Author + information
- Received March 18, 2013
- Accepted April 1, 2013
- Published online July 1, 2013.
- Vasim Farooq, MBChB∗,
- Yvonne Vergouwe, PhD†,
- Philippe Généreux, MD‡,
- Christos V. Bourantas, MD, PhD∗,
- Tullio Palmerini, MD‡,
- Adriano Caixeta, MD‡,
- Hector M. Garcìa-Garcìa, MD, PhD∗,
- Roberto Diletti, MD∗,
- Marie-angèle Morel, BSc§,
- Thomas C. McAndrew, MS‡,
- Arie Pieter Kappetein, MD, PhD⋮,
- Marco Valgimigli, MD¶,
- Stephan Windecker, MD#,
- Keith D. Dawkins, MD∗∗,
- Ewout W. Steyerberg, PhD†,
- Patrick W. Serruys, MD, PhD∗∗ ( and )
- Gregg W. Stone, MD‡
- ∗Department of Interventional Cardiology, Erasmus University Medical Centre, Thoraxcenter, Rotterdam, the Netherlands
- †Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
- ‡Columbia University Medical Center/New York-Presbyterian Hospital, Cardiovascular Research Foundation, New York, New York
- §Cardialysis BV, Rotterdam, the Netherlands
- ⋮Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Thoraxcenter, Rotterdam, the Netherlands
- ¶Department of Interventional Cardiology, Cardiovascular Institute, University of Ferrara, Ferrara, Italy
- #Cardiology Department, Bern University Hospital, Bern, Switzerland
- ∗∗Boston Scientific Corporation, Natick, Massachusetts
- ↵∗Reprint requests and correspondence:
Dr. Patrick W. Serruys, Interventional Cardiology Department, Erasmus MC, 's-Gravendijkwal 230, 3015 CE Rotterdam, the Netherlands.
Objectives This study sought to validate the Logistic Clinical SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score in patients with non–ST-segment elevation acute coronary syndromes (ACS), in order to further legitimize its clinical application.
Background The Logistic Clinical SYNTAX score allows for an individualized prediction of 1-year mortality in patients undergoing contemporary percutaneous coronary intervention. It is composed of a “Core” Model (anatomical SYNTAX score, age, creatinine clearance, and left ventricular ejection fraction), and “Extended” Model (composed of an additional 6 clinical variables), and has previously been cross validated in 7 contemporary stent trials (>6,000 patients).
Methods One-year all-cause death was analyzed in 2,627 patients undergoing percutaneous coronary intervention from the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial. Mortality predictions from the Core and Extended Models were studied with respect to discrimination, that is, separation of those with and without 1-year all-cause death (assessed by the concordance [C] statistic), and calibration, that is, agreement between observed and predicted outcomes (assessed with validation plots). Decision curve analyses, which weight the harms (false positives) against benefits (true positives) of using a risk score to make mortality predictions, were undertaken to assess clinical usefulness.
Results In the ACUITY trial, the median SYNTAX score was 9.0 (interquartile range 5.0 to 16.0); approximately 40% of patients had 3-vessel disease, 29% diabetes, and 85% underwent drug-eluting stent implantation. Validation plots confirmed agreement between observed and predicted mortality. The Core and Extended Models demonstrated substantial improvements in the discriminative ability for 1-year all-cause death compared with the anatomical SYNTAX score in isolation (C-statistics: SYNTAX score: 0.64, 95% confidence interval [CI]: 0.56 to 0.71; Core Model: 0.74, 95% CI: 0.66 to 0.79; Extended Model: 0.77, 95% CI: 0.70 to 0.83). Decision curve analyses confirmed the increasing ability to correctly identify patients who would die at 1 year with the Extended Model versus the Core Model versus the anatomical SYNTAX score, over a wide range of thresholds for mortality risk predictions.
Conclusions Compared to the anatomical SYNTAX score alone, the Core and Extended Models of the Logistic Clinical SYNTAX score more accurately predicted individual 1-year mortality in patients presenting with non–ST-segment elevation acute coronary syndromes undergoing percutaneous coronary intervention. These findings support the clinical application of the Logistic Clinical SYNTAX score.
Dr. Kappetein has reported that he has served on the Steering Committee of the SYNTAX trial. Dr. Valgimigli has reported that he has received research grants for lectures and advisory boards from Iroko, Eli Lilly, Medtronic, and honoraria for lectures and/or advisory boards from Cordis, Medtronic, Abbott, Eisai, Merck & Co., Inc., AstraZeneca, MedCo, and Terumo. Dr. Windecker has reported that he has received research grants (paid to his institution) from Abbott, Biosensors, Biotronik, Cordis, Boston Scientific, Medtronic, and St. Jude Medical. Dr. Dawkins has reported that he is a full-time employee of Boston Scientific and holds stock in Boston Scientific. Dr. Stone has reported that he has served as a consultant to Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Farooq and Vergouwe contributed equally to this paper. David E. Kandzari, MD, has served as Guest Editor.
- Received March 18, 2013.
- Accepted April 1, 2013.
- American College of Cardiology Foundation