality in either the CABG or the PCI settings (interactions), or in both (predictive accuracy), were added to the anatomical SYNTAX score. Comparisons of 4-year mortality predictions between CABG and PCI were made for each patient. Discriminatory performance was quantified by concordance statistics and internally validated with bootstrap resampling. External validation was done in the multinational all comers DELTA registry (n=2891), a heterogeneous population that included patients with three-vessel disease (26%) or complex coronary artery disease (anatomical SYNTAX score ≥33, 30%) who underwent CABG or PCI. The SYNTAX trial is registered with ClinicalTrials.gov, number NCT00114972.
  
  
  RESULTS
  SYNTAX score II contained eight predictors: anatomical SYNTAX score, age, creatinine clearance, left ventricular ejection fraction (LVEF), presence of unprotected left main coronary artery (ULMCA) disease, peripheral vascular disease, female sex, and chronic obstructive pulmonary disease (COPD). SYNTAX score II significantly predicted a difference in 4-year mortality between patients undergoing CABG and those undergoing PCI (p(interaction) 0·0037). To achieve similar 4-year mortality after CABG or PCI, younger patients, women, and patients with reduced LVEF required lower anatomical SYNTAX scores, whereas older patients, patients with ULMCA disease, and those with COPD, required higher anatomical SYNTAX scores. Presence of diabetes was not important for decision making between CABG and PCI (p(interaction) 0·67). SYNTAX score II discriminated well in all patients who underwent CABG or PCI, with concordance indices for internal (SYNTAX trial) validation of 0·725 and for external (DELTA registry) validation of 0·716, which were substantially higher than for the anatomical SYNTAX score alone (concordance indices of 0·567 and 0·612, respectively). A nomogram was constructed that allowed for an accurate individualised prediction of 4-year mortality in patients proposing to undergo CABG or PCI.
  
  
  CONCLUSIONS
  Long-term (4-year) mortality in patients with complex coronary artery disease can be well predicted by a combination of anatomical and clinical factors in SYNTAX score II. SYNTAX score II can better guide decision making between CABG and PCI than the original anatomical SYNTAX score.
  
  
  BACKGROUND
  Boston Scientific Corporation.
authors: Thoraxcenter, Erasmus University Medical Center, Rotterdam, Netherlands.
authors: Vasim
authors: V
authors: Farooq
authors: David
authors: D
authors: van Klaveren
authors: Ewout W
authors: EW
authors: Steyerberg
authors: Emanuele
authors: E
authors: Meliga
authors: Yvonne
authors: Y
authors: Vergouwe
authors: Alaide
authors: A
authors: Chieffo
authors: Arie Pieter
authors: AP
authors: Kappetein
authors: Antonio
authors: A
authors: Colombo
authors: David R
authors: DR
authors: Holmes
authors: Michael
authors: M
authors: Mack
authors: Ted
authors: T
authors: Feldman
authors: Marie-Claude
authors: MC
authors: Morice
authors: Elisabeth
authors: E
authors: Ståhle
authors: Yoshinobu
authors: Y
authors: Onuma
authors: Marie-angèle
authors: MA
authors: Morel
authors: Hector M
authors: HM
authors: Garcia-Garcia
authors: Gerrit Anne
authors: GA
authors: van Es
authors: Keith D
authors: KD
authors: Dawkins
authors: Friedrich W
authors: FW
authors: Mohr
authors: Patrick W
authors: PW
authors: Serruys
mesh_terms: D000367:Age Factors; D015906:Angioplasty, Balloon, Coronary; D001026:Coronary Artery Bypass; D003324:Coronary Artery Disease / Q000401:mortality* / Q000628:therapy*; D003404:Creatinine / Q000032:analysis; D003657:Decision Making; D005260:Female; D006801:Humans; D008297:Male; D018579:Patient Selection; D016491:Peripheral Vascular Diseases / Q000453:epidemiology; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D029424:Pulmonary Disease, Chronic Obstructive / Q000453:epidemiology; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D013318:Stroke Volume
chemical_list: D003404:Creatinine