The SYNTAXES (SYNTAX Extended Survival) was presented at ESC 2019 with somewhat unexpected results in favor of PCI. This is why the SYNTAX continues to be one of the best studies interventional cardiologists can rely on.

The original SYNTAX tested mortality (primary end point) with PCI vs. CABG in patients with multivessel and/or left main disease. After the SYNTAX, several randomized studies have followed suit, using more modern stents, intravascular imaging and coronary physiology to decide for or against PCI.

There has been a debate about long-term outcomes, seeing as, in theory, CABG would have greater benefits. The SYNTAXES is the first large randomized study to provide us with unique ten- year outcomes for PCI (at least in terms of mortality). It is worth noting that a remarkable 94% of the population was able to complete follow up.

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Results showed the equivalence in primary end point (all-cause mortality) between PCI and CABG (27% PCI and 23.5% CABG; p=0.092). There were no differences in patients with left main disease (26.1% PCI and 26.7% CABG; p=0.47) or diabetis (34.2% PCI and 32.1% CABG, p=0.56).

However, there was a difference in survival in favor of CABG in patients with three-vessel disease (27.7% PCI and 20.6% CABG, p=0.006). This difference was driven by patients with SYNTAX score >33. It does not come as a surprise and, for years now, we have known the SYNTAX >33 are not for interventional cardiologists, unless there is CABG counterindication.

These outcomes provide us with the foundation to further PCI, especially in the treatment of diabetics (despite the FREEDOM), and patients with left main disease and three-vessel disease with low or intermediate SYNTAX score.

All this in the context of a stent that has been discontinued and that has clearly been surpassed by the new generation devices (even though we seem to have reached a plateau). Furthermore, there are now more potent antiplatelet agents, coronary physiology to make better informed decisions and intravascular imaging to optimize outcomes.

Original title: Ten-year survival after coronary artery bypass grafting vs PCI: the SYNTAX Extended Survival study.

Reference: Presentado por Daniel Johannes en el ESC 2019. Paris, Francia.

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