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Helenne Joie M. Brown, MD

Comparison of the New Mayo Clinic Risk Scores and Clinical SYNTAX Score in Predicting Adverse Cardiovascular Outcomes following Percutaneous Coronary Intervention at the Philippine Heart Center. Helenne Joie M. Brown, MD. Background. Risk Stratification. Management.

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Helenne Joie M. Brown, MD

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  1. Comparison of the New Mayo Clinic Risk Scores and Clinical SYNTAX Score in Predicting Adverse Cardiovascular Outcomes following Percutaneous Coronary Intervention at the Philippine Heart Center Helenne Joie M. Brown, MD

  2. Background Risk Stratification Management Evaluation of health economics Quality Control Ischemic Heart Disease

  3. Objective New Mayo Clinic Risk Scores Clinical Prognostic Value In-hospital and 30-day Mortality and MACCE

  4. Study Design Prospective Cohort Study Inclusion Criteria All patients who underwent percutaneous coronary intervention at the Philippine Heart Center during the period of April 1, 2011 to September 30, 2011, aged > 18 years were included. Exclusion Criteria Patients with no baseline systolic function.

  5. Study Design Sample Size The computed sample size was > 460 based on 95% confidence level and 80% power to detect statistical significance at assumed difference in area under the curve of 10%. The assumption was based on the paper of Garg et al which presented an AUC of 0.89 for MACE. Garg S et al. A New Tool for the Risk Stratification of Patients with Complex Coronary Artery Disease: The Clinical SYNTAX Score. Circ Cardiovasc Interv. 2010;3:317-326.

  6. Study Design Study Maneuver Ischemic Heart Disease Cardiovascular history and risk factors 2 Interventional Cardiologists Coronary Angiogram PCI

  7. Study Design Study Maneuver New Mayo Clinic Risk Scores Clinical CSS = [SYNTAX Score] x [modified ACEF score] • Age • Serum creatinine • LVEF • Preprocedural shock = 9 points • MI < 24 hours = 4 points • CHF on presentation = 3 points • PAD = 2 points

  8. Study Design Study Maneuver New Mayo Clinic Risk Scores Clinical Risk Stratification Low-risk: < 15.6 Moderate risk: >15.6 <27.5 High risk: >27.5 Mortality Prediction Very low risk: 0-5 Low-risk: 6-7 Moderate risk: 8-10 High risk: 11-12 Very high risk: 13+ MACCE Prediction Very low risk: 0-2 Low-risk: 3-5 Moderate risk: 6-90 High risk: 10-13 Very high risk: 14+ Outcomes In-hospital and 30-day all-cause mortality and MACCE

  9. Study Maneuver Results New Mayo Clinic Risk Scores Clinical N = 482 Risk Stratification Low-risk: < 15.6 Moderate risk: >15.6 <27.5 High risk: >27.5 Mortality Prediction Very low risk: 0-5 Low-risk: 6-7 Moderate risk: 8-10 High risk: 11-12 Very high risk: 13+ MACCE Prediction Very low risk: 0-2 Low-risk: 3-5 Moderate risk: 6-90 High risk: 10-13 Very high risk: 14+ Outcomes In-hospital and 30-day all-cause mortality and MACCE

  10. Results Table 1. Baseline and Procedural Variables

  11. Results Table 1. Baseline and Procedural Variables

  12. Results Table 1. Baseline and Procedural Variables

  13. Results Table 1. Baseline and Procedural Variables

  14. Results New Mayo Clinic Risk Scores Clinical N = 482 Risk Stratification Low-risk: < 15.6 Moderate risk: >15.6 <27.5 High risk: >27.5 Mortality Prediction Very low risk: 0-5 Low-risk: 6-7 Moderate risk: 8-10 High risk: 11-12 Very high risk: 13+ MACCE Prediction Very low risk: 0-2 Low-risk: 3-5 Moderate risk: 6-90 High risk: 10-13 Very high risk: 14+ Outcomes In-hospital and 30-day all-cause mortality and MACCE

  15. Results Table 2. In-hospital Mortality and MACCE following PCI

  16. Figure 1. ROC Curve for In-hospital Mortality for the New Mayo Clinic Risk Score (NMCRS) for Predicting Mortality, the NMCRS for Predicting MACE and the Clinical Syntax Score (CSS).

