SYNTAX Score Research Articles

Abstract 4148096: Discrimination Abilities of Euroscore and SYNTAX score for Prognostic Outcomes in patients with Stable Coronary Artery Disease: A Systematic Review and Meta-analysis

Introduction: There is a lack of good risk prediction models in patients with stable coronary artery disease (SCAD). We conducted a meta-analysis of validation studies to compare and determine the discrimination abilities of Euroscore (ES) and Syntax score (SS) for prognostic outcomes in patients with SCAD. Methods: A comprehensive literature search was conducted across MEDLINE, Cochrane and Embase from inception till May 2024. All studies that reported C-statistic/AUC for predicting all cause mortality, cardiac death or Major adverse cardiovascular events (MACE) for patients with stable coronary artery disease (SCAD) were included in the analysis. Studies lacking confidence intervals (CI) for C-statistic or those which reported C-statistics in patients with acute coronary syndromes or mixed SCAD and ACS patients were excluded. A generic inverse variance method was used to pool C-statistics and their corresponding standard errors (SEs). The SEs were calculated from CI wherever needed. A pooled C statistic of >0.8 was considered to be a good discrimination ability. Results: A total of 5 studies with a patient population of 5903 were included in the meta-analysis. For ES, the pooled C-statistic for all cause mortality (n=2666) was 0.69[0.51-0.87] while for cardiac death (n=2666) it was 0.77[0.60-0.71]. The discrimination ability of ES for MACE as reported by one study (n=305) was 0.54[0.49-0.60]. For SS, the summary AUC for all cause mortality (n=2936) was 0.77[0.69-0.85] while for cardiac death (n=305) it was 0.52[0.46-0.57]. The pooled AUC of SS for occurrence of MACE(n=2666) was 0.56[0.45-0.66]. Conclusion: None of the two scores have a a good discrimination ability for risk stratification in SCAD patients. The predictive accuracy of SS is comparatively better than ES for all cause mortality. However, ES performs better for predicting cardiac death. Better risk prediction models with large scale external validations are needed.

Interleukin-1 Blockade in Patients With ST-Segment Elevation Myocardial Infarction Across the Spectrum of Coronary Artery Disease Complexity.

Patients with ST-segment elevation myocardial infarction (STEMI) and complex coronary artery disease (CAD) face a poor prognosis, including increased heart failure (HF) risk. Phase 2 clinical trials of anakinra have shown inhibition of the acute inflammatory response and prevention of HF after STEMI, but data on its effects based on CAD complexity are lacking. We performed a pooled secondary analysis of 139 patients with STEMI. The SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery), SYNTAX II and Gensini scores were calculated, and patients were divided into two groups below and above the median. We evaluated the effect of anakinra on the area-under-the-curve of high-sensitivity C-reactive protein (hsCRP-AUC) at 14 days, and the composite endpoint of new-onset HF, HF hospitalization, or all-cause death at 1-year follow-up using Kaplan-Meier survival curves, Cox regression analysis for Hazard Ratios (HR), and tested interactions between subgroups. All three CAD complexity scores (SYNTAX, SYNTAX II and Gensini) were associated with an increased risk of adverse events (HR 1.02 to 1.06, all p-values ≤0.025). We found no statistically significant interactions between CAD extent, measured as single-vessel or multi-vessel CAD, SYNTAX score ≤9 or >9, SYNTAX II score ≤24 or >24, Gensini score ≤32 or >32, and treatment effect of anakinra on hsCRP-AUC or the composite clinical endpoint (all p-values for interaction >0.05). In conclusion, among patients with STEMI, IL-1 blockade with anakinra significantly attenuated the acute inflammatory response and reduced the risk of HF-related events regardless of the spectrum of CAD complexity.

Abstract 4137855: Hybrid Coronary Revascularization versus Traditional Coronary Artery Bypass Grafting for Left Main Disease

Background: The current guideline-recommended intervention for left main (LM) disease is coronary artery bypass grafting (CABG). Hybrid coronary revascularization (HCR) combines robotic coronary artery bypass and percutaneous coronary intervention (PCI) and offers a less invasive approach for patients with LM and multivessel coronary artery disease. We aim to compare clinical outcomes at 30 days, 6 months and 1 year between HCR and CABG in patients with LM disease. Methods: We retrospectively screened 761 patients who underwent bypass for LM disease between 2019 and 2023 at a single institution. A total of 118 patients who underwent either HCR (n=59) or CABG (n=59) were included after propensity matching for baseline characteristics. The primary endpoint was major adverse cardiovascular events (MACE), defined as death, myocardial infarction, repeat revascularization and stroke, at 30 days, 6 months and 1 year, which was assessed using chi-squared tests. Secondary outcomes are individual components of MACE at 30 days, 6 months and 1 year. Kaplan-Meier curves were used to visualize the difference in 1-year cumulative MACE-free survival across groups coupled with a log-rank test. Results: The mean age was 68.93±11 years for HCR patients and 68.41±10.11 years for CABG patients (p=0.394). SYNTAX score was high (> 33) for 49.1% of HCR patients and 67.3% of CABG patients (p=0.15). Hospital length of stay was shorter for HCR compared to CABG (4.07 ± 1.21 days vs. 7.58 ± 7.71 days, p<0.001). MACE events were significantly lower in the HCR group at 30 days (0% vs 10.2%; p=0.01), 6 months (0% vs 17%; p=0.002) and 1 year (2.4% vs 20.5%; p=0.01). The cumulative MACE-free survival at 1 year was significantly higher in the HCR group (p=0.007). There were no significant differences in secondary outcomes at any time point with the exception of lower repeat revascularization at 6 months in the HCR group (0% vs 10.9%; p=0.02). Conclusion: This retrospective study demonstrates that HCR is a viable alternative to CABG for LM disease. While randomized clinical trial data is still needed, this less invasive approach is a promising treatment strategy for patients with high surgical risk.

