SYNTAX Guides Decision-Making for Myocardial Revascularization

Gauging a patient’s candidacy for percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery has gotten easier as a result of the SYNTAX (SYNergy between Percutaneous Coronary Intervention with TAXus and Cardiac Surgery) trial. A paper recently published ahead of print in the online Progress in Cardiovascular Diseases highlights some of the clinical lessons and tools that stemmed from the influential trial.

“The landmark SYNTAX trial represents the largest assessment of revascularization with CABG or PCI in subjects with complex coronary artery disease. SYNTAX aimed to supply evidence to support the somewhat established, but non–evidence-based practice of performing PCI in patients with complex coronary artery disease and also sought to identify which patients should only be treated with CABG,” wrote authors Vasim Farooq, MBChB, MRCP, PhD, University of Manchester and Manchester Heart Center, and Patrick W. Serruys, MD, PhD, Imperial College, London. “Through an all-comers design, SYNTAX addressed the limitations of the earlier CABG vs PCI trials, which were plagued by profound selection bias.”

SYNTAX established the heart team, including an interventional cardiologist and cardiac surgeon, as the key decision-maker along with the patient. The anatomical SYNTAX score tool was developed to quantify the patient’s coronary artery disease burden to measure whether equivalent anatomical revascularization was possible. Today, the anatomical SYNTAX score is a recommended tool in both US and European myocardial revascularization guidelines to advise decision-making on whether PCI or CABG is more appropriate for a patient, the authors wrote.

SYNTAX also led to the development of the SYNTAX Score II, an upgrade of the anatomical SYNTAX score that includes more clinical variables and a more personalized approach to decision-making. Prospective validation of the SYNTAX Score III is currently underway in two clinical trials: the EXCEL (Evaluation of XIENCE PRIME or XIENCE V or XCIENCE Xpedition or XCIENCE PRO Everolimus Eluting Stent System Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial and the ongoing SYNTAX II Trial.

“Unquestionably, both [the] SYNTAX [trial] and [the] FREEDOM [trial] have aided in delineating the boundaries on the appropriateness of surgical and percutaneous-based revascularization. SYNTAX has established the heart team as the basis for decision-making in patients with complex coronary artery disease, and allowed for the development of several clinical tools…to aid this process,” the authors wrote. However, they added that “one should not underestimate the vital role of guideline-directed optimal medical therapy, risk factor control, and smoking cessation in reducing coronary artery disease progression and clinical events.”—Jolynn Tumolo


Farooq V, Serruys PW. Bypass grafting versus percutaneous intervention—which is better in multivassel coronary disease: lessons from SYNTAX and beyond [published online ahead of print October 31, 2015]. Prog Cardiovasc Dis. doi:10.1016/j.pcad.2015.10.002.