Clinical Investigation
Interventional Cardiology
Value of the SYNTAX score in patients treated by primary percutaneous coronary intervention for acute ST-elevation myocardial infarction: The MI SYNTAXscore study

https://doi.org/10.1016/j.ahj.2011.01.004Get rights and content

Aims

The aims of this study were to evaluate the SYNTAX score (SXscore) calculated at 2 stages during a primary percutaneous intervention (PPCI), that is, SXscore I (diagnostic) and SXscore II (postwiring), and assess its additional value to standard clinical risk scores in acute myocardial infarction.

Methods and Results

SXscores I and II were applied to 736 consecutive acute ST-elevation myocardial infarction patients referred for PPCI between November 2006 and February 2008. SXscore changed significantly before (I: 16, interquartile range 9.5-23) and after wiring (II: 11, interquartile range 6-19), P < .001. Kaplan-Meier methods were used to compare the primary end point major adverse coronary events (MACE; composite of repeat MI, target vessel revascularization [TVR], and mortality) and secondary end point mortality at 1.5 years in tertiles of SXscore I and SXscore II. Major adverse coronary event was highest in the higher SXscore I tertile (11% vs 15% vs 23%, log-rank <0.01), driven primarily by increased rate of mortality (9% vs 11% vs 17%, log-rank 0.02). Major adverse coronary event was also highest in SXscore II tertile, by a combination of increased mortality and also TVR (TVR rate 2% vs 3% vs 9%, log-rank <0.01). Predictive Cox regression models for mortality and MACE were significantly and similarly improved by the addition of either SXscore I or SXscore II (hazard ratio 1.63, 95% CI 1.18-2.26, P < .01 for MACE) with respective c indices of 0.61 and 0.63 for MACE and 0.60 and 0.61 for mortality.

Conclusions

SXscore during PPCI is a useful tool that provides additional risk stratification to known risk factors of long-term mortality and MACE in patients with ST-elevation myocardial infarction.

Section snippets

Methods

Between November 2006 and February 2008, 736 consecutive patients undergoing primary PCI for STEMI in our institution were screened for inclusion in the MI SYNTAXscore study. All patients in the referral area of the Thoraxcentre, Erasmus MC, Rotterdam, who had symptoms of acute MI (<12 duration) were assessed clinically and by 12-lead electrocardiogram by paramedical personnel or peripheral hospital medical staff. Those who met the criteria of acute MI were transported immediately to our center

Results

From the initial 736 patients screened, 27 were excluded due to unavailability of a complete diagnostic coronary angiogram, whereas 21 were excluded because they had prior CABG. Survival status and follow-up could not be obtained in 19 patients. Thus, the final number of patients included in our analysis was 669 as shown in Figure 1.

Among the 669 patients, 385 (58%) had significant disease in at least 1 vessel other than the IRA. The median SXscore I was 16 (interquartile range [IQR] 9.5-23).

Discussion

The SXscore, originally designed for quantifying stable coronary artery disease, can be usefully utilized in a STEMI population with disease in the native coronary arteries as demonstrated in our study. The extent of coronary artery disease and the successful intervention as determined by angiography at each stage during a PPCI and as graded by SXscores I and II are associated with the rate of mortality and MACEs both at 1.5-year follow-up. Both SXscores are independent predictors of mortality

Conclusion

The SXscore derived from angiography after during PPCI predicts long-term mortality and MACE in patients with STEMI. The score is relatively easy to obtain and has a moderate reproducibility, making it a clinically useful tool.

Acknowledgements

We would like to thank all the interventional cardiologists who performed the procedures during the study period; P. de Jaegere, P. de Feyter, H.J. Duckers, E. Regar, M. van der Ent, A. Dirkali, A.G. de Vries, A.L. Gaster, C. van Mieghem, G. Sianos, S. Ramcharitar, and N. Kukreja; the cardiac catheterization staff of the Thoraxcenter, Erasmus MC; and the staff of hospitals in Rotterdam: Havenziekenhuis, Maasstad Ziekenhuis, Sint Franciscus Gasthius, Ruwaard van Putten Ziekenhuis, Vlietland

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    SYNTAX score was initially applied in stable CAD. Its application in STEMI patients undergoing primary PCI also indicated its relation to mortality, MACE, and stent thrombosis [19]. In the present study, SYNTAX score ≥ 23 (intermediate- high SYNTAX) was related with increased pre-PCI fQRST angle.

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None of the authors report any conflict of interest.

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