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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. Background. Risk Stratification. Management.

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slide1

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

slide2

Background

Risk Stratification

Management

Evaluation of health economics

Quality Control

Ischemic Heart Disease

slide3

Objective

New Mayo Clinic Risk Scores

Clinical

Prognostic Value

In-hospital and 30-day Mortality and MACCE

slide4

Study Design

Prospective Cohort Study

Inclusion Criteria

All 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 Criteria

Patients with no baseline systolic function.

slide5

Study Design

Sample 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.

slide6

Study Design

Study Maneuver

Ischemic Heart Disease

Cardiovascular history and risk factors

2 Interventional Cardiologists

Coronary Angiogram

PCI

slide7

Study Design

Study Maneuver

New Mayo Clinic Risk Scores

Clinical

CSS = [SYNTAX Score] x [modified ACEF score]

  • Age
  • Serum creatinine
  • LVEF
  • Preprocedural shock = 9 points
  • MI < 24 hours = 4 points
  • CHF on presentation = 3 points
  • PAD = 2 points
slide8

Study Design

Study Maneuver

New Mayo Clinic Risk Scores

Clinical

Risk Stratification

Low-risk: < 15.6

Moderate risk: >15.6 <27.5

High risk: >27.5

Mortality Prediction

Very low risk: 0-5

Low-risk: 6-7

Moderate risk: 8-10

High risk: 11-12

Very high risk: 13+

MACCE Prediction

Very low risk: 0-2

Low-risk: 3-5

Moderate risk: 6-90

High risk: 10-13

Very high risk: 14+

Outcomes

In-hospital and 30-day all-cause mortality and MACCE

slide9

Study Maneuver

Results

New Mayo Clinic Risk Scores

Clinical

N = 482

Risk Stratification

Low-risk: < 15.6

Moderate risk: >15.6 <27.5

High risk: >27.5

Mortality Prediction

Very low risk: 0-5

Low-risk: 6-7

Moderate risk: 8-10

High risk: 11-12

Very high risk: 13+

MACCE Prediction

Very low risk: 0-2

Low-risk: 3-5

Moderate risk: 6-90

High risk: 10-13

Very high risk: 14+

Outcomes

In-hospital and 30-day all-cause mortality and MACCE

slide10

Results

Table 1. Baseline and Procedural Variables

slide11

Results

Table 1. Baseline and Procedural Variables

slide12

Results

Table 1. Baseline and Procedural Variables

slide13

Results

Table 1. Baseline and Procedural Variables

slide14

Results

New Mayo Clinic Risk Scores

Clinical

N = 482

Risk Stratification

Low-risk: < 15.6

Moderate risk: >15.6 <27.5

High risk: >27.5

Mortality Prediction

Very low risk: 0-5

Low-risk: 6-7

Moderate risk: 8-10

High risk: 11-12

Very high risk: 13+

MACCE Prediction

Very low risk: 0-2

Low-risk: 3-5

Moderate risk: 6-90

High risk: 10-13

Very high risk: 14+

Outcomes

In-hospital and 30-day all-cause mortality and MACCE

slide15

Results

Table 2. In-hospital Mortality and MACCE following PCI

slide16

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).

slide17

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).

slide18

Results

New Mayo Clinic Risk Scores

Clinical

N = 482

Risk Stratification

Low-risk: < 15.6

Moderate risk: >15.6 <27.5

High risk: >27.5

Mortality Prediction

Very low risk: 0-5

Low-risk: 6-7

Moderate risk: 8-10

High risk: 11-12

Very high risk: 13+

MACCE Prediction

Very low risk: 0-2

Low-risk: 3-5

Moderate risk: 6-90

High risk: 10-13

Very high risk: 14+

Outcomes

In-hospital and 30-day all-cause mortality and MACCE

slide19

Results

Table 2. 30-day Mortality and MACCE following PCI

slide20

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).

slide21

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).

slide22

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).

slide23

versus

Age

Serum creatinine

LVEF

 predictors of adverse outcomes after revascularization

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.

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

slide24

Results

Risk Stratification

Mortality Prediction

MACCE Prediction

Clinical + angiographic variables

Outcomes

Clinical variables

In-hospital and 30-day all-cause mortality and MACCE

slide25

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.

slide26

versus

all-comers study:

1-, 2- 3-vessel CAD

2- or 3-vessel CAD

Excluded:

Previous PTCA

Left Main CAD

Overt CHF

LVEF < 30%

Hx of TIA

Hx of transmural MI

Utility: long-term outcomes

slide27

Conclusion

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.

slide28

Recommendation

  • We therefore recommend the use of the New Mayo Clinic Risk Score for risk stratification of patients who will undergo PCI.
      • simple bedside tool
      • expedient for both the physician and patient in decision-making for revascularization
    • superior discriminative ability over the Clinical Syntax Score for peri-procedural and 30-day adverse outcomes