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Background: A fractional flow reserve (FFR)-fixed-SYNTAX score could decrease the number of high-risk patients. This study explored the prognostic value of non-invasive quantitative flow ratio (QFR)-fixed-SYNTAX I/II scores in multivessel disease patients. Methods: This was a single-center, small-sample, observational study. Multivessel coronary disease patients were enrolled and finished a 1-year follow-up. SYNTAX scores I/II and functional SYNTAX scores I/II based on QFR (cut-off value of 0.85) were calculated for all patients. The composite occurrence of cardiac deaths, any myocardial infarction, or ischemia-driven revascularization were analyzed using a different score system. Results: A total of 160 patients were stratified into risk groups based on a different scoring system. FSS (functional SYNTAX score) and FSSII (functional SYNTAX score II) reduce the radio of high-risk major adverse cardiovascular events (MACEs), transforming the patients from high-risk to medium- and low-risk. Furthermore, FSSII (hazard ratio (HR): 1.069, 95% CI: 1.025–1.115, p = 0.002) showed a better relationship with MACEs than the other score systems. After recalculating SSII, the survival-free ratio stratified by FSSII decreased from 38.46% to 27.27% in the high-risk group and increased from 84.09% to 86.05% in the low-risk group. Conclusions: FSS or FSSII could decrease the number of high-risk patients compared to SYNTAX score (SS) and FSS. SYNTAX II score (SSII) and FSSII showed a better predictive ability than other scoring systems for under-risk stratification.

There are limited prospective clinical studies that use the functional SYNTAX score (FSS) to determine treatment strategies, as compared to the anatomical SYNTAX score (ASS), in patients with multivessel disease (MVD). We sought to compare the change in treatment strategy and healthcare cost benefits between ASS and FSS in patients with chronic stable angina and/or recent acute coronary syndrome with MVD. This was a prospective, multicenter, multi-country, open-label study that enrolled 577 patients from 16 sites across Thailand, India, and Hong Kong. After angiographic assessment, the first treatment strategy was decided based on ASS information. Thereafter, the second treatment strategy was decided based on FSS. Subsequently, the physicians were asked to document the actual treatment received by the patient. The primary endpoint was a proportional change in treatment strategy based on FSS evaluated using κ-statistics and the Bowker–McNemar test. A total of 577 patients with 1833 lesions were assessed. The overall mean ASS was 17.0 ± 8.5, and the mean FSS score was 11.2 ± 9.6. FSS reclassified 28.1% of patients from the high-risk group toward the low-risk group. FSS reclassified more than one-third of patients with ASS > 22 to FSS  ≤  22. FSS-based decision making led to a statistically significant change ( p  < 0.0001) in treatment strategy for 53% of the patients. This change reduced the procedure-related cost by 10%. The overall major adverse cardiovascular events rate at 1-year follow-up was 4.5%. In the real-world setting, FSS significantly influenced the determination of appropriate treatment options among MVD patients and led to a reduction in procedure-related costs.

Background and aim Insulin resistance (IR) plays a significant role in the development of cardiovascular disease (CVD), even in non-diabetic individuals, with a 46% higher likelihood of coronary artery disease (CAD) for each 1 SD increase in IR. The estimated glucose disposal rate (eGDR) is a validated marker for IR. However, its association with the residual SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score (rSS), which assesses residual stenosis severity after percutaneous coronary intervention (PCI), has not been investigated in non-diabetic ST-segment elevation myocardial infarction (STEMI) patients. This study aims to explore the relationship between eGDR and rSS in non-diabetic STEMI patients undergoing PCI. Methods This single-center observational study enrolled 390 non-diabetic STEMI patients who underwent PCI. The complexity of CAD was assessed pre-PCI using the SYNTAX score, and post-PCI, the rSS was calculated. eGDR was derived using waist circumference, HbA1c, and hypertension status, based on a previously validated equation. The association between eGDR and rSS was analyzed using multivariable logistic regression. The optimal eGDR cut-off value for predicting higher rSS was determined using Youden’s index. Results The cohort had a mean age of 58.74 ± 9.01 years and was predominantly male (76.66%). Participants were divided into lower and higher eGDR groups based on the median eGDR value of 7.74. Multivariable logistic regression identified lower eGDR as an independent predictor of higher rSS (adjusted OR = 1.84, 95% CI: 1.59–2.14, p  < 0.001), after adjusting for demographic, clinical, and metabolic factors. The association remained consistent in a secondary model that included additional anatomical and procedural variables (adjusted OR = 1.81; p  < 0.001; 95% CI: 1.37–2.39).The optimal eGDR cut-off value for predicting high rSS was 7.04 (AUC: 0.803, 95% CI: 0.747–0.882, p  < 0.001), with a sensitivity of 76.04% and specificity of 73.20%. Conclusion eGDR, is an independent predictor of higher rSS in non-diabetic patients undergoing PCI for STEMI.

