Lessons from the SYNTAX trial

Abstract

Despite the fact that CABG is the standard of care for patients with multivessel coronary arteries and/or left main stem stenosis, PCI has become a rival to CABG in patients with multivessel coronary artery disease or left main disease. However, the need for repeat revascularization, in-stent stenosis and thrombosis remain the achilis heal of PCI. SYNTAX trial randomized patients with left main disease and/or three-vessel disease to PCI with TAXus stent or CABG with the concept that PCI is not inferior to CABG. At 1 and 2 years follow up, MACCE was significantly increased in PCI patients mainly attributed to increased rate of repeat revascularization; however, stroke was significantly more with CABG. The composite safety endpoint of death/stroke/MI was comparable between the 2 groups. Therefore the criterion for non-inferiority was not met. What we learn from SYNTAX is that multi disciplinary team approach should be the standard of care when recommending treatment in more complex coronary artery disease. SYNTAX makes interventionists and surgeons come together, it may set the benchmark for MVD revascularization. PCI and CABG should be considered complementary rather than competitive revascularization strategies. There is no substitute for sound clinical judgment that takes into account the patient's overall clinical profile, functionality, co-morbidities, as well as the patient's coronary anatomy. The SYNTAX Score should be utilized to decide on treatment of patients with LM/MVD. Patients with low and intermediate score can be treated with PCI or CABG with equal results. Those with high score do better with CABG. SYNTAX trial showed that 66% of patients with 3VD or LMD are still best treated with CABG. In the remaining 1/3 of patients with low syntax score, PCI may be considered as an alternative to surgery. Finally, medical treatment should be optimized in patients going for CABG.

Patients' preferences for coronary bypass grafting or staged percutaneous coronary intervention in multi-vessel coronary artery disease

“…Percutaneous coronary intervention (PCI) was introduced in 1977 and increasing experience with this approach, coupled with improved technology made it possible to treat complex lesions and multi‐vessel CAD . The SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) study, which was specifically designed to compare CABG vs PCI in multi‐vessel CAD demonstrated that patients with low or intermediate SYNTAX‐scores can be treated with CABG or PCI with equal results . It further provided evidence, that CABG and PCI should be considered complementary rather than competitive revascularization strategies .…”

“…It further provided evidence, that CABG and PCI should be considered complementary rather than competitive revascularization strategies . Finally, the SYNTAX study makes interventionalists and cardiac surgeons come together and decide as a “Heart‐Team” about the optimal treatment option …”

“…3 The SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) study, which was specifically designed to compare CABG vs PCI in multi-vessel CAD demonstrated that patients with low or intermediate SYNTAX-scores can be treated with CABG or PCI with equal results. 3,4 It further provided evidence, that CABG and PCI should be considered complementary rather than competitive revascularization strategies. 4 Finally, the SYNTAX study makes interventionalists and cardiac surgeons come together and decide as a "Heart-Team" about the optimal treatment option.…”

“…3,4 It further provided evidence, that CABG and PCI should be considered complementary rather than competitive revascularization strategies. 4 Finally, the SYNTAX study makes interventionalists and cardiac surgeons come together and decide as a "Heart-Team" about the optimal treatment option. 3,4 To achieve effective patient centred care, patients should be integrated into the decision process, so that their views and preferences can be considered when formulating treatment plans.…”

“…4 Finally, the SYNTAX study makes interventionalists and cardiac surgeons come together and decide as a "Heart-Team" about the optimal treatment option. 3,4 To achieve effective patient centred care, patients should be integrated into the decision process, so that their views and preferences can be considered when formulating treatment plans. Particularly where different treatments offer similar expectations of clinical success, individual patient preferences become increasingly important.…”