Left Main Coronary Artery Disease Revascularization According to the SYNTAX Score

Evan Shlofmitz, Philippe Généreux, Shmuel Chen, Ovidiu Dressler, Ori Ben-Yehuda, Marie Claude Morice, John D. Puskas, David P. Taggart, David E. Kandzari, Aaron Crowley, Björn Redfors, Ghazaleh Mehdipoor, Arie Pieter Kappetein, Joseph F. Sabik, Patrick W. Serruys, Gregg W. Stone

Research output: Contribution to journalArticle

Abstract

BACKGROUND: The SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score (SS), a measure of anatomic coronary artery disease (CAD) extent and complexity, has proven useful in past studies to determine the absolute and relative prognosis after revascularization with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). We sought to assess contemporary outcomes after PCI and CABG in patients with left main CAD according to SS and revascularization type from a large randomized trial. METHODS: The EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) randomized patients with left main CAD and site-assessed SS≤32 to PCI with everolimus-eluting stents or CABG. Four-year outcomes were examined according to angiographic core laboratory-assessed SS using multivariable Cox proportional hazards regression. RESULTS: A total of 1840 patients with left main CAD randomized to PCI (n=914) versus CABG (n=926) had angiographic core laboratory SS assessment. The mean SS was 26.5±9.3 (range 5-74); 24.1% of patients had angiographic core laboratory-assessed SS ≥33. The 4-year rate of the primary major adverse cardiac event end point of death, stroke, or myocardial infarction was similar between PCI and CABG (18.6% versus 16.7%, respectively; P=0.40) and did not vary according to SS (Pinteraction=0.33). Rates of ischemia-driven revascularization rose with increasing SS after PCI, but not after CABG. As a result, the major secondary composite end point of major adverse cardiac or cerebrovascular events (major adverse cardiac event or ischemia-driven revascularization) occurred more frequently with PCI than CABG (28.0% versus 22.0%, P=0.01), a difference which rose progressively with increasing SS (Pinteraction=0.03). CONCLUSIONS: In the EXCEL trial, the 4-year primary composite major adverse cardiac event end point of death, myocardial infarction, or stroke was similar after PCI with everolimus-eluting stents and CABG and was independent of the baseline anatomic complexity and extent of CAD. In contrast, the relative and absolute hazard of major adverse cardiac or cerebrovascular events with PCI compared with CABG rose progressively with the SS. These data should be considered by the heart team when deciding between PCI versus CABG for revascularization in patients with left main CAD. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier NCT01205776.

Original languageEnglish (US)
Pages (from-to)e008007
JournalCirculation. Cardiovascular interventions
Volume12
Issue number9
DOIs
StatePublished - Sep 1 2019
Externally publishedYes

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Percutaneous Coronary Intervention
Coronary Artery Bypass
Coronary Artery Disease
Stents
Ischemia
Stroke
Myocardial Infarction
Taxus
Thoracic Surgery
Clinical Trials