  17. Figure 6. ROC Curve for In-hospital Composite Endpoints for the New Mayo Clinic Risk Score (NMCRS) for Predicting Mortality, the NMCRS for Predicting MACE and the Clinical Syntax Score (CSS).

  18. Results New Mayo Clinic Risk Scores Clinical N = 482 Risk Stratification Low-risk: < 15.6 Moderate risk: >15.6 <27.5 High risk: >27.5 Mortality Prediction Very low risk: 0-5 Low-risk: 6-7 Moderate risk: 8-10 High risk: 11-12 Very high risk: 13+ MACCE Prediction Very low risk: 0-2 Low-risk: 3-5 Moderate risk: 6-90 High risk: 10-13 Very high risk: 14+ Outcomes In-hospital and 30-day all-cause mortality and MACCE

  19. Results Table 2. 30-day Mortality and MACCE following PCI

  20. Figure 4. ROC Curve for 30-day Mortality for the New Mayo Clinic Risk Score (NMCRS) for Predicting Mortality, the NMCRS for Predicting MACE and the Clinical Syntax Score (CSS).

  21. Figure 7. ROC Curve for 30-day Composite Endpoints for the New Mayo Clinic Risk Score (NMCRS) for Predicting Mortality, the NMCRS for Predicting MACE and the Clinical Syntax Score (CSS).

  22. Figure 8. ROC Curve for In-hospital and 30-day Composite Endpoints for the New Mayo Clinic Risk Score (NMCRS) for Predicting Mortality, the NMCRS for Predicting MACE and the Clinical Syntax Score (CSS).

  23. versus Age Serum creatinine LVEF  predictors of adverse outcomes after revascularization Garg et al. A New Tool for the Risk Stratification of Patients with Complex Coronary Artery Disease: The Clinical SYNTAX Score. Circ Cardiovasc Interv. 2010;3:317-326. Ranucci et al. Risk of Assessing Mortality Risk in Elective Cardiac Operations: Age, Creatinine, Ejection Fraction, and the Law of Parsimony. Circulation. 2009;119:3053-3061.  not subject to interobserver variability

  24. Results Risk Stratification Mortality Prediction MACCE Prediction Clinical + angiographic variables Outcomes Clinical variables In-hospital and 30-day all-cause mortality and MACCE

  25. versus “… despite exclusion of angiographic variables, the NMCRS can accurately estimate peri-procedural risk from PCI.” Singh et al. Bedside Estimation of Risk from Percutaneous Coronary Intervention: The New Mayo Clinic Risk Scores. Mayo Clin Proc June 2007;82(6):701-708. Our study demonstrated that the prognostic utility of the NMCRS for predicting mortality and MACCE can be extended to estimation of mortality and MACCE 30 days after a patient undergoes PCI.

  26. versus all-comers study: 1-, 2- 3-vessel CAD 2- or 3-vessel CAD Excluded: Previous PTCA Left Main CAD Overt CHF LVEF < 30% Hx of TIA Hx of transmural MI Utility: long-term outcomes

  27. Conclusion This study demonstrates the superior ability of a risk stratification tool which uses purely clinical variables, i.e. (1) the NMCRS for Predicting Mortality to predict in-hospital mortality and composite MACCE and (2) the NMCRS for Predicting MACE to predict 30-day mortality and composite MACCE, when compared with the CSS which uses angiographic and clinical variables.

  28. Recommendation • We therefore recommend the use of the New Mayo Clinic Risk Score for risk stratification of patients who will undergo PCI. • simple bedside tool • expedient for both the physician and patient in decision-making for revascularization • superior discriminative ability over the Clinical Syntax Score for peri-procedural and 30-day adverse outcomes

  29. Good afternoon.

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