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Signal Acquisition, Score Interpretation, and Economics of a Non-Invasive Point-of-Care Test for Coronary Artery Disease
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Overall coronary disease burden modifies the prognostic benefit of CTO-PCI: a SYNTAX score-stratified meta-analysis

Nino Cocco1, Kambis Mashayekhi2, Agostino Spanò1

  • 1Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Via Álvaro del Portillo 21, Rome 00128, Italy.

European Heart Journal Open
|April 3, 2026
PubMed

Insights

Successful percutaneous coronary intervention for chronic total occlusion (CTO-PCI) significantly reduces cardiovascular mortality, especially in patients with extensive coronary artery disease (CAD). The survival benefit of CTO-PCI increases with higher anatomical complexity, as indicated by the SYNTAX score.

Area of Science:

  • Cardiology
  • Interventional Cardiology
  • Health Outcomes Research

Background:

  • Extensive coronary artery disease (CAD) with chronic total occlusion (CTO) is linked to poor outcomes.
  • Patients with advanced CAD are often underrepresented in clinical trials.
  • The impact of CTO percutaneous coronary intervention (CTO-PCI) on prognosis across varying anatomical complexity is unclear.

Purpose of the Study:

  • To investigate if the overall burden of CAD, measured by the SYNTAX score (SS), modifies the prognostic effect of CTO-PCI.
  • To evaluate the relationship between anatomical complexity and the effectiveness of CTO-PCI.

Main Methods:

  • A systematic literature search was conducted across major databases (PubMed, Embase, Google Scholar, Cochrane).
  • Seventeen studies (3 randomized, 14 observational) involving 11,001 patients were included, comparing successful CTO-PCI versus no CTO-PCI.
  • Pooled hazard ratios for annualized cardiovascular mortality were calculated; meta-regression and subgroup analyses explored the influence of the SYNTAX score.

Main Results:

  • Successful CTO-PCI was associated with a significant reduction in cardiovascular mortality (HR 0.54; P < 0.001).
  • The survival benefit of CTO-PCI increased with CAD complexity: HRs were 0.61 (low SS), 0.44 (intermediate SS), and 0.10 (high SS).
  • Meta-regression confirmed a complexity-dependent effect, with approximately 1.5% lower annual CV mortality per 10-point SS increase (P = 0.001).

Conclusions:

  • The survival benefit of CTO-PCI appears to be amplified in patients with a higher extent of coronary artery disease.
  • Patients with greater anatomical complexity (higher SYNTAX score) may experience a more substantial prognostic improvement from successful CTO revascularization.
Abstract

Keywords:
Cardiac sudden deathChronic total occlusionGlobal atherosclerotic burdenPercutaneous coronary interventionRefractory cardiac arrest

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