All Science Journal Classification (ASJC) codes

  • Cardiology and Cardiovascular Medicine

Cite this

Shlofmitz, Evan ; Généreux, Philippe ; Chen, Shmuel ; Dressler, Ovidiu ; Ben-Yehuda, Ori ; Morice, Marie Claude ; Puskas, John D. ; Taggart, David P. ; Kandzari, David E. ; Crowley, Aaron ; Redfors, Björn ; Mehdipoor, Ghazaleh ; Kappetein, Arie Pieter ; Sabik, Joseph F. ; Serruys, Patrick W. ; Stone, Gregg W. / Left Main Coronary Artery Disease Revascularization According to the SYNTAX Score. In: Circulation. Cardiovascular interventions. 2019 ; Vol. 12, No. 9. pp. e008007.
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abstract = "BACKGROUND: The SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score (SS), a measure of anatomic coronary artery disease (CAD) extent and complexity, has proven useful in past studies to determine the absolute and relative prognosis after revascularization with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). We sought to assess contemporary outcomes after PCI and CABG in patients with left main CAD according to SS and revascularization type from a large randomized trial. METHODS: The EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) randomized patients with left main CAD and site-assessed SS≤32 to PCI with everolimus-eluting stents or CABG. Four-year outcomes were examined according to angiographic core laboratory-assessed SS using multivariable Cox proportional hazards regression. RESULTS: A total of 1840 patients with left main CAD randomized to PCI (n=914) versus CABG (n=926) had angiographic core laboratory SS assessment. The mean SS was 26.5±9.3 (range 5-74); 24.1{\%} of patients had angiographic core laboratory-assessed SS ≥33. The 4-year rate of the primary major adverse cardiac event end point of death, stroke, or myocardial infarction was similar between PCI and CABG (18.6{\%} versus 16.7{\%}, respectively; P=0.40) and did not vary according to SS (Pinteraction=0.33). Rates of ischemia-driven revascularization rose with increasing SS after PCI, but not after CABG. As a result, the major secondary composite end point of major adverse cardiac or cerebrovascular events (major adverse cardiac event or ischemia-driven revascularization) occurred more frequently with PCI than CABG (28.0{\%} versus 22.0{\%}, P=0.01), a difference which rose progressively with increasing SS (Pinteraction=0.03). CONCLUSIONS: In the EXCEL trial, the 4-year primary composite major adverse cardiac event end point of death, myocardial infarction, or stroke was similar after PCI with everolimus-eluting stents and CABG and was independent of the baseline anatomic complexity and extent of CAD. In contrast, the relative and absolute hazard of major adverse cardiac or cerebrovascular events with PCI compared with CABG rose progressively with the SS. These data should be considered by the heart team when deciding between PCI versus CABG for revascularization in patients with left main CAD. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier NCT01205776.",
author = "Evan Shlofmitz and Philippe G{\'e}n{\'e}reux and Shmuel Chen and Ovidiu Dressler and Ori Ben-Yehuda and Morice, {Marie Claude} and Puskas, {John D.} and Taggart, {David P.} and Kandzari, {David E.} and Aaron Crowley and Bj{\"o}rn Redfors and Ghazaleh Mehdipoor and Kappetein, {Arie Pieter} and Sabik, {Joseph F.} and Serruys, {Patrick W.} and Stone, {Gregg W.}",
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Shlofmitz, E, Généreux, P, Chen, S, Dressler, O, Ben-Yehuda, O, Morice, MC, Puskas, JD, Taggart, DP, Kandzari, DE, Crowley, A, Redfors, B, Mehdipoor, G, Kappetein, AP, Sabik, JF, Serruys, PW & Stone, GW 2019, 'Left Main Coronary Artery Disease Revascularization According to the SYNTAX Score', Circulation. Cardiovascular interventions, vol. 12, no. 9, pp. e008007. https://doi.org/10.1161/CIRCINTERVENTIONS.118.008007

Left Main Coronary Artery Disease Revascularization According to the SYNTAX Score. / Shlofmitz, Evan; Généreux, Philippe; Chen, Shmuel; Dressler, Ovidiu; Ben-Yehuda, Ori; Morice, Marie Claude; Puskas, John D.; Taggart, David P.; Kandzari, David E.; Crowley, Aaron; Redfors, Björn; Mehdipoor, Ghazaleh; Kappetein, Arie Pieter; Sabik, Joseph F.; Serruys, Patrick W.; Stone, Gregg W.

In: Circulation. Cardiovascular interventions, Vol. 12, No. 9, 01.09.2019, p. e008007.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Left Main Coronary Artery Disease Revascularization According to the SYNTAX Score

AU - Shlofmitz, Evan

AU - Généreux, Philippe

AU - Chen, Shmuel

AU - Dressler, Ovidiu

AU - Ben-Yehuda, Ori

AU - Morice, Marie Claude

AU - Puskas, John D.

AU - Taggart, David P.

AU - Kandzari, David E.

AU - Crowley, Aaron

AU - Redfors, Björn

AU - Mehdipoor, Ghazaleh

AU - Kappetein, Arie Pieter

AU - Sabik, Joseph F.

