Author + information
- Received July 30, 2018
- Revision received September 13, 2018
- Accepted September 14, 2018
- Published online December 3, 2018.
- Rodrigo B. Esper, MD, PhDa,b,∗,
- Michael E. Farkouh, MD, MScc,∗∗ (, )@drmikefarkouh@PMunkCardiacCtr@UofT,
- Expedito E. Ribeiro, MD, PhDa,
- Whady Hueb, MD, PhDa,
- Michael Domanski, MDd,
- Taye H. Hamza, PhDe,
- Flora S. Siami, MPHe,
- Lucas Colombo Godoy, MDa,c,
- Verghese Mathew, MDf,
- John French, MBChB, PhDg and
- Valentin Fuster, MD, PhDh,i
- aHeart Institute of the University of São Paulo Medical School, São Paulo, Brazil
- bPrevent Senior Institute, São Paulo, Brazil
- cPeter Munk Cardiac Centre and the Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada
- dDepartment of Medicine, Mount Sinai Medical Center, New York, New York
- eNew England Research Institutes, Watertown, Massachusetts
- fDivision of Cardiology, Loyola University Stritch School of Medicine, Maywood, Illinois
- gDepartment of Cardiology, University of New South Wales, Liverpool Hospital, Sydney, New South Wales, Australia
- hIcahn School of Medicine at Mount Sinai, New York, New York
- iCentro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
- ↵∗Address for correspondence:
Dr. Michael E. Farkouh, Peter Munk Cardiac Centre and the Heart and Stroke Richard Lewar Centre, University of Toronto, 585 University Avenue—4N474, Toronto, Ontario M5G 2N2, Canada.
Background Diabetes mellitus (DM) is associated with complex coronary artery disease (CAD), which in turn results in increased morbidity and mortality from cardiovascular disease.
Objectives This study sought to evaluate the utility of SYNTAX score (SS) for predicting future cardiovascular events in patients with DM and complex CAD undergoing either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI).
Methods The FREEDOM (Future REvascularization Evaluation in patients with Diabetes mellitus: Optimal management of Multivessel disease) trial randomized patients with DM and multivessel CAD to undergo either PCI with drug-eluting stents or CABG. The SS was calculated retrospectively by a core laboratory. The endpoint of hard cardiovascular events (HCE) was a composite of death from any cause, nonfatal myocardial infarction, and nonfatal stroke, while the endpoint of major adverse cardiac and cerebrovascular events (MACCE) was a composite of HCE and repeat revascularization.
Results A total of 1,900 patients were randomized to PCI (n = 953) or CABG (n = 947). The SS was considered an independent predictor of 5-year MACCE (hazard ratio per unit of SS: 1.02; 95% confidence interval: 1.00 to 1.03; p = 0.014) and HCE (hazard ratio per unit of SS: 1.03; 95% confidence interval: 1.01 to 1.04; p = 0.002) in the PCI cohort, but not in the CABG group. There was a higher incidence of MACCE in PCI patients with low, intermediate, and high SS compared with those who underwent CABG (36.6% vs. 25.9%, p = 0.02; 43.9% vs. 26.8%, p < 0.001; 48.7% vs. 29.7%, p = 0.003, respectively).
Conclusions In DM patients with multivessel CAD, the complexity of CAD evaluated by the SS is an independent risk factor for MACCE and HCE only in patients undergoing PCI. The SS should not be utilized to guide the choice of coronary revascularization in patients with DM and multivessel CAD. (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes [FREEDOM]; NCT00086450)
↵∗ Drs. Esper and Farkouh contributed equally to this work.
The FREEDOM trial was funded by the National Heart, Lung, and Blood Institute. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 30, 2018.
- Revision received September 13, 2018.
- Accepted September 14, 2018.
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