SYNTAX residual in long-term outcomes prognosis of endovascular revascularization in myocardial infarction with ST elevation and multivessel disease

Aim. To study prognostic significance of coronary atherosclerosis
severity (residual SYNTAX) after primary percutaneous intervention (PCI) in myocardial infarction patients with STE (STEMI) and multivessel coronary lesion, in long term period.

Material and methods. Totally, 317 STEMI patients included, having multivessel coronary atherosclerosis, underwent primary PCI. Patients were excluded if having hemodynamically significant left coronary stem stenosis (≥50%), and with signs of cardiogenic shock or pulmonary edema. Patients were selected to 2 groups depending on the residual lesion after primary PCI, by SYNTAX: ≤8 points (n=243) and ≥9 points (n=74). Mean follow-up was 36,7±24,3 months. The adverse cardiovascular events were taken: death, myocardial infarction (MI), second revascularization of the target and non-target vessel, as the cases of stent thrombosis.

Results. Patients with the significant after primary PCI residual coronary atherosclerosis, comparing to those with mild residual SYNTAX were older — 63,1±10,6 y. vs 58,8±9,9 y., resp. (р=0,001), females predominated — 55,9% vs 31,3%, resp. (р=0,03), more significant was part of multivessel disease — 37,8% vs 24,3%, resp. (р=0,03), three vessel lesion predominated — 83,8% vs 49% (0,0001) and less common performing of the strategy of primary PCI — 9,5% vs 32,9%, resp. (р=0,0001). In long term follow-up (36,7±24,3 months.) among those with SYNTAX ≥9 comparing to those SYNTAX ≤8 pts. there was worse prognosis, that represented as higher mortality from all causes — 16,2% vs 5,3%, resp. (р=0,005), odds ratio (OR) 3,4 (1,5-7,9; 95% CI), (р=0,004); second MI — 16,2% vs 6,6%, resp. (р=0,02), OR 2,7 (1,2-6,1; 95% CI), (р=0,01), second non-target revascularization — 18,9% vs 8,2%, resp. (р=0,02), OR 2,6 (1,2-5,5; 95% CI), (р=0,01).

Conclusion. Value of residual coronary lesion by SYNTAX ≥9 showed higher prognostic significance, seriously raising the probability of most adverse cardiovascular events. Therefore, STEMI patients with multivessel disease and residual SYNTAX ≥9 pts. after primary PCI should undergo complete myocardial revascularization that can be done via broader application of the strategy of multivascular stenting under primary PCI, and staged PCI within optimal time frame (in-hospital period).

1. Wijns W, Kolh P, Danchin N, et al. 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). Eur Heart J 2010; 31(20): 2501- 55.

2. Widimsky P, Holmes Jr, David R. How to treat patients with ST-elevation acute myocardial infarction and multi-vessel disease? Eur Heart J 2010; Advance Access published November 30, 2010. European Heart Journal doi:10.1093/eurheartj/ehq410.

3. Windecker S, Kolh Ph, Alfonso F, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization. Eur. Heart J 2014; 278: 25-7.

4. Wald DS, Joan K, et al. PRAMI Investigators Randomized Trial of Preventive Angioplasty in Myocardial Infarction. N Engl J Med 2013; 369: 1115-23.

5. Addala S, Grines CL, Dixon SR, et al. Predicting mortality in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention (PAMI risk score). Am J Cardiol 2004; 93: 629-32.

6. Halkin A, Singh M, Nikolsky E, et al. Prediction of mortality after primary percutaneous coronary intervention for acute myocardial infarction: the CADILLAC risk score. JAСC 2005; 45: 1397-405.

7. Morrow DA, Antman EM, Charlesworth A, et al. TIMI risk score for ST-elevation myocardial infarction: a convenient, bedside, clinical score for risk assessment at presentation: an intravenous nPA for treatment of infarcting myocardium early II trial substudy. Circulation 2000; 102: 2031-7.

8. Eagle KA, Lim MJ, Dabbous OH. GRACE Investigators, et al. A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry. JAMA 2004; 291: 2727-33.

9. De Luca G, Suryapranata H, van’t Hof AW, et al. Prognostic assessment of patients with acute myocardial infarction treated with primary angioplasty: implications for early discharge. Circulation 2004; 109: 2737-43.

10. Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous Coronary Intervention versus Coronary-Artery Bypass Grafting for Severe Coronary Artery Disease. New Engl J Med 2009; 360(10): 961-72.

11. Serruys PW, Onuma Y, Garg S, et al. Assessment of the SYNTAX score in the SYNTAX study. EuroIntervention 2009; 5: 50-6.

12. Garg S, Sarno G, Serruys РW, et al. Prediction of 1-Year Clinical Outcomes Using the SYNTAX Score in Patients With Acute ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. JACC 2011; 4(1): 66-75.

13. Yang CH, Hsieh MJ, Chen CC, et al. SYNTAX score: an independent predictor of long- term cardiac mortality in patients with acute ST-elevation myocardial infarction. Coron Artery Di 2012; 23(7): 445-9.

14. Tarasov RS, Ganyukov VI, Shushpannikov PA, et al. SYNTAX score estimates of coronary stenosis severity and outcomes of various revascularization strategies in patients with ST segment elevation myocardial infarction and multi-vessel coronary pathology. Russ J Cardiol 2013; 2(100): 31-7. Russian (Тарасов Р. С., Ганюков В. И., Шушпанников П. А. и др. Исходы различных стратегий реваскуляризации у больных инфарктом миокарда с элевацией сегмента ST при многососудистом поражении в зависимости от тяжести стенозирования коронарного русла по шкале “SYNTAX”. Российский кардиологический журнал 2013; 2(100): 31-7).

15. Farooq V, Serruys PW, Bourantas CV, et al. Quantification of incomplete revascularization and its association with five-year mortality in the synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) trial validation of the residual SYNTAX score. Circulation 2013; 128(2): 141-51.

16. Melina G, Angeloni E, Refice S, et al. Prognostic Value of the Residual SYNTAX Score to Quantify Untreated Coronary Artery Disease After Coronary Artery Bypass Grafting. Circulation 2013; 128: A17110.

17. Généreux SP, Palmerini T, Caixeta A, et al. Quantification and Impact of Untreated Coronary Artery Disease After Percutaneous Coronary Intervention The Residual SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery). JACC 2012; 59: 2165-74.