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北京朝阳医院心脏中心 李惟铭王乐丰

北京朝阳医院心脏中心 李惟铭王乐丰. 慢性稳定性冠心病 PCI 推荐指征. SYNTAX EuroSCORE NERS CSS GRC FSS rSS Grace 评分 TIMI 评分. SYNTAX TRIAL DESIGN. Source: M.C.Morice on behalf of the SYNTAX investigators, TCT 2011. SYNTAX 积分的运算法则. 1 、优势型 2 、病变数 3 、每个病变累及的节段 病变特点 4 、完全闭塞 受累节段数 完全闭塞的时间（ >3 个月）

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北京朝阳医院心脏中心 李惟铭王乐丰

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  1. 北京朝阳医院心脏中心 李惟铭王乐丰

  2. 慢性稳定性冠心病PCI推荐指征

  3. SYNTAX EuroSCORE NERS CSS GRC FSS rSS Grace评分 TIMI评分

  4. SYNTAXTRIALDESIGN Source:M.C.MoriceonbehalfoftheSYNTAXinvestigators,TCT2011

  5. SYNTAX积分的运算法则 • 1、优势型 • 2、病变数 • 3、每个病变累及的节段 • 病变特点 • 4、完全闭塞 • 受累节段数 • 完全闭塞的时间（>3个月） • 钝圆残端 • 桥侧枝 • 闭塞远端由前向或逆向侧枝灌注显影的首个节段 • 涉及分支 • 5、三分叉 • 病变节段数 • 6、分叉 • 类型 • 远端主支血管和分支之间的夹角<70º • 7、主动脉开口病变 • 严重扭曲 • 长度>20mm • 严重钙化 • 血栓 • 弥漫性病变/小血管 SYNTAX积分的应用 0~22分：PCI 22~32分：PCI或CABG >32分：CABG

  6. 1.Introduction/background SyntaxScore:segmentweighting Leamanetal, Circ1981;63:285

  7. 1.Introduction/background SyntaxScore:segmentweightXmultiplicationfactor •Multiplicationfactorbasedonseverityofstenosis (specific%stenosisisnotused) TotalOcclusion x5 DS100% Significantlesion50-99% x2 DS50%-99% EuroInterv2005;1:219-227

  8. 2.SyntaxScorecalculator:definitions Syntax Score calculator (11 Questions) • • • • • • • • • • • Q1: Q2: Q3: Q4: Q5: Q6: Q7: Q8: Q9: Q10: Q11: Dominance Specifydiseasedsegmentnumbers TotalOcclusion Trifurcation Bifurcation AortaOstial SevereTortuosity Length HeavyCalcification Thrombus Diffuselydiseasedandnarrowedsegments

  9. 计算方法举例

  10. MACCEto2YearsbySYNTAXScore TercileLowScores(0-22) CABG 5.5% PCI 5.1% Pvalue 0.85 CABG(N=171) TAXUS(N=181) 3VD Death 40 CVA 1.9% 1.2% 0.57 30 P=0.25 4.2% 9.7% 3.9% 8.4% 0.90 0.67 MI Death, CVAorMI 21.9% 16.5% CumulativeEventRate(%) 20 10 0 Revasc. 7.6% 17.1% 0.01 0 12 24 MonthsSinceAllocation CumulativeKMEventRate±1.5SE;log-rankPvalue SYNTAXScoreandeuroSCOREinMVD•TCT2009•Morice Site-reportedData;ITTpopulation SanFrancisco,CA•22Sep09•Slide

  11. MACCEto2YearsbySYNTAXScore TercileIntermediateScores(23-32) CABG 4.1% PCI 6.4% Pvalue 0.30 CABG(N=208) TAXUS(N=207) 3VD Death 40 CVA 3.1% 2.0% 0.50 30 P=0.02 2.6% 8.6% 7.4% 11.7% 0.03 0.29 MI Death, CVAorMI 23.0% 13.7% CumulativeEventRate(%) 20 10 0 Revasc. 7.3% 16.1% 0.006 0 12 24 MonthsSinceAllocation CumulativeKMEventRate±1.5SE;log-rankPvalue SYNTAXScoreandeuroSCOREinMVD•TCT2009•Morice Site-reportedData;ITTpopulation SanFrancisco,CA•22Sep09•Slide1