Background Our aim was to evaluate SYNTAX Score II for its ability to predict mortality in all-comers undergoing isolated coronary artery bypass grafting. Methods External validation of SYNTAX Score II was performed in a retrospective analysis of 2 tertiary care centers. Mortality at 4 years after surgery was defined as the primary outcome variable. External validation included assessment of calibration (calibration-in-the-large, observed-expected ratio, calibration slope) and discrimination (concordance statistic, Receiver Operating Characteristic curve). Additionally, SYNTAX Score II’s performance was compared with the performance of EuroSCORE II, the logistic EuroSCORE, and ACEF Score. Results The study cohort included 1454 patients (Medical University of Vienna, n  = 782; Medical University of Innsbruck, n  = 672). Kaplan-Meier survival curves showed that tertiles of SYNTAX Score II were significantly associated with mortality (log-rank test, p  < 0.001). In a stratified multivariable Cox proportional-hazards regression model, the following score components were independently associated with mortality: age (hazard ratio 1.03, 95% confidence interval 1.00 to 1.06), creatinine clearance (hazard ratio 0.98, 95% confidence interval 0.97 to 0.99), left-ventricular ejection fraction (hazard ratio 0.97, 95% confidence interval 0.95 to 0.98), and chronic obstructive pulmonary disease (hazard ratio 2.02, 95% confidence interval 1.34 to 3.05). The anatomical SYNTAX Score was not independently associated with mortality (hazard ratio 1.00, 95% confidence interval 0.98 to 1.02). Assessment of SYNTAX Score II calibration revealed an observed-expected ratio of 0.61 and a calibration slope of 0.62 ( p  < 0.001 for comparison with slope = 1.0), indicating general overestimation of 4-year mortality. The c-statistic amounted to 0.73. Performance of SYNTAX Score II was comparable with the performance of EuroSCORE II (c-statistic 0.73), the logistic EuroSCORE (c-statistic 0.74) and ACEF Score (c-statistic 0.72). Conclusions Our analysis shows that SYNTAX Score II has acceptable discriminative strength with respect to 4-year mortality in all-comers undergoing isolated coronary artery bypass grafting. Notably, mortality is over-estimated in patients with higher SYNTAX Score II values. SYNTAX Score II, EuroSCORE II, the logistic EuroSCORE, and ACEF Score offer comparable predictive value towards 4-year mortality.

