Implementation of a simplified anatomical automatically computed score can be adapted to patient registry data with implications for real-time assessment of procedural risk in order to provide prognostic information after coronary revascularization, according to a study published in JAMA Cardiology.
In this cross-sectional observational cohort study, researchers used data from the Department of Veterans Affairs (VA) Clinical Assessment, Reporting, and Tracking Program to evaluate all patients aged >18 years who were undergoing coronary angiography at VA catheterization laboratories between January 1, 2010, and September 30, 2017 (N=50,226). Patients were included if they had >50% stenosis in at least 1 epicardial coronary artery at the time of angiography and subsequently underwent revascularization using percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) within 90 days of diagnosis either inside or outside the VA healthcare system.
VA Synergy Between PCI With Taxus and Cardiac Surgery (SYNTAX) scores were calculated for each patient and categorized by tertiles. To assess the feasibility of use in automatically calculating anatomical complexity and to validate the score’s ability to discriminate between outcomes across tertiles of anatomical complexity in external data sets, this score was applied to data from the EXCEL (Evaluation of XIENCE vs Coronary Artery Bypass Surgery for Effectiveness of LeftMain Revascularization) trial.
The primary outcome was a composite of death, revascularization, rehospitalization for myocardial infarction, or stroke after initial revascularization (major adverse cardiovascular and cerebrovascular events [MACCEs]).
There was a mild increase in the anatomical risk score for patients undergoing PCI from 2010 (9.5) to 2017 (10.5), P <.001 for trend, and CABG from 2010 (10.5) to 2017 (11.0), P =.02 for trend. Rates of clinical outcomes as a function of VA SYNTAX score were stratified by revascularization method.
Proportions of composite MACCEs increased among increasing tertiles of VA SYNTAX scores for patients undergoing PCI, which included 51 in tertile 1 (17.6%), 114 in tertile 2 (18.3%), and 117 in tertile 3 (21.9%). The highest tertile of anatomical complexity was associated with an increased risk of MACCEs (adjusted hazard ratio 2.12; 95% confidence interval, 2.01-2.23).
Study limitations included the possible residual confounding beyond the VA SYNTAX score. Researchers were unable to determine the completeness of coronary revascularization. Subsets of revascularization such as unprotected left main stenoses or multivessel coronary disease were not differentiated. Limitations in the data set also prevented researchers from ascertaining granular procedural details for CABG or PCI, such as percentage of arterial grafts.
The simplified anatomical scoring system can provide valuable prognostic information and may be easily implemented across large data sets of existing registry data for patients undergoing coronary revascularization.
Disclosure: Multiple authors disclosed affiliations with pharmaceutical companies. See the reference for complete disclosure information.
Valle JA, Glorioso TJ, Bricker R, et al. Association of coronary anatomical complexity with clinical outcomes after percutaneous or surgical revascularization in the veterans affairs clinical assessment reporting and tracking program [published online June 26, 2019]. JAMA Cardiol. doi:10.1001/jamacardio.2019.1923