Key result
Higher SYNTAX score links to ~2% greater 5-year MACCE risk per unit after PCI, not CABG.
Why the study?
Diabetes mellitus is associated with complex CAD and increased cardiovascular morbidity and mortality. The utility of the SYNTAX score for predicting future cardiovascular events in patients with DM and complex CAD undergoing CABG or PCI required evaluation.
Does the SYNTAX score predict 5-year major adverse cardiac and cerebrovascular events and hard cardiovascular events in patients with diabetes mellitus and multivessel coronary artery disease undergoing PCI with drug-eluting stents versus CABG?
RCT (n=1,900)
Randomized
Does the SYNTAX score predict 5-year major adverse cardiac and cerebrovascular events and hard cardiovascular events in patients with diabetes mellitus and multivessel coronary artery disease undergoing PCI with drug-eluting stents versus CABG?
In patients with diabetes and multivessel coronary artery disease, CABG reduces major adverse cardiovascular events compared to PCI across all SYNTAX score tertiles, indicating that the SYNTAX score should not be used to guide the choice of revascularization strategy in this population.
SYNTAX score should not guide PCI vs CABG choice in diabetes; challenges anatomic scoring for strategy selection and reinforces CABG preference.
BACKGROUND Diabetes mellitus (DM) is associated with complex coronary artery disease (CAD), which in turn results in increased morbidity and mortality from cardiovascular disease. OBJECTIVES This study sought to evaluate the utility of SYNTAX score (SS) for predicting future cardiovascular events in patients with DM and complex CAD undergoing either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). METHODS The FREEDOM (Future REvascularization Evaluation in patients with Diabetes mellitus: Optimal management of Multivessel disease) trial randomized patients with DM and multivessel CAD to undergo either PCI with drug-eluting stents or CABG. The SS was calculated retrospectively by a core laboratory. The endpoint of hard cardiovascular events (HCE) was a composite of death from any cause, nonfatal myocardial infarction, and nonfatal stroke, while the endpoint of major adverse cardiac and cerebrovascular events (MACCE) was a composite of HCE and repeat revascularization. RESULTS A total of 1,900 patients were randomized to PCI (n = 953) or CABG (n = 947). The SS was considered an independent predictor of 5-year MACCE (hazard ratio per unit of SS: 1.02; 95% confidence interval: 1.00 to 1.03; p = 0.014) and HCE (hazard ratio per unit of SS: 1.03; 95% confidence interval: 1.01 to 1.04; p = 0.002) in the PCI cohort, but not in the CABG group. There was a higher incidence of MACCE in PCI patients with low, intermediate, and high SS compared with those who underwent CABG (36.6% vs. 25.9%, p = 0.02; 43.9% vs. 26.8%, p < 0.001; 48.7% vs. 29.7%, p = 0.003, respectively). CONCLUSIONS In DM patients with multivessel CAD, the complexity of CAD evaluated by the SS is an independent risk factor for MACCE and HCE only in patients undergoing PCI. The SS should not be utilized to guide the choice of coronary revascularization in patients with DM and multivessel CAD. (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes [FREEDOM]; NCT00086450).
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Ésper et al. (2018) conducted an RCT in Diabetes mellitus and multivessel coronary artery disease (n=1,900). Percutaneous coronary intervention (PCI) with drug-eluting stents vs. Coronary artery bypass grafting (CABG) was evaluated on 5-year major adverse cardiac and cerebrovascular events (MACCE: composite of death from any cause, nonfatal myocardial infarction, nonfatal stroke, and repeat revascularization) (HR 1.02 per unit of SYNTAX score in PCI cohort, 95% CI 1.00-1.03, p=0.014). SYNTAX score independently predicted 5-year MACCE in patients with diabetes undergoing PCI (HR 1.02 per unit; 95% CI 1.00-1.03; P=0.014) but not CABG.
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