北京朝阳医院心脏中心北京朝阳医院心脏中心李惟铭王乐丰李惟铭王乐丰

慢性稳定性冠心病慢性稳定性冠心病 PCIPCI 推荐指征推荐指征指征指征 推荐推荐

类别类别证据证据水平水平 证据来源证据来源

有较大范围心肌缺血的客观证据有较大范围心肌缺血的客观证据 ⅠⅠ AA ACMEACME ，， ACIPACIP

自体冠状动脉的原发病变常规置入支自体冠状动脉的原发病变常规置入支架架 ⅠⅠ AA BENESTENTBENESTENT ， ， STRESSSTRESS

静脉旁路血管的原发病变常规置入支静脉旁路血管的原发病变常规置入支架架 ⅠⅠ AA SAVEDSAVED ， ， VENESTENTVENESTENT

慢性完全闭塞病变慢性完全闭塞病变 ⅡⅡaa CC

外科手术高风险患者外科手术高风险患者 ⅡⅡaa BB AWESOMEAWESOME

多支血管病变无糖尿病，病变适合多支血管病变无糖尿病，病变适合PCIPCI

ⅡⅡaa BBBARIBARI ， ， ARTSARTS ，， HoffmanHoffman 等，等，TakagiTakagi 等，等， DaemenDaemen 等等

多支病变合并糖尿病多支病变合并糖尿病 ⅡⅡbb CC

经选择的无保护左主干病变经选择的无保护左主干病变 ⅡⅡbb BB SYNTAXSYNTAX ，， MAIN-COMPAREMAIN-COMPARE

SYNTAX SYNTAX EuroSCOREEuroSCORE NERS CSS GRC FSS rSS GraceGrace 评分评分 TIMITIMI 评分评分

SYNTAX TRIAL DESIGN

Source: M.C.Morice on behalf of the SYNTAX investigators, TCT 2011

1 、优势型2 、病变数3 、每个病变累及的节段

病变特点4 、完全闭塞

受累节段数 完全闭塞的时间（ >3 个月） 钝圆残端 桥侧枝 闭塞远端由前向或逆向侧枝灌注显影的首个节段 涉及分支

5 、三分叉 病变节段数

6 、分叉类型远端主支血管和分支之间的夹角 <70º

7 、主动脉开口病变严重扭曲长度>20mm严重钙化血栓弥漫性病变 /小血管

SYNTAX 积分的运算法则

SYNTAX 积分的应用0~22分： PCI

22~32分： PCI 或 CABG

>32分： CABG

1. Introduction/ background

Syntax Score: segment weighting

Leaman et al,Circ 1981;63:285

Total Occlusion

x5

DS 100%

Significant lesion 50-99%

x2

DS 50% - 99%

EuroInterv 2005;1:219-227

1. Introduction/ background

Syntax Score: segment weight X multiplication factor

• Multiplication factor based on severity of stenosis(specific % stenosis is not used)

•

•

•

•

•

•

•

•

•

•

•

Q1:

Q2:

Q3:

Q4:

Q5:

Q6:

Q7:

Q8:

Q9:

Q10:

Q11:

Dominance

Specify diseased segment numbers

Total Occlusion

Trifurcation

Bifurcation

Aorta Ostial

Severe Tortuosity

Length

Heavy Calcification

Thrombus

Diffusely diseased and narrowed segments

2. Syntax Score calculator: definitions

Syntax Score calculator (11 Questions)

计算方法举例

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Death

CABG

5.5%

PCI

5.1%

P value

0.85

CVA 1.9% 1.2% 0.57

MI

Death,CVA or MI

4.2%

9.7%

3.9%

8.4%

0.90

0.67

Revasc. 7.6% 17.1% 0.01

Months Since Allocation

P=0.25

3VD

CABG (N=171)

TAXUS (N=181)

MACCE to 2 Years by SYNTAX ScoreTercile Low Scores (0-22)

21.9%

16.5%

Site-reported Data; ITT populationSan Francisco, CA • 22Sep09 • Slide

Cumulative KM Event Rate ± 1.5 SE; log-rank P valueSYNTAX Score and euroSCORE in MVD • TCT 2009 • Morice

0 12 24

40

0

30

20

10

Cu

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(%

)

Death

CABG

4.1%

PCI

6.4%

P value

0.30

CVA 3.1% 2.0% 0.50

MI

Death,CVA or MI

2.6%

8.6%

7.4%

11.7%

0.03

0.29

Revasc. 7.3% 16.1% 0.006

Months Since Allocation

Site-reported Data; ITT populationSan Francisco, CA • 22Sep09 • Slide 1

P=0.02

3VD

CABG (N=208)

TAXUS (N=207)

MACCE to 2 Years by SYNTAX ScoreTercile Intermediate Scores (23-32)

Cumulative KM Event Rate ± 1.5 SE; log-rank P valueSYNTAX Score and euroSCORE in MVD • TCT 2009 • Morice