Abstract 4135708: Obesity and the risk of cardiac death in coronary artery disease

Background: The prevalence of obesity is increasing worldwide reaching epidemic proportions. Obesity increases the risk of coronary artery disease (CAD), but there is little prospective evidence about the effect of obesity on the risk of cardiac death in CAD patients. Aim: We aimed to investigate the effect of obesity and the risk of cardiac death in a prospective cohort of CAD patients. Methods: We have prospectively enrolled 1,946 patients with CAD (mean age 66.9±8.6, 68% male), with a mean follow-up of 8.7±2.2 years. BMI was measured at baseline and was categorized into 4 groups: 1) BMI 18.5-24.9 kg/m 2 (normal weight, reference group), 2) BMI 25-29.9 kg/m 2 (overweight), 3) BMI 30-34.9 kg/m 2 (class 1 obesity), and 4) BMI >35 kg/m 2 (class 2 obesity). The primary endpoint was cardiac death and secondary endpoints were sudden cardiac death/arrest (SCD/SCA), non-sudden cardiac death, non-cardiac death, and heart failure (HF) hospitalization. Statistical analysis was performed with Cox regression and was adjusted for age, sex, type 2 diabetes, CCS class, kidney function (eGFR), systolic and diastolic blood pressure, LDL, smoking, SYNTAX score, and left ventricle ejection fraction. Results: The prevalence of BMI 18.5-24.9 kg/m 2 was 18.5% (n=359), BMI 25-29.9 kg/m 2 was 47.8% (n=929), BMI 30-34.9 kg/m 2 was 24.0% (n=466), and BMI>35 kg/m 2 was 9.7% (n=189). During the follow-up, cardiac death occurred in 156 subjects, SCD/SCA in 75 subjects, non-sudden cardiac death in 81 subjects, and non-cardiac death in 197 subjects. BMI >35 kg/m 2 was associated with an increased trend of cardiac death (adjusted HR 1.92, 95% CI 0.92-4.01; p=0.08) and an increased risk of non-sudden cardiac death (adjusted HR 4.11, 95% CI 1.58-10.68; p=0.004) and HF hospitalization (adjusted HR 2.83, 95% CI 1.06-7-54; p=0.04), but not with SCD/SCA (adjusted HR 0.79, 95% CI 0.24-2.56; p=0.69) or noncardiac death (adjusted HR 0.85, 95% CI 0.43-1.69; p=0.64). The risk of cardiac death or secondary endpoints was not increased in patients with overweight or class 1 obesity. Conclusions: Class 2 obesity was associated with an increased risk of non-sudden cardiac death and heart failure hospitalization among CAD patients. Obesity may have adverse long-term effects on cardiac function and prognosis among CAD patients, supporting the benefit of optimal weight control therapy.

Abstract 4117731: Interleukin-1 Blockade in Patients With ST-Segment Elevation Myocardial Infarction Across the Spectrum of Coronary Artery Disease Complexity.

Background: Patients with ST-segment elevation myocardial infarction (STEMI) and complex coronary artery disease (CAD) face a poor prognosis, including increased heart failure (HF) risk. Interleukin-1 (IL-1) blockade with Anakinra inhibits the acute inflammatory response and prevent HF after STEMI, but data on its effects based on CAD complexity are lacking. Aims: To assess the effects of Anakinra in patients with STEMI, across the spectrum of CAD complexity. Methods: We performed a pooled secondary analysis of 139 patients with STEMI from three randomized clinical trials (VCUART studies) comparing Anakinra (N=84) versus placebo (N=55). Multivessel CAD was defined as the presence of at least one ≥70% stenosis in a non-culprit vessel of >2.5 mm diameter, not stented during index coronary intervention. The SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery), SYNTAX II and Gensini scores were calculated, and patients were divided by the median. We evaluated a composite endpoint of new-onset HF, HF hospitalization, or all-cause death at 1-year follow-up using Kaplan-Meier survival curves, Cox regression analysis for Hazard Ratios, and calculated interactions between groups. Results: We included 139 patients with STEMI, 85 (61%) with single vessel CAD and 54 (39%) with multivessel CAD. According to the spectrum of CAD complexity, 60 (43%) presented a SYNTAX score >9, 59 (42%) a SYNTAX II score >24 and 65 (47%) a Gensini score >32. New-onset HF, HF hospitalization, or all-cause death occurred in a total of 23 patients: 7 among the 84 subjects in the Anakinra group and 16 within the 55 patients in the placebo group. We found no statistically significant interactions between CAD complexity and allocation to Anakinra or placebo for the composite endpoint (Figure). Conclusions: Among patients with STEMI, IL-1 blockade with Anakinra significantly reduced the risk of new-onset HF, HF hospitalization, or all-cause death compared to placebo, regardless of the number of vessels affected and the spectrum of CAD complexity.

