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Performance of the J-CTO score versus other risk scores for predicting procedural difficulty in coronary chronic
Wenjie Zuo1, Jie Lin1,2, Renhua Sun3
1Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China.
Insights
The Japanese chronic total occlusion (J-CTO) score effectively predicts 30-minute wire crossing success but shows moderate performance for technical success. Current evidence does not strongly support newer models over the J-CTO score, highlighting the need for standardized CTO score assessment.
Area of Science:
- Cardiovascular Interventions
- Interventional Cardiology
- Medical Decision Making
Background:
- The Japanese chronic total occlusion (J-CTO) score is a widely utilized tool for assessing the complexity of chronic total occlusion (CTO) revascularization.
- Validation studies have reported conflicting results regarding the J-CTO score's effectiveness, necessitating a quantitative evaluation.
Approach:
- A systematic literature search was conducted across major databases (PubMed, Embase, Cochrane Library, ClinicalTrials.gov) from 2011 to 2021.
- Meta-analysis was performed on eligible studies using a random-effects model to pool estimates of discrimination and calibration.
- Risk of bias was assessed using the Prediction model Risk Of Bias ASsessment Tool (PROBAST), adhering to PRISMA guidelines.
Key Points:
- The J-CTO score demonstrated significant discrimination for 30-minute wire crossing (C-statistic 0.76) and technical success (C-statistic 0.68), despite considerable heterogeneity.
- In pairwise comparisons, the J-CTO score's performance varied, outperforming some scores while underperforming others.
- Methodological limitations were noted, particularly in the appropriate evaluation of model calibration, with only one study meeting the criteria.
Conclusions:
- The J-CTO score offers useful predictive discrimination for time-efficient wire crossing and moderate utility for angiographic success.
- There is a lack of robust independent evidence to suggest that newer CTO scoring models consistently outperform the J-CTO score.
- Standardized reporting and statistical methodologies are crucial for accurate comparison and understanding of CTO scores, especially concerning calibration.
Background:
Although the Japanese chronic total occlusion (J-CTO) score is widely used to assess the complexity of revascularization for CTO lesions, ambiguous and conflicting results are reported in validation studies. Therefore, we aimed to quantitatively evaluate the effectiveness of the J-CTO score and explore the heterogeneity of its comparison with other CTO scores.
Methods:
PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov databases were systematically searched from January 1st, 2011 to December 23rd, 2021. Studies that examined the accuracy of the J-CTO score were eligible. Where feasible, estimates of discrimination and calibration were pooled with a random-effects model. The Prediction model Risk Of Bias ASsessment Tool (PROBAST) was used for risk-of-bias assessment. This study was reported according to PRISMA guidelines and prospectively registered with PROSPERO (CRD42019126161).
Results:
Of 28 included studies (N = 34,944 lesions), 24 were eligible for meta-analysis. The J-CTO score demonstrated significant discrimination for 30-min wire crossing (summary C-statistic 0.76; 95% CI 0.68-0.84) and technical success (0.68; 95% CI 0.61-0.74) despite significant heterogeneity. Only 19 (33%) of the 58 pairwise comparisons with 14 competing scores that were based on discrimination reported a statistical result. The J-CTO score performed worse (relative difference of C-statistics >5%) in eight out of 33 independent comparisons but better in another 13. Methodological shortcomings resulted from only one study evaluating model calibration appropriately.
Conclusion:
The discrimination power of the J-CTO score was useful for time-efficient wire crossing and moderate for angiographic success. Head-to-head comparisons of CTO scores would benefit from standardized reporting and appropriate statistical methods.Key messagesThe J-CTO score has useful discrimination in predicting 30-min wire crossing while performing moderately for technical success.After excluding optimism bias, there is insufficient independent evidence supporting the superiority of newly introduced models over the J-CTO score.Standardized methodology and assessment are needed to achieve a better understanding of CTO scores, especially for their calibration.
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