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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 44  |  Issue : 3  |  Page : 127-133

SYNTAX score II as a predictor of incomplete ST-segment resolution in patients with acute myocardial infarction treated with primary percutaneous intervention


Department of Cardiovascular Medicine, Tanta Faculty of Medicine, Tanta, Egypt

Date of Submission18-Apr-2016
Date of Acceptance28-May-2016
Date of Web Publication19-Jan-2017

Correspondence Address:
Mohamed Naseem
Department of Cardiovascular Medicine, Tanta Faculty of Medicine, Tanta, 31111
Egypt
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DOI: 10.4103/1110-1415.198656

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  Abstract 

Background Incomplete ST-segment resolution (STR) is a marker of impaired myocardial perfusion and adverse clinical outcome after primary percutaneous coronary intervention (PPCI). Synergy between percutaneous coronary intervention with TAXUS and cardiac surgery score II (SS-II) has been developed combining anatomical and clinical variables. The aim of the present study was to evaluate the SS-II as a predictor of incomplete STR in patients with ST-segment elevation myocardial infarction (STEMI) treated with PPCI.
Patients and methods The present study prospectively included 100 patients with STEMI treated with PPCI. SS-II was determined in all patients. The sum of ST-segment elevation was measured from standard 12-lead ECG obtained on admission and from a second ECG recorded 60 min after PPCI. STR resolution was defined as either complete (≥50%) or incomplete (<50%). Patients were divided into two groups according to STR: patients with complete STR (positive STR) were 76 in number (76%) and patients with incomplete STR (negative STR) were 24 in number (24%).
Results Patients in the negative STR group were older, had higher prevalence of peripheral vascular disease, lower creatinine clearance (CrCl), higher peak troponin, lower ejection fraction and a higher SS-II (P value = <0.001, 0.018, <0.001, <0.001, <0.001 and <0.001 respectively). Patients in the negative STR group also had a longer time to reperfusion (P=0.016) and higher prevalence of myocardial blush grade 0/1 (P=0.016 and <0.001, respectively). On multivariable logistic regression analysis, SS-II was an independent predictor of incomplete STR (odds ratio=0.224, 95% confidence interval, 0.209–0.778, P=0.001). Receiver-operating characteristic curve analysis identified SS-II greater than 25 as the best cutoff value predictive for incomplete STR with a sensitivity of 79.2%, specificity of 73.9%, and area under receiver-operating characteristic curve of 79.2.
Conclusion SS-II is an independent predictor of incomplete STR in patients with STEMI treated with PPCI.

Keywords: acute myocardial infarction, primary percutaneous coronary intervention, st-segment resolution, SYNTAX score II


How to cite this article:
Naseem M. SYNTAX score II as a predictor of incomplete ST-segment resolution in patients with acute myocardial infarction treated with primary percutaneous intervention. Tanta Med J 2016;44:127-33

How to cite this URL:
Naseem M. SYNTAX score II as a predictor of incomplete ST-segment resolution in patients with acute myocardial infarction treated with primary percutaneous intervention. Tanta Med J [serial online] 2016 [cited 2020 Nov 29];44:127-33. Available from: http://www.tdj.eg.net/text.asp?2016/44/3/127/198656


  Introduction Top


Primary percutaneous coronary intervention (PPCI) is the preferred treatment modality for ST-segment elevation myocardial infarction (STEMI) because it achieves rapid and complete reperfusion of an infarct-related artery [1].

Despite restoration of thrombolysis in myocardial infarction (TIMI) flow grade 3, some patients may have impaired microvascular and myocradial perfusion and poor prognosis [2],[3],[4],[5].

ST monitoring after reperfusion therapy is a simple, noninvasive and readily available method for evaluation of the efficacy of reperfusion therapy [6],[7],[8],[9]. Lack of ST-segment elevation resolution (STR) on ECG is considered as a marker of impaired myocardial reperfusion and adverse clinical outcome in patients with acute myocardial infarction [10].