Clinical and angiographic characteristics of patients with familial hypercholesterolemia presenting with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

Familial hypercholesterolemia (FH) is a world public health problem that enhances the risk of premature coronary artery disease (CAD) with a high incidence of acute coronary syndrome. This study aimed to evaluate the clinical and angiographic characteristics of the patients with and without FH who had ST-elevation myocardial infarction (STEMI). It included 690 patients who presented with the first attack of STEMI and underwent primary percutaneous coronary interventions (PPCI). The patients were analyzed to diagnose FH according to the Dutch Lipid Clinic Network (DLCN) criteria. All angiograms were analyzed for the number of diseased vessels, Syntax score, thrombus burden grade, and final Thrombolysis in Myocardial Infarction (TIMI) flow grade. The majority of patients were male (72.6%) with a mean age of 54 ± 12 years. Based on DLCN criteria, they were classified into unlikely/possible FH (86.1%) and probable/definite FH (13.9%) groups. Probable/definite FH patients were significantly younger, and higher incidence of males < 55 years compared with unlikely/possible FH patients (p < 0.001 for each). Moreover, probable/definite FH patients had a higher frequency of three-vessel disease (p = 0.007) and Syntax score (p < 0.001) with a moderate positive correlation with the DLCN score (r = 0.592, p < 0.001). Furthermore, probable/definite FH patients showed a higher thrombus burden and final TIMI slow/no-reflow when compared to the unlikely/possible FH patients (p = 0.006 and p = 0.027, respectively). Patients with probable/definite FH and LDL-C level were independent predictors of high thrombus burden besides males < 55 years, and the number of diseased vessels. In conclusion, STEMI patients with FH were younger males and associated with severe CAD with frequent multivessel CAD, high anatomical complexity of CAD, and frequent high thrombus burden. Furthermore, FH was one of the predictors of high thrombus burden.

Systemic immune inflammatory response index (SIIRI) in acute myocardial infarction.

Different treatment approaches exist for non-ST elevation acute coronary syndrome (ACS) patients. This study assessed the systemic immune inflammatory response index (SIIRI) for its prognostic value and incremental clinical utility in determining optimal timing for percutaneous coronary intervention (PCI) in non-ST elevation myocardial infarction (NSTEMI) patients, particularly when troponin levels are initially negative. This study included 1270 ACS patients: 437 STEMI, 422 NSTEMI, and 411 unstable angina. Patients were stratified by SIIRI levels measured at admission, and coronary artery disease severity was evaluated using the SYNTAX score. The primary endpoint was major adverse cardiovascular events (MACE), including cardiovascular death, non-fatal myocardial infarction, stroke, and revascularization. Secondary endpoints encompassed individual MACE components and heart failure hospitalisations. The mean age was 54.93 years (83% male). SIIRI levels were significantly higher in STEMI patients (6.83 ± 6.43 × 105) compared to NSTEMI (4.5 ± 5.39 × 105) and unstable angina (3.48 ± 2.83 × 105) (P < 0.001). Area under the curve for SIIRI distinguished NSTEMI and unstable angina from STEMI (0.81 and 0.80), with optimal cut-off points of 4.80 × 105 and 4.25 × 105. In NSTEMI, 24.6% presented within 2 h of symptom onset, were troponin-negative, yet had elevated SIIRI. Post-PCI, SIIRI > 4.93 × 105 correlated with increased MACE at 1 year (17.2% vs 5%). NSTEMI and unstable angina patients with SIIRI values >4.80 × 105 and 4.25 × 105 respectively, may require urgent intervention (<2 h). SIIRI can be of significant utility in patients of NSTEMI who present earlier with negative troponins. SIIRI can also aid in identifying high-risk individuals post-PCI, providing a valuable tool for early and accurate assessment.

Enhancing Coronary Revascularization Decisions: The Promising Role of Large Language Models as a Decision-Support Tool for Multidisciplinary Heart Team.

