Prior to coronary interventional procedures and therapy, a patient's awareness of the likelihood of problems may reduce the incidence of complications. The SYNTAX score (SS) is a grading system used to assess the complexity of CAD, choose the most effective revascularization procedure, and identify patients at risk for significant adverse events after PCI [7, 10].
Due to their efficacy, these assessments have been included in clinical practice for predicting long-term prognosis and determining the most expedient CAD therapy strategy [11].
The efficiency of MDCT in identifying and visualizing coronary artery lesions is increasing. MDCT has been shown as a feasible approach for detecting the severity of the coronary vascular affection in patients with suspected CAD, with good diagnostic accuracy and negative predictive values over 95% [12].
Few studies have assessed the use of coronary CT angiography to guide patient care, such as assessing the necessity for revascularization or the most effective revascularization technique (e.g., PCI vs CABG surgery) [13].
In this study, we evaluate the role of coronary MSCT in the assessment of multi-vessel CAD on basis of SS.
SS derived from CCTA, and ICA are concordant, which is consistent with the findings of Bartorelli et al. [14], who discovered that CCTA provides an anatomy and noninvasive functional road map for planning for myocardial revascularization strategies, and Shalev et al. [3], who evaluated the feasibility and accuracy of a CCTA-derived SS to predict complex CAD. Comparing the CCTA-derived SS to an ICA-derived SS reference standard, the research group demonstrated outstanding concordance and diagnostic accuracy. In addition, higher SYNTAX scores determined from CCTA were associated with more complex coronary revascularization. While Yuceler et al. [12] showed strong agreement between the SS-ICA and SS-MDCT, researchers identified substantial agreement between the SS-ICA and SS-MDCT. The SS-MDCT average score was 14.5, whereas the SS-ICA average score was 15.9. In the group with low SS, there was a significant connection between SS-MDCT and SS-ICA (r = 0.63, P = 0.043), however, in the group with high SS, there was no correlation.
Also, we found that there was a statistically significant difference between the treatment recommendation by anatomical SS I and SS-II of the anatomy and comorbidity PCI Vs CABG, (P < 0.0001) this was consistent with the finding of Xu et al. [15] who found that compared with the strictly anatomic SS-scoring systems combining clinical variables and anatomic SS (clinical SS, logistic SS, and SS-II) had better discrimination and similar calibration for the prediction of long-term mortality Specifically, the SS-II had better discrimination (C-statistic: baseline SS ¼ 0.591 vs. SS-II ¼ 0.694, P < 0.0001) than the anatomic SS alone, The SS-II significantly improved mortality predictability by appropriately reclassifying several patients. Chen et al. [16] conducted a meta-analysis comparing the SS to the clinical SS to determine their potential to predict adverse clinical outcomes; the clinical SS was associated with a greater predictive value for predicting all causes of mortality. According to Escaned et al. [17], patients with 3-vessel diseases and the vast majority of SS-II trial participants should use this critical decision-making tool.
We discovered a direct correlation and significant relationship between SS-II for PCI, which represents the absolute risk (%), and CT-derived SS I (P = 0.001), as well as a direct correlation and significant relationship between the CT-SS and PCI mortality rate, indicating that patients with a high SS have an increased risk of mortality with PCI. Patients with a low SS-II had a considerably low mortality rate following PCI, while patients with a high SS-II had a significantly higher risk of mortality.
We discovered an inverse relationship between SS-II and CABG mortality and a direct relationship between SS-II and PCI mortality rate, indicating that individuals with a higher SS-II had a lower CABG mortality rate and a greater PCI mortality rate. Head et al. [18] observed a significant treatment selection by SS interaction (P = 0.01) in a subgroup analysis based on lesion complexity, which is consistent with our findings. Despite the primary conclusion of the trial that PCI with drug-eluting stents is inferior to CABG, there were no differences in MACCE between CABG and PCI in patients with a SS of 22 or below (13.6 percent vs. 14.7 percent, respectively; P = 0.71). CABG was better than PCI in individuals with SYNTAX scores of 33 or more (10.9% vs. 23.4%, respectively; P < 0.001).
Kundu et al. [19] discovered that the SS and SS-II are helpful predictive markers for directing the therapy of diabetic individuals with advanced coronary artery disease. PCI should be explored as an alternative to CABG in patients with low to moderate SYNTAX scores (equal to or less than 32), but CABG is preferable in operable individuals with high SYNTAX scores (equal to or more than 33).
We found that there is significant and direct relationship between the SS and SS-II with PCI and mortality rate and this was in line with Cavalcante et al. [20] who found that the rate of the composite of death, MI, or stroke was similar in the PCI and CABG arms in patients with low and intermediate (equal to or less than 32) SYNTAX scores while it was significantly higher in the PCI arm in patients with high (equal to or more than 33) SYNTAX scores (24.5 vs.13.2%, respectively; P = 0.018).
Also, we found that 47 patients out of 60 cases were male representing 78.3% of the cases and 13 cases out of 60 were female representing 21.7%. This came in agree with Rong et al. [21] found that male patients accounted for 71.4%, also Suh et al. [13] found that 61% were male, and Shalev et al. [3] who found that 66% were male.
The mean age of the patients was 57 (± 8.8) year, Rong et al. [21] found that the mean age of 68.4 ± 9.4, Yuceler et al. [12] found the mean age of 64.6 ± 6.3 years.
We found that 17 patients were diabetic (28.33%), 25 patients showing abnormal lipid profile (42.67%), 9 patients had COPD (15%) and 2 patients (3.33%) had peripheral vascular disease, and the smoker's percentage (45%), Pozo et al. [9] found that 20% were diabetics, 46% had hyperlipidemia, 22% smoker and ex-smoker, 65% had peripheral arterial disease, and Shalev et al. [3] found that Diabetes account about 41% of the cases, smoking at 21%, and dyslipidemia 15% of the cases.
We found a significant relationship between smoking, diabetes, and dyslipidemia. This is consistent with the findings of El-Kersh et al. [22], who showed that there was a statistically significant link between diabetes, dyslipidemia, and smoking, but not with age, as we did not discover a significant correlation with age. We agree that there was an association between the patient's weight and diabetes that is statistically significant.
The observed negative association between SS and LVEF parallels the findings of Van Dongen et al. [23], who discovered that patients with a SS above the median had a lower LVEF and a greater death rate. We discovered that the SS is a negative independent predictor of LVEF.
Finally, the present study and the previous reports demonstrate that Coronary computed tomographic angiography (CCTA) has high diagnostic accuracy compared to ICA Coronary computed tomographic angiography (CCTA) and in clinical practice can be used to determine the most convenient treatment procedure and predict long-term prognosis for CAD management.
The limitation of the study was as follow
The limited number of the cases who underwent CT angiography showing multi-vessels coronary arteries affection as in assessment of patient with typical chest pain the PCI is more commonly done, but in our study we insure that the CT scan noninvasively can diagnose the patient and guide the heart team for the appropriate strategy of the treatment. Some cases were excluded as we cannot obtain their PCI result, and we need longer time to detect the long-term major adverse effect to assess the external validation of syntax score PCI and CABG.