Comparison of the New Mayo Clinic Risk Scores and Clinical SYNTAX Score in Predicting Adverse...
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Comparison of the New Mayo Clinic Risk Scores and Clinical SYNTAX Score in Predicting Adverse Cardiovascular Outcomes following Percutaneous Coronary Intervention at the Philippine Heart Center Helenne Joie M. Brown, MD
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Transcript of Comparison of the New Mayo Clinic Risk Scores and Clinical SYNTAX Score in Predicting Adverse...
Comparison of the New Mayo Clinic Risk Scores and Clinical SYNTAX
Score in Predicting Adverse Cardiovascular Outcomes following Percutaneous Coronary Intervention
at the Philippine Heart Center
Helenne Joie M. Brown, MD
Ischemic Heart Disease
Risk StratificationBackgroundBackground
Management
Quality ControlEvaluation of
health economics
ObjectiveObjective
Clinical
Prognostic Value
In-hospital and 30-day Mortality and MACCE
New Mayo Clinic Risk Scores
Study DesignStudy DesignProspective Cohort Study
Inclusion CriteriaAll patients who underwent
percutaneous coronary intervention at the Philippine
Heart Center during the period of April 1, 2011 to
September 30, 2011,
aged > 18 years were included.
Exclusion CriteriaPatients with no baseline
systolic function.
Study DesignStudy DesignSample Size
The computed sample size was > 460 based on 95% confidence level and 80% power to detect statistical significance at assumed difference in area under the curve of 10%. The assumption was based on the paper of Garg et al which presented an AUC of 0.89 for MACE.
Garg S et al. A New Tool for the Risk Stratification of Patients with Complex Coronary Artery Disease: The Clinical SYNTAX Score. Circ
Cardiovasc Interv. 2010;3:317-326.
Study DesignStudy DesignStudy Maneuver
Ischemic Heart Disease
PCI
Cardiovascular history and risk factors
Coronary Angiogram
2 Interventional Cardiologists
ClinicalNew Mayo Clinic
Risk Scores
Study DesignStudy DesignStudy Maneuver
• Age
• Serum creatinine
• LVEF
• Preprocedural shock = 9 points
• MI < 24 hours = 4 points
• CHF on presentation = 3 points
• PAD = 2 points
CSS = [SYNTAX Score] x [modified
ACEF score]
ClinicalNew Mayo Clinic
Risk Scores
Study DesignStudy DesignStudy Maneuver
Risk Stratification
Low-risk: < 15.6 Moderate risk: >15.6 <27.5
High risk: >27.5 Mortality PredictionVery low risk: 0-5
Low-risk: 6-7Moderate risk: 8-10
High risk: 11-12Very high risk: 13+
MACCE PredictionVery low risk: 0-2
Low-risk: 3-5Moderate risk: 6-90
High risk: 10-13Very high risk: 14+
Outcomes
In-hospital and 30-day all-cause mortality and
MACCE
ClinicalNew Mayo Clinic
Risk Scores
Study Maneuver
Risk Stratification
Low-risk: < 15.6 Moderate risk: >15.6 <27.5
High risk: >27.5 Mortality PredictionVery low risk: 0-5
Low-risk: 6-7Moderate risk: 8-10
High risk: 11-12Very high risk: 13+
MACCE PredictionVery low risk: 0-2
Low-risk: 3-5Moderate risk: 6-90
High risk: 10-13Very high risk: 14+
Outcomes
In-hospital and 30-day all-cause mortality and
MACCE
Results
N = 482
Variable n = 482
Mean SD
Age, + SD, years 59.8 + 11.4
Serum Creatinine, mg/dl 1.2 + 0.9
Creatinine Clearance,
ml/min
74.1 + 29.6
LVEF, % 55.3 + 9.4
Table 1. Baseline and Procedural Variables
ResultsResults
Variable n= 482
No. %
Gender
Male
Female
367
115
76.1
23.9
Myocardial Infarction < 24 hours 98 20.3
Unstable Angina 176 36.5
Non-elective PCI 82 17.0
Diabetes mellitus 175 36.3
Current and previous smoker 253 52.5
Hypertension 373 77.4
Dyslipidemia 373 77.4
CHF on presentation 64 13.3
Table 1. Baseline and Procedural VariablesResultsResults
Variable n= 482
No. %
NYHA Class III or IV 22 4.6
PAD 23 4.8
Previous PCI 40 8.3
Previous CABG 29 6.0
Previous MI 138 28.6
Previous CVA 20 4.1
Family History of IHD 86 17.8
Table 1. Baseline and Procedural VariablesResultsResults
Variable n= 482
No. %
Meds at Screening
ASA 425 88.2
Clopidogrel 298 61.8
B-blockers 233 48.3
ACE inhibitors/ARBs 405 84.0
Statins 446 92.5
Table 1. Baseline and Procedural VariablesResultsResults
ClinicalNew Mayo Clinic
Risk Scores
Risk Stratification
Low-risk: < 15.6 Moderate risk: >15.6 <27.5
High risk: >27.5 Mortality PredictionVery low risk: 0-5
Low-risk: 6-7Moderate risk: 8-10
High risk: 11-12Very high risk: 13+
MACCE PredictionVery low risk: 0-2
Low-risk: 3-5Moderate risk: 6-90
High risk: 10-13Very high risk: 14+
Outcomes
In-hospital and 30-day all-cause mortality and
MACCE
Results
N = 482
Event n= 482
No. %
Mortality 22 4.6
Myocardial Infarction 5 1
Emergency CABG 1 0.2
CVA 9 1.9
Table 2. In-hospital Mortality and MACCE following PCI
ResultsResults
Figure 1. ROC Curve for In-hospital Mortality for the New Mayo Clinic Risk Score (NMCRS) for Predicting Mortality, the NMCRS
for Predicting MACE and the Clinical Syntax Score (CSS).
