title: Prediction of 1-year mortality in patients with acute coronary syndromes undergoing percutaneous coronary intervention: validation of the logistic clinical SYNTAX (Synergy Between Percutaneous Coronary Interventions With Taxus and Cardiac Surgery) score.
abstract: OBJECTIVE
  This study sought to validate the Logistic Clinical SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score in patients with non-ST-segment elevation acute coronary syndromes (ACS), in order to further legitimize its clinical application.
  
  
  BACKGROUND
  The Logistic Clinical SYNTAX score allows for an individualized prediction of 1-year mortality in patients undergoing contemporary percutaneous coronary intervention. It is composed of a "Core" Model (anatomical SYNTAX score, age, creatinine clearance, and left ventricular ejection fraction), and "Extended" Model (composed of an additional 6 clinical variables), and has previously been cross validated in 7 contemporary stent trials (>6,000 patients).
  
  
  METHODS
  One-year all-cause death was analyzed in 2,627 patients undergoing percutaneous coronary intervention from the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial. Mortality predictions from the Core and Extended Models were studied with respect to discrimination, that is, separation of those with and without 1-year all-cause death (assessed by the concordance [C] statistic), and calibration, that is, agreement between observed and predicted outcomes (assessed with validation plots). Decision curve analyses, which weight the harms (false positives) against benefits (true positives) of using a risk score to make mortality predictions, were undertaken to assess clinical usefulness.
  
  
  RESULTS
  In the ACUITY trial, the median SYNTAX score was 9.0 (interquartile range 5.0 to 16.0); approximately 40% of patients had 3-vessel disease, 29% diabetes, and 85% underwent drug-eluting stent implantation. Validation plots confirmed agreement between observed and predicted mortality. The Core and Extended Models demonstrated substantial improvements in the discriminative ability for 1-year all-cause death compared with the anatomical SYNTAX score in isolation (C-statistics: SYNTAX score: 0.64, 95% confidence interval [CI]: 0.56 to 0.71; Core Model: 0.74, 95% CI: 0.66 to 0.79; Extended Model: 0.77, 95% CI: 0.70 to 0.83). Decision curve analyses confirmed the increasing ability to correctly identify patients who would die at 1 year with the Extended Model versus the Core Model versus the anatomical SYNTAX score, over a wide range of thresholds for mortality risk predictions.
  
  
  CONCLUSIONS
  Compared to the anatomical SYNTAX score alone, the Core and Extended Models of the Logistic Clinical SYNTAX score more accurately predicted individual 1-year mortality in patients presenting with non-ST-segment elevation acute coronary syndromes undergoing percutaneous coronary intervention. These findings support the clinical application of the Logistic Clinical SYNTAX score.
authors.affiliation: Department of Interventional Cardiology, Erasmus University Medical Centre, Thoraxcenter, Rotterdam, the Netherlands.
authors.forename: Vasim
authors.initials: V
authors.lastname: Farooq
authors.forename: Yvonne
authors.initials: Y
authors.lastname: Vergouwe
authors.forename: Philippe
authors.initials: P
authors.lastname: Généreux
authors.forename: Christos V
authors.initials: CV
authors.lastname: Bourantas
authors.forename: Tullio
authors.initials: T
authors.lastname: Palmerini
authors.forename: Adriano
authors.initials: A
authors.lastname: Caixeta
authors.forename: Hector M
authors.initials: HM
authors.lastname: Garcìa-Garcìa
authors.forename: Roberto
authors.initials: R
authors.lastname: Diletti
authors.forename: Marie-angèle
authors.initials: MA
authors.lastname: Morel
authors.forename: Thomas C
authors.initials: TC
authors.lastname: McAndrew
authors.forename: Arie Pieter
authors.initials: AP
authors.lastname: Kappetein
authors.forename: Marco
authors.initials: M
authors.lastname: Valgimigli
authors.forename: Stephan
authors.initials: S
authors.lastname: Windecker
authors.forename: Keith D
authors.initials: KD
authors.lastname: Dawkins
authors.forename: Ewout W
authors.initials: EW
authors.lastname: Steyerberg
authors.forename: Patrick W
authors.initials: PW
authors.lastname: Serruys
authors.forename: Gregg W
authors.initials: GW
authors.lastname: Stone
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D000368:Aged; D017023:Coronary Angiography; D003661:Decision Support Techniques; D016002:Discriminant Analysis; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality*; D011446:Prospective Studies; D015203:Reproducibility of Results; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome
keywords: ACS; BMS; CrCl; DES; IQR; LVEF; PCI; PVD; SYNTAX score; acute coronary syndrome; acute coronary syndromes; bare-metal stent(s); creatinine clearance; drug-eluting stent(s); drug-eluting stents; interquartile range(s); left ventricular ejection fraction; mortality; percutaneous coronary intervention; peripheral vascular disease; predictions; validation