SYNTAX Score and Outcomes of Coronary Revascularization in Diabetic Patients
Purpose of Review
This review describes the dynamic relationship between diabetes mellitus (DM) and coronary artery disease (CAD) with respect to different revascularization strategies and how angiographic tools such as the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score can supplement clinical decision-making.
The SYNTAX score characterizes the anatomical extent of CAD in terms of the number of lesions, functional importance, and complexity. Studies not limited to patients with DM suggest that percutaneous coronary intervention (PCI) is a reasonable alternative to coronary artery bypass grafting (CABG) in patients with low-medium SYNTAX scores, while patients with high SYNTAX scores should be revascularized with CABG if operable. Similar findings were also observed for diabetes patients with multivessel disease in retrospective pooled analysis. The SYNTAX II score combines anatomical and clinical risk to improve upon the decision regarding the optimal revascularization strategy. The SYNTAX II score can be applied to patients with DM.
The SYNTAX scores provide guidance to clinicians faced with determining the optimal revascularization strategy in patients with DM and advanced CAD. Using a heart team approach, the information can be considered along with other factors that influence PCI or CABG risk.
KeywordsDiabetes PCI CABG SYNTAX
Compliance with Ethical Standards
Conflict of Interest
Amartya Kundu, Partha Sardar, Kevin O’Day, Saurav Chatterjee, and Theophilus Owan declare that they have no conflict of interest.
Dr. J. Dawn Abbott reports clinical trial consulting for Pfizer (antihyperlipidemic therapy) and Recor (renal denervation).
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 3.Center for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the US 2011. Washington, DC: US Department of Health and Human Services.Google Scholar
- 10.Morice MC, Serruys PW, Kappetein AP, Feldman TE, Ståhle E, Colombo A, et al. Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial. Circulation. 2010;121:2645–53.CrossRefPubMedGoogle Scholar
- 13.GN L, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2011;124:e574–651.CrossRefGoogle Scholar
- 14.Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;124:e652–735.CrossRefPubMedGoogle Scholar
- 16.Farooq V, van Klaveren D, Steyerberg EW, Meliga E, Vergouwe Y, Chieffo A, et al. Anatomical and clinical characteristics to guide decision making between coronary artery bypass surgery and percutaneous coronary intervention for individual patients: development and validation of SYNTAX score II. Lancet. 2013;381:639–50.CrossRefPubMedGoogle Scholar
- 20.Kim LJ, King SB 3rd, Kent K, Brooks MM, Kip KE, Abbott JD, et al. Factors related to the selection of surgical versus percutaneous revascularization in diabetic patients with multivessel coronary artery disease in the BARI 2D (bypass angioplasty revascularization investigation in type 2 diabetes) trial. JACC Cardiovasc Interv. 2009;2(5):384–92.CrossRefPubMedPubMedCentralGoogle Scholar
- 21.Kapur A, Hall RJ, Malik IS, Qureshi AC, Butts J, de Belder M, et al. Randomized comparison of percutaneous coronary intervention with coronary artery bypass grafting in diabetic patients: 1-year results of the CARDia (Coronary Artery Revascularization in Diabetes) trial. J Am Coll Cardiol. 2010;55(5):432–40.CrossRefPubMedGoogle Scholar
- 22.Kern M. What is the SYNTAX score and how should we use it? Cath Lab Digest. 2009;17:(8). Google Scholar
- 23.• Kappetein AP, Head SJ, Morice MC, Banning AP, Serruys PW, Mohr FW, et al. Treatment of complex coronary artery disease in patients with diabetes: 5-year results comparing outcomes of bypass surgery and percutaneous coronary intervention in the SYNTAX trial. Eur J Cardio-thoracic Surg. 2013;43(5):1006–13. Valuable 5-year follow-up of the landmark SYNTAX trial in diabetic patients. CrossRefGoogle Scholar
- 24.•• Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M, et al. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med. 2012;367(25):2375–84. This is the first and largest randomized trial with diabetic patients and multivessel disease assigned to different revascularization strategies. CrossRefPubMedGoogle Scholar
- 27.Mohr FW, Rastan AJ, Serruys PW, Kappetein AP, Holmes DR, Pomar JL, et al. Complex coronary anatomy in coronary artery bypass graft surgery: impact of complex coronary anatomy in modern bypass surgery? Lessons learned from the SYNTAX trial after two years. J Thorac Cardiovasc Surg. 2011;141(1):130–40.CrossRefPubMedGoogle Scholar
- 28.•• Ikeno F, Brooks MM, Nakagawa K, Kim MK, Kaneda H, Mitsutake Y, et al. SYNTAX score and long-term outcomes: the BARI-2D trial. J Am Coll Cardiol. 2017;69(4):395–403. This study investigated associations between SYNTAX scores and revascularization outcomes in the BARI 2D trial. CrossRefPubMedGoogle Scholar
- 29.Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2014;35:2541–619.CrossRefPubMedGoogle Scholar
- 33.Cavalcante R, Sotomi Y, Mancone M, Whan Lee C, Ahn JM, Onuma Y, et al. Impact of the SYNTAX scores I and II in patients with diabetes and multivessel coronary disease: a pooled analysis of patient level data from the SYNTAX, PRECOMBAT, and BEST trials. Eur Heart J. 2017;38:1969–77.CrossRefPubMedGoogle Scholar
- 34.Fihn SD, Blankenship JC, Alexander KP, Bittl JA, Byrne JG, Fletcher BJ, et al. ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2014;64:1929–49.CrossRefPubMedGoogle Scholar
- 35.Mäkikallio T, Holm NR, Lindsay M, Spence MS, Erglis A, Menown IB, et al. Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial. Lancet. 2016; https://doi.org/10.1016/S0140-6736(16)32052-9.
- 37.Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA. ACCF/SCAI/ STS/AATS/AHA/ASNC 2009 appropriateness criteria for coronary revascularization: a report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, and the American Society of Nuclear Cardiology: endorsed by the American Society of Echocardiography, the Heart Failure Society of America, and the Society of Cardiovascular Computed Tomography. Circulation. 2009;119:1330–52.CrossRefPubMedGoogle Scholar
- 38.Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JAACCF. SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol. 2012;59(9):857–81.CrossRefPubMedGoogle Scholar