While clinical practice guidelines advocate for multidisciplinary heart team (MDHT) discussions in coronary revascularization, variability in implementation across health care settings remains a challenge. This variability could potentially be addressed by language learning models like ChatGPT, offering decision-making support in diverse health care environments. Our study aims to critically evaluate the concordance between recommendations made by MDHT and those generated by language learning models in coronary revascularization decision-making. From March 2023 to July 2023, consecutive coronary angiography cases (n=86) that were referred for revascularization (either percutaneous or surgical) were analyzed using both ChatGPT-3.5 and ChatGPT-4. Case presentation formats included demographics, medical background, detailed description of angiographic findings, and SYNTAX score (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery; I and II), which were presented in 3 different formats. The recommendations of the models were compared with those of an MDHT. ChatGPT-4 showed high concordance with decisions made by the MDHT (accuracy 0.82, sensitivity 0.8, specificity 0.83, and kappa 0.59), while ChatGPT-3.5 (0.67, 0.27, 0.84, and 0.12, respectively) showed lower concordance. Entropy and Fleiss kappa of ChatGPT-4 were 0.09 and 0.9, respectively, indicating high reliability and repeatability. The best correlation between ChatGPT-4 and MDHT was achieved when clinical cases were presented in a detailed context. Specific subgroups of patients yielded high accuracy (>0.9) of ChatGPT-4, including those with left main disease, 3 vessel disease, and diabetic patients. The present study demonstrates that advanced language learning models like ChatGPT-4 may be able to predict clinical recommendations for coronary artery disease revascularization with reasonable accuracy, especially in specific patient groups, underscoring their potential role as a supportive tool in clinical decision-making.

Relationship between Myocardial Performance Index (Tei Index) and angiographic severity of coronary artery disease in patients with Acute ST Elevation Myocardial Infarction

Background: Tei index is a Doppler derived measure of combined systolic and diastolic myocardial function and a better predictor of global LV function and outcome in patients with acute STEMI. The objective of this study was to determine the relationship between the myocardial performance index of LV (Tei index) and angiographic severity of coronary artery disease as assessed by SYNTAX score in patients with acute STEMI. Methods: This was a prospective, observational single centered study conducted from March 2022 to November 2022 at Manmohan Cardiothoracic Vascular and Transplant Centre, Institute of Medicine. (MCVTC, IOM). 160 patients with acute STEMI were enrolled. LV Tei index was calculated with the help of 2D and Tissue Doppler imaging, and the lesion severity was categorized with the help of SYNTAX score after the patients underwent coronary angiography. Results: The mean age was 61.23±12.33 years with a male preponderance. 107 (67%) were male with male to female ratio of 2:1. Tei index was significantly higher among the hypertensive (0.74±0.17) and diabetic (0.78±0.18) patients. 64 (40%), 51(31.9%) and 45(28.1%) had Single vessel disease (SVD), Double vessel disease (DVD) and Triple vessel disease (TVD) respectively with the Mean Tei index values 0.57 ± 0.10, 0.76 ± 0.11, and 0.88±0.11 (p&lt;0.05). The Tei index increased when patients were divided into low, mid, and high SYNTAX score groups as 0.58±0.11, 0.61±0.73, 0.88±0.13 respectively, p-value &lt; 0.05). Moreover, the study showed a positive correlation between Tei index and SYNTAX score with increasing severity of coronary artery stenosis. (r=0.654, p-value&lt;0.001). Proximal LAD, LCx and RCA lesions had greater Tei index than the distal lesions. Conclusion: More proximally located LAD, LCx, RCA lesions had higher value of Tei index, as assessed with the SYNTAX score.

Gender-Dependent Association Between Thyroid Hormones and Severity of Coronary Artery Disease by SYNTAX Score

Thyroid function has been shown to be associated with cardiovascular diseases. Moreover, sex can influence on the association between thyroid function and other diseases. We aimed to evaluate the relationship between thyroid hormones and the severity of coronary artery disease (CAD) and outcomes. In a prospective study, patients with chest pain undergoing diagnostic coronary angiography were evaluated. Patients were categorized based on the number of involved coronary arteries. Moreover, the severity of CAD was quantitatively calculated using the Syntax score (SS). All patients were also followed up for 3-month duration. The level of TSH in 150 patients was significantly higher in females than males (3.1 [1.7, 5] versus 1.8 [1, 3.3] mU/L; P=0.002). There was significant correlation between THS and the SS among females (ρ=0.477, P&lt;0.001), but not males. Among both sexes, thyroid hormones were comparable between those with or without events during follow-up. The main predictors of high SS values included age (odds ratio [OR] 1.060, 95% confidence interval [CI] 1.018-1.104; P=0.005) and female (OR 2.941, 95% CI 1.198-7.218). The main predictors of multivessel disease were age (OR 1.077, 95% CI 1.026-1.132), female (OR 5.853, 95% CI 1.880-18.222), thyroxin (OR 0.733, 95% CI 0.547-0.981), and thyrotropin (OR 1.333, 95% CI 1.079-1.647). Thyroid hormones are associated with the presence and the severity of CAD, but it might be sex-related. However, thyroid hormone levels could not predict short-term outcomes of patients.

