What Happens When We Are Blinded by Left Main Disease and Ignore All Other Lesions?

According to this recent Excel analysis, mortality seems to rise when the SYNTAX II score is not taken into account when defining the revascularization strategy. The difference does not reach statistical significance and further studies are required, but the message is clear: the left main coronary artery is not the only thing that matters; other lesions should be considered as well, particularly because they may occasionally tilt the scales in cases when left main disease is resolved with a simple angioplasty. All of this was presented by Dr. Patrick Serruys at the most recent PCR scientific sessions.

The SYNTAX II score derives from the original SYNTAX trial and it was developed to predict long-term mortality after left main and multivessel revascularization. SYNTAX II combines anatomic lesion data, included in the original score, and clinical characteristics such as age, sex, chronic obstructive pulmonary disease, peripheral vascular disease, ejection fraction, or creatinine clearance.

Noncompliance with the score’s recommendation indicating that the patient could benefit more from a surgical strategy (therefore treating the patient with angioplasty) was associated with a trend toward higher all-cause mortality at 4 years.

The main EXCEL study included 1900 low-to-moderate risk patients with unprotected left main lesions who were randomized to angioplasty or surgery. At 3 years, results for both strategies were comparable in terms of death, stroke, or infarction.


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This new analysis included 1807 patients from EXCEL who had a SYNTAX II score. Among patients whose SYNTAX II score suggested surgery as the best option, only 78 were randomized to surgery while 81 underwent angioplasty.

Similarly, among patients whose score suggested angioplasty as the best option, 184 underwent surgery and 158, angioplasty. Overall, the concordance rate between SYNTAX II score recommendations and treatment strategy was 85%.

In patients whose score recommendation matched treatment, 4-year mortality was not significantly different between strategies (9% vs. 7.5%; hazard ratio [HR]: 1.19; 95% confidence interval [CI]: 0.81-1.75).

However, results were markedly different for patients whose score recommendation did not match the treatment strategy. When the SYNTAX II score recommended surgery, 4-year mortality was 5.3% in those randomized to surgery vs. 14.1% in those randomized to angioplasty (p = 0.07).


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In the group for whom the score recommended angioplasty, short-term mortality was much higher with surgery (5% vs. 0% at 6 months with angioplasty). However, at 4 years, the curves intersected, but differences remained non-significant (13.6% for angioplasty vs. 7.8% for surgery, p = 0.11).

The low number of patients for whom randomization did not match score recommendation means that this analysis is underpowered to detect differences. However, it helps us prevent potential mistakes and it warns us against forcing indications.

Original title: Non-respect of SYNTAX score II treatment recommendation of surgery (PCI treated) negatively impacts 4-year mortality in patients with LM CAD—the EXCEL trial.

Reference: Serruys P et al. Presentado en el EuroPCR 2019.


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