Combination of clinical and angiographic scoressummitmd.com/pdf/pdf/2181_Tamburino.pdf · this presentationthis presentation Ferrarotto Hospital University of Catania. The Ideal Risk

Combination of Angiographic and ClinicalRisk Scores in Left Main Revascularization

Corrado Tamburino, MD, PhDFull Professor of Cardiology, Director of Postgraduate School of Cardiology

Chief Cardiovascular Department, Director Cardiology Division, Interventional Cardiology and Heart Failure Unit, University of Catania, Ferrarotto Hospital, Catania, Italy

Ferrarotto HospitalUniversity of CataniaFerrarotto HospitalUniversity of Catania

Disclosure Statement of Financial Interest

I, Corrado Tamburino, DO NOT have a financial interest/arrangement or affiliationfinancial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflictbe perceived as a real or apparent conflict of interest in the context of the subject of this presentationthis presentation


The Ideal Risk Stratification tool

Easy to apply at the bed-side or in the cath-labReproducibleUses data routinely available before the procedurep ocedu eAccurate


Accuracy is a function of two characteristics

0.00

The The idealidealscore for score for LM PCILM PCI

1.00

0.00sh

ow

ette

r

Discrimination

LM PCILM PCI

2.00

mer

-Lem

es

tion

be

DiscriminationMeasures how much the score can differentiate between

3.00Hos

m

alib

rat differentiate between

poor and good outcomes

0.60 0.65 0.70 0.75 0.80

4.00

Ca

CalibrationMeasures how close the estimates are to a

C-statistic

Discrimination betterreal probability


Risk Stratification in LM Disease

Angiographic Clinical Combined Functional• SYNTAX score

(Sxscore)• Residual

SYNTAX score

• EuroSCORE• EuroSCORE 2*• STS score*

C

• GRC• CSS• Logistic CSS*

S

• FunctionalSYNTAX score (FSS)*

• Non invasiveSYNTAX score (rSS)*

• ACEF score • NERS • Non-invasive FSS*

*not yet presented or validated in LM PCI


Risk Stratification in LM Disease

Angiographic Clinical Combined Functional• SYNTAX score

(Sxscore)• Residual

SYNTAX score

• EuroSCORE• EuroSCORE 2*• STS score*

C

• GRC• CSS• Logistic CSS*

S

• FunctionalSYNTAX score (FSS)*

• Non invasiveSYNTAX score (rSS)*

• ACEF score • NERS • Non-invasive FSS*

*not yet presented or validated in LM PCI


Stand-Alone Clinical Scores (ACEF, EuroSCORE) versus SYNTAX score in LM PCI

EuroSCORE ACEF score SYNTAX scoreP < 0.001 P < 0.001 P < 0.001

EuroSCORE ACEF score SYNTAX score

Δ = 17% Δ = 14% Δ = 12%ΔHIGH-LOW = 17% ΔHIGH-LOW = 14% ΔHIGH-LOW = 12%

Hosmer-Lemeshow: 1.607c-statistic: 0.69

Hosmer-Lemeshow: 0.216c-statistic : 0.69

Hosmer-Lemeshow: 2.448c-statistic : 0.73


Capodanno D et al. JACC Interv 2011;4:287-97

Stand-alone Scores Are Far from Perfection

0.00The The idealidealscore forscore forACEF

1.00

0.00

show

ette

rscore for score for LM PCILM PCI

ACEF

2.00

mer

-Lem

es

tion

be EuroSCORE

SYNTAX Score

3.00Hos

m

alib

rat SYNTAX Score

0.60 0.65 0.70 0.75 0.80

4.00

Ca

C-statistic

Discrimination better



Combined Risk models in LM PCI: The best of both worlds?