Figure 6. ROC Curve for In-hospital Composite Endpoints for the New Mayo Clinic Risk Score (NMCRS) for Predicting Mortality, the NMCRS for Predicting
MACE and the Clinical Syntax Score (CSS).
ClinicalNew Mayo Clinic
Risk Scores
Risk Stratification
Low-risk: < 15.6 Moderate risk: >15.6 <27.5
High risk: >27.5 Mortality PredictionVery low risk: 0-5
Low-risk: 6-7Moderate risk: 8-10
High risk: 11-12Very high risk: 13+
MACCE PredictionVery low risk: 0-2
Low-risk: 3-5Moderate risk: 6-90
High risk: 10-13Very high risk: 14+
Outcomes
In-hospital and 30-day all-cause mortality and
MACCE
Results
N = 482
Event n= 482
No. %
Mortality 9 2
Myocardial Infarction 9 2
Emergency CABG 0 0
CVA 1 0.2
Table 2. 30-day Mortality and MACCE following PCI
ResultsResults
Figure 4. ROC Curve for 30-day Mortality for the New Mayo Clinic Risk Score (NMCRS) for Predicting Mortality, the NMCRS for Predicting MACE and the
Clinical Syntax Score (CSS).
Figure 7. ROC Curve for 30-day Composite Endpoints for the New Mayo Clinic Risk Score (NMCRS) for Predicting Mortality, the NMCRS for Predicting MACE
and the Clinical Syntax Score (CSS).
Figure 8. ROC Curve for In-hospital and 30-day Composite Endpoints for the New Mayo Clinic Risk Score (NMCRS) for Predicting Mortality, the NMCRS for
Predicting MACE and the Clinical Syntax Score (CSS).
versus
AgeSerum creatinine
LVEF
Garg et al. A New Tool for the Risk Stratification of Patients with Complex Coronary Artery Disease: The Clinical SYNTAX Score. Circ Cardiovasc Interv.
2010;3:317-326.
predictors of adverse outcomes after revascularization
Ranucci et al. Risk of Assessing Mortality Risk in Elective Cardiac Operations: Age, Creatinine, Ejection Fraction, and the Law of Parsimony. Circulation.
2009;119:3053-3061.
not subject to interobserver variability
Risk Stratification
Mortality Prediction MACCE PredictionOutcomes
In-hospital and 30-day all-cause mortality and
MACCE
Results
Clinical variables
Clinical + angiographic
variables
versus
“… despite exclusion of angiographic variables, the NMCRS can accurately estimate peri-procedural risk from PCI.”
Singh et al. Bedside Estimation of Risk from Percutaneous Coronary Intervention: The New Mayo Clinic Risk Scores. Mayo Clin Proc June
2007;82(6):701-708.
Our study demonstrated that the prognostic utility of the NMCRS for predicting mortality and MACCE can be extended to estimation of mortality and MACCE 30 days after a patient undergoes PCI.
versus
all-comers study: 1-, 2- 3-vessel CAD
2- or 3-vessel CADExcluded: Previous PTCA Left Main CAD Overt CHF LVEF < 30% Hx of TIA Hx of transmural MIUtility: long-term outcomes
ConclusionConclusion
This study demonstrates the superior ability of a risk stratification tool which uses purely clinical variables, i.e. (1) the NMCRS for Predicting Mortality to predict in-hospital mortality and composite MACCE and (2) the NMCRS for Predicting MACE to predict 30-day mortality and composite MACCE, when compared with the CSS which uses angiographic and clinical variables.
RecommendationRecommendation
• We therefore recommend the use of the New Mayo Clinic Risk Score for risk stratification of patients who will undergo PCI.
simple bedside toolexpedient for both the physician and patient in decision-making for revascularizationsuperior discriminative ability over the Clinical Syntax Score for peri-procedural and 30-day adverse outcomes
Good afternoon.Good afternoon.
