Risk assessment for percutaneous coronary intervention of the unprotected left main coronary artery in a real-world
Peter Kayaert1, Walter Desmet, Peter Sinnaeve
1Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.
Insights
Existing scoring systems inaccurately predict outcomes for unprotected left main coronary artery revascularization. An integrated risk model combining multiple factors offers a more balanced and accurate prediction of patient events.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Risk Stratification
Background:
- Current clinical and angiographic scoring systems inadequately predict outcomes in patients undergoing unprotected left main coronary artery (ULMCA) revascularization.
- Real-world data is crucial for evaluating the effectiveness of these scoring systems.
Purpose of the Study:
- To prospectively assess major adverse cardiac and cerebrovascular events (MACCE) in a real-world ULMCA percutaneous coronary intervention (PCI) population.
- To compare observed mortality and MACCE with predictions from logistic EuroSCORE and SYNTAX SCORE.
- To develop and evaluate a novel integrated risk model for ULMCA PCI outcomes.
Main Methods:
- Prospective assessment of 240 patients undergoing ULMCA PCI over 12 years.
- Calculation and comparison of logistic EuroSCORE and SYNTAX SCORE against observed 30-day mortality and 1-year MACCE.
- Development of 1-year Global Risk Charts incorporating drug-eluting stents, diabetic status, and factors precluding surgery.
Main Results:
- Logistic EuroSCORE and SYNTAX SCORE significantly overestimated and underestimated mortality, respectively.
- The SYNTAX SCORE substantially underestimated cumulative 1-year MACCE.
- The developed Global Risk Charts provided a more balanced prediction of 1-year clinical outcomes.
Conclusions:
- Existing scoring systems demonstrate limitations in predicting ULMCA PCI outcomes.
- An integrated risk evaluation, combining EuroSCORE, SYNTAX SCORE, stent type, diabetic status, and general condition, shows promise for more accurate outcome prediction.
- Further validation in larger, multicenter settings is warranted.
Background:
Available clinical and angiographic scoring systems fail to predict clinical outcomes in real-world patients undergoing revascularization of the unprotected left main coronary artery (ULMCA).
Methods:
We prospectively assessed major adverse cardiac and cerebrovascular events (MACCE) in a real-world population undergoing percutaneous coronary intervention (PCI) for ULMCA disease. Cumulative risk-adjusted mortality in our patients was compared with expected mortality at 30 days based on logistic EuroSCORE and SYNTAX SCORE. Similarly, we plotted cumulative risk-adjusted MACCE at 1 year based on SYNTAX SCORE. Finally, both scores were combined in 1 year Global Risk Charts, including the use of drug-eluting stents (DES), diabetic status, and several factors precluding coronary surgery.
Results:
Over a 12-year period, 240 patients underwent elective (76%) or urgent (24%) PCI of the ULMCA. Median logistic EuroSCORE and SYNTAX SCORE were 8.7% (3.5; 21) and 23% (14; 31). During the first year of follow-up, 89 patients presented MACCE (37.1%) (46 deaths [19.2%], 18 acute myocardial infarctions [7.5%], 45 revascularizations [18.8%] and 4 strokes [1.7%]). Cumulative risk-adjusted mortality based on individual logistic EuroSCORE and SYNTAX SCORE pointed towards significant overestimation (+19 deaths) and underestimation (-35 deaths) of risk by these respective scoring systems. Similarly, the anatomic SYNTAX SCORE largely underestimated cumulative risk-adjusted MACCE (-60 MACCE). The Global Risk Charts provided a more balanced view on 1-year clinical outcome.
Conclusion:
An integrated risk evaluation combining EuroSCORE, SYNTAX SCORE, diabetic status, stent type and general condition, may predict outcomes more accurately awaiting validation in a larger and multicentre setting.
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