Hypertensive Disorders of Pregnancy Increase the Risk for Myocardial Infarction: APopulation-Based Study.

Angiographic evidence of the anatomy of coronary arteries and the type of coronary artery lesions in women with a history of hypertensive disorders of pregnancy (HDP) are poorly documented. This study sought to determine the role of a history of HDP as a unique risk factor for early coronary artery disease (CAD) and type of acute coronary syndrome (ACS) (ie, atherosclerotic vs myocardial infarction with nonobstructive coronary arteries [MINOCA]) in women who underwent coronary angiography. This study used a population-based cohort of parous female patients with incident CAD who underwent coronary angiography and age-matched control subjects. The SYNTAX (Synergy between PCI [percutaneous coronary intervention] with TAXUS [Boston Scientific] and Cardiac Surgery) score was assessed to determine the complexity and degree of CAD; MINOCA was diagnosed in the presence of clinical acute myocardial infarction in the absence of obstructive coronary disease. A total of 506 parous female Olmsted County, Minnesota (USA) residents had incident CAD and angiographic data from November 7, 2002 to December 31, 2016. Women with HDP were younger than normotensive women at the time of the event (median: 64.8 years vs 71.8 years; P=0.030). There was a strong association between HDP and ACS (unadjusted P=0.018). Women with HDP compared with women with normotensive pregnancies were more likely to have a higher SYNTAX score (OR: 2.28; 95%CI: 1.02-5.12; P=0.046), and MINOCA (OR: 2.08; 95%CI: 1.02-4.25; P=0.044). A history of HDP is associated with CAD earlier in life and with a future risk for myocardial infarction with both obstructive and nonobstructive coronary arteries. This study underscores the need for timely detection and treatment of nonobstructive disease, in addition to traditional risk factors.

Sex Differences in a Real-World Registry Examining Coronary Lithotripsy for Calcified Lesions

Intravascular lithotripsy (IVL) has established as a safe and effective treatment for coronary artery calcification (CAC). This study aimed to evaluate sex-related differences in the treatment with IVL in a real-world, all-comers international registry. Patients undergoing IVL between May 2019 and February 2024 were enrolled from the BENELUX-IVL registry. Patients were divided into men and women groups. Efficacy endpoints included device success (delivery of the IVL-balloon across the target lesion and administration of therapy without related complications), technical success (TIMI 3 flow and residual stenosis <30% by quantitative coronary analysis and/or fluoroscopically) and procedural success (composite of technical success with absence of in-hospital major adverse cardiovascular events (MACE: cardiac death, myocardial infarction or target vessel revascularization). Safety endpoints were IVL-related complications and MACE at one-year follow-up. 454 patients (73±9.0 years) were treated with IVL, comprising 342 (75%) men and 112 (25%) women. More women presented with acute coronary syndrome (41% in men vs 54% in women; p=0.014) and aorto-ostial lesions (17% in men vs. 29% in women; p=0.009), while the Syntax score (23.5±14.2 in men vs. 17.1±1.0 in women; p<0.001) was higher in men. Rates of device success (97% vs. 98%; p=1.000), technical success (90% vs. 91%; p=0.821) procedural success (90% vs. 88%; p=0.749), IVL-related complications (1% vs 2%; p=0.362) and one-year MACE rates (12% vs 17%; p=0.456) were comparable. In conclusion, despite differences in clinical presentation and lesion types, IVL seems to be safe and effective for both sexes across various clinical and anatomical scenarios.

Percutaneous Coronary Intervention in High-Risk Patients

Ischemic heart disease (IHD) with severe coronary artery disease (SYNTAX score &gt;22 points) in combination with various comorbidities is often a reason for refusal of coronary artery bypass grafting in such patients. Thus, a new term has emerged, "high-risk percutaneous coronary intervention"; however, the criteria, indications and results of these interventions have not yet been sufficiently studied. Therefore, according to current clinical guidelines, the treatment tactics for this patient cohort is determined by the decision of a council, the so-called Heart Team. This analytical review summarizes the criteria for high-risk percutaneous coronary interventions based on the literature, and describes the effect of various comorbidities on the results of direct myocardial revascularization.

Evolving use and clinical outcomes of coronary intravascular lithotripsy: insights from an international, multicentre registry

BackgroundIntravascular lithotripsy (IVL) is increasingly used for treatment of coronary artery calcification. This study aimed to evaluate contemporary utilisation patterns, safety and efficacy of IVL in an unselected real-world patient cohort.MethodsWe included 454 patients undergoing IVL from May 2019 to February 2024 across seven centres in two European countries. Key endpoints included device success, technical success, procedural success, IVL-related complications and major adverse cardiovascular events (MACE) at 1-year follow-up.ResultsThe cohort (mean age 73±9 years, 75% male) had a mean SYNTAX Score of 22.0±13.6. Device, technical and procedural success were achieved in 98%, 91% and 89% of patients, respectively. IVL-related complications occurred in six patients (1%). At 1-year follow-up, MACE was observed in 37 patients (13%). Over time, IVL use increased in patients with acute coronary syndrome (p=0.004) and in combination with intracoronary imaging (p=0.002), while use of other calcium modification devices decreased (p=0.034).ConclusionIn this real-world registry, IVL demonstrated efficacy across diverse clinical and anatomical settings. High success rates, low complication rates and MACE rates were observed acutely and at 1-year follow-up. Utilisation patterns evolved over time, with increased adoption in acute scenarios and alongside intracoronary imaging.