Angiographic• SYNTAX score

(Sxscore)

Clinical• EuroSCORE• ACEF score

Combined• NERS• CSS(Sxscore) • ACEF score • CSS• GRC


Angiography is not enoughg g p y g

5% Clinical and angiographic1917%

11%5%

ore

Clinical and angiographic scores summarize very different information in patients with unprotected

<19

18%8%

10%

NTA

X sc

o patients with unprotected LM19-27

17%

8%

5%8%

SYN Low Spearman rank

correlation coefficient between SYNTAX score > 27

5% and EuroSCORE(RS=0.204, p = 0.001)

0-2 3-6 > 6EuroSCORE

The frequency of patients for each cross-tabulation cell is shown within a rectangle that is proportional in size to the frequency


Capodanno et al, Am Heart J 2010:159:103-9

The New Risk Classification (NERS) ( )

Based on 17 clinical 4 proceduralBased on 17 clinical, 4 procedural, and 33 angiographic variablesBetter discriminates a broad array of endpoints than SYNTAX scoreof endpoints than SYNTAX score, including MACE, Death, MI, TVR and ST in patients undergoing LM PCI

BackgroundTh t ti l t ib ti f li i lThe potential contributions of clinical, procedural, and angiographic indices in LM patients have not been fully elucidatedelucidated


Chen SL et al. JACC Interv. 2010;3:632-41

Caveats of NERS

Labor-intensive54 variables

OverfittedOverfitted126 variables tested in 260 patients

No prospective validationUtility in decision-making remains uncertainUtility in decision making remains uncertain

Does include procedural variables, cannot be calculated upfrontcalculated upfront


Clinical SYNTAX score (CSS)( )

Calculated as SYNTAXCalculated as SYNTAX score*modified ACEF scoreBetter discriminates 5-Year Death and MACE in multivessel CAD thanand MACE in multivessel CAD than SYNTAX scoreBetter discriminates 5-Year Death in All-Comers PCI

BackgroundB i l l b d i hi

All Comers PCI

Being solely based on angiographicvariables, the SYNTAX score cannot account for the variability related to clinical factors which are widelyclinical factors which are widely acknowledged to impact on long-term outcomes


Garg S et al. Circ Card Interv 2010;3:317-26Girasis C et al. Eur Heart J 2011;32:3115-27

CSS – No improvement in discrimination of MACE vs. SYNTAX score Better discrimination in mortality but limitations remain

Death

score. Better discrimination in mortality, but limitations remain

MACET til t i

P<0.001 P<0.001CSS

17.4±20.5

Tertiles are not in the anticipated order

M d t i iModest gain in calibration vsSYNTAX score (⎟2 8 vs 6)

SYNTAX score P≤0.03 P≤0.03

c-statistic = 0.62 c-statistic = 0.66

11.7±7.3

c-statistic = 0 61 c-statistic = 0 58


Nam CW et al. J Am Coll Cardiol 2011;58:1211-8

c-statistic = 0.61 c-statistic = 0.58

Ferrarotto HospitalUniversity of CataniaFerrarotto HospitalUniversity of CataniaSerruys PW, ACC 2012

Global Risk Classification (GRC)( )

Developed as an Integration of theDeveloped as an Integration of the SYNTAX score and the EuroSCOREBetter discriminates in-hospital and 2-Year Cardiac Death in LM PCI than2 Year Cardiac Death in LM PCI than SYNTAX score alone

ConclusionsIncorporation of clinical risk factors and comorbidities into existing estimation systems may refine their prognostic ability and guide clinical decisions


Capodanno D et al. Am Heart J 2010;159:103-9

GRC – Prognostic ability in improving bothdiscrimination and calibration vs SYNTAX score

%) 10

th fr

ee s

urvi

val (

% 100

90

80

96.1%

94.6%

78.1%P = 0.004*SYNTAX score

Car

diac

dea

t

70

60SYNTAX score

LOWMIDDLEHIGHL L I0-2

<19 19-27 >27SYNTAX score

E

Time (months)0 12 24

val (

%) 10

098.4%

L L IL L I3-6

uroS

CO

RE

c de

ath

free

sur

viv

90

80

70

84.0%

P < 0.001*I I H> 6Eu

Car

diac 70

60

Time (months)0 12 24

GRC68.6%LOW

MIDDLEHIGH

* log rank test; n = 255 LM patients undergoing PCI


Capodanno D et al. Am Heart J 2010;159:103-9

Cardiac death to 2 Years by stratification ofGRC and CSS in LM PCI (N = 400)

LOW MIDDLE HIGHLOW MIDDLE HIGH

)