  12. MACCEto2YearsbySYNTAXScore TercileHighScores(≥33) CABG 2.5% PCI 8.5% Pvalue 0.02 CABG(N=166) TAXUS(N=155) 3VD Death 40 CVA 1.9% 2.1% 0.95 P=0.003 30 26.8% MI 1.9% 7.2% 0.02 CumulativeEventRate(%) 20 6.3% 13.7% 0.03 Death, CVAorMI 13.3% 10 0 Revasc. 7.7% 19.3% 0.002 0 12 24 MonthsSinceAllocation CumulativeKMEventRate±1.5SE;log-rankPvalue SYNTAXScoreandeuroSCOREinMVD•TCT2009•Morice Site-reporteddata;ITTpopulation SanFrancisco,CA•22Sep09•Slide1

  13. MACCEto2YearsvsSYNTAXScore CABG(N=897) P=0.81 TAXUS(N=903) P=0.02 30 25 20 15 17.4 16.4 15.4 Patients,% P=0.11 10 5 0 P=0.27 P=0.007 ≤2223-32 ≤22 23-32 ≥33 ≥33 SYNTAXScore KMeventrates;log-rankPvalue SYNTAXScoreandeuroSCOREinMVD•TCT2009•Morice RCTITTpts;site-reporteddata SanFrancisco,CA•22Sep09•Slide1

  14. MACCEto2YearsvsSYNTAXScore 3VDSubset CABG(N=897) P=0.61 TAXUS(N=903) P=0.53 30 25 20 15 16.5 Patients,% 13.7 13.3 P=0.42 10 5 0 P=0.75 P=0.27 ≤2223-32 ≤22 23-32 ≥33 ≥33 SYNTAXScore KMeventrates;log-rankPvalue SYNTAXScoreandeuroSCOREinMVD•TCT2009•Morice RCTITTpts;site-reporteddata SanFrancisco,CA•22Sep09•Slide1

  15. SYNTAX4-YEARS MACCEbySYNTAXScore;LowScores(0-22) Source:M.C.MoriceonbehalfoftheSYNTAXinvestigators,TCT2011

  16. SYNTAX4-YEARS MACCEbySYNTAXScore;IntermediateScores (23-32) Source:M.C.MoriceonbehalfoftheSYNTAXinvestigators,TCT2011

  17. SYNTAX4-YEARS MACCEbySYNTAXScore;HighScores(≥33) Source:M.C.MoriceonbehalfoftheSYNTAXinvestigators,TCT2011

  18. EuroSCOREComponents Operation-related Emergencysurgery Concomitant surgery Thoracicaorta surgery Postinfarctseptal rupture Patient-related Age Sex COPD PAD Neurol.Dysfunction Priorsurgery ↑Serumcreatinine Activeendocarditis Criticalpre-opstate Cardiac-related Unstableangina LVdysfunction RecentMI PulmonaryHTN AdditiveEuroSCORE 0-2:lowrisk 3-5:mediumrisk 6+:highrisk Nashefetal.EurJCardiothoracSurg1999;16:9-13 SanFrancisco,CA•22Sep09•Slide SYNTAXScoreandeuroSCOREinMVD•TCT2009•Morice

  19. TheEuroSCOREPredictsPost- OperativeMortality SYNTAXScoreandeuroSCOREinMVD•TCT2009•Morice SanFrancisco,CA•22Sep09•Slide

  20. Background Purpose Methods Results Conclusions EuroSCORE:PCI–LeftMain Study Kim,2006 Migliorini,2006 Sukiennik,2008 Rademacher,2008 Pavei,2008 Tamburino,2009 Vaquerizo,2009 RekikS,2010 N 176 101 204 81 148 210 291 246 Endpoint Death/AMI9months Death6months Periproceduralmortality MACE9months Death(≈29months) MACE12months CardiacDeath2years CardiacDeath/MACE4years Results EuroSCORE≥6 HR3.4(1.2-9.6) OR1.03(1.0-1.06) EuroSCORE≥6 AUC:0.876(0.823-0.918) EuroSCORE≤5:24% EuroSCORE>5:27% EuroSCORE≥6 OR3.9(1.1-14-1) EuroSCORE>6 HR2.24(1.05-4.77) 1EuroSCOREpoint 15%(2.9-28.2%) EuroSCORE>6 AUC0.687/0.589 p 0.023 0.024 <0.001 0.5 0.037 0.04 0.013 0.005/ 0.038

  21. FreedomfromMACCEto2Years bySYNTAXScoreTercile LowScores(0-22) CABG(N=152)CABG(N=123) TAXUS(N=168)TAXUS(N=131) 50 40 50 40 EUROSCORE<4 P=0.11 EUROSCORE≥4 P=0.39 23.8% 30 20 30 20 18.8% CumulativeEventRate(%) CumulativeEventRate(%) 10 10 20.2% 12.2% 24 0 0 0 12 0 12 24 MonthsSinceAllocation KMeventrate±1.5SE,log-rankPvalue MonthsSinceAllocation SYNTAXScoreandeuroSCOREinMVD•TCT2009•Morice SanFrancisco,CA•22Sep09•Slide1

