SYNTAX score for assessing coronary artery disease burden and complexity: past, present, and future

The anatomical synergy between percutaneous coronary intervention with TAXUS and cardiac surgery (SYNTAX) score remains a cornerstone for quantifying coronary artery disease complexity and guiding decisions between percutaneous coronary intervention and coronary artery bypass grafting. Developed from the SYNTAX trial in 2009, the score uses a standard methodological approach to systematically define coronary lesion attributes and yields an overall score that allows stratification of coronary complexity. A commonly accepted stratification divides patients into low (≤ 22), intermediate (23-32), and high (≥ 33) SYNTAX score, with higher categories associated with an increased risk of adverse cardiovascular events. This review article traces the history, evolution, and integration of the SYNTAX score in ESC and ACC/AHA guidelines. We also discuss its role in clinical trials and its contribution to Heart Team deliberations in patients with complex coronary artery disease. Patient benefits include adding precision for treatment selection with a historical potential to lower mortality in high-score cases by favoring coronary artery bypass grafting. Artificial intelligence and advanced imaging, such as coronary computed tomography angiography, are advancing automated, noninvasive SYNTAX score computation with superior accuracy. Future directions involve artificial intelligence-hybrid models for real-time, personalized assessments. This review article evaluates the enduring impact of the SYNTAX score and its evolving role in precision medicine.