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Better stents, IVUS, FFR, medical therapy…or the integration of all? The SYNTAX-II trial

Reported from the European Society of Cardiology ESC Congress 2017 in Barcelona

In patients with three-vessel disease, CABG showed better outcomes than PCI in the SYNTAX and FREEDOM trials, where first-generation drug-eluting stents were used, but also in the BEST trial using newer-generation drug-eluting stents. Not surprisingly, every time there is progress or novel device iteration in the field of PCI (i.e. a new stent, more liberal use of intravascular imaging and physiology assessment, better risk stratification with scoring tools) there is also the systematic temptation to refute the conclusions of older trials and call for new contemporary comparisons of PCI and CABG. Yet, if we look at large outcome studies, the ambition to see PCI performing significantly better than CABG in three-vessel disease patients has been so far regularly frustrated.

At the ESC Congress 2017 in Barcelona, Javier Escaned presented the results of another clinical investigation that refuels the debate, with simultaneous publication in the European Heart Journal. The SYNTAX II study implemented a set of “best practices” in PCI (now called “the SYNTAX II strategy”), pursuing the best possible clinical outcomes in 454 PCI patients with three-vessel disease through the integration of heart team decision-making utilizing the SYNTAX Score II, coronary physiology guided revascularization, implantation of thin strut bioresorbable-polymer drug-eluting stents, IVUS guided stent implantation, contemporary CTO revascularization techniques and guideline-directed medical therapy.

The study showed a lower rate of major adverse cardiac and cerebrovascular events at 12 months than in comparable PCI patients from the SYNTAX trial. The benefit was driven by less myocardial infarction, revascularization and definite stent thrombosis. The outcomes of PCI patients undergoing this so-called “SYNTAX-II strategy” were similar to those of comparable CABG patients from the SYNTAX trial. Since this is a “historical comparison” rather than a randomized trial, caution suggests to avoid over-interpretation, but the study remains solid and well conducted prospective science suggesting that integrating technological developments of PCI may achieve better outcomes than in the past. These results give new energy to the belief that a new trial of “contemporary PCI with the SYNTAX-II strategy” and CABG in three-vessel disease is - once again - necessary.