A Global Risk Approach to Identify Patients With Left Main or 3-Vessel Disease Who Could Safely and Efficaciously Be Treated With Percutaneous Coronary Intervention

Abstract

In comparison with the SXscore, the Global Risk, with a simple treatment algorithm, substantially enhances the identification of low-risk patients who could safely and efficaciously be treated with CABG or PCI.

A Tale of Two Techniques: Demystifying the Myth

“…These findings also are in contrast to a substudy of the SYNTAX trial 18 that suggested patients with high clinical comorbidity, i.e. additive EuroSCORE ≥ 6 with 3VD irrespective of the anatomical complexity (SYNTAX score), 19 might derive a prognostic benefit from undergoing CABG rather than PCI provided an acceptable threshold of operative risk is not exceeded.…”

“…[13][14][15][16] However, the SYNTAX score is open to criticism since it relies solely on scoring coronary anatomy and does not take potentially important prognostic information into consideration in the absence of clinical factors. 17,18 Consequently, several risk stratification tools have attempted to merge the SYNTAX score with clinically based risk scores to improve the risk stratification of patients with 3VD/ULMCA disease undergoing CABG or PCI compared with the SYNTAX score alone. Examples include the Clinical SYNTAX score (a combination of the SYNTAX score and the modified ACEF score [i.e.…”

“…age/ejection fraction + 1 point for every 10 ml/ min reduction in creatinine clearance below 60 ml/ min/1.73 m 2 (up to a maximum of 6 points)]), the Global Risk score (a combination of the SYNTAX score and EuroSCORE) and the EuroHeart score. [18][19][20][21][22][23][24][25][26][27] The latest addition to this risk stratification mélange is the SYNTAX score II, which includes a nomogram for bedside application to obtain long-term mortality predictions for individual patients considering CABG or PCI. 28 This score, which was externally validated in the multinational DELTA (n=2,891) and Credo-KYOTO (n=3,896) registries, 8,29 consists of two anatomical (SYNTAX score and ULMCA disease) and six clinical (age, creatinine clearance, left ventricular ejection fraction, sex, chronic obstructive pulmonary disease and peripheral vascular disease) variables.…”

“…28 This score, which was externally validated in the multinational DELTA (n=2,891) and Credo-KYOTO (n=3,896) registries, 8,29 consists of two anatomical (SYNTAX score and ULMCA disease) and six clinical (age, creatinine clearance, left ventricular ejection fraction, sex, chronic obstructive pulmonary disease and peripheral vascular disease) variables. Unlike the anatomical SYNTAX score, which is more predictive of clinical outcomes in patients undergoing PCI than in those undergoing CABG, for whom it is not predictive, 18,30 the SYNTAX score II provides individual mortality predictions for both CABG and PCI in addition to a measure of the magnitude of their differences, with clinically applicable accuracy. Currently, validation of the SYNTAX score II is a prespecified endpoint in the ongoing randomized EXCEL trial (NCT01205776) and the planned SYNTAX II trial, both of which will use SYNTAX score II to recruit patients on the grounds of patient safety.…”

Significance of Microvascular Function in Visual—Functional Mismatch Between Invasive Coronary Angiography and Fractional Flow Reserve

“…The seminal study by Gould et al reported that hyperemic flow begins to decline in the presence of stenosis with a reduction in diameter larger than 50% 1. This cut‐off value has been used for the threshold of inducible ischemia; therefore, it is accepted as the gold standard for guiding revascularization, validating noninvasive testing, and evaluating outcomes after revascularization strategies 2, 3, 4. However, cumulative evidence suggests that angiographically determined anatomical stenosis severity often underestimates or overestimates the functional significance of lesions 5, 6, 7.…”