Background: The SYNTAX score (SS) is useful for predicting clinical outcomes in patients undergoing percutaneous coronary intervention (PCI). The clinical SYNTAX score (CSS), developed by combining clinical parameters with the SS, enhances the risk model’s ability to predict clinical outcomes. However, prior research has not yet evaluated the prognostic capacity of CSS in patients with complex coronary artery disease (CAD) and chronic renal insufficiency (CRI) who are undergoing PCI. We aimed to demonstrate the prognostic potential of CSS in assessing long-term adverse events in this high-risk patient cohort. Methods: A total of 962 patients with left main and/or three-vessel CAD and CRI were enrolled in the study spanning from January 2014 to September 2017. The CSS was calculated by multiplying the SS by the modified age, creatinine, and left ventricular ejection fraction (ACEF) score (age/ejection fraction + 1 for each 10 mL of creatinine clearance <60 mL/min per 1.73 m2). The patients were categorized into three groups based on their CSS values: low-CSS group (CSS <18.0, n = 321), mid-CSS group (18.0 ≤ CSS < 28.3, n = 317), and high-CSS group (CSS ≥28.3, n = 324) as per the tertiles of CSS. The primary endpoints were all-cause mortality (ACM) and cardiac mortality (CM). The secondary endpoints included myocardial infarction (MI), unplanned revascularization, stroke, and major adverse cardiac and cerebrovascular events (MACCE). Results: At the median 3-year follow-up, the high-CSS group exhibited higher rates of ACM (19.4% vs. 6.6% vs. 3.6%, p < 0.001), CM (15.6% vs. 5.1% vs. 3.2%, p = 0.003), and MACCE (33.8% vs. 29.0% vs. 20.0%, p = 0.005) in comparison to the low and mid-CSS groups. Multivariable Cox regression analysis revealed that CSS was an independent predictor for all primary and secondary endpoints (p < 0 .05). Moreover, the C-statistics of CSS for ACM (0.666 vs. 0.597, p = 0.021) and CM (0.668 vs. 0.592, p = 0.039) were significantly higher than those of SS. Conclusions: The clinical SYNTAX score substantially enhanced the prediction of median 3-year ACM and CM in comparison with SS in complex CAD and CRI patients following PCI.

The residual SYNTAX score (rSS) is employed for the quantification of residual coronary lesions and to guide revascularization. rSS can be combined with other examinations to evaluate the severity of vascular disease and play an evaluative and guiding role in various scenarios. Furthermore, combining rSS with other indicators, benefits prognosis evaluation, and rSS-derived scores have been increasingly used in clinical practice. This article reviews the progress in the clinical application of rSS and its derived scores for complex coronary arteries and other aspects, based on relevant literature.

Background: The SYNTAX score II (SS II) has earned widespread recognition for use on individuals with coronary artery disease (CAD) due to its reliable predictions of 4-year all-cause mortality (ACM). This research focuses on substantiating the prognostic significance of using the SS II for patients experiencing concurrent chronic renal insufficiency (CRI) and CAD who have undergone percutaneous coronary intervention (PCI). Methods: This study retrospectively examined 2468 patients with concurrent CAD and CRI who underwent PCI. Based on their SS II, these participants were sorted into low-, medium-, and high-risk groups and monitored over a median of three years. The evaluation of the predictive precision of different SYNTAX scores for clinical outcomes in patients with CRI after PCI involved using time-dependent receiver operating characteristic (ROC) curves. These included the standard SS (SS), SS II, clinical SS (CSS), and residual SS (rSS). The primary outcomes were ACM and cardiac mortality (CM), while the secondary outcomes covered major adverse cardiovascular and cerebrovascular events (MACCEs), stroke, unplanned revascularization, and myocardial infarction (MI). Results: Higher 5-year cumulative incidences of MACCEs, MI, CM, and ACM were observed significantly in patients in the high SS II category relative to those in the low and medium SS II categories. Multivariable Cox regression analysis confirmed that the SS II independently predicts ACM, CM, MI, and MACCEs as a prognostic marker. Additionally, the analysis of the time-dependent ROC curve demonstrated that the areas under the curve (AUC) for predicting CM and ACM were 0.772 and 0.767, respectively, which are superior to those of other SYNTAX scores (p < 0.05). Conclusions: As an independent predictor, the SS II is notable for its ability to forecast long-term adverse outcomes, including MACCEs, CM, ACM, and MI. For patients with coexisting CAD and CRI undergoing PCI, it provides significantly improved prognostic accuracy for 5-year ACM and CM compared to other SYNTAX scores.