23.0%

13.7%

40

0

30

20

10

0 12 24

Cu

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Death

CABG

2.5%

PCI

8.5%

P value

0.02

CVA 1.9% 2.1% 0.95

MI 1.9% 7.2% 0.02

Death,CVA or MI

6.3% 13.7% 0.03

Revasc. 7.7% 19.3% 0.002

Months Since Allocation

3VD

CABG (N=166)

TAXUS (N=155)

MACCE to 2 Years by SYNTAX ScoreTercile High Scores (≥33)

Site-reported data; ITT populationSan Francisco, CA • 22Sep09 • Slide 1

Cumulative KM Event Rate ± 1.5 SE; log-rank P valueSYNTAX Score and euroSCORE in MVD • TCT 2009 • Morice

P=0.003

26.8%

13.3%

40

0

20

30

10

0 12 24

Pa

tie

nts

, % 17.4 16.4 15.4

10

5

0

20

15

30

25

≥33

MACCE to 2 Years vs SYNTAX Score

23-32 ≥33≤22

CABG (N=897)

P=0.81

TAXUS (N=903)

P=0.02

P=0.27

P=0.007

≤22 23-32

P=0.11

SYNTAX ScoreRCT ITT pts; site-reported data

San Francisco, CA • 22Sep09 • Slide 1KM event rates; log-rank P valueSYNTAX Score and euroSCORE in MVD • TCT 2009 • Morice

Pa

tie

nts

, %

16.5

13.7 13.3

10

5

0

20

15

30

25

≥33

MACCE to 2 Years vs SYNTAX Score3VD Subset

23-32 ≥33≤22

CABG (N=897)

P=0.61

TAXUS (N=903)

P=0.53

P=0.75

P=0.27

≤22 23-32

P=0.42

SYNTAX ScoreRCT ITT pts; site-reported data

San Francisco, CA • 22Sep09 • Slide 1KM event rates; log-rank P valueSYNTAX Score and euroSCORE in MVD • TCT 2009 • Morice

SYNTAX 4-YEARSMACCE by SYNTAX Score; Low Scores (0-22)

Source: M.C.Morice on behalf of the SYNTAX investigators, TCT 2011

SYNTAX 4-YEARSMACCE by SYNTAX Score; Intermediate Scores

(23-32)

Source: M.C.Morice on behalf of the SYNTAX investigators, TCT 2011

SYNTAX 4-YEARSMACCE by SYNTAX Score; High Scores (≥33)

Source: M.C.Morice on behalf of the SYNTAX investigators, TCT 2011

SYNTAX Score and euroSCORE in MVD • TCT 2009 • Morice

EuroSCORE Components

Patient-relatedAgeSex

COPDPAD

Neurol. DysfunctionPrior surgery

↑ Serum creatinineActive endocarditisCritical pre-op state

Operation-relatedEmergency surgery

Concomitantsurgery

Thoracic aortasurgery

Postinfarct septalrupture

Cardiac-relatedUnstable anginaLV dysfunction

Recent MIPulmonary HTN

Additive EuroSCORE0-2: low risk

3-5: medium risk6+: high risk

Nashef et al. Eur J Cardiothorac Surg 1999; 16:9-13San Francisco, CA • 22Sep09 • Slide

SYNTAX Score and euroSCORE in MVD • TCT 2009 • Morice San Francisco, CA • 22Sep09 • Slide

The EuroSCORE Predicts Post-Operative Mortality

Background Purpose Methods Results Conclusions

Study

Kim, 2006

Migliorini, 2006

Sukiennik, 2008

Rademacher, 2008

Pavei, 2008

Tamburino, 2009

Vaquerizo, 2009

Rekik S, 2010

N

176

101

204

81

148

210

291

246

Endpoint

Death / AMI 9 months

Death 6 months

Periprocedural mortality

MACE 9 months

Death (≈ 29 months)

MACE 12 months

Cardiac Death 2 years

Cardiac Death / MACE 4 years

Results

EuroSCORE ≥6HR 3.4 (1.2-9.6)

OR 1.03 (1.0-1.06)

EuroSCORE ≥6AUC: 0.876 (0.823-0.918)

EuroSCORE ≤5: 24%EuroSCORE >5: 27%

EuroSCORE ≥6OR 3.9 (1.1-14-1)

EuroSCORE >6HR 2.24 (1.05-4.77)

1 EuroSCORE point 15% (2.9-28.2%)

EuroSCORE >6AUC 0.687 / 0.589

p

0.023

0.024

<0.001

0.5

0.037

0.04

0.013

0.005 /0.038

EuroSCORE: PCI – Left Main

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Cu

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SYNTAX Score and euroSCORE in MVD • TCT 2009 • Morice San Francisco, CA • 22Sep09 • Slide 1

Months Since Allocation

KM event rate ± 1.5 SE, log-rank P value

10

30

20

0 12

EUROSCORE <4P=0.11

Freedom from MACCE to 2 Yearsby SYNTAX Score TercileLow Scores (0-22)

