Research on coronary artery lesion and prognostic by syntax score, clinical syntax score in patients with acute myocardial infarction undergoing percutaneous coronary intervention

ctions: Background (02 pages); General Overview (32 pages); Subjects and methods (23 pages); Results (36 pages); Discussion (31 pages); Conclusion (02 pages); Recommendation (01 page). This thesis has 51 tables, 22 charts, 10 figures. This thesis has 150 references, including 14 Vietnamese references and 136 English references. CHAPTER 1: GENERAL OVERVIEW 1.1. Coronary artery disease in the world and in Vietnam 1.1.1. In the world Myocardial infarction is attributed for nearly 1.8 million deaths annually in Europe., which accounts for a total of 20% of deaths. 1.1.2. In Vietnam According to Vietnam National Heart Institute (2003), the rate of acute myocardial infarction increased from 4.5% in 2003 to 9.1% in 20074.5% to 2007 was 9.1%. Particularly, in Cho Ray hospital for example, there were 7,421 hospitalizations for angina, 1,538 hospitalizations and treatments for acute coronary syndrome, and 267 deaths in 2010. 1.2. Diagnosis of acute myocardial infarction * By WHO / ESC / AHA / ACC 2012 Myocardial infarction is defined as having an increase and / or decrease in myocardial biomarkers at least in excess of 99% and at least one of the following characteristics: - Chest pain. - Change the electrocardiogram. - Regional movement disorder due to newly occurring myocardial ischemia by diagnostic imaging (echocardiography, MRI, ...) - There is evidence of coronary thrombosis on coronary angiography or autopsy. 1.3. The scales to track prognosis after coronary intervention 1.3.1. SYNTAX score scale * SYNTAX score developed based on the following scores: 1. Coronary branching according to AHA (ARTS study). 2. Leaman score. 3. Classification of injuries according to ACC / AHA. 4. Duke and ICPS classification systems (according to Medina). * Grading steps follow SYNTAX. - Depending on the location of different lesions, the effect on myocardial perfusion is also different so there will be coefficients for each segment. Step 1. Determine the right or left of the coronary arteries Step 2. Number of lesions of the coronary artery system Step 3. The segments of each lesion have been identified Step 4. Completely clogged coronary arteries Step 5. Lesions in place divided by 3 (Trifurcations) Step 6. Split lesions (Bifurcations) Step 7. Injury at the entrance (Aorto-ostial) Step 8. Serious meandering injury, is it serious? Step 9. Lesions above 20 mm long Step 10. Heavy calcium Step 11. Thrombosis Step 12. Diffuse lesions / small vessels 1.3.2. Clinical SYNTAX score * SYNTAX clinical score formula. CSS = SS x (AGE / EF) + 1 (For each reduction of 10ml / min creatinine clearance <60ml / min / 1.73m2) 1.4. Research overview of SYNTAX and clinical SYNTAX score 1.4.2. In Vietnam There are very few researches studying this topic. For instance, its, Nguyen Hong Son, Nguyen Van Tuan have the prognostic value of Syntax scores in patients after short-term coronary intervention. 1.4.1. In the world There are many studies showing independent values ​​in mortality prognosis and cardiovascular events of clinical SYNTAX (CSS) and SYNTAX score for patients with coronary artery disease and acute myocardial infarction. percutaneous coronary artery interventions in long term . Many studies also compare Syntax score, clinical Syntax score with other score such as Euroscore, PAMI, ACEF, ... the results is Syntax score is more valuable in prognosis of major cardiovascular for patients after intervention.. CHAPTER 2: SUBJECTS AND METHODS 2.1. Subjects 579 patients with acute myocardial infarction at Vietnam National Heart Institute and Hospital 103, from May 2015 to February 2018. There were 296 patients follow-up undergoing percutaneous coronary intervention from 30 days to 12 months. 