Mis-estimation of coronary lesions and rectification by SYNTAX score feedback for coronary revascularization appropriateness

Shen Lin, Heng Zhang, Si-Peng Chen, Chen-Fei Rao, Fan Wu, Fa-Jun Zhou, Yun Wang, Hong-Bing Yan, Ke-Fei Dou, Yong-Jian Wu, Yi-Da Tang, Li-Hua Xie, Chang-Dong Guan, Bo Xu, Zhe Zheng, Shen Lin, Heng Zhang, Si-Peng Chen, Chen-Fei Rao, Fan Wu, Fa-Jun Zhou, Yun Wang, Hong-Bing Yan, Ke-Fei Dou, Yong-Jian Wu, Yi-Da Tang, Li-Hua Xie, Chang-Dong Guan, Bo Xu, Zhe Zheng

Abstract

Background: Imprecise interpretation of coronary angiograms was reported and resulted in inappropriate revascularization. Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score is a comprehensive system to evaluate the complexity of the overall lesions. We hypothesized that a real-time SYNTAX score feedback from image analysts may rectify the mis-estimation and improve revascularization appropriateness in patients with stable coronary artery disease (CAD).

Methods: In this single-center, historical control study, patients with stable CAD with coronary lesion stenosis ≥50% were consecutively recruited. During the control period, SYNTAX scores were calculated by treating cardiologists. During the intervention period, SYNTAX scores were calculated by image analysts immediately after coronary angiography and were provided to cardiologists in real-time to aid decision-making. The primary outcome was revascularization deemed inappropriate by Chinese appropriate use criteria for coronary revascularization.

Results: A total of 3245 patients were enrolled and assigned to the control group (08/2016-03/2017, n = 1525) or the intervention group (03/2017-09/2017, n = 1720). For SYNTAX score tertiles, 17.9% patients were overestimated and 4.3% were underestimated by cardiologists in the control group. After adjustment, inappropriate revascularization significantly decreased in the intervention group compared with the control group (adjusted odds ratio [OR]: 0.83; 95% confidence interval [CI]: 0.73-0.95; P = 0.007). Both inappropriate percutaneous coronary intervention (adjusted OR: 0.82; 95% CI: 0.74-0.92; P < 0.001) and percutaneous coronary intervention utilization (adjusted OR: 0.88; 95% CI: 0.79-0.98; P = 0.016) decreased significantly in the intervention group. There was no significant difference in 1-year adverse cardiac events between the control group and the intervention group.

Conclusions: Real-time SYNTAX score feedback significantly reduced inappropriate coronary revascularization in stable patients with CAD.

Clinical trial registration: Nos. NCT03068858 and NCT02880605; https://www.clinicaltrials.gov.

Conflict of interest statement

None.

Figures

Figure 1
Figure 1
Study enrollment. AUC: Appropriate use criteria; CABG: Coronary artery bypass graft; PCI: Percutaneous coronary intervention; SYNTAX: Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery.
Figure 2
Figure 2
Agreement on SYNTAX score tertiles assessment between cardiologists and image analysts. Among 1525 patients in the control group, we recorded 1233 subjective SYNTAX score tertiles assessment by 12 enrolled cardiologists. SYNTAX: Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery.
Figure 3
Figure 3
Subgroup analyses of inappropriate coronary revascularization. ∗No outcome events occurred in the subgroup of triple vessel and left main disease because revascularization procedures in the present study were all deemed appropriate according to Chinese appropriate use criteria. CI: Confidence interval; SYNTAX: Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery.
Figure 4
Figure 4
Kaplan-Meier cumulative event curves for 1-year clinical outcomes. Kaplan-Meier curves are shown for 1-year MACE (A), death (B), myocardial infarction (C), repeat revascularization (D) between control and intervention groups. MACE: Major adverse cardiac events; SYNTAX: Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery; HR: Hazard ratio; CI: Confidence interval.

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Source: PubMed

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