The SYNTAX (synergy between percutaneous coronary intervention with TAXUS and cardiac surgery) score has been shown to be predictive of clinical outcome in different clinical settings in patients undergoing percutaneous coronary intervention (PCI) [11],[12],[13],[14],[15],[16],[17],[18].

The major limitation of the SYNTAX score is the lack of inclusion of clinical variables. Patients with equivalent scores may have different clinical outcomes because of the presence of different comorbidities [19].

The SYNTAX score II (SS-II) has been recently developed and incorporates both clinical and anatomical variables; thus, it may ensure a better prediction of the clinical outcome in patients with complex coronary artery disease (CAD) [20].

The aim of this study was to evaluate the SS-II as a predictor of incomplete STR in patients with STEMI treated with PPCI.


  Patients and methods Top


Study population

One hundred consecutive patients with recent first STEMI who underwent PPCI in the Cardiology Department of Tanta University were prospectively included in the study from June 2014 until August 2015.

The study inclusion criteria were as follows: (a) confirmed first acute STEMI based on the presence of typical anginal pain more than 30 min, new ST-segment elevation at J point in two or more contiguous leads greater than or equal to 0.2 mV, and elevation in troponin or ck-MB; (b) onset of symptoms less than 12 h before hospital admission; and (c) TIMI flow 3 and less than 30% residual lesion at the occluded site at the end of the procedure.

The exclusion criteria were presence of left or right bundle branch block and other conduction abnormalities, and presence of a permanent pacemaker.

Angiographic procedure

Coronary angiography and PCI were performed following the femoral approach. All patients received the following regimen: (a) clopidogrel 300–600 mg loading dose orally, followed by a maintenance dose of 75 mg/day; (b) aspirin 300 mg followed by 81–325 mg/day; and (c) unfractionated heparin (100 IU/kg) during the procedure; the dose was reduced to 70 IU/kg in case of administration of glycoprotein IIb/IIIa inhibitor (eptifibatide).

TIMI flow rate [21] was assessed before and at the end of PPCI. Myocardial blush grade (MBG) [22] was also assessed at the end of the procedure.

The use of manual thrombus aspiration was left to the operator’s discretion.

ECG evaluation

Standard 12-lead ECG was obtained on admission and a second ECG was recorded 60 min after PPCI. ST-segment elevation (in mm) was measured 20 ms after the J point. The sum of ST-segment elevations was calculated in leads I, aVL, and V1 through V6 for anterior infarctions and in leads II, III, aVF, V5, and V6 for nonanterior infarctions. STR was defined as percentage reduction in the sum of ST-segment elevation from admission ECG to that on the second ECG. STR was defined as complete (≥50%) or incomplete (<50%) [23],[24],[25]. Accordingly, patients were divided into two groups: patients with complete STR (positive STR) and patients with incomplete STR (negative STR).

Determination of the SYNTAX score II

The baseline SYNTAX score was computed from the diagnostic coronary angiogram. Each significant coronary lesion (defined as stenosis diameter ≥50% in vessels with minimum diameter ≥1.5 mm) was scored [13]. The SS-II combines two anatomical variables (anatomical SYNTAX score and unprotected left main CAD) and six clinical variables [age, creatinine clearance (CrCl), left ventricular ejection fraction (LVEF), sex, chronic obstructive pulmonary disease (COPD), and peripheral vascular disease (PVD)]. SS-II was calculated using an SS-II nomogram as previously described [26].

CrCl was measured using the Cockcroft and Gault [27] formula. COPD was defined according to the EuroSCORE definition as the long-term use of bronchodilators or steroids for lung disease [28]. PVD was defined as the presence of aorta and arteries, other than coronaries, with claudication, history of previous revascularization surgery, reduced or absent pulse, or the presence of angiographic stenosis of more than 50% or combinations of these criteria [29].

