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How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium. http://cardio-aalst.be & William.Wijns@olvz-aalst.be. Global appraisal of the patient’s condition & risk. Use of risk scores. - PowerPoint PPT Presentation
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How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ?
William WIJNS Aalst, Belgium
http://cardio-aalst.be & William.Wijns@olvz-aalst.be
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 ?
STEMINSTEMI and NSTE-ACSStable CAD
http://cardio-aalst.be & William.Wijns@olvz-aalst.be
www.escardio.org/guidelines
Joint ESC - EACTS Guidelineson Myocardial Revascularisation
Joint Task Force on Myocardial Revascularisation ofthe European Society of Cardiology (ESC) and
the European Association for Cardio-Thoracic Surgery (EACTS)
Developed with the special contribution ofthe European Association for
Percutaneous Cardiovascular Interventions (EAPCI)
European Heart Journal (2010) 31, 2501-2555European 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 delaysECGreperfusion
http://cardio-aalst.be & William.Wijns@olvz-aalst.be
How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ?
NSTEMI and NSTE-ACS
http://cardio-aalst.be & William.Wijns@olvz-aalst.be
www.escardio.org/guidelines
Intended Early Invasive vs. Conservative Strategy
Fox KA et al. JACC 2010;55(22):2435-45
Long term outcome by initial Risk ScoreMeta-analysis of 3 major trials
Selective invasive 2746 2452 2351 2178 2077 2005
Routine invasive 2721 2485 2410 2235 2166 2079
Selective invasiveRoutine invasive High
Intermediate
Low
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
0 1 2 3 4 5
Cumulativepercentage
Follow-up time (years)
www.escardio.org/guidelinesJoint 2010 ESC - EACTS Guidelineson Myocardial Revascularisation
Calculating GRACE Risk ScoreKillip Pointsclass
I 0
II 17
III 34
IV 51
Systolic PointsBP
≤70 66
70-89 53
90-109 40
110-129 27
≥130 19
Heart Pointsrate
≤70 10
70-89 15
90-109 26
110-129 32
130-149 24
150-169 16
170-199 8
≥200 0
Age Points
≤30 0
30-49 10
50-69 29
70-79 56
80-89 73
≥90 91
Creatinine Points
0-0.39 3
0.4-0.9 9
1.0-1.9 32
≥2 51
Baseline risk factors Points
Cardiac arrest at admission 38
ST-segment deviation 18
Positive cardiac markers 14
STEMI 14
Total from clinical evaluation
www.escardio.org/guidelinesJoint 2010 ESC - EACTS Guidelineson Myocardial Revascularisation
Calculating GRACE Risk Score
http://www.outcomes-umassmed.org/grace
www.escardio.org/guidelines
Specification Class Level
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.
I A
An early invasive strategy (< 24 h) is indicated in patients with GRACE score > 140 or multiple other high-risk criteria.
I A
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.
I A
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).
IIa C
An invasive strategy should not be performed in patients:• at low overall risk,• at a particularly high-risk for invasive diagnosis or intervention.
III A
Recommendations forrevascularisation in NSTE-ACS
How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ?
Stable CAD
http://cardio-aalst.be & William.Wijns@olvz-aalst.be
www.escardio.org/guidelines
ACEF score = [Age/Ejection Fraction (%)] + 1 (if Creatinine > 2 mg/dL).
Recommended risk stratification scoresto be used in candidates for PCI or CABG
● For PCI, SYNTAX scoreemerges as preferred scoreto quantify complexity ofCAD, but needs to be testedin other trials.
● For CABG, both EuroSCOREand STS score are wellvalidated, mostly based onclinical variables.
● STS score is undergoingperiodic adjustment whichmakes longitudinalcomparisons difficult.
Score Validated outcomesClass/Level
PCI CABG
EuroSCORE Short and long-term mortality IIb B I B
SYNTAX score Quantify coronary artery disease complexity IIa B III B
Mayo Clinic Risk Score MACE and procedural death IIb C III C
NCDR CathPCI In-hospital mortality IIb B -
Parsonnet score 30-day mortality - III B
STS score
Operative mortality, stroke, renal failure, prolonged ventilation, deep sternal infection, re-operation, morbidity, length of stay < 6 or > 14 days
- I B
ACEF score Mortality in elective CABG - IIb C
www.escardio.org/guidelinesJoint 2010 ESC - EACTS Guidelineson Myocardial Revascularisation
www.syntaxscore.com
www.escardio.org/guidelinesJoint 2010 ESC - EACTS Guidelineson Myocardial Revascularisation
www.escardio.org/guidelines
Indications for CABG versus PCI in stablepatients with lesions suitable for both procedures and
low predicted surgical mortality
In the most severe patterns of CAD, CABG appears to offer a survival advantageas well as a marked reduction in the need for repeat revascularisation
Subset of CAD by anatomy Favours CABG Favours PCI
1VD or 2VD - non-proximal LAD IIb C I C
1VD or 2VD - proximal LAD I A IIa B
3VD simple lesions, full functional revascularisation achievable with PCI, SYNTAX score ≤ 22
I A IIa B
3VD complex lesions, incomplete revascularisation achievable with PCI, SYNTAX score > 22
I A III A
Left main (isolated or 1VD, ostium/shaft) I A IIa B
Left main (isolated or 1VD, distal bifurcation) I A IIb B
Left main + 2VD or 3VD, SYNTAX score ≤ 32 I A IIb B
Left main + 2VD or 3VD, SYNTAX score ≥ 33 I A III B
Further validation of SYNTAX Score
- SYNTAX Score works for non SYNTAX trial populationTested on all-comers population from Resolute trialC-index 0.62
Garg S et al, JACC Cardiovasc Interv. 2011 Apr;4(4):432-41
http://cardio-aalst.be & William.Wijns@olvz-aalst.be
New scores to be further validated
- EuroHeart Score (based on EuroHeart Survey) for PCILarge dataset of 46.064 pts, 1:1 training:validation set16 clinical and angiographic variables predict mortalityC-index 0.91
De Mulder M et al, Eur Heart J. 2011 Jun;32(11):1398-408. Epub 2011 Feb 22.
http://cardio-aalst.be & William.Wijns@olvz-aalst.be
Currently used clinical and angiographic scores
Score
Number of variables used to calculate risk
Validated OutcomesRecommendation/
Level of evidenceClinical Angiographic PCI CABG
EuroSCORE 17 0 Short and long-term mortality IIb B I B
SYNTAX score 0 11 (per lesion)Quantify coronary artery
disease complexityIIa B III B
Why not combine EuroSCORE and SYNTAX score?
Global Risk Classification
Risk scores
Global Risk Classification
EuroSCORE
SYNTAX score
<22 23-32 >33
0-2 low low mid
3-5 low low mid
>6 mid mid high
low, mid and high
Presented by P. W. Serruys
5.3%
P=0.004
14.8%
6.5%
0 12 24Months Since Allocation
Cum
ula
tive E
vent
Rate
(%
)
30
60
0
36
P<0.00130.0%
13.1%
2.7%
0 12 24Months Since Allocation
Cum
ula
tive E
vent
Rate
(%
)
30
60
0
36
All-cause mortality to 3 yearsLM Patients (randomized + registry)
ITT populationCumulative KM Event Rate ± 1.5 SE; log-rank P value
EuroSCORE
SYNTAX Score
<22 23-32 >33
0-2 low low mid
3-5 low low mid
>6 mid mid 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
http://cardio-aalst.be & William.Wijns@olvz-aalst.be
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