title: Lessons from the SYNTAX trial.
abstract: Despite the fact that CABG is the standard of care for patients with multivessel coronary arteries and/or left main stem stenosis, PCI has become a rival to CABG in patients with multivessel coronary artery disease or left main disease. However, the need for repeat revascularization, in-stent stenosis and thrombosis remain the achilis heal of PCI. SYNTAX trial randomized patients with left main disease and/or three-vessel disease to PCI with TAXus stent or CABG with the concept that PCI is not inferior to CABG. At 1 and 2 years follow up, MACCE was significantly increased in PCI patients mainly attributed to increased rate of repeat revascularization; however, stroke was significantly more with CABG. The composite safety endpoint of death/stroke/MI was comparable between the 2 groups. Therefore the criterion for non-inferiority was not met. What we learn from SYNTAX is that multi disciplinary team approach should be the standard of care when recommending treatment in more complex coronary artery disease. SYNTAX makes interventionists and surgeons come together, it may set the benchmark for MVD revascularization. PCI and CABG should be considered complementary rather than competitive revascularization strategies. There is no substitute for sound clinical judgment that takes into account the patient's overall clinical profile, functionality, co-morbidities, as well as the patient's coronary anatomy. The SYNTAX Score should be utilized to decide on treatment of patients with LM/MVD. Patients with low and intermediate score can be treated with PCI or CABG with equal results. Those with high score do better with CABG. SYNTAX trial showed that 66% of patients with 3VD or LMD are still best treated with CABG. In the remaining 1/3 of patients with low syntax score, PCI may be considered as an alternative to surgery. Finally, medical treatment should be optimized in patients going for CABG.
authors: Departments of Cardiology, Prince Sultan Cardiac Centre, Riyadh, Saudi Arabia and the Department of Surgery, Benghazi Medical Centre, Benghazi, Libya.
authors: Hussein S
authors: HS
authors: Alamri
authors: Mohammed
authors: M
authors: Alotaiby
authors: Abdulrahman
authors: A
authors: Almoghairi
authors: Rieda M
authors: RM
authors: El Oakley
keywords: Coronary surgery; Syntax trial
references: Curr Atheroscler Rep. 2007 Oct;9(4):305-11
references: 18173958
references: JAMA. 2005 May 4;293(17):2126-30
references: 15870416
references: BMJ. 2008 Aug 29;337:a1331
references: 18757996
references: Ann Thorac Surg. 1968 Apr;5(4):334-9
references: 5647919
references: Eur J Cardiothorac Surg. 2004 Jan;25(1):116-22
references: 14690742
references: Ann Intern Med. 2007 Nov 20;147(10):703-16
references: 17938385
references: Ann Thorac Surg. 2006 Jun;81(6):1949-57
references: 16731112
references: JAMA. 2002 Nov 20;288(19):2411-20
references: 12435254
references: N Engl J Med. 2009 Mar 5;360(10):961-72
references: 19228612
references: Lancet. 2002 Sep 28;360(9338):965-70
references: 12383664
references: EuroIntervention. 2006 May;2(1):53-60
references: 19755237
references: N Engl J Med. 2001 Aug 16;345(7):494-502
references: 11519503
references: N Engl J Med. 2006 Apr 20;354(16):1706-17
references: 16531616
references: N Engl J Med. 2007 Mar 8;356(10):1020-9
references: 17296821
references: N Engl J Med. 2009 Mar 5;360(10):1024-6
references: 19228611
references: Ther Adv Cardiovasc Dis. 2008 Jun;2(3):157-66
references: 19124419
references: Circulation. 1998 Nov 10;98(19 Suppl):II1-6
references: 9852872
references: Eur J Cardiothorac Surg. 2007 Sep;32(3):488-92
references: 17651981
references: J Am Coll Cardiol. 2010 Feb 2;55(5):432-40
references: 20117456
references: J Am Coll Cardiol. 2008 Sep 30;52(14):1134-40
references: 18804739
references: Ann Thorac Surg. 2002 May;73(5):1387-93
references: 12022522
references: N Engl J Med. 2006 Feb 2;354(5):483-95
references: 16452560
references: Heart Lung Circ. 2008 Aug;17(4):299-304
references: 18294911
references: J Am Coll Cardiol. 2003 Apr 16;41(8):1293-304
references: 12706924
references: N Engl J Med. 2008 Jan 24;358(4):331-41
references: 18216353
references: Lancet. 2007 Feb 24;369(9562):667-78
references: 17321312
references: Eur J Cardiothorac Surg. 2004 Feb;25(2):203-7
references: 14747113
references: Eur Heart J. 2007 Sep;28(17):2118-25
references: 17656352
references: Ann Thorac Surg. 2008 Apr;85(4):1473-82
references: 18355565
references: J Am Coll Cardiol. 2009 Feb 10;53(6):530-53
references: 19195618
references: N Engl J Med. 1996 Oct 24;335(17):1290-302
references: 8857010
references: Circulation. 2004 Aug 31;110(9):1168-76
references: 15339866
references: Am J Cardiol. 2008 May 1;101(9):1259-62
references: 18435954
references: J Am Coll Cardiol. 2005 Aug 16;46(4):575-81
references: 16098418
references: Catheter Cardiovasc Interv. 2009 Apr 1;73(5):618-9
references: 19309708
references: Lancet. 1978 Feb 4;1(8058):263
references: 74678
references: Ann Thorac Surg. 2004 Mar;77(3):794-9; discussion 799
references: 14992873