2.1.1. Criteria for selecting The diagnosis of acute myocardial infarction of ESC 2012: * Clinical: - Chest pain > 20 minutes, spreads to the neck, lower jaw or left arm, does not decrease with Nitroglycerin * Subclinical:  - The 12-lead ECG must be recorded as soon as possible, within 10 minutes. + Electrocardiogram: ST elevation compared to J point, appears in at least two consecutive leads and ≥ 0.25 mV in men under 40, ≥ 0.2 mV in men over 40, or ≥ 0.15 mV in women on V2-V3 and / or ≥ 0.1 mV on other leads. In patients with inferior myocardial infarction, an ST segment elevation should be found in the right precordial leads (V3R and V4R) to determine right ventricular infarction. + Non-shaped ECG: with left bundle branch block, right ventricular pacing or patient without ST elevation but persistent ischemic chest pain or ST elevation in aVR.. - Myocardial biomarkers is routinely recommended during the acute phase but no waiting for results to be for reperfusion. 2.1.2. Exclusion criteria - Patient had previous coronary revascularization by surgery or percutaneous coronary intervention. - Patients with acute myocardial infarction with cardiogenic shock, heart rupture, ventricular septal perforation, - Contraindications to using anti-platelet drugs such as aspirine, clopidogrel or contrast medicine. - There are serious comorbidities such as severe renal impairment, severe liver failure, terminal cancer, diabetic coma. - Patients do not agree for study. 2.2. Methods 2.2.1. Research design: cross sectional description, vertical tracking. 2.2.2. Content and methods               The participants were selected from a unified patient sample including risk factors for coronary artery disease, clinical symptoms of acute myocardial infarction, subclinical , intervention. * Calculate SYNTAX scores, clinical SYNTAX scores - Based on the recorded coronary angiography image, we identify coronary artery lesions according to coronary anatomy classification. We through the Calculator syntax sore 2.11 calculator Clinical SYNTAX score calculator The formula: CSS = SS x (AGE / EF) + 1 (For each reduction of 10ml / ph Creatinine clearance <60ml / min / 1.73m2). * The time of monitoring and how to collect patient data after intervention: In hospital and 1 month, 6 months, 12 months: Death with all causes, myocardial infarction, stroke, target vessel re-intervention. 2.3. Analyze data: Data were entered into EPI DATA (version? ) and transferred to SPSS, version 21.0 software for Windows, for analysis For comparison control, we used algorithms "T-test", test c2, odds ratio (Odds ratio), Logistic Regestion algorithm, test log-rank, linear regression (HR). The research results were considered to be statistically significant when p <0.05. CHAPTER 3: RESULTS Study of 579 patients with acute myocardial infarction undergoing percutaneous coronary intervention, following results: 3.1. General characteristics Table 3.4. General clinical Characterstics ± SD or n(%) (N=579) Chest pain 518(89,5) Dyspnea 201(34,7) Systolic blood hypertension (mmHg) 123,68 ± 23,32 Diastolic blood hypertension (mmHg) 75,68 ± 14,26 Heart rate 80,15 ± 17,59 Killip ≥ 2 86(14,9) Chest pain accounted for 89.5%. Killip ≥2 accounting for 14.9%. 3.2. Clinical SYNTAX score and SYNTAX scores Frequency SYNTAX SCORE Figure 3.3. Distribution of SYNTAX score        The number of patients with SYNTAX score around 20 points with a high rate. The lowest is 2 points, the highest is 54 points. Mean±SD SYNTAX score was 19.48 ± 9.40 Figure 3.4. Distribution of clinical SYNTAX score The clinical SYNTAX score around 25 points is high rate. The lowest is 2.5 points, the high is 123.7 points. Mean±SD clinical SYNTAX score was 30.28 ± 18.84. Table 3.26. Characterristics of lesion coronary artery by SYNTAX score and clinical SYNTAX score Characterristics Amount (N=579) Percentage (%) ≥1 Bifucations 225 38,9 ≥1 Trifucations 6 1,0 ≥1 Total occlusion 356 61,5 ≥1 Severe tortuosity 32 5,5 ≥1 Lesions long ≥20mm 258 44,6 ≥1 Heavy calcification 65 11,2 ≥1 Thrombus 406 70,1 ≥1 Aorto-ostial lesion 53 9,2 The total occlusion was high 67.0% and 406 patients has been thrombus with 70.1%. 