  22. FreedomfromMACCEto2Years bySYNTAXScoreTercile HighScores(33+) CABG(N=147)CABG(N=168) TAXUS(N=123)TAXUS(N=167) 50 40 30 20 10 50 40 30 20 10 EUROSCORE<4 P=0.37 18.9% 15.4% EUROSCORE≥34.9% P<0.001 15.4% CumulativeEventRate(%) CumulativeEventRate(%) 0 0 0 12 24 0 12 24 MonthsSinceAllocation KMeventrate±1.5SE,log-rankPvalue MonthsSinceAllocation SYNTAXScoreandeuroSCOREinMVD•TCT2009•Morice SanFrancisco,CA•22Sep09•Slide1

  23. CTOandLMsummit–NewYork,23February2011–Slide12 SYNTAXandbeyond-Capodanno TheNewRiskClassification(NERS) Basedon17clinical,4procedural, and33angiographicvariables Betterdiscriminatesabroadarray ofendpointsthanSYNTAXscore, includingMACE,Death,MI,TVRand STinpatientsundergoingLMPCI Background Thepotentialcontributionsofclinical, procedural,andangiographicindicesin LMpatientshavenotbeenfully elucidated FerrarottoHospital UniversityofCatania ChenSLetal.JACCInterv.2010;3:632-41

  24. CTOandLMsummit–NewYork,23February2011–Slide14 SYNTAXandbeyond-Capodanno ClinicalSYNTAXscore(CSS) CalculatedasSYNTAX score*modifiedACEFscore Betterdiscriminates5-YearDeath andMACEinmultivesselCADthan SYNTAXscore Betterdiscriminates5-YearDeathin All-ComersPCI Background Beingsolelybasedonangiographic variables,theSYNTAXscorecannot accountforthevariabilityrelatedto clinicalfactorswhicharewidely acknowledgedtoimpactonlong-term outcomes FerrarottoHospital UniversityofCatania GargSetal.CircCardInterv2010;3:317-26 GirasisCetal.EurHeartJ2011;32:3115-27

  25. CTOandLMsummit–NewYork,23February2011–Slide16 SYNTAXandbeyond-Capodanno GlobalRiskClassification(GRC) DevelopedasanIntegrationofthe SYNTAXscoreandtheEuroSCORE Betterdiscriminatesin-hospitaland 2-YearCardiacDeathinLMPCIthan SYNTAXscorealone Conclusions Incorporationofclinicalriskfactorsand comorbiditiesintoexistingestimation systemsmayrefinetheirprognostic abilityandguideclinicaldecisions FerrarottoHospital UniversityofCatania CapodannoDetal.AmHeartJ2010;159:103-9

  26. CTOandLMsummit–NewYork,23February2011–Slide28 SYNTAXandbeyond-Capodanno FunctionalSYNTAXscore(FSS) Gradesonlyischemia-producing lesionswithFFR≤0.80 Decreasesthenumberofhigher- riskpatients Betterdiscriminatesriskfor1-Year MACEinmultivesselCADPCI Improvesreproducibilityduetoless chancefordisagreement Background PCIofafunctionallynonsignificant stenosisisnotofbenefittothepatient, eitherfromaprognosticorfroma symptomaticpointofview(FAMEtrial) FerrarottoHospital UniversityofCatania NamCWetal.JAmCollCardiol2011;58:1211-8

  27. CTOandLMsummit–NewYork,23February2011–Slide32 SYNTAXandbeyond-Capodanno Quantifyingincompleterevascularization:the ResidualSYNTAXscore(rSS) WhataboutscoringSYNTAXscoreafter theprocedure? rSS=0meanscompleterevascularization rSS>0quantifiesincreasinglevelsof   incompleterevascularization rSS>5foundtobeanindependent predictorofmortalityin2403VD±LM patients.Furthervalidationawaited FerrarottoHospital UniversityofCatania MalkinCJetal.Eurointervention2011(7)Suppl.(abstract)

  28. Grace评分 • 来自Grace注册研究 • 指标:年龄 充血性心衰病史 心梗病史 基础心率 收缩压 ECG ST段压低 肌酐水平 心肌酶升高 住院期间是否PCI • 应用于急性冠脉综合征的危险分层 • 也应用于PCI风险的预测指标

  29. TIMI评分 • 应用于非ST段抬高急性冠脉综合征危险分层 • 七个指标代表七分 • 4分以上代表高危,是急诊PCI适应症

  30. 谢谢

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