It has been long since the SYNTAX (NEJM 2009) came out comparing percutaneous coronary intervention (PCI) against coronary artery bypass grafting (CABG). That emblematic study associated PCI with first generation drug eluting stents (Taxus) with increased major cardiac and cerebrovascular events (all-cause mortality, AMI, stroke, or any revascularization – MACCE) vs. CABG, at 5 years, which has been an important reference for decision making heart teams following guidelines and recommendations.
In these 13 years, stent technology and complementary advances associated to them have made great strides; for example, the use of coronary physiology measured with IFR and FFR to avoid unnecessary intervention, and the use of intravascular ultrasound (IVUS) to guide stent implantation.
In 2017 the SYNTAX II was published, mainly looking into whether the introduction of these technologies (IFR/FFR and IVUS), associated to correct patient selection, might improve PCI outcomes in patients with de novo three-vessel disease (except for patients with left main lesions) compared against a matched cohort from SYNTAX I.
This study recently published in the European Heart Journal reported the five-year followup of SYNTAX II clinical outcomes, which included patients with comparable risk according to SYNTAX score II, eligible both for PCI and CABG.
In this study, the SYNTAX II strategy (pre-intervention use of IFR/FFR and post implantation use of IVUS) was compared against matched PCI and CABG cohorts from the SYNTAX. Primary end point was a composite of MACCE, including new revascularization.
Read also: IVUS-Guided Coronary Angioplasty: Promising Results at 3-Year Follow-Up.
At five years, looking at primary end point, the presence of MACCE in SYNTAX II was significantly lower compared against the SYNTAX PCI cohort (HR 0.54, CI95% 0.41-0.71; P<0.001), as was all cause mortality (HR 0.57, CI 95% 0.37-0.90; P=0.015). Secondary end points saw a significant reduction of spontaneous AMI (2.3% vs 6.9%, P=0.004), new revascularization at 5 years (HR 0.56, CI 95% 0.39-0.78; P<0.001) and stent thrombosis (HR 0.25, CI 95% 0.10-0.64; P=0.04). As regards the matched CABG comparable cohort from SYNTAX, there were no significant differences in MACCE at 5 years (HR 0.87, CI 95% 0.64-1.17; P=0.35).
Conclusions
The SYNTAX II strategy was associated to significant MACCE reduction, which entails fewer revascularization procedures, spontaneous AMI, and lower mortality rate.
This shows that the use of complementary procedures such as IFR/FFR and IVUS is beneficial in patients with de novo three-vessel disease undergoing PCI. Results compared against SYNTAX CABG results (non-contemporary cohorts) which showed no significant differences, suggest a hypothesis that should be assessed in further randomized studies.
Dr. Omar Tupayachi.
Member of the Editorial Board in SOLACI.org .
Reference: Banning, Adrian P et al. European heart journal vol. 43,13 (2022): 1307-1316. doi:10.1093/eurheartj/ehab703.
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