Adult: Coronary
Comparison of SYNTAX score strata effects of percutaneous and surgical revascularization trials: A meta-analysis

https://doi.org/10.1016/j.jtcvs.2021.05.036Get rights and content

Abstract

Objectives

The evidence supporting the use of the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) score for risk stratification is controversial. We performed a systematic review and meta-analysis of all the randomized controlled trials comparing percutaneous coronary intervention versus coronary artery bypass grafting that reported their outcomes stratified by SYNTAX score, focusing on between-strata comparisons.

Methods

A systematic review of MEDLINE, EMBASE, Cochrane Library databases was performed. Incidence rate ratios were pooled with a random effect model. Between-group statistical heterogeneity according to accepted SYNTAX score tertiles was computed in the main analysis. Ratios of incidence rate ratios were computed to appraise between-strata effect, as sensitivity analysis. Primary and secondary outcomes were major adverse cardiac and cerebrovascular events and all-cause mortality, respectively. Separate sub-analyses were performed for left main and multivessel disease.

Results

From 425 citations, 6 trials were eventually included (8269 patients [4134 percutaneous coronary interventions, 4135 coronary artery bypass graftings]; mean follow-up: 6.2 years [range: 3.8-10]). Overall, percutaneous coronary intervention was associated with a significant increase in major adverse cardiac and cerebrovascular events (incidence rate ratio, 1.39, 95% confidence interval, 1.27-1.51) and nonsignificant increase in all-cause mortality (incidence rate ratio, 1.17, 95% confidence interval, 0.98-1.40). There was no significant statistical heterogeneity of treatment effect by SYNTAX score for major adverse cardiac and cerebrovascular events or mortality (P = .40 and P = .34, respectively). Results were consistent also for patients with left main and multivessel disease (major adverse cardiac and cerebrovascular events: P = .85 in left main, P = .78 in multivessel disease 0.78; mortality: P = .12 in left main; P = .34 in multivessel disease). Results of analysis based on ratios of incidence rate ratios were consistent with the main analysis.

Conclusions

No significant association was found between SYNTAX score and the comparative effectiveness of percutaneous coronary intervention and coronary artery bypass grafting. These findings have implications for clinical practice, future guidelines, and the design of percutaneous coronary intervention versus coronary artery bypass grafting trials.

Graphical abstract

Summary of the findings of this systematic review and meta-analysis, highlighting the use of IRRs (an estimator of the hazard ratio) and their ratios, as a means to test the comparative between-strata effects of PCI versus CABG in randomized trials according to different groups of SYNTAX angiographic score.

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Section snippets

Materials and Methods

The Institutional Review Board did not approve this study due to the lack of individual patients' information. Patient written consent for the publication of the study was not received due to the lack of individual patients' information.

Included Trials and Patients' Characteristics

A total of 425 citations were evaluated of which 6 trials met the eligibility criteria and were included in the final meta-analysis (Table 1).12, 13, 14, 15, 16, 17, 18 Two trials involved centers located in different continents (Evaluation of XIENCE vs Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization,14 SYNTAX12,18), 2 trials were conducted in Asia (BEST13 and PRECOMBAT17), one in the United States (Future Revascularization Evaluation in Patients with Diabetes

Discussion

The SYNTAX trial randomized 1800 patients with left main or 3-vessel CAD to either PCI with the early-generation paclitaxel-eluting stent or CABG.19 An important feature introduced by the trials' investigators was the stratification of patients according to the complexity of the CAD, expressed using the SYNTAX score.12 The SYNTAX score is based on the angiographic assessment of coronary lesions and is calculated by summing the points assigned to each lesion causing more than 50% diameter

Conclusions

We found no association between the SYNTAX score and the outcome of the trials comparing PCI and CABG. Our findings have implications for clinical practice, as well as future guidelines and the design of trials comparing PCI and CABG. The use of the SYNTAX score as the primary approach to stratify patients with coronary artery disease and to identify the most appropriate revascularization method in the individual patient is not supported by the current evidence.

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    The Institutional Review Board did not approve this study because of the lack of individual patients' information. Patient written consent for the publication of the study was not received because of the lack of individual patients' information.

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