40

)

40Global Risk Classification Clinical SYNTAX score

ent R

ate

(%)

30

ent R

ate

(%)

30P < 0.001* P < 0.001*24.2% 25.6%

ΔHIGH LOW = 23 6% ΔHIGH LOW = 23 0%HL = 0.357 c-statistic = 0.74 HL = 3.833 c-statistic = 0.76

mul

ativ

e Ev

e

20

10

mul

ativ

e Ev

e

20

108.7%

ΔHIGH-LOW = 23.6% ΔHIGH-LOW = 23.0%

Cu

0

Ti ( th )0 12 24

Cu

0

Ti ( th )0 12 24

0.6% 2.6%

1.0%

* log rank test; higher HL (Hosmer-Lemeshow) statistic indicates poorer calibration; higher ΔHIGH-LOW (Index of separation) indicates better discrimination

Time (months) Time (months)



GRC approaches the ideal model for LM PCI

0.00ACEF The The idealideal

score forscore forACEF GRC

1.00

0.00

show

ette

rEuroSCORE

score for score for LM PCILM PCI

ACEF GRC

2.00

mer

-Lem

es

tion

be

SYNTAX Score

EuroSCORE

SYNTAX Score

3.00Hos

m

alib

rat SYNTAX Score

CSS

0.60 0.65 0.70 0.75 0.80

4.00

Ca

C-statistic

Discrimination better



Lessons on the GRC from the SYNTAX trial

DeathMACCE

Excellent mortality stratificationImproved MACCE stratification

The GRC may help to identify a population at very low risk of events after LM PCI


Serruys et al., presented at LM Summit 2011

PCI vs CABG in LM Patients with Low GRC in the SYNTAX Trial at 3 Years

HR 0.16, 95% CI HR 0.16, 95% CI 0.030.03--0.70, 0.70, P=0.005P=0.005

HR 0.64, 95% CI 0.39HR 0.64, 95% CI 0.39--1.07, 1.07, P=0.088P=0.088


Serruys et al. J Am Coll Cardiol 2011;58:87 (abstract)

Decision-making based on the Global RiskClassification

≤22 22-32 ≥32

SYNTAX score The comparative role of PCI and CABG in LM patients in the intermediate

PCI PCI ?0-2

patients in the intermediate GRC risk group (≈40%) is not well defined

PCI PCI ?3-5

roSC

OR

E

? ? CABG≥6

Eur


Decision-making based on the Global RiskClassification: cardiac death

PCI

≤22 22-32 ≥32

SYNTAX score P=0.65

PCI PCI INT20-2

PCI PCI INT23-5

roSC

OR

E

CABG

P=0 22

INT1 INT1 CABG≥6

Eur P 0.22

INT1 = high clinical/acceptable angiographic riskINT2 = acceptable clinical/high angiographic risk


Capodanno D et al. Int J Cardiol 2011;150:116-7

2 g g g

Decision-making based on the Global RiskClassification

≤22 22-32 ≥32

SYNTAX score Performing CABG in patients with SYNTAX score ≥32 complies with

PCI PCI CABG0-2

score ≥32 complies with guidelines

The efficacy and safety of

PCI PCI CABG3-5

roSC

OR

E The efficacy and safety of performing PCI in patients with SYNTAX score <33 will be addressed by the

PCI /CABG

PCI /CABG CABG≥6

Eur be addressed by the

EXCEL trial

/CABG /CABG


Capodanno D et al. Int J Cardiol 2011;150:116-7

Conclusions

Risk stratification in LM PCI aims to govern gthe unpredictability of random variation Risk estimation and classification are bestRisk estimation and classification are best achieved by integrating clinical, angiographic and functional informationangiographic and functional informationWith multiplication of risk scoring systems

d difi ti f i ti d land modifications from existing models, expert consensus on how to use these tools f d i i ki i ti l t idfor decision-making is essential to avoid a “Tower of Babel” effect


Documents

Combination of clinical and angiographic scoressummitmd.com/pdf/pdf/2181_Tamburino.pdf · this presentationthis presentation Ferrarotto Hospital University of Catania. The Ideal Risk