3.3. Investigate the value prognosis of clinical SYNTAX score and SYNTAX score of some major events in patients with acute myocardial infarction undergoing percutaneous coronary intervention. Follow-up 579 and 296 patients with acute myocardial infarction undergoing percutaneous coronary intervention up to 12 months. We obtained the following results: Table 3.33. Number of events MACE Time Mortality MACE In hospital 9(1.6) 12(2.1) 1 month 32(10.8) 25(8.4) 6 month 37(12.5) 30(10.1) 12 month 47(15.9) 34(11.5) SYNTAX Score Curn Survival (%) Time (day) Figure 3.8. Kaplan-Meier survival curves three group of SYNTAX score Survival after 1 month, 6 months of SS3 score is the lowest. After 12 months, the group with SS3 score had the lowest survival rate of 77.9%, then of SS2 and SS1 with statistically significant differences. Table 3.38. Linear regression analysis between SYNTAX score groups and mortality Mortality HR1,2 (CI95%) p HR1,3 (CI95%) p HR2,3 (CI95%) p 1 month 1,08 (0,34-3,45) 0,896 3,06 (1,04-9,05) 0,043 2,86 (1,30-6,25) 0,008 6 month 1,52 (0,49-4,61) 0,462 3,28 (1,12-9,65) 0,031 2,17 (1,09-4,35) 0,028 12 month 1,85 (0,69-4,9) 0,217 2,99 (1,11-7,84) 0,029 1,59 (0,87-2,94) 0,128 At 1 month , the mortality rate in SS3 group was 3.06 times higher than in SS1 group (HR = 3.06 and 95% CI from 1.04 to 9.05 with p = 0.043). 6 months, mortality in SS3 group was 3.28 times higher than in SS1 group (HR = 3.28 and 95% CI from 1.12 to 9.65 with p = 0.031). After 12 months , the mortality rate in SS3 group was 2.99 times higher than in SS1 group (HR = 2.99 and 95% CI from 1.11 to 7.84 with p = 0.029). Figure 3.12. Kaplan-Meier survival curves three group of clinical SYNTAX score   Survival of CSS 3 group after 1 month, 6 months is lower than the mid and low groups. After 12 months, survival rate of CSS3 group was the lowest at 73.8%, then CSS2 and low CSS1 with p (log-rank) <0.001. Table 3.43. Linear regression analysis between clinical SYNTAX score and mortality Mortality HR1,2 (CI95%) p HR1,3 (CI95%) p HR2,3 (CI95%) p 1 month 1,57 (0,45-5,41) 0,478 5,12 (1,94-13,53) 0,001 3,23 (1,23-8,33) 0,017 6 month 2,51 (0,82-7,69) 0,106 5,69 (2,17-14,94) <0,001 2,72 (1,02-5,05) 0,045 12 month 2,19 (0,88-5,44) 0,092 4,23 (1,94-9,36) <0,001 1,96 (0,97-3,85) 0,061 The mortality rate in CSS3 group was 5.12 times higher than in CSS1 group (HR = 5.12 and 95% CI from 1.94 to 13.53 with p = 0.001). Similarly, after 6 months the mortality rate in CSS3 group was higher than in CSS2 and CSS1 group, the difference was statistically significant. 12 months , mortality in CSS3 group was 4.23 times higher than in CSS1 group with p <0.001). SYNTAX score Curn Survival (%) Time (day) Figure 3.15. Kaplan-Meier relation cardiac event –free survival curves three group of SYNTAX score The rate of no events in SS3 was the lowest at 83.2% compared two SYNTAX score groups, the rate of no event in SS1 group was the highest at 91.8%. But this difference is not significant with p (log-rank) = 0.065. Figure 3.18. Kaplan-Meier relation cardiac event–free survival curves three group of clinical SYNTAX score         The rate of no event –free survival in the CSS1 and CSS2 groups was 88.70% and 91.9% higher than the CSS3 group (86.0% ). But the difference is not significant with p (log-rank) = 0.445. Sensityvity 1-specificity Figure 3.20. ROC curve related mortality of clinical SYNTAX and SYNTAX score Area under the ROC curve of SYNTAX score is 0.614 clinical SYNTAX score are 0.690, so the ability to predict mortality of CSS is better than SS. Sensityvity 1-specificity Figure 3.22. ROC curve related MACE of clinical SYNTAX score and SYNTAX score Area under the ROC curve of clinical SYNTAX and SYNTAX score is not different, so the ability to predict non-fatal events of CSS is no more than SS. CHAPTER 4: DISCUSSION 4.1. Clinical SYNTAX and SYNTAX scores      Mean±SD of SS score is 19.49 ± 9.39, around the 20 point level with the highest rate. Mean±SD of CSS score is 30,28 ± 18,84, around the 25 point level with the highest rate. (chart 3.3 and 3.4). Garg S et al. Studied 6,508 patients with coronary artery disease in general who found that their SS scores ranged from 0 to 83 points, an average of 15 points and mean ±SD is 16.7 ± 11.1. Terlite group to clinical SYNTAX and SYNTAX