Key result
Mid-to-high SYNTAX score predicts ~36% higher 5-year major cardiovascular events.
Why the study?
The extent of coronary disease affects clinical outcomes and may predict the effectiveness of CABG or PCI. Whether SYNTAX scores predicted outcomes and the effectiveness of coronary revascularization compared with medical therapy in the BARI-2D trial needed to be determined.
Does coronary revascularization (CABG or PCI) compared with medical therapy reduce major cardiovascular events over 5 years in patients with diabetes and stable ischemic heart disease stratified by baseline SYNTAX score?
RCT (n=1,550)
Investigators masked to patient characteristics and outcomes for SYNTAX score calculation
Does coronary revascularization (CABG or PCI) compared with medical therapy reduce major cardiovascular events over 5 years in patients with diabetes and stable ischemic heart disease stratified by baseline SYNTAX score?
In patients with type 2 diabetes and stable ischemic heart disease, a mid/high SYNTAX score (≥23) predicts higher rates of major cardiovascular events and identifies patients who derive significant benefit from CABG revascularization over medical therapy.
BACKGROUND: The extent of coronary disease affects clinical outcomes and may predict the effectiveness of coronary revascularization with either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI). The SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score quantifies the extent of coronary disease. OBJECTIVES: This study sought to determine whether SYNTAX scores predicted outcomes and the effectiveness of coronary revascularization compared with medical therapy in the BARI-2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial. METHODS: Baseline SYNTAX scores were retrospectively calculated for BARI-2D patients without prior revascularization (N = 1,550) by angiographic laboratory investigators masked to patient characteristics and outcomes. The primary outcome was major cardiovascular events (a composite of death, myocardial infarction, and stroke) over 5 years. RESULTS: A mid/high SYNTAX score (≥23) was associated with a higher risk of major cardiovascular events (hazard ratio: 1.36, confidence interval: 1.07 to 1.75, p = 0.01). Patients in the CABG stratum had significantly higher SYNTAX scores: 36% had mid/high SYNTAX scores compared with 13% in the PCI stratum (p < 0.001). Among patients with low SYNTAX scores (≤22), major cardiovascular events did not differ significantly between revascularization and medical therapy, either in the CABG stratum (26.1% vs. 29.9%, p = 0.41) or in the PCI stratum (17.8% vs. 19.2%, p = 0.84). Among patients with mid/high SYNTAX scores, however, major cardiovascular events were lower after revascularization than with medical therapy in the CABG stratum (15.3% vs. 30.3%, p = 0.02), but not in the PCI stratum (35.6% vs. 26.5%, p = 0.12). CONCLUSIONS: Among patients with diabetes and stable ischemic heart disease, higher SYNTAX scores predict higher rates of major cardiovascular events and were associated with more favorable outcomes of revascularization compared with medical therapy among patients suitable for CABG. (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes; NCT00006305).
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Ikeno et al. (2017) conducted an RCT in Type 2 diabetes and stable ischemic heart disease (n=1,550). Coronary revascularization (CABG or PCI) stratified by baseline SYNTAX score vs. Medical therapy (and low SYNTAX score ≤22) was evaluated on Major cardiovascular events (a composite of death, myocardial infarction, and stroke) over 5 years (HR 1.36, 95% CI 1.07-1.75, p=0.01). Mid/high SYNTAX scores (≥23) predicted higher 5-year major cardiovascular events (HR 1.36, 95% CI 1.07-1.75, p=0.01) and lower events with CABG vs medical therapy (15.3% vs 30.3%, p=0.02).
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