Author + information
- Christopher Lee Clancy,
- Robert Habib,
- Jeremy Joseph,
- Milo Engoren,
- Shaylyn Bennett,
- Mark Bonnell and
- Thomas A. Schwann
Coronary interventional approach remains non-uniform across institutions, and is often based on clinical judgment as opposed to using objective tools to direct choice between CABG and PCI. We examined the potential for combining coronary SYNTAX Scoring (SS) and STS CABG operative mortality risk (STS-RS) as a means to direct optimal CAD intervention.
We retrospectively reviewed coronary angiography films corresponding to 385 consecutive clinically driven elective interventions at a single institution [2009-2010; 203 PCI and 182 isolated CABG]. SS were derived for all patients, and were grouped into Low (SSLo:0-22), Intermediate (SSInt: 23-32) and High (SSHi:>33) SS terciles. Corresponding STS-RS was calculated via the STS risk calculator. Appropriateness of clinical judgment driven revascularization strategy was compared to an arbitrarily chosen rising threshold of unacceptable STS-RS operative risk across the SS terciles from 1, 2, or 3 % commensurate with increasing CABG benefit across the terciles.
Mean SS was significantly higher for CABG versus PCI [31±10 (range: 7-70) vs. 19±8 (2-39); p<0.01] with significant overlap between cohorts. STS-RS was lower for CABG vs. PCI [1.78±2.25 vs. 1.96±2.67;p=0. 48]. Actual mortality was 1.0% in PCI and 2.7% in CABG(p=0.19). CABG/PCI distributions were as follows: SSLo (n=153; 19%/81%), SSIn (n=143; 54%/46%), and SSHi (n=83; 87%/13%). Applying intervention appropriateness criteria versus performed (clinical judgment) revascularization strategy showed a 42% (CABG/PCI: 21%/ 62%) overall discordance (kappa: 0.17) that is nearly 3-fold greater in case of PCI but decreased predicted CABG mortality to 0.85% (p<0.01). This appropriate vs. actual discordance was also varied across SS terciles: SSLo (52%; CABG/PCI: 34%/56%), SSInt (44%; 20%/74%) and SSHi (22%; 17%/55%).
Combining SS and STS-RS is a useful objective approach to assist experienced clinical judgment in determining appropriate revascularization strategy in CAD patients. This approach identifies better risk patients to reap the long term benefits of CABG, and protects poor CABG candidates from unacceptably high perioperative mortality.
Poster Sessions, Expo North
Monday, March 11, 2013, 9:45 a.m.-10:30 a.m.
Session Title: Therapeutic Approaches in Chronic CAD and Stable Ischemic Heart Disease
Abstract Category: 11. Chronic CAD/Stable Ischemic Heart Disease: Therapy
Presentation Number: 1281-59
- 2013 American College of Cardiology Foundation