Quantitative myocardial blood flow distribution derived from CCTA and determination of myocardium at risk in the FAST TRACK CABG trial

Abstract Background In the anatomic SYNTAX score derived from invasive coronary angiography, the ischemic impact of each stenotic coronary segment is weighed with a fixed score based on the severity of luminal diameter narrowing and the theoretical amount of blood flow supplied to the myocardium(1). This method neither accounts for individual variation nor reflects the true extent of myocardium ischemia. Purpose We aim to provide a quantitative CT SYNTAX score derived from coronary computed tomography angiography (CCTA) with customized percent blood flow distribution to the myocardium supplied by each stenotic coronary segment to determine the myocardium at risk of ischemia. Methods Patients with 3VD and/or left main coronary artery disease (CAD) were included in the first-in-human FAST TRACK CABG trial and received surgical revascularization guided solely by CCTA and fractional flow reserve derived from CCTA (FFRCT). The recently reported anatomic CT-SYNTAX score was calculated for all cases. The FFRCT value and percent myocardial blood flow distribution(%MBF) were computed for all 16 SYNTAX score segments using the validated method of Keulards et al(2). On the pre-CABG CCTA, the segments located distal to the site where the FFRCT value dropped below 0.80 were considered at risk of ischemia, and the individual weight point per segment was calculated as 6×%MBF for each segment. The SYNTAX score derived from %MBF is compared to the anatomic and functional CT-SYNTAX score. Results Out of 114 patients enrolled, FFRCT and %MBF were analyzable in 106 patients. After excluding vessels with total occlusion, the coronary flow distribution between the right and left coronary systems was 20.5% vs 79.5%, respectively, similar to the 1:5 ratio in the anatomic SYNTAX score. The anatomic and functional CT-SYNTAX scores were 43.6 and 41.1, respectively. The average total %MBF per patient was 72.0(19.1)%, and the average SYNTAX score derived from %MBF was 38.0. There is a strong correlation between functional SYNTAX score and SYNTAX score derived from %MBF (Peason’s R=0.93). Passing-Bablock regression trends showed that the functional SYNTAX score slightly overestimated the SYNTAX score derived from %MBF (Figure 1). The coronary segment weight varied significantly per individual, especially in the presence of total occlusion. Overall, the fixed weight of the anatomic SYNTAX score is a good surrogate for the individualized weighing based on %MBF (Figure 2). Conclusion CCTA-derived %MBF enabled clinicians to quantify the individualized myocardium at risk of ischemia or injury in patients with severe CAD. Retrospectively, the fixed weight score used in the anatomical SYNTAX score appeared to be a robust surrogate for myocardial blood flow distribution.Figure 1Figure 2

Correlation between LDL/HDL-cholesterol ratio and long term prognosis after acute coronary syndrome and severity of coronary artery disease

Abstract Introduction Dyslipidaemia is an important correctable risk factor for coronary artery disease (CAD). Many studies have confirmed that the lower the low-density lipoprotein cholesterol (LDL-C) levels are, the lower is the CAD morbidity and mortality rates (1). However, many patients who achieved low levels of LDL-C still experience a major adverse cardiovascular event (MACE) because of the other residual risk factors. Therefore, there is a constant need for better stratification of patients who are at higher risk for novel MACE following their first acute coronary syndrome (ACS). Evidence increasingly suggests that the ratio of LDL-C/HDL-C might be a new and better marker of cardiovascular disease, as it simultaneously evaluates the levels of both LDL-C and HDL-C (2). Purpose The aim of this study was to investigate the prediction value of LDL-C/HDL-C ratio for long term prognosis after ACS as well as its correlation with CAD severity. Methods We included patients hospitalized at out centre with ACS from January 2017 to January 2024. Demographic data, data on LDL-C and HDL-C levels on admission and calculated Syntax score were used. Syntax score is a comprehensive angiographic scoring system which determines complexity by using coronary anatomy and lesion characteristics (3). Follow-up data were collected either by clinical follow-up visits or by telephone interviews. The MACE was defined as the composite of cardiovascular death, acute coronary syndrome and need for elective or urgent percutaneous or surgical revascularization. Results This registry-based study included 2471 patients with ACS, median age of 64 (interquartile range 56-73) years, 31% female. Total of 1099 patients (44%) had non-ST elevation ACS and 1372 (54%) had ST elevation myocardial infarction (STEMI). Median Syntax score was 13 (IQR 7-20.5), with 1494 (61%) patients having low Syntax score (≤16), 508 (21%) patients medium (16-22), and 448 (18%) high score (&amp;gt;22), respectively. Median follow up was 17 (3-27) months. LDL-C/HDL-C ratio correlated significantly with cardiovascular death, with weak coefficient (2.94 vs. 2.54 p&amp;lt;0.001; rho=0.102, p&amp;lt;.0001), however did not correlate with MACE (2.88 vs. 2.92, p=0.188, rho=0.06, p=0.77). This remained identical when tested for patients with STEMI and non-STE ACS. In addition, LDL-C/HDL-C ratio did not correlate with CAD severity as assessed with Syntax score (low 2.92 vs. medium 2.83 vs. high 2.86, p=0.597; rho=0.4, p=0.09). Conclusion Our data suggest that LDL-C/HDL-C ratio cannot be used as a relevant predictor of post-ACS long-term MACE or cardiovascular death, nor it can be correlated with CAD severity. Further studies are needed to establish the real value of LDL-C/HDL-C ratio as a post-ACS predictor.

