The SYNTAX Trial

Abstract

The introduction of coronary artery bypass surgery (CABG) in 1968 resulted in a paradigm shift in the management of coronary artery disease. Subsequent randomized studies in patients with chronic stable angina established the superiority of CABG over medical therapy in patients with left main coronary artery disease and multivessel disease with left ventricular dysfunction, especially if the proximal left anterior descending artery was involved. The beneficial effect of CABG on the relief of angina was noted in all trials.1–3 In many respects, these trials are obsolete because medical therapy at that time was extremely limited, as were methods of secondary prevention. Nonetheless, the important message of these trials still applies—the greatest benefit of revascularization is among those subgroups at greater risk based on the severity of symptoms or ischemia, the presence of multivessel disease and left ventricular dysfunction, and the extent of myocardial jeopardy.4 The introduction of percutaneous transluminal coronary angioplasty as a nonsurgical alternative in 1977 by Gruntzig5 dramatically altered the landscape. Although it is noteworthy that 2 of the first 5 coronary balloon dilations ever performed were in the left main, complications from acute vessel closure precluded the widespread use of multivessel percutaneous transluminal coronary angioplasty in patients with severe coronary disease. The demonstration that bare-metal stents markedly reduced such short-term complications6–8 and improved subsequent long-term outcome (primarily through a reduction in restenosis compared with balloon angioplasty alone) raised the possibility that percutaneous intervention may offer an appealing alternative to CABG in the management of patients with multivessel disease. This, in turn, spawned a new generation of well-conducted, albeit somewhat small, randomized trials. Nonetheless, the benefits of bare-metal stent and drug-eluting stents (DES) have been on the end points of restenosis and repeat target vessel revascularization and not on death or myocardial infarction (MI). …