SYNTAX Score 2020

The SYNTAX Score 2020 and related scores are intended to provide medical advice or guidance as to appropriate treatment strategies for individual patients Albeit, the results and recommendations provided by this application are not intended to, and should not replace clinical judgment of the care provider. Risks and benefits should be carefully considered for each patient taking into account all available data and treatment options. Treating physicians and other healthcare providers should always exercise their own clinical judgment for any given situation. In addition, it is important to note that the safety and effectiveness of drug-eluting stents have not yet been fully established in complex and extensive coronary artery disease. Physicians are strongly encouraged to review the indications, contraindications, warnings and instructions included in the products’ Directions for Use of the various stents available on the market.

Foreword

“Prior to the start of the SYNTAX trial the trial designers’ concern was the accurate, semi-quantitative assessment -by surgeons and interventional cardiologists- of the extent and anatomical complexity of coronary artery disease (CAD) before inclusion of patients in the landmark SYNTAX trial. Originally, the anatomical SYNTAX Score was simply a scoring tool to force the physicians to meticulously inspect and assess the anatomical complexity of the coronary anatomy visualized either by invasive cine angiography (ICA) or more recently by non-invasive computerized tomographic angiography (CTA).

To create the anatomic SYNTAX Score tool, numerous existing scores stemming from the literature were combined: the Leaman score, the ACC/AHA lesion classification system, a chronic total occlusion score, the Medina score, a thrombus score, a calcification score and so on. This amalgam of scores were then organized in a complex hierarchical algorithm.

The prognostic value of the score in predicting the rates of major adverse cardiac and cerebrovascular events (death, stroke, myocardial infarction, or revascularization) in the various SYNTAX scores substrata ≤22, 23-32, and ≥33) of patients treated by either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) became only evident once the outcome of the SYNTAX trial was unraveled in 2009 (1 year follow up) and 2013 (5 years follow up). Of note, the prognosis of surgical cases was hardly affected by the anatomical SYNTAX score since the surgeon had the option to “bypass” all these anatomical complex obstacles. At the same time, it was realized that the prognosis of a surgical case was more related to comorbidities and clinical characteristic best described, for instance, by the EuroSCORE, STS score, and ACEF score.

The undermentioned table summarizes the evolution of the anatomic SYNTAX Score, following its merging with clinical characteristics and comorbidities (SYNTAX Score II [Lancet, 2013], SYNTAX Score 2020 [Lancet 2020] and logistic SYNTAX Score) and its further refinement after functional and weighing adjustment (so called functional score) using physiological assessment such as instantaneous wave-free ratio (iFR), fractional flow reserve (FFR) or quantitative flow ratio (QFR) (SYNTAX Score III = anatomy + comorbidity + functionality).”

The SYNTAX Score and related variants were developed under the leadership of the SYNTAX and Multivessel TALENT Steering Committee, in collaboration with the CORRIB Core Lab of the National University of Ireland in Galway. Smartphone application and Web site were produced by the CORRIB Core Lab and Sahajanand Medical Technologies (SMT) to support practitioners in their treatment decision making for patients with complex CAD.

Reference: Serruys PW, Hara H, Onuma Y. Did the SYNTAX Score Pass the Test of Time? JACC. Cardiovasc Interv. 2020 May 25;13(10):1207-1210. doi: 10.1016/j.jcin.2020.03.040. PMID: 32438991.

Table: SYNTAX Score and its variants

1. Anatomic SYNTAX Score (2005): Anatomy (ICA), population strata outcome, PCI versus CABG

• Predict MACCE (all-cause mortality, stroke, myocardial infarction, revascularization) prognosis from 1 to 5 years in the SYNTAX trial (PCI vs. CABG in three-vessel disease and left main)^1-3 and mortality up to 10 years in the SYNTAXES study.⁴

2. SYNTAX Score II (2013): Anatomy (ICA) and comorbidity, PCI versus CABG

• Predict 4-year all-cause mortality in the SYNTAX trial.⁵

• Used as an inclusion criteria for PCI population based on equipoise prediction of all-cause mortality after PCI versus surgery in three-vessel disease and left main (the SYNTAX II trial).⁶

3. Functional SYNTAX Score (2011, 2018): Anatomy (ICA and CTA) and functionality (iFR, FFR, FFR_CT), PCI population

• Treatment decision making based on anatomy and functionality.^13-14

4. Logistic clinical SYNTAX Score (2020): Anatomy (ICA) and comorbidity, individualized outcome for “all-comers” PCI

• Predict all-cause mortality at 2 years in “all-comers” PCI trials.^7-11

5. SYNTAX Score III: Anatomy (CTA), comorbidity, and functionality (FFR_CT), PCI and CABG

• Treatment decision making between PCI and CABG in three-vessel disease and left main based solely on multi-slice CT scan with FFR_CT in the SYNTAX III REVOLUTION trial.¹⁸

6. SYNTAX Score III: Anatomy (CTA), comorbidity, and functionality (FFR_CT), CABG population

• Planning and execution of surgery in three-vessel disease and left main applying SYNTAX Score III derived solely on CTA scan with FFR_CT (the FASTTRACK CABG trial, First in men).¹⁹

7. SYNTAX Score 2020 (2020): Anatomy (ICA) and comorbidity, PCI versus CABG

• Predict 5-year MACE and 10-year all-cause mortality based on cross validation in the SYNTAX trial and on external validation in the FREEDOM, BEST, and PRECOMBAT trials. (Lancet 2020 in press)

CABG: coronary artery bypass grafting; CTA: computed tomography angiography; FFR: fractional flow reserve; ICA: invasive coronary angiography; iFR: instantaneous wave-free ratio; PCI: percutaneous coronary intervention.

Terms and Conditions