Syntax Score I and II for Predicting Carotid Artery Stenosis in Patients with Multivessel Coronary Artery Disease: A Propensity Score Matching Analysis

Abstract

[...]SS I may be less powerful than Gensini score to predict atherosclerotic burden. [...]extent of coronary atherosclerosis may not be thoroughly represented with SS I. A recent study found CAS as an independent predictor of high SYNTAX score (>32), however, the study population was heterogeneous and comprised patients with single and multivessel disease16. Limitations The relatively small number of patients and the retrospective nature of the study are major limitations. Since Doppler ultrasound was performed before surgery with the intention to identify critical CAS, CIMT, which may have a further contribution, was not evaluated. [...]our findings are valid for a restricted patient group.

After propensity score matching analysis (66 vs. 66), SS II PCI and CABG were significantly higher in patients with CAS than those without CAS 37.4 (30.9-43.5) vs. 33 (29.3-36.9); P=0.03. SS I was similar between groups. Age was significantly higher in patients with CAS. Characteristics of the population before and after matching are presented in Table 1.

In the matched population, age, SS II PCI and CABG were associated with CAS in univariate logistic regression analysis OR=1.086, 95% CI (1.032-1.143), P<0.001; OR=1.054, 95% CI (1.010-1.101), P=0.02; OR=1.078, 95% CI (1.029-1.129), P<0.01. The results of univariate analysis are listed in Table 2.

[ Table Omitted - see PDF ]

DISCUSSION

Approximately 16% of the patients in our study had significant CAS. The present study demonstrated increased SS II PCI and CABG score in patients with CAS compared to those without CAS by means of propensity score matched analysis. SS II is associated with significant CAS in a population with multivessel disease. SS II CABG had a better diagnostic accuracy, albeit not statistically significant. SS I was not found to be associated with CAS.

Carotid intima-media thickness (CIMT) was shown to be associated with cardiovascular mortality. Several studies demonstrated a close association between CIMT and SS I^9-11. A recent study showed that CIMT correlated with SS II¹². Two previous studies concluded that SS I is not a predictor of CAS^13,14. Compatible with these studies, SS I was not associated with CAS whereas age was an independent predictor of CAS in our study¹⁴. A latter study by the same group of researchers confirmed a relationship between SS II and CAS¹⁵. A recent study by Avci et al.¹³ demonstrated the association between SS I and CAS, however, this association was not independent. As argued in various studies, SS is a weighted score taking into account anatomical properties such as tortuosity and calcification, in addition to atherosclerotic lesions. Thus, SS I may be less powerful than Gensini score to predict atherosclerotic burden. Therefore, extent of coronary atherosclerosis may not be thoroughly represented with SS I.

A recent study found CAS as an independent predictor of high SYNTAX score (>32), however, the study population was heterogeneous and comprised patients with single and multivessel disease¹⁶. Up to date, only a single study investigated the relationship between SS II and CAS¹⁵. Baseline characteristics and risk factors of patients in this study were similar to ours. Age was the most important risk factor for CAS in both studies. SS I only reflects anatomical complexity of coronary artery disease. Recently, SS II incorporates clinical factors such as age, sex, and eGFR, in addition to SS I. However, we think high SS II in our study seems to be more related to age and peripheral arterial disease (PAD) rather than other variables in the scoring system, since they are not associated with CAS in the regression analysis. Apart from the previous studies, we used propensity score matching in order to balance patient characteristics. Nevertheless, CAS seems to be more related to age rather than the complexity of coronary atherosclerosis and clinical risk factors in patients with multivessel disease.

Limitations

The relatively small number of patients and the retrospective nature of the study are major limitations. Since Doppler ultrasound was performed before surgery with the intention to identify critical CAS, CIMT, which may have a further contribution, was not evaluated. Subjects enrolled in our study have multivessel disease and most patients had intermediate to high SS scores. This restriction causes a limitation to generalize the study. Thus, our findings are valid for a restricted patient group.

CONCLUSION

SS I is not associated with significant carotid artery stenosis. SS II is useful to predict carotid artery stenosis in patients with multivessel coronary artery disease.

This study was carried out at Haseki Training and Research Hospital, Istanbul, Turkey.

No financial support.

References

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