Appropriateness of Myocardial Revascularization Assessed by the SYNTAX Score II in a Centre Without On-Site Cardiac Surgery
Bojan M. Stanetic, MD1 †; Miodrag C. Ostojic, MD, PhD1; Tamara Kovacevic-Preradovic, MD, PhD1; Sasa Loncar, MD1; Zeljko Zivanovic, MD1; Svetozar Srdic, MD1; Kurt Huber, MD, PhD2; Patrick W. Serruys, MD, PhD3
Author’s affiliations:
1 Department of Cardiology, University Hospital Clinical Centre Banja Luka, Banja Luka, Bosnia and Herzegovina
2 Wilhelminenspital, 3rd Medical Department – Cardiology, Vienna, Austria
3 International Centre of Circulatory Health, Imperial College London, London, United Kingdom
† Address for correspondence:
Bojan M. Stanetic, MD
12 beba bb, 78 000 Banja Luka, Republic of Srpska, Bosnia and Herzegovina
Tel: +387 51 342 558; Fax: +387 51 342 553
E-mail:
All authors ave made substantial contribution to the intellectual content of the paper in: conceived and designed the research, performed statistical analysis, drafted the manuscript, made critical revision of the manuscript for key intellectual content.
All authors declare that the study complies with the Declaration of Helsinski. The relevant ethic committee approved the research protocol. Due to the retrospective nature of the study, written informed consent from the patients was waived, excluding those who refused participation in the study when contacted for follow-up.
Background: The recently published SYNTAX score II is a clinical tool that allows for objective, individualized decision-making on the most appropriate revascularisation strategy in patients with complex coronary artery disease. The SYNTAX Score II uses 4-year mortality predictions following percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) to aid the heart team in the decision-making process. The purpose of the present study was to investigate whether indications for PCI or CABG based on the clinical judgment of PCI-operators without on-site surgical facilities correlates to the objective decision-making undertaken with the SYNTAX Score II.
Methods: We retrospectively analysed 560 elective patients with 3-vessel (81.6%) or unprotected left main coronary artery (18.4%) disease treated by PCI or referred to other institutions for CABG by a centre without on-site cardiac surgery facilities (Banja Luka, Bosnia and Hercegovina) between January 2008 and May 2010. The actual treatment performed according to the clinical judgment was retrospectively compared with the SYNTAX Score II recommendation. Differences in outcomes were analysed using Kaplan-Meier estimates at 4-year follow-up.
Results: Out of 560 subjects, 362 (64.6%) underwent PCI and 198 (35.4%) were referred for CABG. Based on an assessment of the predicted 4-year mortality by the SYNTAX score II, CABG would have been the treatment of choice in 232/560 (41.4%) patients, PCI in 3/560 (0.6%) patients, and CABG or PCI in 325/560 (58.0%) patients. Out of 232 patients in whom CABG was recommended by the SYNTAX Score II, 99/232 (42.7%) were referred for CABG and 57.3% (133/232) underwent PCI. In 426/560 patients (76.1%) there was concordance between clinical judgment and SSII recommendations. In the remaining 134/560 patients (23.9%) there was discordance between the clinical judgment and SSII recommendation. Overall mortality in the entire cohort of 560 patients at 4-year follow-up was 8.4%. Discordance between the SSII recommendation and clinical decision was associated with a significantly higher 4-year mortality compared to when there was concordance between SSII recommendation and clinical decision (12.7% vs. 6.3%; log rank p value =0.028).
Conclusion: The present study demonstrated that the SYNTAX Score II provided more objective decision-making on the most appropriate revascularisation strategy in patients with complex coronary artery disease. Discordance between the SYNTAX Score II recommended revascularisation strategy and the clinical decision was met with a higher long-term 4 year mortality.
Keywords: decision making, SYNTAX score II, on-site cardiac surgery