Automatically computed anatomic complexity scores can be used to assess the longitudinal risk for residual ischemic disease after percutaneous coronary intervention (PCI), a new study concludes. The findings published Monday online ahead of the Dec 26 issue of JACC: Cardiovascular Interventions point to a future with automated angiographic scoring providing actionable prognostic information both before and after PCI. “Increasing burden of residual ischemic disease as calculated by the Veterans Affairs (VA) SYNTAX score was associated with an increased hazard of long-term major adverse cardiovascular events (MACE) after PCI in a contemporary national cohort,” the authors wrote, later adding: “These findings have important implications for the management of patients with complex coronary artery disease (CAD) and strategies to optimize cardiovascular outcomes across health care systems.” Study methodology The research team began assessing 112,515 unique patients who underwent PCI and 103,167 unique patients who underwent coronary angiography within 90 days prior to PCI. After excluding patients for various reasons (such as prior coronary artery bypass graft, missing or inadequate data to compute the SYNTAX score, and length of hospital stay >90 days), the final analytical cohort included 57,476 patients across 77 centers, with nearly all of the patients (97.8%) being male, and having a mean age of 66 ± 9 years. Led by Christopher P. Kovach, MD, MSc, from the University of Colorado and the Rocky Mountain Regional Veterans Affairs Medical Center, both in Aurora, Colorado, the team then calculated VA SYNTAX scores for each patient in the final cohort. These scores were determined following coronary angiography (baseline VA SYNTAX score) and following PCI (residual VA SYNTAX score). The scores were then categorized by tertiles across all patients in the study population. Patients who achieved residual VA SYNTAX scores of zero were deemed to have complete anatomical revascularization (CR). The change in VA SYNTAX score between the baseline and residual values (delta VA SYNTAX score) was also calculated. The primary outcome was a composite of death, rehospitalization for myocardial infarction (MI), repeat revascularization and rehospitalization for stroke (MACE) at 1 and 3 years. Individual clinical events were assessed as secondary outcomes, except for stroke because of insufficient events for analysis. Investigational findings After adjustment, the highest tertile of residual VA SYNTAX score was associated with increased risk of MACE (hazard ratio [HR]: 2.06; 95% confidence interval [CI]: 1.98-2.15). This tertile was also linked to an increased risk of death (HR: 1.50; 95% CI: 1.41-1.59) at 3 years compared to complete revascularization (residual VA SYNTAX score = 0). The findings suggested that the risk of 1- and 3-year MACE increased as a function of residual disease, regardless of baseline disease severity or initial presentation with acute or chronic coronary syndrome. “Residual ischemic disease was strongly associated with long-term clinical outcomes in a contemporary national cohort of PCI patients,” the study concluded. “The implementation of an automatically calculated assessment of residual ischemic burden can be leveraged across large health care systems.” “Furthermore, this automatic calculation again demonstrates that increasingly complete anatomic revascularization is associated with improved clinical outcomes regardless of patient presentation among patients with single-vessel or multivessel CAD.” Scoring application to “big data” In an accompanying editorial, Morton J. Kern, MD, and Arnold H. Seto, MD, MPA, both from the Long Beach Veterans Administration Hospital, California, simply stated that the more severe the residual angiographic disease, the more adverse events occurred over time. “The investigators’ results make clear that: 1) increasing burden of residual disease is associated with an increased MACE after PCI; 2) complete anatomical revascularization is better than incomplete revascularization for outcomes after PCI; 3) for incomplete revascularization, increased mortality was concentrated only in the highest tertile of angiographic complexity,” the editorialists wrote. “The poor outcomes of high residual VA SYNTAX scores should discourage incomplete revascularization strategies.” Kern and Seto went on to commend the investigators for simplifying and automating the SYNTAX score, which allows the application of angiographic scoring to a real-world, “big-data” cohort, and confirming the findings of much smaller (n = <2,000) randomized trials. Sources: Kovach CP, Hebbe A, Glorioso TJ, et al. Association of residual ischemic disease with clinical outcomes after percutaneous coronary intervention. JACC Cardiovasc Interv. 2022;15:2475–2486. Morton JK, Seto AH. Can Automating the SYNTAX Score Move Practice Beyond the Angiogram Alone? JACC Cardiovasc Interv. 2022;15:2487–2489. Image Credit: Peakstock – stock.adobe.com