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Coronary atherosclerotic burden assessed by SYNTAX scores and outcomes in surgical, percutaneous, or medical strategies: A retrospective cohort study


Scudeler, Thiago et al. (2022), Coronary atherosclerotic burden assessed by SYNTAX scores and outcomes in surgical, percutaneous, or medical strategies: A retrospective cohort study, Dryad, Dataset,


Coronary atherosclerotic burden and SYNTAX score (SS) are predictors of cardiovascular events. 
To investigate the value of SYNTAX scores (SS, SSII and residual SS [rSS]) for predicting cardiovascular events in patients with coronary artery disease (CAD). 
Retrospective cohort study. 
Single tertiary centre. 
Medicine, Angioplasty or Surgery Study (MASS) database patients with stable multivessel CAD and preserved ejection fraction. 
Interventions CAD patients undergoing coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), or medical treatment (MT) alone from January 2002 to December 2015. 
Primary and secondary outcomes Primary: 5-year all-cause mortality. Secondary: composite of all-cause death, myocardial infarction, stroke, and subsequent coronary revascularization at 5 years. 
A total of 1,719 patients underwent PCI (n = 573), CABG (n = 572), or MT (n = 574) alone. The SS was not considered an independent predictor of 5-year mortality in the PCI (low, intermediate and high SS 6.5%, 6.8% and 4.3%, respectively, p=0.745), CABG (low, intermediate and high SS 5.7%, 8.0% and 12.1%, respectively, p=0.194) and MT (low, intermediate and high SS 6.8%, 6.9% and 6.5%, respectively, p=0.993) cohorts. The SSII (low, intermediate and high SSII, 3.6% vs. 7.9% vs. 10.5%, respectively, p <0.001) was associated with a higher mortality risk in the overall population. Within each treatment strategy, SSII was associated with a significant 5-year mortality rate, especially in CABG patients with higher SSII (low, intermediate and high SSII, 1.8%, 9.7% and 10.0%, respectively, p = 0.004) and in MT patients with high SSII (low, intermediate and high SSII, 5.0%, 4.7% and 10.8%, respectively, p = 0.031). SSII demonstrated a better predictive accuracy for mortality compared with SS and rSS (c-index = 0.62) 
Coronary atherosclerotic burden alone was not associated with significantly increased risk of all-cause mortality. The SSII better discriminates the risk of death. 


Study Design

This is a single-center retrospective study that enrolled patients from the Medicine, Angioplasty or Surgery Study (MASS) unit database at the Heart Institute of the University of Sao Paulo, Brazil. Patients with multivessel CAD (defined as stenosis ≥ 70% in at least 2 of the 3 main coronary arteries) and preserved LVEF who underwent coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or medical treatment (MT) between January 2002 and December 2015 were included in this study.

Data Collection and Criteria

SS and SSII were calculated by scoring all coronary lesions with a diameter stenosis ≥ 50%, in vessels with a diameter ≥ 1.5 mm, using the SS algorithm, which is described in full elsewhere. Two experienced clinical cardiologists and two interventional cardiologists blinded to clinical outcomes calculated the SS retrospectively for each patient. Clinical data were obtained from the medical records for the calculation of SSII. Intraobserver and interobserver variability for the SS were performed for 100 coronary angiograms according to the kappa [k] coefficient. Coefficients ranging from 0.21 to 0.40 are considered fair, from 0.41 to 0.60 moderate, from 0.61 to 0.80 substantial, and over 0.81 excellent. For ordinal variables, the weighted kappa coefficient was used to express the degree of agreement inter-observer and intra-observer. 

For the SS and SSII calculation of the MT group, we used the CABG group as a reference. This option assumed that surgery is the strategy that provides the most complete revascularization in patients with multivessel CAD. The residual SYNTAX Score (rSS) was calculated for each coronary lesion that was evaluated with the SS but was not treated. The coronary angiogram performed immediately after the percutaneous intervention or the surgical report of the CABG patients was used to calculate the rSS. For the MT group, the rSS is similar to the SS. A higher value of rSS suggests that more CAD lesions were untreated. Finally, patients were categorized within each score as low, intermediate, and high.


Patients were categorized according to three coronary revascularization strategies: MT, PCI and CABG. Patients in the three groups received intensive secondary prevention with lifestyle and pharmacologic interventions, using “treat-to-target” algorithms. All patients were treated according to the current guidelines at the time of study enrollment. 

Among patients undergoing PCI, target-lesion revascularization was always attempted, and complete revascularization was performed as clinically appropriate. Subjects in the PCI group received plain bare metal stents (BMS), or drug eluting stents (DES), as available. A successful PCI was defined as a normal coronary artery flow or less than 20% stenosis in the luminal diameter after coronary stent implantation, as assessed by visual estimation of the angiograms before and after the procedure. Clinical success was defined as angiographic success plus the absence of in-hospital myocardial infarction (MI), emergency CABG, or death.  

CABG was performed in accordance with the best current practices. The use of cardiac extracorporeal circulation was defined at the discretion of the surgical team, but the surgical team had experience in both on-pump and off-pump surgery.  

Study Endpoints

The primary endpoint was death from any cause at 5 years. Secondary endpoint was major adverse cardiac and cerebrovascular events (MACCE), defined as the composite of all-cause death, MI, stroke, and subsequent coronary revascularization measured.

Usage notes

Continuous variables were summarized as mean ± SD and compared using the Student unpaired t test or the Mann-Whitney test, as appropriate. The normality assumption for continuous variables was evaluated using the Kolmogorov-Smirnov test. Categorical variables were summarized as counts and percentages and compared with the chi-square test when appropriate. Otherwise, the Fisher exact test was used. Cox regression analysis was used to find independent predictors of mortality in the PCI, CABG, and MT groups. The variables with a probability value of <0.20 in the univariate analyses were included in the backward stepwise multivariable model. Only variables with statistical significance (p <0.05) remained in the Cox multivariable model. No correction was made for multiple tests. Receiver-operating characteristic (ROC) curves were created to evaluate the capacity of each score to discriminate MACCE in the PCI, CABG, and MT groups. Survival curves were constructed using Kaplan-Meier estimates and compared by using the log-rank test at 5 years of follow-up. A 2-sided p-value <0.05 was considered statistically significant. All analyses were conducted using the statistical package SPSS 25.0 (IBM®) software for Windows.