Lipidomics-based deep learning algorithms can enhance prediction of obstructive coronary artery disease

Abstract Background Lipidomics emerge as a promising research field with the potential to help in personalized risk stratification and also improve our understanding on the functional role of individual lipid species in the metabolic perturbations occurring in coronary artery disease (CAD). The existing technological challenges to detect diverse yet structurally similar lipids and their isomers, as well as the need for novel statistical and computational tools to handle the high-dimensional lipidome may be responsible for the reduced clinical translation of the very first lipidomics research outcomes. Methods To that end, this post-hoc analysis of the prospective CorLipid trial aimed to investigate the predictive capability of a lipidomics panel for obstructive CAD risk through an extreme gradient boosting (XGBoost) machine learning (ML) approach. The lipid profiles of 146 individuals with suspected CAD were investigated through liquid chromatography-mass spectrometry. Fasting blood samples were drawn prior to invasive coronary angiography execution. Obstructive CAD was defined as SYNTAX Score (SS) &amp;gt;0 compared to non-obstructive CAD (SS=0). Results Study participants (75.3% male, mean age: 61 ±10.5 years old) were divided into two categories based on the existence of obstructive CAD (54.8% with SS&amp;gt;0 and 45.2% with SS=0). In total, 517 lipid species were identified, from which 290 lipid species were finally quantified in participants’ serum [glycerophospholipids (52.1%), glycerolipids (28.6%) and sphingolipids (19.3%)]. The levels of glycerophospholipid, sphingolipid and glycerolipid classes were significantly different in patients with obstructive CAD. Finally, a ML XGBoost algorithm identified a panel of 17 serum biomarkers (5 sphingolipids, 7 glycerophospholipids, triacylglycerols, galectin-3, glucose, LDL and LDH) as totally sensitive (100% sensitivity, 62.1% specificity and 100% negative predictive value) for the prediction of obstructive CAD. Conclusions These findings provide molecular insights into the role of dysregulated lipid metabolism in the development and progression of CAD while validating the existing body of evidence from similar research studies. Further (ML-based) investigation of lipid metabolism could hold promises for novel therapeutic strategies and improvement of the existing risk stratification schemes.Lipidomics panel importance

Long-term outcome of diabetic patients after unprotected left main percutaneous coronary interventions