scores: SYNTAX score: Low group (SS1): 0 - 11.75; medium group (SS2): 11.75 - 23.25; High group (SS3): ≥ 23.25. Clinical SYNTAX score: Low group (CSS1): 0 – 22.95; medium group (CSS2): 22.95 – 35.95; High group (CSS3): ≥ 35.95 Frank Scherff et al, studying 114 patients with acute coronary syndrome, the author divided patients into three groups of SYNTAX, the low score group was 23. Karabag Y, study divided the CSS scores into three low groups ≤ 24.6, medium 24.6-34.4 and high ≥ 34.4. Rencuzogullari I, study was divided into two groups of low-medium ≤34.1 and high ≥34.1. Burlacu A, the study of 181 patients with acute myocardial infarction took data from the REN_ACS trial dividing clinical SYNTAX (CSS) scores into three lower groups ≤19.2 and high groups ≥38.9 and middle groups. This category has the same results as our CSS score groups. 4.2. The degree of coronary artery lesions with SYNTAX score and clinical SYNTAX score Resolute trial, study 2.292 patients, including 2.033 patients with SS, CSS. Divided into 3 group: low group 17. When analyzing the common lesion characteristics of the high group >17 for the highest rate compared with low group and mid group. The difference is statistically significant (with p<0.0001). Safarian H et al., study 381 patients. Divided into 3 group: low group 22. When analyzing the common lesion characteristics of the high group >22 for the highest rate compared with low group and mid group. The difference is statistically significant (with p<0.0001). 4.3.The relationship between mortality and major cardiovascular events with clinical SYNTAX and SYNTAX scores 4.3.1 Relate the SYNTAX score with mortality and major cardiovascular events * Mortality In the Kaplan-Meier chart, the survival rate in SS3 high score group was the lowest compared to SS2 and SS1 low score group, the difference was statistically significant with p (log-rank). <0.05 (chart 3.8). in study of Ayca B et al., 538 patients with acute myocardial infarction who received percutaneous coronary intervention from 1/2012 to 12/2012. Tertile group: Low score group 22. During the short-term follow-up, the death rate in the high SYNTAX score group> 22 was 0.9% compared with 0.2% in the low SYNTAX score <22 with p = 0.021. Scot Garg, et al, studied on 945 patients with 807 patients with acute myocardial infarction who had percutaneous coronary intervention, accounting for 85.4% with SYNTAX score. The patients were divided into three groups according to SYNTAX score levels; Low SS group ≤ 9: 311 patients, medium group 9 16 has 262 patients. After 12 months of follow-up, the survival rate in the high score group was 90.8% compared to the medium score group of 95.7% with p = 0.03 and compared with the low group was 96.8% with p = 0.001. The area under the ROC curve of the SS is 0.65 (AUC = 0.65; 95% CI from 0.57 to 0.74, p = 0.001). SYNTAX scores have independent predictor of mortality risk for patients with acute myocardial infarction who have undergoing percutaneous coronary intervention . Yang CH et al. Studied 153 patients with acute myocardial infarction who received percutaneous coronary artery bypass surgery from January 2008 to December 2009 at Chang Gung Hospital. There were 141 patients followed up 30 ± 11 months. Low SYNTAX score of 0-22 and medium to high score > 22 . Results, according to Kaplan-Meier analysis, the survival rate was 99.1% in the low score group compared to 78.6% in the medium and high group after 42 months, with p <0.001 is statistically significant. For all causes of death, the survival rate for the low score group was 93.1% compared to 78.6% in the medium and high score group after 42 months , with p = 0.002. When linear regression analysis, the risk of death in the medium-high score group was 15.90 times higher than the low score group (OR = 15.90; 95% CI from 1.04 to 24.21). COMFORTABLE AMI clinical trial in 1,132 patients with acute myocardial infarction undergoing percutaneous coronary intervention. After 12 months, MACE (death, myocardial infarction, re-intervention) in the high SYNTAX score ≥19 were 15% compared to the mean score (11-18) was 9% compared to the with low score ≤ 10 was 5%. The difference is statistically significant with p<0.001. * Major cardiovascular events Kaplan-Meier chart, SS3 high score group has the lowest free-survival rate compared to SS2 score group and SS1 low score group, the difference is not statistically significant with p (log-rank) = 0.065 (chart 3.15). Sixteen studies with a total number of 19,751 participants (8589 participants with a low versus 11,162 participants with a high SYNTAX score) were included. Current results showed mortality to be significantly higher with a higher SYNTAX score (RR 2.09, 95% CI 1.78-2.46, P = .00001). Cardiac death also significantly favored a low SYNTAX score (RR 2.08, 95% CI 1.66-2.61, P = .00001. Similarly, myocardial infarction, major adverse cardiac events, repeated revascularization, and stent thrombosis were significantly higher following a high SYNTAX score (RR 1.71, 95% CI 1.45-2.03, P = .00001; RR 2.03, 95% CI 1.81-2.26, P = .00001; RR 1.96, 95% CI 1.69-2.28, P = .00001; and RR 3.16, 95% CI 2.17-4.59, P = .00001, respectively). Even when patients with ST-segment elevation myocardial infarction were separately analyzed, a low SYNTAX score was still significantly associated with lower adverse outcomes.. Jou YL et al, studied 198 patients with unprotected LM disease undergoing PCI. Comparing with the SYNTAX score, the predictive accuracy of CSS for 30-day and 1-year all-cause death and MACE were significantly higher (c-statistics, CSS versus SYNTAX score: P < 0.01 for 30-day and 1-year all-cause death; P < 0.05 for 30-day and 1-year MACE, respectively). Furthermore, in the multivariate Cox regression analysis, both EuroSCORE and CSS were identified as the independent predictors of 30-day and 1-year all-cause death and MACE, but the SYNTAX score was not. 4.3.2. Relate the clinical SYNTAX score with mortality and major cardiovascular events * Mortality Kaplan-Meier chart, we see that the CSS3 high score group has the lowest probability of living compared to the CSS2 mideum score group and the low CSS score, the difference is statistically significant with p (log-rank). <0.05 (chart 3.12). Cetinkal G et al., .study of 433 patients who were diagnosed with STEMI and underwent p-PCI. CSS was calculated by multiplying the anatomically derived SYNTAX score (Sx) by the modified age, creatinine, and ejection fraction score. Patients were divided into tertiles according to the CSS: CSS(Low)≤14 (n=141), 1426 (n=148). The primary endpoints were defined as all-cause mortality, myocardial infarction, and cerebrovascular events over 15 months' follow-up. Primary endpoints were achieved in 9.2% of patients with CSS≤14, 12.5% of those with 1426 (P26 group had a significantly higher incidence of primary endpoints [P (log-rank)26 was identified as an independent predictor for all-cause mortality, myocardial infarction, and cerebrovascular events (hazard ratio 3.58, 95% confidence interval 1.68-7.60, P=0.001). Receiver operating characteristic analysis found areas under the curve of 0.66, 0.59, and 0.64 for CSS, Sx score, and age, creatinine, and ejection fraction score (P<0.001, P=0.01, P<0.001, respectively). Kurniawan E et al., data from three consecutive years of octogenarian undergoing pertaneseous coronary intervention (PCI) from Ruijin Hospital (Shanghai, China) was retrospectively collected (n = 308). Follow up clinical data at one year including all cause mortality, cardiac mortality and main adverse cardiovascular and cerebrovascular events (MACCE) were collected. Patients were stratified according to tertiles of clinical SYNTAX score (SS-II) for PCI: SS-II ≤ 26 (n = 104), SS-II: 27-31 (n = 102), SS-II > 31 (n = 102). After adjustment for confounding factors, SS-II for PCI was an independent risk factors for all cause mortality (odds ratio: 2.77, 95% CI: 1.13-8.06; P = 0.04). Kaplan-Meier curves showed higher event rates for all cause mortality and cardiac mortality in higher tertile of SS-II for PCI (Log-Rank test P = 0.002 and P = 0.001, respectively). SS-II for PCI predicted one year mortality in octogenarian