A novel scoring system devised by an international large-scale coronary bifurcation registry to guide the optimal choice between the 1- and 2-stent strategy: the BIFURCAT Two-Stent (BTS) score

Abstract

Abstract Background and Aims Previous studies used predefined criteria to evaluate the outcomes of two stents over one stent. We sought to devise a scoring system based on data-driven criteria for the guiding the optimal choice between two approaches. Methods We analyzed an international coronary bifurcation cohort with 2nd-generation drug-eluting stents, the combined insights from the unified RAIN and COBIS bifurcation registries (BIFURCAT) registry. The primary endpoint was major adverse cardiac events (MACE), a composite of death, myocardial infarction, and target lesion failure. Results We analyzed 5333 patients (mean age: 66.2 years; male: 76%; 1-stent: 82%). We found one clinical and five angiographic factors associated with lower MACE risk when two stents were implanted compared with one. We assigned one point per each component the patient was positive for and defined this as the BIFURCAT Two-Stent (BTS) score. The 2-stent strategy was associated with significantly higher MACE rate in the total patient cohort (HR: 1.49; 95% CI: 1.19-1.87; P<0.001) and BTS score<4 (HR: 2.04; 95% CI: 1.64-2.56; P<0.001). However, the two stents had a lower chance of MACE in BTS score≥4 (HR: 0.56; 95% CI: 0.35-0.89; P=0.014) with or without adjustment for baseline and procedural characteristics and antiplatelet therapy. Conclusions Approximately 80% of the patients had low (<4) BTS score that showed favorable outcomes with the 1-stent strategy. However, those with high BTS scores (≥4) proved favorable outcomes with the 2-stent strategy. The BTS score may be able to guide interventionists to select an optimal stenting strategy in bifurcation lesions.