CABG (N=152) CABG (N=123)

TAXUS (N=168) TAXUS (N=131)

0

50

40

Months Since Allocation

10

30

20

0 12 24

EUROSCORE ≥4P=0.39

0

50

40

18.8%

12.2%

24

20.2%

23.8%

Cu

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Cu

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SYNTAX Score and euroSCORE in MVD • TCT 2009 • Morice San Francisco, CA • 22Sep09 • Slide 1

Months Since Allocation

KM event rate ± 1.5 SE, log-rank P value

0 12 24

0

50

40

30

20

10

Months Since Allocation

0 12 24

0

50

40

30

20

10

Freedom from MACCE to 2 Yearsby SYNTAX Score TercileHigh Scores (33+)

CABG (N=147) CABG (N=168)

TAXUS (N=123) TAXUS (N=167)

EUROSCORE <4P=0.37

18.9%

15.4%

EUROSCORE ≥34.9%P<0.001

15.4%

Ferrarotto HospitalUniversity of Catania

SYNTAX and beyond - Capodanno CTO and LM summit – New York, 23 February 2011 – Slide 12

The New Risk Classification (NERS)

Based on 17 clinical, 4 procedural,and 33 angiographic variables

Better discriminates a broad arrayof endpoints than SYNTAX score,including MACE, Death, MI, TVR andST in patients undergoing LM PCI

BackgroundThe potential contributions of clinical,procedural, and angiographic indices inLM patients have not been fullyelucidated

Chen SL et al. JACC Interv. 2010;3:632-41

Ferrarotto HospitalUniversity of Catania

CTO and LM summit – New York, 23 February 2011 – Slide 14

Garg S et al. Circ Card Interv 2010;3:317-26Girasis C et al. Eur Heart J 2011;32:3115-27

SYNTAX and beyond - Capodanno

Clinical SYNTAX score (CSS)

Calculated as SYNTAXscore*modified ACEF score

Better discriminates 5-Year Deathand MACE in multivessel CAD thanSYNTAX score

Better discriminates 5-Year Death inAll-Comers PCI

BackgroundBeing solely based on angiographicvariables, the SYNTAX score cannotaccount for the variability related toclinical factors which are widelyacknowledged to impact on long-termoutcomes

Ferrarotto HospitalUniversity of Catania

SYNTAX and beyond - Capodanno CTO and LM summit – New York, 23 February 2011 – Slide 16

Capodanno D et al. Am Heart J 2010;159:103-9

Global Risk Classification (GRC)

Developed as an Integration of theSYNTAX score and the EuroSCORE

Better discriminates in-hospital and2-Year Cardiac Death in LM PCI thanSYNTAX score alone

ConclusionsIncorporation of clinical risk factors andcomorbidities into existing estimationsystems may refine their prognosticability and guide clinical decisions

Ferrarotto HospitalUniversity of Catania

SYNTAX and beyond - Capodanno CTO and LM summit – New York, 23 February 2011 – Slide 28

Functional SYNTAX score (FSS)

Grades only ischemia-producinglesions with FFR ≤0.80

Decreases the number of higher-risk patients

Better discriminates risk for 1-YearMACE in multivessel CAD PCI

Improves reproducibility due to lesschance for disagreement

BackgroundPCI of a functionally nonsignificantstenosis is not of benefit to the patient,either from a prognostic or from asymptomatic point of view (FAME trial)

Nam CW et al. J Am Coll Cardiol 2011;58:1211-8

Ferrarotto HospitalUniversity of Catania

SYNTAX and beyond - Capodanno CTO and LM summit – New York, 23 February 2011 – Slide 32

Malkin CJ et al. Eurointervention 2011(7) Suppl. (abstract)

Quantifying incomplete revascularization: theResidual SYNTAX score (rSS)

What about scoring SYNTAX score afterthe procedure?

rSS = 0 means complete revascularization

rSS > 0 quantifies increasing levels ofincomplete revascularization

rSS > 5 found to be an independentpredictor of mortality in 240 3VD±LMpatients. Further validation awaited

GraceGrace 评分评分 来自来自 GraceGrace 注册研究注册研究 指标指标 :: 年龄 充血性心衰病史 心梗病史 基础年龄 充血性心衰病史 心梗病史 基础

心率 收缩压 心率 收缩压 ECG STECG ST 段压低 肌酐水平 段压低 肌酐水平 心肌酶升高 住院期间是否心肌酶升高 住院期间是否 PCIPCI

应用于急性冠脉综合征应用于急性冠脉综合征 的危险分层的危险分层 也应用于也应用于 PCIPCI 风险的预测指标 风险的预测指标

TIMITIMI 评分评分 应用于非应用于非 STST 段抬高急性冠脉综合征危险分段抬高急性冠脉综合征危险分

层层

七个指标代表七分七个指标代表七分

44 分以上代表高危分以上代表高危 ,,是急诊是急诊 PCIPCI 适应症适应症

谢谢