How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ?

1. How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? William WIJNS Aalst, Belgium http://cardio-aalst.be & William.Wijns@olvz-aalst.be

2. Global appraisal of the patient’s condition & risk • Use of risk scores • Use of a standard check list (adapted to each institution) • Clinical information, psychological profile and culture • Co-morbid factors • Possible interference with DAPT • Biochemical markers • LV and valvular function • Testing for ischemia/viability • Coronary angiography

3. Global appraisal of the patient’s condition & risk • Why using Risk scores in day-to-day practice? • Physicians are risk-averse and driven by personal experience • High-risk patients are denied the potentially large benefit of invasive therapies, be it with increased risk • Using risk scores helps reducing bias and targeting treatment strategies to personnalized needs • Adherences to guidelines increases, with subsequent improvement in outcomes

4. How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? STEMI NSTEMI and NSTE-ACS Stable CAD http://cardio-aalst.be & William.Wijns@olvz-aalst.be

5. Joint ESC - EACTS Guidelineson Myocardial Revascularisation Joint Task Force on Myocardial Revascularisation ofthe European Society of Cardiology (ESC) andthe European Association for Cardio-Thoracic Surgery (EACTS) Developed with the special contribution ofthe European Association forPercutaneous Cardiovascular Interventions (EAPCI) European Heart Journal (2010) 31, 2501-2555 European Journal of Cardio-thoracic Surgery 38, S1 (2010) S1-S52

6. How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? STEMI - no recommendation, except for cardiogenic shock - practice driven by: time delays ECG reperfusion http://cardio-aalst.be & William.Wijns@olvz-aalst.be

7. How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? NSTEMI and NSTE-ACS http://cardio-aalst.be & William.Wijns@olvz-aalst.be

8. Intended Early Invasive vs. Conservative Strategy 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Long term outcome by initial Risk ScoreMeta-analysis of 3 major trials Selective invasive Routine invasive High Cumulativepercentage Intermediate Low 0 1 2 3 4 5 Follow-up time (years) Fox KA et al. JACC 2010;55(22):2435-45

9. Calculating GRACE Risk Score Killip Points class I 0 II 17 III 34 IV 51 Systolic Points BP ≤70 66 70-89 53 90-109 40 110-129 27 ≥130 19 Age Points ≤30 0 30-49 10 50-69 29 70-79 56 80-89 73 ≥90 91 Creatinine Points 0-0.39 3 0.4-0.9 9 1.0-1.9 32 ≥2 51 Heart Points rate ≤70 10 70-89 15 90-109 26 110-129 32 130-149 24 150-169 16 170-199 8 ≥200 0 Baseline risk factors Points Cardiac arrest at admission 38 ST-segment deviation 18 Positive cardiac markers 14 STEMI 14 Total from clinical evaluation

10. Calculating GRACE Risk Score http://www.outcomes-umassmed.org/grace

11. Recommendations forrevascularisation in NSTE-ACS

12. How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? Stable CAD http://cardio-aalst.be & William.Wijns@olvz-aalst.be

13. Recommended risk stratification scoresto be used in candidates for PCI or CABG For PCI, SYNTAX scoreemerges as preferred scoreto quantify complexity ofCAD, but needs to be testedin other trials. For CABG, both EuroSCOREand STS score are wellvalidated, mostly based onclinical variables. STS score is undergoingperiodic adjustment whichmakes longitudinalcomparisons difficult. ACEF score = [Age/Ejection Fraction (%)] + 1 (if Creatinine > 2 mg/dL).

14. www.syntaxscore.com

16. Indications for CABG versus PCI in stablepatients with lesions suitable for both procedures and low predicted surgical mortality • In the most severe patterns of CAD, CABG appears to offer a survival advantageas well as a marked reduction in the need for repeat revascularisation

17. Further validation of SYNTAX Score • SYNTAX Score works for non SYNTAX trial population • Tested on all-comers population from Resolute trial • C-index 0.62 • Garg S et al, JACC Cardiovasc Interv. 2011 Apr;4(4):432-41 http://cardio-aalst.be & William.Wijns@olvz-aalst.be

18. New scores to be further validated • EuroHeart Score (based on EuroHeart Survey) for PCI • Large dataset of 46.064 pts, 1:1 training:validation set • 16 clinical and angiographic variables predict mortality • C-index 0.91 • De Mulder M et al, Eur Heart J. 2011 Jun;32(11):1398-408. Epub 2011 Feb 22. http://cardio-aalst.be & William.Wijns@olvz-aalst.be

19. Currently used clinical and angiographic scores Why not combine EuroSCORE and SYNTAX score? Global Risk Classification

20. Risk scores Global Risk Classification low, mid and high Presented by P. W. Serruys

21. All-cause mortality to 3 yearsLM Patients (randomized + registry) Low GRC(N=235) Low GRC(N=185) 60 60 Cumulative Event Rate (%) Cumulative Event Rate (%) 30 30 0 0 36 36 0 0 12 12 24 24 Months Since Allocation Months Since Allocation N=1079 Intermediate GRC(N=177) Intermediate GRC(N=294) High GRC(N=118) High GRC(N=70) PCI GABG P<0.001 30.0% P=0.004 14.8% 13.1% 6.5% 2.7% 5.3% Cumulative KM Event Rate ± 1.5 SE; log-rank P value ITT population

22. How to use the SYNTAX Score and other Anatomic and Clinical Risk Scores in day-to-day Practice ? Just use them routinely http://cardio-aalst.be & William.Wijns@olvz-aalst.be