POINT OF VIEW
A More Meaningful Scoring System for shortcomings, I devised a system that takes into consideration
the geometrically increasing severity of lesions, the cumulative
Determining the Severity of Coronary effects of multiple obstructions, the significance of their lo-
cations, the modifying influence of the collaterals, the size and
Heart Disease quality of the distal vessels, and the importance of the status
of myocardial function [Fig. 1]. . . . The fundamental concept
forming the basis of this system is the hypothesis that the
severity of coronary artery disease must be regarded as a
GOFFREDO G. G E N S I N I , MD consequence of the functional significance of the vascular
narrowing and the extent of the area perfused by the involved
vessel or vessels; the presence of an effective collateral situa-
tion may, on the other hand, modify the functional signifi-
Selzer ~ in a recent editorial criticized the classification of the cance of a severe obstruction or occlusion. . . . Although this
severity of coronary artery disease (CAD) which is currently method may not be ideal, it provides more useful information
used in all randomized trials on the surgical versus medical than the simple division of patients into single-, double-, and
therapy of CAD. He pointed out that the classification of triple-vessel disease. The advantages of this scoring method
single-, double-, triple-vessel and main left (SDTML) coro- are as follows: (l) it provides an accurate stratification of pa-
nary artery disease allows the inclusion in each subgroup of tients according to the functional significance of their disease;
a mixture of patients with both a favorable and an unfavorable (2) it lends itself to computer elaboration, storage, retrieval,
prognosis and provides, at best, only marginal differentiation and analysis; (3) it provides an opportunity to match patients
of medically and surgically treated patients. He further sug- with similar degrees of coronary artery disease who are re-
gested that patients with CAD should be identified on the ceiving different forms of treatment; and (4) it allows for
basis of severity of narrowings, cardiac performance, effec- continuous, microprocessor-assisted studies of interobserved
tiveness of coronary collateral circulation, amount of myo- and intraobserver variability. Computer hardware and soft-
cardium jeopardized by ischemia, and possibly other factors ware to elaborate and store this type of information are readily
as well. available and are inexpensive."
I wholeheartedly share these views, as described in my book Thus, the challenge of Selzer had already been met several
in 1975.2 An updated version of this scoring and stratifying years ago by a classification of patients with CAD, but this
method and a critique of the SDTML disease classification classification has not been utilized by others. It is time for
appeared in 1980.3 There I stated: "A method that assigns a cardiologists to adopt a more meaningful measurement of the
different severity score depending on the degree of luminal severity of CAD.
narrowing and the geographical importance of its location References
would be desirable . . . . Several years ago, recognizing these
1. Seizer A. On the limitation of therapeutic intervention trials in ischemtc heart
disease: a clinician's viewpoint. Am J Cardiol 1982;49:252-255.
2. Gensini GG. Coronary arteriography. Mt. Kisco, NY: Futura, 1975:488.
From Msgr. Toomey Cardiovascular Laboratory, St. Joseph's Hospital 3. Gensini GG. Coronary arteriography. In: Heart Disease. Braunwald E, ed.
Health Center, Syracuse, New York. Philadelphia: WB Saunders, 1980:352-353.
Concentric les Eccentnc plaque i : i X5 X25
', MLCA, Prox
25 1 ,.:, ",, :
'; .,'.':';..': ""
I°D
Xl
x' t.. .": ,',...: " 200
50 2 :':t,: ~ i (5
75 4 Xl
90 8
it,/~~xl',
:,_,-:-~-~ Prox X2 5
,..,'~...[!i~"~..~- :. (35)
Prox -- proximal segment
7",:;" ."rf~."
"" "' "," Mid m mtdsegment
>,99<, 16 • ;( .: oM,, Dist --
PD~
MLCA--
dtstalsegment
postenor descending
main left coronary artery
l°D - first dtagonal
100% m
Reduction of lumen diameter
32
Seventy score
2° D -
Aptc-
OM m
PL --
second diagonal
aptcal
obtuse marginal
posterolateral
FIGURE 1. Left panel, roentgenographic appearance of concentric lesions and eccentric plaques resulting in, respectively, 25, 50, 75, 90, and
99 % obstruction as well as complete occlusion (100 % ). The right column in this panel indicates the relative severity of these lesions using a score
of 1 for 25 % obstruction and doubling that number as the severity of the obstructions progresses according to the indicated reduction of lumen
diameter (left column). Right panel, the principal vascular segments of (from left to right) the right coronary artery, the left anterior descending,
and the circumflex. Each segment is followed by a multiplying factor such as Xl, X2.5, and so on, depending on the functional significance of
the area supplied by that segment.
606
