#RISK ENGINE SCORE FOR CAD TRIAL#
7īased on the results of the landmark SYNTAX trial where a systematic evaluation of its score was used for the first time, 8 SYNTAX scores of >22 and >32 should contraindicate (class III) revascularisation by PCI in patients with multivessel or left main disease, respectively. percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). As endorsed by European guidelines, the SYNTAX score should be implemented as a tool to inform the decision-making processes between different revascularisation strategies (i.e. 12 questions ranging from anatomy to characteristics of lesion subsets such as bifurcations or chronic total occlusions). The SYNTAX score evaluates the anatomical burden and complexity of CAD by using a multi-parametric quantification tool based on coronary angiography (i.e.
Different risk scores can be useful aids to better inform the heart team discussion. In contrast with ACS management, where timely intervention is required and prognostically beneficial, stable CAD allows for a detailed diagnostic and therapeutic workup. In patients with stable CAD, a shared multidisciplinary therapeutic decision-making process looking at the identification of the best treatment strategy – the local heart team discussion – is standard of care in clinical practice. Risk scores for ruling out the presence of CAD have been discussed in detail elsewhere and are beyond the scope of this article. prediction of ischaemic or bleeding risk) ( Figure 2). pre-treatment, treatment, post-treatment/discharge and follow-up) clinical presentation (stable CAD undergoing PCI versus ACS presentation) and outcome prognostication (i.e. This article aims to review the most accepted prognostic risk models for patients with evidence of CAD.įor the sake of clarity, risk scores have been grouped according to the following criteria: logical temporal sequence of CAD management (i.e. In recent years, the multiplication of risk scoring systems for CAD has generated some degree of uncertainty regarding whether, when and how predictive models should be adopted in driving clinical decisions. Finally, a risk score should prove to be effective (‘valid’) in similar but independent populations. The performance of a score, which concerns its accuracy in term of prediction, is measured by the Brier score, with values ranging from 0 (perfect prediction) to 1 (worst prediction). 4 “Calibration”, which illustrates the similarity between predicted and observed risk, is identified by the Hosmer-Lemeshow goodness-of-fit test, with a chi-squared distribution in which the lower the value, the higher the calibration. The ability to distinguish between high and low risk is called “discrimination”, and this is mathematically represented by a measure of concordance, the c-statistic (whose values range from 0.5 for worst discrimination and 1.0 for perfect discrimination). 3Īn ideal prognostic risk score should satisfy different characteristics ( Figure 1). Risk scores can be diagnostic or prognostic, and the latter is more difficult to develop and validate because of the stochastic and time-varying nature of clinical outcomes. In making decisions when more than one treatment is available, physicians may rely entirely on their judgement, use clinical algorithms or be assisted by risk scores. Directing appropriate treatment strategies to the right individuals is a clinical challenge. It is increasingly understood that personalised medicine that takes these factors into account achieves superior results than “one-size-fits-all” approaches, which may ignore, for example, individual risk of ischaemia or propensity to bleed with antithrombotics. 2Ī variety of individual factors and circumstances other than clinical presentation and treatment type contribute to determining the outcome of CAD. Guideline-directed medical therapy and revascularisation using percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) are the main treatment strategies across the spectrum of CAD. unstable angina, non-ST-elevation MI and ST-elevation myocardial infarction ). chronic angina pectoris) to acute coronary syndromes (ACS), which encompass a variety of clinical scenarios (e.g.
1 Based on clinical presentation and prognosis, CAD spans from stable presentations (e.g.
Although a combination of multiple strategies to prevent and treat coronary artery disease (CAD) has led to a relative reduction in cardiovascular mortality over recent decades, CAD remains the greatest cause of morbidity and mortality worldwide.
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