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Original Investigation
June 26, 2019

Association of Coronary Anatomical Complexity With Clinical Outcomes After Percutaneous or Surgical Revascularization in the Veterans Affairs Clinical Assessment Reporting and Tracking Program

Author Affiliations
  • 1Department of Medicine, Division of Cardiology, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
  • 2Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora
  • 3Department of Medicine, Division of Cardiology, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
  • 4Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
  • 5Department of Medicine, Division of Cardiology, Durham Veterans Affairs Medical Center, Durham, North Carolina
  • 6National Heart and Lung Institute, Imperial College of Science, Technology and Medicine, London, United Kingdom
  • 7Thoraxcenter, Erasmus MC, Rotterdam, the Netherlands
  • 8Department of Surgery, University Hospitals of Cleveland Medical Center, Cleveland, Ohio
  • 9Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
  • 10Center for Interventional Vascular Therapy, New York Presbyterian Hospital, Columbia University Medical Center, New York
JAMA Cardiol. Published online June 26, 2019. doi:10.1001/jamacardio.2019.1923
Key Points

Question  Can a simplified anatomical scoring system adapted for registry data reproduce the established associations between increasing anatomical complexity and adverse outcomes after revascularization?

Findings  In this cross-sectional multiple-center study of 50 226 patients undergoing percutaneous or surgical revascularization, adaptation of the Veterans Affairs SYNTAX simplified anatomical scoring system for coronary artery disease complexity found an association between increasing anatomical complexity and adverse events among patients undergoing percutaneous revascularization but not among patients undergoing surgical revascularization.

Meaning  The Veterans Affairs SYNTAX score may be able to assess longitudinal risk of revascularization using registry data based on coronary anatomical complexity and may represent a powerful tool in understanding longitudinal risk in large data sets.


Importance  Anatomical scoring systems for coronary artery disease, such as the SYNTAX (Synergy Between Percutaneous Coronary Intervention [PCI] With Taxus and Cardiac Surgery) score, are well established tools for understanding patient risk. However, they are cumbersome to compute manually for large data sets, limiting their use across broad and varied cohorts.

Objective  To adapt an anatomical scoring system for use with registry data, allowing facile and automatic calculation of scores and association with clinical outcomes among patients undergoing percutaneous or surgical revascularization.

Design, Setting, and Participants  This cross-sectional observational cohort study involved procedures performed in all cardiac catheterization laboratories in the largest integrated health care system in the United States, the Veterans Affairs (VA) Healthcare System. Patients undergoing coronary angiography in the VA Healthcare System followed by percutaneous or surgical revascularization within 90 days were observed and data were analyzed from January 1, 2010, through September 30, 2017.

Main Outcomes and Measures  An anatomical scoring system for coronary artery disease complexity before revascularization was simplified and adapted to data from the VA Clinical Assessment, Reporting, and Tracking Program. The adjusted association between quantified anatomical complexity and major adverse cardiovascular and cerebrovascular events (MACCEs), including death, myocardial infarction, stroke, and repeat revascularization, was assessed for patients undergoing percutaneous or surgical revascularization.

Results  A total of 50 226 patients (49 359 men [98.3%]; mean [SD] age, 66 [9] years) underwent revascularization during the study period, with 34 322 undergoing PCI and 15 904 undergoing coronary artery bypass grafting (CABG). After adjustment, the highest tertile of anatomical complexity was associated with increased hazard of MACCEs (adjusted hazard ratio [HR], 2.12; 95% CI, 2.01-2.23). In contrast, the highest tertile of anatomical complexity among patients undergoing CABG was not independently associated with overall MACCEs (adjusted HR, 1.04; 95% CI, 0.92-1.17), and only repeat revascularization was associated with increasing complexity (adjusted HR, 1.34; 95% CI, 1.06-1.70) in this subgroup.

Conclusions and Relevance  These findings suggest that an automatically computed score assessing anatomical complexity can be used to assess longitudinal risk for patients undergoing revascularization. This simplified scoring system appears to be an alternative tool for understanding longitudinal risk across large data sets.