SYNTAX score. Number & location of lesions. Dominance. Left Main. Calcification. 3 Vessel. Thrombus. Total Occlusion. Bifurcation.

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1 PCI vs CABG for Multivessel Disease: Calculatio of Risk ad Log Term Outcome Pawel Buszma, MD, PhD, FESC, FACC Professor of Medicie, Medical Uiversity of Silesia, Katowice, Polad TCT AP 2010

2 Strategy qlocal Heart team (surgeo & itervetioal cardiologist) assessed each patiet i regards to: qpatiet s operative risk (EuroSCORE & Parsoet score, Clevelad score) qoperative risk scores predict perioperative ad i-hospital surgical risk of death or sever complicatios qcoroary lesio complexity (SYNTAX score) qsyntax score provides guidace o optimal revascularizatio strategies for patiets with high-risk lesios based o results of SYNTAX Study qpci risk score: risk of techical failure ad hemodyamic collapse qpredictio of log term outcome ( years) after PCI ad CABG

3 Assessemet of extet of coroary artery disease SYNTAX Score: Calcificatio Domiace Number & locatio of lesios Left Mai Thrombus SYNTAX score 3 Vessel Bifurcatio Total Occlusio Tortuosity EuroIterv 2005;1:

4 Sytax score vs 12/12 outcome

5 Logistic EuroScore Age Sex (per 5 years or part thereof over 60 years) 1 female Chroic pulmoary disease Extracardiac arteriopathy logterm use of brochodilators or steroids for lug disease 1 ay oe or more of the followig: claudicatio, carotid occlusio or >50% Extracardiac arteriopathy ay oe or more of the followig: claudicatio, carotid occlusio or >50% steosis, previous or plaed itervetio o the abdomial aorta,limb arteries or carotids 2 Neurological dysfuctio disease severely affectig ambulatio or day-to-day fuctioig 2 Previous cardiac surgery Serum creatiie Active edocarditis requirig opeig of the pericardium 3 >200m micromol/l preoperatively 2 patiet still uder atibiotic treatmet for edocarditis at the time of surgery 3 ay oe or more of the followig: vetricular tachycardia or fibrillatio or Critical preoperative state aborted sudde death, preoperative cardiac massage, preoperative vetilatio before arrival i the aaesthetic room,preoperative iotropic support, itraaortic balloo couterpulsatio or preoperative acute real failure (auria or oliguria<10 ml/hour) 3 Cardiac-related related factors Ustable agia 2 LV dysfuctio Score rest agia requirig iv itrates util arrival i the aaesthetic room moderate or LVEF30-50% 1 poor or LVEF <30 3 Recet myocardial ifarct Pulmoary hypertesio 2 Operatio-related related factors Emergecy 2 Other tha isolated CABG (<90 days) 2 Systolic PA pressure>60 mmhg Score carried out o referral before the begiig of the ext workig day major cardiac procedure other tha or i additio to CABG 2

6 EuroScore calculator: additive ad logistic

7 Euroscore - calculator

8 SYNTAX TRIAL: Predictors of CABG Variable 12 moth MACCE: Pre- procedure Odds Ratio [95% CI] P value COPD 2.45 [1.25, 4.80] Ustable Agia 1.88 [1.14, 3.09] 0.01 Moderate or Poor LVEF 1.98 [1.13, 3.47] 0.02 SYNTAX Score 0.97 [0.95, 1.00] 0.02 Race 0.33 [0.14, 0.82] 0.02 Emerget Revasc [1.08, 7.17] 0.03 Prior MI 0.57 [0.33, 0.99] Age 1.03 [1.00, 1.05] TAXUS Medically Treated Diabetes 2.07 [1.40, 3.05] <0.001 SYNTAX Score 1.02 [1.00, 1.04] 0.02 Age 1.02 [1.00, 1.04] 0.03

9 Sytax Trial Euroscore additive Sytax Score 1 year mortality 1 year MACE PCI RCT 3,8 28,4 4,3 17,8 CABG RCT 3,8 29,1 3,5 12,1 PCI Reg. 5,8 31,6 7,4 20,5 CABG Reg 3,8 35,5 2,5 8,8

10 Decisio diagram EuroScore High Risk PCI PCI??? (PCI vs Rx?) 5 Low Risk PCI PCI or CABG: LM = PCI 3vd ad DM = CABG CABG >33 Sytax Score

11 High risk populatio Acute coroary sydrome patiets LMCA disease Depressed LV fuctio Diabetes, Real Failure etc.

12 LE MANS Registry (=252)

13 LE MANS REGISTRY Results: ui ad multivariate aalysis with Odds Ratio for log term follow-up Age >60 y.o. LVEF<50% Stet diam.<3,8mm DES p=0,03 OR:2,48 (1,03-5,95 p=0,01 OR:3,25 (1,45-7,27) p=0,04 OR:2,48 (0,99-5,7) p=0,11 OR:0,53 (0,23-1,18) Euroscore>9 p=0,04 OR:2,48 (1,1-4,56) The Cox multivariate aalysis for idepedet risk factors showed that EF<50% decreased survival rate, while DES implatatio decreased ad stet diameter <3,8mm icreased the risk of MACCE.