Echocardiographic evaluation

Echocardiography was performed according to the recommendations of the American Society of Echocardiography using the commercially available GE Vivid 7 echocardiograph (General Electric, Norway) with a 2.5 MHz transducer, and left ventricular ejection fraction was evaluated using the biplane Simpson method [30].

Informed consent was taken from all patients and the study was approved by the local ethical committee.

Statistical study

All statistical studies were carried out using the statistical package for social sciences (18.0 for Windows; SPSS Inc., Chicago, Illinois, USA).

Quantitative variables are expressed as mean±SD. Qualitative data are expressed as counts and percentages. The Student t-test and the χ2-test were used to compare quantitative and qualitative values, respectively. Multivariable logistic regression analysis was performed to identify independent predictors of incomplete STR. The receiving operator characteristic (ROC) curve was used to detect optimal cutoff values of SS-II for predicting incomplete STR. A P value less than 0.05 was considered statistically significant.


  Results Top


One hundred patients with recent first STEMI who underwent PPCI were included in the study. Patients were divided into two groups according to STR. The positive STR group included 76 patients (76%) and the negative STR group included 24 patients (24%).

Baseline clinical characteristics

There were no significant differences between the two groups regarding sex, hypertension, dyslipidemia, diabetes mellitus, smoking status, family history of premature CAD, BMI, prevalence of COPD, and Killip class on admission. Patients in the negative STR group were older, had higher prevalence of PVD, lower CrCl, higher peak troponin, lower ejection fraction, and a higher SS-II (P<0.001, 0.018, 0.001, 0.001, 0.001, and 0.001, respectively, [Table 1]).
Table 1: Baseline clinical characteristics of the studied patients

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Angiographic characteristics

There were no significant differences between the groups regarding the number of diseased vessels, rate of stent utilization, infarct-related artery, reference vessel diameter, stent length, stent diameter, rate of use of glycoprotein IIb/IIIa inhibitors, rate of use of thrombus aspiration device, or TIMI flow rate before PPCI. The time to perfusion was significantly longer in the negative STR group (P=0.016). MBG was significantly different between the two groups with higher prevalence of MBG 0/1 in the negative STR group, P<0.001 ([Table 2]).
Table 2: Angiographic characteristics of the studied patients

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A multivariable logistic regression model was built to identify the independent predictors of incomplete STR. The SS-II (odds ratio=0.224, 95% confidence interval, 0.209–0.778, P=0.001) and the time to reperfusion (odds ratio=0.457, 95% confidence interval, 0.119–0.655, P=0.038) were independent predictors for incomplete STR ([Table 3]). ROC curve analysis identified SS-II greater than 25 as the best cutoff value predictive of incomplete STR with sensitivity 79.2%, specificity 73.9%, and area under ROC curve 79.2 ([Figure 1]).
Table 3: Multivariable logistic regression analysis to detect independent predictors of incomplete STR

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Figure 1: Receiver operating curve characteristic (Roc) curve analyses for SYNTAX score II as predictor for incomplete ST-segment resolution.

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  Discussion Top


The present study evaluated the ability of the SS-II to predict incomplete STR in patients with STEMI treated with PPCI.

The main findings of the present study were as follows. (a) Incomplete STR occurred in 24% of patients with STEMI treated with PPCI despite achievement of TIMI 3 flow. (b) Patients with incomplete STR were older, had higher prevalence of PVD, lower CrCl, higher peak troponin, lower ejection fraction, longer time to reperfusion, and higher incidence of MBG 0/1. (c) The multivariable logistic regression model identified SS-II and time reperfusion as independent predictors of incomplete STR. (d) ROC curve analysis revealed that SS-II greater than 25 had a sensitivity of 79.2%, specificity of 73.9%, and area under the ROC curve of 79.2 for predicting incomplete STR.