AU - Serruys, Patrick W.

AU - Stone, Gregg W.

PY - 2019/9/1

Y1 - 2019/9/1

N2 - BACKGROUND: The SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score (SS), a measure of anatomic coronary artery disease (CAD) extent and complexity, has proven useful in past studies to determine the absolute and relative prognosis after revascularization with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). We sought to assess contemporary outcomes after PCI and CABG in patients with left main CAD according to SS and revascularization type from a large randomized trial. METHODS: The EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) randomized patients with left main CAD and site-assessed SS≤32 to PCI with everolimus-eluting stents or CABG. Four-year outcomes were examined according to angiographic core laboratory-assessed SS using multivariable Cox proportional hazards regression. RESULTS: A total of 1840 patients with left main CAD randomized to PCI (n=914) versus CABG (n=926) had angiographic core laboratory SS assessment. The mean SS was 26.5±9.3 (range 5-74); 24.1% of patients had angiographic core laboratory-assessed SS ≥33. The 4-year rate of the primary major adverse cardiac event end point of death, stroke, or myocardial infarction was similar between PCI and CABG (18.6% versus 16.7%, respectively; P=0.40) and did not vary according to SS (Pinteraction=0.33). Rates of ischemia-driven revascularization rose with increasing SS after PCI, but not after CABG. As a result, the major secondary composite end point of major adverse cardiac or cerebrovascular events (major adverse cardiac event or ischemia-driven revascularization) occurred more frequently with PCI than CABG (28.0% versus 22.0%, P=0.01), a difference which rose progressively with increasing SS (Pinteraction=0.03). CONCLUSIONS: In the EXCEL trial, the 4-year primary composite major adverse cardiac event end point of death, myocardial infarction, or stroke was similar after PCI with everolimus-eluting stents and CABG and was independent of the baseline anatomic complexity and extent of CAD. In contrast, the relative and absolute hazard of major adverse cardiac or cerebrovascular events with PCI compared with CABG rose progressively with the SS. These data should be considered by the heart team when deciding between PCI versus CABG for revascularization in patients with left main CAD. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier NCT01205776.

AB - BACKGROUND: The SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score (SS), a measure of anatomic coronary artery disease (CAD) extent and complexity, has proven useful in past studies to determine the absolute and relative prognosis after revascularization with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). We sought to assess contemporary outcomes after PCI and CABG in patients with left main CAD according to SS and revascularization type from a large randomized trial. METHODS: The EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) randomized patients with left main CAD and site-assessed SS≤32 to PCI with everolimus-eluting stents or CABG. Four-year outcomes were examined according to angiographic core laboratory-assessed SS using multivariable Cox proportional hazards regression. RESULTS: A total of 1840 patients with left main CAD randomized to PCI (n=914) versus CABG (n=926) had angiographic core laboratory SS assessment. The mean SS was 26.5±9.3 (range 5-74); 24.1% of patients had angiographic core laboratory-assessed SS ≥33. The 4-year rate of the primary major adverse cardiac event end point of death, stroke, or myocardial infarction was similar between PCI and CABG (18.6% versus 16.7%, respectively; P=0.40) and did not vary according to SS (Pinteraction=0.33). Rates of ischemia-driven revascularization rose with increasing SS after PCI, but not after CABG. As a result, the major secondary composite end point of major adverse cardiac or cerebrovascular events (major adverse cardiac event or ischemia-driven revascularization) occurred more frequently with PCI than CABG (28.0% versus 22.0%, P=0.01), a difference which rose progressively with increasing SS (Pinteraction=0.03). CONCLUSIONS: In the EXCEL trial, the 4-year primary composite major adverse cardiac event end point of death, myocardial infarction, or stroke was similar after PCI with everolimus-eluting stents and CABG and was independent of the baseline anatomic complexity and extent of CAD. In contrast, the relative and absolute hazard of major adverse cardiac or cerebrovascular events with PCI compared with CABG rose progressively with the SS. These data should be considered by the heart team when deciding between PCI versus CABG for revascularization in patients with left main CAD. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier NCT01205776.

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