Abstract Background Diabetes mellitus (DM) represents an elevated risk in terms of percutaneous coronary intervention (PCI), especially in patients with significant left main (LM) disease. Purpose Our aims were to investigate the 60-month mortality and event-free survival of consecutive patients with DM undergoing unprotected LM PCI at our centre and sought to determine the independent predictors of event-free survival. Methods We included all patients undergoing unprotected LM PCI at our tertiary care centre between 1 January 2007 and 31 December 2014. The primary endpoint was the composite of all-cause mortality, myocardial infarction, and target lesion revascularization at 60 months. Survival curves were constructed using the Kaplan-Meier non-parametric estimator. ROC analysis was used to investigate the predictive power of conventional risk scores (SYNTAX, SYNTAX II, EuroSCORE II, additive and logistic EuroSCORE, ACEF, GRACE 2). Independent predictors were determined by univariate and multivariate analysis. Results A total of 513 patients (mean age 68 ± 12 years, 64% male) underwent unprotected LM PCI during this period, among these 310 (60%) were non-diabetic (non-DM) and 203 (40%) were diabetic (DM). In terms of indication, 157 (31%) elective and 356 (69%) acute LM PCI were performed. There was no significant difference between the non-DM and DM groups in terms of acute indication (218 (70%) vs. 138 (68%), p=0.574). Within the DM group, 135 (67%) were treated with oral antidiabetics (OAD) and 68 (33%) were treated with insulin (IDM). The mean survival (34.6 vs. 39.7 vs. 43.1 months, p=0.003) and event-free survival (29.3 vs. 34.7 vs. 39.3 months, p=0.001) were significantly lower in the IDM and OAD groups compared to non-DM, respectively. Of the risk scores, the SYNTAX score was the most predictive in diabetic patients (AUC=0.767). Based on the SYNTAX score, diabetic patients with a low SYNTAX score (&amp;lt;23) had less events (59% vs. 66%, p=0.043) than those having a moderate/high SYNTAX score (≥23). LVEF (HR 0.976; 95% CI, 0.965-0.987, p&amp;lt;0.001), right coronary artery occlusion (HR 2.031; 95% CI, 1.346-3.064, p=0.001), acute coronary syndrome (HR 1.861; 95% CI, 1.252-2.767, p=0.002), use of FFR (HR 0.481; 95% CI, 0.265-0.871, p=0.016), true bifurcation lesion (HR 1.559; 95% CI, 1.068-2.277, p=0.021) and newer DES generation (HR 0.706; 95% CI, 0.568-0.877, p=0.002) were predictors of event-free survival in diabetics by univariate analysis. Glomerular filtration rate (HR 0.982; 95% CI, 0.973-0.991, p&amp;lt;0.001) emerged as an independent predictor according to multivariate analysis. Conclusion Consecutive diabetic patients with significant unprotected LM stenosis have poor long-term outcome after LM PCI. Anatomical complexity of the lesions is a significant predictor of event-free survival. Careful intervention planning and the use of appropriate tools can improve the outcome in this high-risk population.

Clinical significance of residual ischemia in acute myocardial infarction complicated by cardiogenic shock undergoing VA-ECMO

Abstract Background Although culprit-only revascularization during the index procedure has been recommended in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS), the reduction of residual ischemia is also emphasized to improve clinical outcomes. However, few data are available about the significance of residual ischemia in patients undergoing mechanical circulatory supports. Objectives This study aimed to evaluate the effects of residual ischemia on clinical outcomes in AMI patients undergoing venoarterial-extracorporeal membrane oxygenation (VA-ECMO). Methods AMI patients with multivessel disease who underwent VA-ECMO due to refractory CS were pooled from the RESCUE and SMC-ECMO registries. The included patients were classified into three groups according to residual ischemia evaluated using the residual SYNTAX score (rSS): rSS=0, 0&amp;lt;rSS≤8, and rSS&amp;gt;8. The primary outcome was 1-year all-cause death. Results A total of 408 patients were classified into the rSS=0 (N=100, 24.5%), 0&amp;lt;rSS≤8 (N=136, 33.3%), and rSS&amp;gt;8 (N=172, 42.2%) groups. The cumulative incidence of the primary outcome differed significantly according to rSS (33.9% vs. 55.4% vs. 66.1% for rSS=0, 0&amp;lt;rSS≤8, and rSS&amp;gt;8, respectively, overall P&amp;lt;0.001). In a multivariable model, rSS was independently associated with the risk of 1-year all-cause death (HRadj 1.03, 95% CI 1.01–1.05, P=0.003). Conversely, the baseline SYNTAX score was not associated with the risk of the primary outcome. Furthermore, when patients were stratified by rSS, the primary outcome did not differ significantly between the high and low delta SYNTAX score groups. Conclusions In AMI patients with refractory CS who underwent VA-ECMO, residual ischemia was associated with an increased risk of 1-year mortality. Therefore, revascularization strategies to minimize residual ischemia should be considered in advanced CS, particularly in cases requiring VA-ECMO.

The impact of SYNTAX score on culprit lesion morphology of acute coronary syndrome

Abstract Background The SYNTAX score quantifies the complexity of coronary artery morphology and is useful in determining the indication for CABG (Coronary Artery Bypass Grafting) or PCI (Percutaneous Coronary Intervention), which often reflect coronary artery disease severity. However, how SYNTAX score affects etiology of ACS (Acute Coronary Syndrome) patients observed by OCT (Optical Coherence Tomography) has been unclear. Methods This is a sub study of TACTICS OCT registry (n=702) which include ACS patients who underwent OCT guided PCI. Based on SYNTAX score, patients were divided into low-SYNTAX-group (1-22 points) and high-SYNTAX-group (23 points or higher). ACS culprit lesions were classified into plaque rupture (PR), plaque erosion (PE), and calcified nodule (CN). We compared patient characteristics and culprit lesions in low-group and high-group. Results High-SYNTAX-group was significantly younger with relatively greater prevalence of diabetes and lower body mass index. Peak CK, LVEF, Multi vessel and TIMI grade were also significantly greater in high-SYNTAX-group than low-SYNTAX-group. Although PR and PE were 2 most common etiologies of ACS in both groups, proportion of CN was much greater in high-SYNTAX-group than low-SYNTAX-group. Conclusion High-SYNTAX score was likely to have impact on ACS etiology increasing proportion of CN.