In the Journals

Higher SYNTAX score may predict benefit from CABG vs. medical therapy

At 5 years, elevated rates of major CV events were found in patients with diabetes and stable ischemic heart disease when baseline SYNTAX scores were higher, according to new data from the BARI-2D trial.

Higher SYNTAX scores also were found to be predictive of more favorable outcomes of revascularization in patients treated with CABG compared with medical therapy, researchers reported.

The BARI-2D trial included 1,550 patients with type 2 diabetes and evidence of myocardial ischemia who had not previously undergone revascularization. Baseline SYNTAX scores were calculated retrospectively. Follow-up was 5 years, with major CV events (a composite of death, MI and stroke) as the primary outcome.

Scores and outcomes

A SYNTAX score 23 was linked to a greater risk for major CV events at 5 years (HR = 1.36; 95% CI, 1.07-1.75), according to the researchers.

Patients who underwent revascularization with CABG had significantly higher SYNTAX scores vs. patients who underwent PCI (36% vs. 13%; P < .001).

Major CV events did not differ significantly between revascularization and medical therapy when the SYNTAX scores were 22. This was found in the patients who underwent either CABG (26.1% vs. 29.9%; P = .41) or PCI (17.8% vs. 19.2%; P = .84), according to the findings.

However, patients with higher SYNTAX scores who underwent CABG had fewer major CV events after revascularization vs. patients with higher SYNTAX scores who received medical therapy (15.3% vs. 30.3%; P = .02). This was not the case with patients who had higher SYNTAX scores and underwent PCI vs. patients who received medical therapy (35.6% vs. 26.5%; P = .12).

“The key observation from this study is that higher levels of the SYNTAX score predict particular therapeutic benefit from CABG compared with medical therapy. We found a far more striking reduction in major [CV] events in patients with medium or high SYNTAX scores (HR = 0.46) than in patients with low SYNTAX scores (HR = 0.88). This observation is consistent with earlier studies that found a greater survival benefit from CABG compared with medical therapy for patients with three-vessel or left main disease,” Fumiaki Ikeno, MD, from the Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, and colleagues wrote.

'Cherry-picked'

In an accompanying editorial, Patrick W. Serruys, MD, PhD, from the department of interventional cardiology at the Erasmus University in Rotterdam, the Netherlands, and the International Centre for Circulatory Health, NHLI, Imperial College London, and Vasim Farooq, MBCHB, PhD, from the St. George’s University Hospital, London, wrote: “The main limitation of BARI-2D is that patients appeared to have been cherry-picked for randomization, with a minority actually having [three-vessel disease]. ... Not unexpectedly, [three-vessel disease] was substantially more prevalent in the CABG stratum compared with the PCI stratum.” by Suzanne Reist

Disclosure: The BARI-2D trial receives significant supplemental funding from Abbott Laboratories, Astellas Pharma, GlaxoSmithKline, Lantheus Medical Imaging, Merck and Pfizer. Generous support is given by Abbott Laboratories, Bayer Diagnostics, Becton, Dickinson and Co., Centocor, Eli Lilly, ILipoScience, J. R. Carlson Labs, MediSense Products, Merck Sante, Novartis and Novo Nordisk. Farooq, Ikeno and Serruys report no relevant financial disclosures. One researcher reports receiving a research grant from Gilead.

At 5 years, elevated rates of major CV events were found in patients with diabetes and stable ischemic heart disease when baseline SYNTAX scores were higher, according to new data from the BARI-2D trial.

Higher SYNTAX scores also were found to be predictive of more favorable outcomes of revascularization in patients treated with CABG compared with medical therapy, researchers reported.

The BARI-2D trial included 1,550 patients with type 2 diabetes and evidence of myocardial ischemia who had not previously undergone revascularization. Baseline SYNTAX scores were calculated retrospectively. Follow-up was 5 years, with major CV events (a composite of death, MI and stroke) as the primary outcome.

Scores and outcomes

A SYNTAX score 23 was linked to a greater risk for major CV events at 5 years (HR = 1.36; 95% CI, 1.07-1.75), according to the researchers.

Patients who underwent revascularization with CABG had significantly higher SYNTAX scores vs. patients who underwent PCI (36% vs. 13%; P < .001).

Major CV events did not differ significantly between revascularization and medical therapy when the SYNTAX scores were 22. This was found in the patients who underwent either CABG (26.1% vs. 29.9%; P = .41) or PCI (17.8% vs. 19.2%; P = .84), according to the findings.

However, patients with higher SYNTAX scores who underwent CABG had fewer major CV events after revascularization vs. patients with higher SYNTAX scores who received medical therapy (15.3% vs. 30.3%; P = .02). This was not the case with patients who had higher SYNTAX scores and underwent PCI vs. patients who received medical therapy (35.6% vs. 26.5%; P = .12).

“The key observation from this study is that higher levels of the SYNTAX score predict particular therapeutic benefit from CABG compared with medical therapy. We found a far more striking reduction in major [CV] events in patients with medium or high SYNTAX scores (HR = 0.46) than in patients with low SYNTAX scores (HR = 0.88). This observation is consistent with earlier studies that found a greater survival benefit from CABG compared with medical therapy for patients with three-vessel or left main disease,” Fumiaki Ikeno, MD, from the Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, and colleagues wrote.

'Cherry-picked'

In an accompanying editorial, Patrick W. Serruys, MD, PhD, from the department of interventional cardiology at the Erasmus University in Rotterdam, the Netherlands, and the International Centre for Circulatory Health, NHLI, Imperial College London, and Vasim Farooq, MBCHB, PhD, from the St. George’s University Hospital, London, wrote: “The main limitation of BARI-2D is that patients appeared to have been cherry-picked for randomization, with a minority actually having [three-vessel disease]. ... Not unexpectedly, [three-vessel disease] was substantially more prevalent in the CABG stratum compared with the PCI stratum.” by Suzanne Reist

Disclosure: The BARI-2D trial receives significant supplemental funding from Abbott Laboratories, Astellas Pharma, GlaxoSmithKline, Lantheus Medical Imaging, Merck and Pfizer. Generous support is given by Abbott Laboratories, Bayer Diagnostics, Becton, Dickinson and Co., Centocor, Eli Lilly, ILipoScience, J. R. Carlson Labs, MediSense Products, Merck Sante, Novartis and Novo Nordisk. Farooq, Ikeno and Serruys report no relevant financial disclosures. One researcher reports receiving a research grant from Gilead.