Objective: Stress is known to be a significant risk factor for coronary atherosclerosis and adverse cardiovascular events; however, the stress-related coronary atherosclerotic burden has not yet been investigated. The aim of this study was to investigate the relationship between the Perceived Stress Scale (PSS) and the SYNTAX scores in patients with ST-segment elevation myocardial infarction (STEMI). Methods: A total of 440 patients with STEMI were prospectively enrolled and divided into 2 groups according to the PSS score with a ROC curve analysis cut-off value of 17.5. In all, 361 patients with a low PSS score were categorized as Group 1 and 79 patients with a high PSS score were categorized as Group 2. Results: The SYNTAX score [Group 1, 16.0 (10.0–22.5); Group 2, 22.5 (15.0–25.5); p<0.001] and the SYNTAX score II were significantly higher in Group 2 [Group 1, 24.8 (19.0–32.6); Group 2, 30.9 (22.3–38.9); p<0.001]. Spearman analysis demonstrated that the PSS score was associated with the SYNTAX score (r=0.153; p=0.001) and the SYNTAX score II (r=0.216; p<0.001). Additionally, the PSS (odds ratio: 2.434, confidence interval: 1.446-4.096; p=0.001) was determined to be an independent predictor of a moderate-to-high SYNTAX score. The PSS score of patients with in-hospital mortality was also higher than those who survived [15 (10–20); 9 (4–16), respectively; p=0.007]. Conclusion: Stress appears to accelerate the coronary atherosclerotic process and the associated burden. An increased stress level was found to be an independent predictor of a high SYNTAX score.

In patients with multivessel disease (MVD), functional information on lesions improves the prognostic capability of the SYNTAX score. Quantitative flow ratio (QFR®) is an angiography‐derived fractional flow reserve (FFR) that does not require a pressure wire or pharmacological hyperemia. We aimed to investigate the feasibility of QFR‐based patient information in Heart Teams' discussions to determine the optimal revascularization strategy for patients with MVD. We hypothesized that there is an acceptable agreement between treatment recommendations based on the QFR approach and recommendation based on the FFR approach. The DECISION QFR study is a prospective, multicenter, randomized controlled trial that will include patients with MVD who require revascularization. Two Heart Teams comprising cardiologists and cardiac surgeons will be randomized to select a revascularization strategy (percutaneous coronary intervention or coronary artery bypass graft) according to patient information either based on QFR or on FFR. All 260 patients will be assessed by both teams with reference to the anatomical and functional SYNTAX score/SYNTAX score II 2020 derived from the allocated physiological index (QFR or FFR). The primary endpoint of the trial is the level of agreement between the treatment recommendations of both teams, assessed using Cohen's κ. As of March 2022, the patient enrollment has been completed and 230 patients have been discussed in both Heart Teams. The current trial will indicate the usefulness of QFR, which enables a wireless multivessel physiological interrogation, in the discussions of Heart Teams to determine the optimal revascularization strategy for MVD.

SYNTAX score II (SS-II) has a powerful prognostic accuracy in patients with stable complex coronary artery disease who have undergone revascularization; however, there is limited data regarding the prognosis of patients with ST segment elevation myocardial infarction (STEMI). The aim of this study is to examine both the predictive performance of SS-II in determining in-hospital and long term mortality of STEMI patients and to compare SYNTAX score (SS) and TIMI risk score (TRS). Consecutive 1912 STEMI patients treated with primary percutaneous coronary intervention (p-PCI) retrospectively reviewed, and the remaining 1708 patients constituted the study population after exclusion. The patients were divided into three groups according to increased SS-II value: low (n:562; SS-II ≤ 24.6); intermediate (n:563; 24.6 < SS-II < 34.4); and high tertile (n:583; SS-II ≥ 34.4). In-hospital and long term mortality rate from all causes (0 vs. 0.5 vs. 10.6% and 1.8 vs. 3.2 vs. 18.1% respectively, p ≤ 0.001) were significantly increased with SS-II tertiles and SS-II was found to be independent predictor of in-hospital and long term mortality (HR: 1.076 95% CI 1.060–1.092, p < 0.001) and (HR: 1.070 95% CI 1.050–1.090, p < 0.0001). The predictive power of SS-II, SS, and TRS were compared by ROC curve and decision curve analysis. SS-II surpassed SS and TRS in long-term and in-hospital mortality prediction. SS-II is a powerful tool to predict in-hospital and long-term mortality from all causes in STEMI patients treated with p-PCI.