14 ACS Registry PL-ACS ( pts i Polad) Substudy: revascularizatio for MVD i 3787 pts (Years ) 2009)

15 Results 30 day mortality p=0,1

16 PCI better tha CABG for MVCAD ad NST-ACS? 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% 78% 76% 74% 72% 70% Two years cumulative survival: PCI vs. CABG Time (days) CABG PCI

17 Sigle ad idepedet risk factors ifluecig log term mortality i ACS + MVCAD CABG* Male Ustable Agia NSTEMI Cardiogeic shock * Tobacco Hypertesio Dyslipidemia Diabetes Obesity Prior MI Prior CABG Prior PCI * Idepedet risk factor 0, Odds ratio

18 DES for ACS subaalysis of all comers studies AHP Registry

19 Sigle risk / beefit factors ifluecig 2 year mortality Age>65 Male Ustable agia NSTEMI STEMI Killip>1 Euroscore<7 BMI>27 Hypertesio DM Obesity Tobacco Hyperlipidemia Family History Creatiie>0,9 COPD prior MI prior PCI prior CABG 0,0316 0,3162 3, ,6228 Odds ratio

20 Sigle risk / beefit factors ifluecig 2 year mortality Sigle risk / beefit factors ifluecig two year mortality LVEF<50% MVD LM disease 2 d ge DES Cypher Biomatrix Edeavor Xiece Stet diam.<3,0 Resteotic lesio CTO predilatatio Complete revasc GPI 0,0316 0,3162 3, ,6228 Odds ratio

21 100% 100% 99% 99% 98% 98% 97% 97% 96% 96% 95% 95% 94% 94% 93% 93% 92% 92% 91% 91% 90% Cumulative survival: DES 1 st ge vs DES 2 d ge F-Cox p = 0, Time (days) DES 2d ge DES 1st ge

22 PCI scorig system to predict early ad log term outcome Cliical risk factors: SA/UA/NSTEMI/STEMI Killip class LV fuctio Biomarkers Risk of bleedig Atiplatelet pre-treatmet, bedside platelet reactivity Diabetes Mellitus, Real Failure, PAD Hyperlipidemia ad pre-treatmet with statis

23 PCI scorig system to predict early ad log term outcome Agiographic risk vessel CAD LMCA disease Sytax score! Peri- ad post PCI risk (residual risk) DES vs BMS No of stets Overlappig stets Appositio ad strut expasio, residual steosis (IVUS!) adge dissectio Prox/dist lesios, TIMI flow post PCI Complete revascularizatio Bleedig, MI

24 Algorhytm to predict outcome after PCI or CABG Based o data from the large registries ad radomized trials (PCI, CABG) a risk calculator should be desiged to predict the late outcome after PCI or CABG i a particular case!

25 Previous experiece Patiet Specific Predictios ad Comparisos for Patiets with Coroary Artery Disease. DC Naftel, EH Blackstoe, JW Kirkli Software ver.1.0, Summit Medical Systems JACC 1991;17: Circulatio 1991;83: (data icludig ca 6000 CABG ad 300 PCI pts)

26 The Cardiologist as a gatekeeper Is recascularizatio ecessary? Yes, if progostic or symptomatic idicatios Ca we perform PCI? Yes, if techically feasible at low periprocedural risk Ca we do it as good as the surgeos? Log term results? SYNTAX score, EUROSCORE, PCI/CABG calculator? Should I do it? Oly if the experiece i multivessel, complex

27 SYNTAX Score: guidig selectio of revascularizatio

28 Sytax Score Examples Left Mai Radomized Score 25 LM & 3VD Radomized Score 39 LM & 3VD Registry Score 50

29 Euroscore - calculator

30 100% Euroscore > 7 vs <7 99% 98% 97% 96% 95% F-Cox p = 0,01 94% 93% 92% 91% 90% Time (days) ES < 7 ES > 7

31 100% DM vs. o DM 99% 98% 97% F-Cox p = 0,02 96% 95% 94% 93% 92% Time (days) DM

32 MACCE at 12 Moths by SYNTAX Score Tercile All Terciles PCI Registry Cumulative Evet Rate (%) High (³33) Itermediate (23-32) 16.1% 16.1% Low (0-22) Moths Sice Allocatio 26.9% Kapla-Meier rates Per-protocol populatio

33 Overall MACCE to 12 Moths TAXUS RCT ad PCI Registry TAXUS RCT* (=903) PCI Reg (=192) Cumulative Evet Rate (%) % % Moths Sice Allocatio Evet Rate ± 1.5 SE * For descriptive purposes oly; o statistical comparisos doe Per-protocol populatio Kapla-Meier rates