Is Visual Angiographic Estimation of Coronary Disease Burden and Anatomical Risk Adequate in Multi-Vessel Disease?

Abstract

Background: Assessment of anatomical complexity provides the basis for instructing decisions regarding the modality of revascularisation undertaken. The SYNTAX score has been used for over a decade, and validated in numerous revascularisation trials guiding contemporary practice. However, utilisation of this scoring system in routine clinical practice remains indifferent. We assessed the relationship between visual estimation of risk compared to objectively scoring with the SYNTAX score. Methods: SYNTAX score was calculated for twenty consecutive patients who had multi-vessel coronary artery disease by seven interventional cardiologists, blinded to treatment modality. Comparisons were made between visually estimated tertile of risk, versus consensus stratified risk by SYNTAX (low, intermediate or high). Inter-observer variability of the SYNTAX score was determined amongst the group. Results: Angiograms were scored in 3.5 minutes (mean). Visual estimate of risk compared to SYNTAX scored angiograms (weighted kappa coefficient of 0.44 vs 0.62 (p = 0.007) respectively) had a reduced concordance compared to the consensus determined risk. Resulting in a change in risk tertile in 34% of cases, with 68% classed in a lower tertile. CTOs and bifurcation lesions were the cause of over estimation of risk when visually estimated. Inter-observer correlation of SYNTAX was good, with an intra-class coefficient of 0.61. Conclusion: Visual estimation of anatomical risk may not be as accurate as perceived. Presence of complex lesions such as CTOs and bifurcations may lead to overestimation of risk. Objective evaluation of anatomical risk with the SYNTAX score should be considered routine clinical practice to optimally guide revascularisation decisions.