SYNTAX SCORE.pptx

 An angiographic tool grading the complexity
of coronary artery disease
 A semiquantitative visual score that will help
us to be aware of the anatomical complexity
and to anticipate procedural difficulties

 One drawback in these comparisons is that
there is heterogencity in the complexity of
CAD of the patients enrolled.
 Absence of grading of severity of CAD and
lack of comparison of lesion complexity
between various groups severely limits the
interpretation of results.

 For example pts with distal LM trifurcation
disease with occluded RCA is pooled together
as TVD with patients with 3 focal lesions in
midportion of the 3 coronary arteries.
 The first has a greater therapeutic challenge
for PCI and both have completely different
prognosis regardless of revascularisation.

 SYNTAX (Synergy between PCI with TAXUS
stent and cardiac surgery) trial was organised
for patients with significant lesion in LM and
/or TVD.
 The syntax score has been used in this study
to categorize the coronary vasculature with
respect to the number of lesions their
functional impact,location and complexity.

 The SYNTAX score has been developed based on the
following:
 1. The AHA classification of the coronary tree
segments modified for the ARTS study
 2. The Leaman score
 3. The ACC/AHA lesions classification system
 4. The total occlusion classification system
 5. The Duke and ICPS classification systems for
bifurcation lesions
 6. Consultation of experts

 Arterial tree is divided into 16 segments
 This system has been adopted for the syntax
scoring.

 Based on severity of luminal diameter
narrowing
 Weighed according to usual blood flow to LV
by each vessel

 significant lesion-50% reduction in lumen
diameter by visual assessment in vessels
>1.5mm in diameter.
 Less severe lesions not included
 Percent diameter stenosis is not included
 Only occlusive lesions (100% stenosis)-MF 5
 And non occlusive lesions (50-99% stenosis)-
MF 2

 In right dominant system
-RCA supplies 16%
-LCA supplies 84% of flow to LV
 Of the 84%,66% is by LAD and 33% by LCX.
 The LM supplies approximately 5 times ,the
LAD app.3.5 times and LCX app.1.5 times
blood as the RCA to the LV.

 For left dominant system
-LM supplies 100%(hence multiplication
factor 6)
-LAD 58% (MF-3.5)
-LCX 42% (MF-2.5)
 The contribution is used as a multiplication
factor
-

 Type A (high success ,low risk)
 Type B (mod success ,mod risk)
 Type C (low success ,high risk)

 No antegrade flow is visible distal to lesion
 Distal segments may be filled via bridging
,ipsilateral or contralateral collaterals.
 Parameters included are
-Age of occlusion
-blunt stump
-presence of bridging collaterals
-presence of side branch
-occlusion length

 Defined as junction of main vessel and a side
branch (1.5mm)
 Not involving ostium(A,B,C)
 Involving ostium(D,E,F,G)

 5/6/11
 6/7/9
 7/8/10
 11/13/12a
 13/14/14a
 3/4/16
 13/14/15

 3/4/16/16a
 5/6/11/12
 11/12a/12b/13
 6/7/9/9a
 7/8/10/10a

 Aorto ostial: A lesion is classified as aorto-
ostial when it is located immediately at the
origin of the coronary vessels from the aorta
(applies only to segments 1 and 5, or to 6 and 11
in case of double ostium of the LCA).
 Severe tortuosity: One or more bends of 90°
or more, or three or more bends of 45° to 90°
proximal of the diseased segment.
 Length >20mm: Estimation of the length of
that portion of the stenosis that has ≥ 50%
reduction in luminal diameter in the projection
where the lesion appears to be the longest. (In
case of a bifurcation lesion at least one of the
branches has a lesion length of >20mm).

 Heavy calcification: Multiple persisting
opacifications of the coronary wall visible
in more than one projection surrounding the
complete lumen of the coronary artery at the
site of the lesion.
 Thrombus: Spheric, ovoid or irregular
intraluminal filling defect or lucency
surrounded on three sides by contrast
medium seen just distal or within the
coronary stenosis in multiple projections

 The SYNTAX score is lesion based
 A separate number calculated per lesion is
Summed to generate the total SYNTAX score
 Questions 1-3: determine dominance, total
no. of lesions(max.12) and vessel
segments/lesion
 Questions 4-12: detail adverse lesion
characteristics; are repeated for each
lesion.
 The SYNTAX score is calculated after
answering a set of sequential, interactive
self-guided questions

 Does not entail any clinical variable
 Comorbidities are known to impact early
outcomes of patients undergoing
revascularisation.
 Hence limited use in guiding decision making
between CABG and PCI.
 Relies on pure visual interpretation of lesion
severity and subjective variables.

 Syntax score +
 Age
 Creatinine
 EF

 Anatomical syntax score
 Age
 Creatinine clearance
 LVEF
 ULMCA
 Peripheral Vascular Disease
 Female sex
 COPD

 broadly accepted instrument to help predict
early outcomes in patients who undergo
coronary artery bypass grafting (CABG).

MACCE to 5 years by Syntax Score T
ercile
Left Main Disease
CABG
PCI or CABG
PCI or CABG

The SYNTAX population represents the most
complex patients ever studied for PCI in a
randomised trial.
 The more complex patients are better
treated by CABG, but PCI is an acceptable
alternative for those with less complex
disease(ie, SYNTAX Scores 22 or less).

 The SYNTAX score is a new, innovative tool to
describe the complexity of vasculature
 The raw SYNTAX score is a good predictor of
MACE
 PCI patients with lower raw SYNTAX scores
have similar 12-month MACE rates to CABG
patients.
 Increasing SYNTAX scores (and lesion
complexity) are related to increased adverse
outcomes in PCI, whereas outcomes of CABG
are independent of SYNTAX score.

SYNTAX SCORE.pptx

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