population undergoing PCI. He C et al., A study of 6,099 patients with acute coronary congestion treated at FuWai Hospital from January 2013 to December 2013, 6,099 consecutive patients with ACS admitted to FuWai hospital and underwent PCI were enrolled in this study. Based on CSS, patients were divided into low CSS group (CSS ≤ 6.5; 2,012 patients), mid-CSS group (6.5 < CSS < 13.8; 2,056 patients), and high CSS group (CSS ≥ 13.8; 2,031 patients). At 2-year follow-up, rates of cardiac death and major adverse cardiac events (MACE) were significantly higher in the high CSS group. Compared with baseline SS, CSS demonstrated significantly improved performance for 2-year cardiac death (receiver-operating characteristic curve C-statistic: 0.74 vs 0.62, p <0.001) but not for MACE (receiver-operating characteristic curve C-statistic: 0.60 vs 0.59, p = 0.29). Numerous studies have demonstrated clinical SYNTAX scores as independent factors for predicting all-cause mortality and cardiac death in patients with coronary artery disease including those with acute myocardial infarction. acute undergoing percutaneous coronary intervention. * Major cardiovascular events The Pyxaras SA, study on 221 patients with severe calcified coronary disease who underwent percutaneous coronary intervention. Patients were categorized according to groups of scores according to ACEF and CSS scores. After 1 year, the event rates were significantly higher in the ACEF high score group (24% for high ACEF vs 13% for average ACEF compared to 9% for low ACEF; p = 0.017) and CSS was (25% for high CSS compared to 12% for CSS mideum compared to 8% for low CSS; p = 0.008). The predictive accuracy for both ACEF and CSS scores is moderate (0.629 and 0.638). Both ACEF score and the predictive CSS score were reasonably accurate for cardiovascular events after 1 year in patients with heavily calcification of coronary stenosis undergoing percutaneous coronary intervention. 4.3.3. Prognostic value of clinical SYNTAX and SYNTAX scores * Compare the ability to predict non-fatal events of SS and CSS scores The area under the ROC curve of the SYNTAX score is 0.542 (AUC = 0.542 and 95% CI from 0.435 to 0.664 with p = 0.428). The area under the ROC curve of the clinical SYNTAX score is 0.50 (AUC = 0.50 and 95% CI from 0.403 to 0.616 with p = 0.862) (chart 3.20). In this study, we have not seen the difference of clinical SYNTAX score in prediction of main cardiovascular events (except for mortality) compared with SYNTAX score. * Compare death prediction ability of SS and CSS score The area under the ROC curve of the SYNTAX point is 0.623 (AUC = 0.623; 95% CI from 0.530 to 0.715 with p = 0.005). The area under the ROC curve of the clinical SYNTAX score is 0.698 (AUC = 0.698; 95% CI from 0.616 to 0.780 with p <0.001) (chart 3.18). Long-term follow-up of the ability to predict all-cause mortality of clinical SYNTAX (CSS) is better than SYNTAX (SS) scores. Cetinkal G et al., .study of 433 patients who were diagnosed with STEMI and underwent pertaneseous coronary intervention (PCI). CSS was calculated by multiplying the anatomically derived SYNTAX score (Sx) by the modified age, creatinine, and ejection fraction score. Patients were divided into tertiles according to the CSS: CSS(Low)≤14 (n=141), 1426 (n=148). Receiver operating characteristic analysis found areas under the curve of 0.66, 0.59, and 0.64 for CSS, Sx score, and age, creatinine, and ejection fraction score (P<0.001, P=0.01, P<0.001, respectively). CSS may be better than the Sx score for predicting long-term prognosis in patients with STEMI undergoing PCI. In the SIRTAX trial of 848 patients. Divide patients into SYNTAX score and clinical SYNTAX score high, low, mideum . The area under the curve of the SYNTAX and clinical SYNTAX score for the occurrence of major events, deaths from all causes and cardiac deaths were 0.61 (95% CI from 0.56 to 0.65) and 0.62 (95% CI from 0.57 to 0.67); 0.58 (95% CI from 0.51 to 0.65) and 0.66 (95% CI from 0.59 to 0.73); 0.63 (95% CI from 0.54 to 0.72) and 0.72 (95% CI from 0.63 to 0.81). CSS may be better than the Sx s