Department of Interventional Cardiology, Erasmus University Medical Centre, Thoraxcenter, Rotterdam, the Netherlands.
JACC Cardiovasc Interv. 2013 Jul;6(7):737-45. doi: 10.1016/j.jcin.2013.04.004.
This study sought to validate the Logistic Clinical SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score in patients with non-ST-segment elevation acute coronary syndromes (ACS), in order to further legitimize its clinical application.
The Logistic Clinical SYNTAX score allows for an individualized prediction of 1-year mortality in patients undergoing contemporary percutaneous coronary intervention. It is composed of a "Core" Model (anatomical SYNTAX score, age, creatinine clearance, and left ventricular ejection fraction), and "Extended" Model (composed of an additional 6 clinical variables), and has previously been cross validated in 7 contemporary stent trials (>6,000 patients).
One-year all-cause death was analyzed in 2,627 patients undergoing percutaneous coronary intervention from the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial. Mortality predictions from the Core and Extended Models were studied with respect to discrimination, that is, separation of those with and without 1-year all-cause death (assessed by the concordance [C] statistic), and calibration, that is, agreement between observed and predicted outcomes (assessed with validation plots). Decision curve analyses, which weight the harms (false positives) against benefits (true positives) of using a risk score to make mortality predictions, were undertaken to assess clinical usefulness.
In the ACUITY trial, the median SYNTAX score was 9.0 (interquartile range 5.0 to 16.0); approximately 40% of patients had 3-vessel disease, 29% diabetes, and 85% underwent drug-eluting stent implantation. Validation plots confirmed agreement between observed and predicted mortality. The Core and Extended Models demonstrated substantial improvements in the discriminative ability for 1-year all-cause death compared with the anatomical SYNTAX score in isolation (C-statistics: SYNTAX score: 0.64, 95% confidence interval [CI]: 0.56 to 0.71; Core Model: 0.74, 95% CI: 0.66 to 0.79; Extended Model: 0.77, 95% CI: 0.70 to 0.83). Decision curve analyses confirmed the increasing ability to correctly identify patients who would die at 1 year with the Extended Model versus the Core Model versus the anatomical SYNTAX score, over a wide range of thresholds for mortality risk predictions.
Compared to the anatomical SYNTAX score alone, the Core and Extended Models of the Logistic Clinical SYNTAX score more accurately predicted individual 1-year mortality in patients presenting with non-ST-segment elevation acute coronary syndromes undergoing percutaneous coronary intervention. These findings support the clinical application of the Logistic Clinical SYNTAX score.
本研究旨在验证非 ST 段抬高型急性冠状动脉综合征（ACS）患者的 Logistic Clinical SYNTAX（经皮冠状动脉介入治疗与心脏手术之间的协同作用）评分，以进一步使其临床应用合法化。
Logistic Clinical SYNTAX 评分可对接受当代经皮冠状动脉介入治疗的患者进行 1 年死亡率的个体化预测。它由“核心”模型（解剖学 SYNTAX 评分、年龄、肌酐清除率和左心室射血分数）和“扩展”模型（由另外 6 个临床变量组成）组成，并且之前已经在 7 项当代支架试验中进行了交叉验证（>6000 例患者）。
对 ACUITY（急性血管造影和紧急介入治疗分诊策略）试验中接受经皮冠状动脉介入治疗的 2627 例患者进行了 1 年全因死亡分析。使用一致性（C）统计量评估核心和扩展模型对死亡率的预测，以评估区分度，即区分有无 1 年全因死亡的能力（通过一致性[C]统计量评估），并使用验证图评估校准度，即观察结果与预测结果之间的一致性。进行决策曲线分析，权衡使用风险评分进行死亡率预测的危害（假阳性）和益处（真阳性），以评估临床实用性。
在 ACUITY 试验中，中位数 SYNTAX 评分为 9.0（四分位距 5.0 至 16.0）；约 40%的患者有 3 支血管病变，29%有糖尿病，85%接受药物洗脱支架植入术。验证图证实了观察到的死亡率与预测死亡率之间的一致性。与单独的解剖学 SYNTAX 评分相比，核心和扩展模型在预测 1 年全因死亡率方面具有显著提高的判别能力（C 统计量：SYNTAX 评分：0.64，95%置信区间[CI]：0.56 至 0.71；核心模型：0.74，95%CI：0.66 至 0.79；扩展模型：0.77，95%CI：0.70 至 0.83）。决策曲线分析证实，与核心模型相比，扩展模型能够更准确地识别出在广泛的死亡率风险预测阈值下将在 1 年内死亡的患者，从而正确识别出患者。
与单独的解剖学 SYNTAX 评分相比，Logistic Clinical SYNTAX 评分的核心和扩展模型更准确地预测了接受经皮冠状动脉介入治疗的非 ST 段抬高型急性冠状动脉综合征患者的 1 年个体死亡率。这些发现支持 Logistic Clinical SYNTAX 评分的临床应用。