It has been demonstrated that patients with STEMI who have successful epicedial flow restoration may have impaired perfusion at the tissue level [4]. Different techniques have been used to assess myocardial perfusion, such as myocardial contrast echocardiography [31], nuclear imaging [32], magnetic resonance imaging [33], intracoronary Doppler flow wire [34], and multidetector computed tomography [35].

STR is a simple bedside ECG sign for assessing tissue-level reperfusion after both thrombolytic therapy and mechanical reperfusion [36],[37]. Patients with incomplete STR have a larger final infarct size, lower LVEF, and poor clinical outcome compared with those who achieve complete STR [38],[39]. In the present study patients with incomplete STR also had lower LVEF.

The anatomical SYNTAX score was developed as a part of the SYNTAX trial aiming to help clinicians quantify the severity of CAD and choose the best revascularization strategy in patients with complex CAD [11],[13],[40],[41],[42]. The major limitation of the SYNTAX score is the lack of inclusion of clinical variables [20]. The SS-II was developed incorporating both anatomical and clinical variables for better prediction of the clinical outcome and more accurate decision making in the management of patients with CAD [43].

Campos et al. [44] studied the long-term mortality of 3896 patients undergoing PCI (n=2190) or CABG (n=1796). The SS-II had a better predictive accuracy for long-term mortality compared with the anatomical SYNTAX score. In addition, the SS-II surpassed the anatomical SYNTAX score in discriminating between CABG and PCI.

Salvatore et al. [45] evaluated the SS-II in acute coronary syndrome patients with that in patients with severe CAD (three-vessel disease and/or left main involvement). The presence of left main disease and SS-II greater than or equal to 29 were the only predictors of clinical outcome at 1 year.

Xu et al. [43] prospectively collected the data from 1528 consecutive patients undergoing unprotected left main PCI. In this group of patients, the SS-II was a useful tool to risk-stratify patients and predict adverse outcome, including mortality.

The different components of the SS-II are associated with adverse clinical outcome [43].

Previous studies demonstrated that more diffuse and severe CAD with higher anatomical SYNTAX score was associated with no-reflow in patients with STEMI treated with PPCI. In 669 consecutive patients with STEMI treated with PPCI, Magro et al. [46] found that the SYNTAX score was an independent predictor of no-reflow. The study identified SYNTAX score greater than 21 as the best cutoff value increasing the risk for no-reflow. Similarly, Şahin et al. [47] in a study of 880 patients with STEMI treated with PPCI reported that SYNTAX score with a cutoff value of 19.75 was an independent predictor of no-reflow.

Age has been demonstrated as an independent predictor of mortality [48].

In a cohort of 11 774 patients presenting with acute coronary syndrome, including ST and non-ST-segment elevation acute myocardial infarction and unstable angina, Santopinto et al. [49] reported that admission CrCl is an independent predictor of hospital mortality and major bleeding. Impaired renal function has been also associated with markers of inflammation and impaired endothelial function [50].

Several reports demonstrated the relation between PVD and CAD [51],[52]. Matsuzawa et al. [53] reported a relation between peripheral vascular endothelial dysfunction and coronary microcirculation.

LVEF is a known predictor of adverse clinical outcome in patients with STEMI [54]. In a previous report, Vakili et al. [55] studied 304 patients with STEMI who had undergone PPCI. The authors reported that LVEF less than or equal to 50% is associated with a higher incidence of in-hospital adverse outcome. In addition, absent STR after PPCI had significantly higher rates in patients with low LVEF.

According to the results of the present study, patients with SS-II greater than 25 may benefit from receiving measures that decrease microvascular damage, such as thrombus aspiration and adjunctive pharmacological agents like glycoprotein IIb/IIIa inhibitors and vasodilators drugs.

Study limitation

Small sample size is considered the main limitation of the study. Therefore, larger-scale studies are required to confirm the value of SS-II in predicting impaired myocardial reperfusion.


  Conclusion Top


The findings of the present study suggest that SS-II may be a useful predictor of incomplete STR in patients with STEMI treated with PPCI.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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