SYNTAX AT 4 YEARS. EACT 2011, LISBON

Last week, Dr Patrick Serruys was our spokesman at the European Association of Cardiothoracic Surgeons Annual Meeting in Lisbon. He was there to present the 4 years follow-up of the Syntax trial. The Syntax trial, which began enrollment in 2004, is a study of 1,800 patients with LMS and 3VD CAD randomised to CABG or PCI using the TAXUS stent. At the 1st year, PCI was inferior to CABG, driven mainly by the higher TLR rate in PCI. There was no difference in the hard endpoints of death/CVA/AMI. At 2 years the trend was basically the same with the curve diverging slightly. Last year ( 3 years ), the curve was still diverging but the CVA rates ( which was more in the CABG arm at year one ) had flattened out. Now at year 4, the CABG arm was clearly better as the end points of death ( CV and all cause mortality ) and AMIs were both higher in the PCI arms and the stroke rates were flat for the last 2 years.

SYNTAX 4-year cumulative results

Outcome	CABG surgery, n=819 (%)	PCI, n=879 (%)	p
MACCE	23.6	33.5	<0.001
Death/stroke/MI	14.6	18	0.07
All-cause mortality	8.8	11.7	0.048
Cardiac death	4.3	7.6	0.004
Stroke	3.7	2.3	0.06
MI	3.8	8.3	<0.001
Repeat revascularization	11.9	23	<0.001

Basically, it looks like after 4 years, CABG is better than PCI with the TAXUS stent. Of course, interventionist will argue that 4 years later, we know that the TAXUS stent was not as good as we first thought and now we have the scond generation Xience V / Prime stent, which will match CABG. In fact, this is the subject of the on-going EXCEL study, whose results we await, expectantly. The best form of treatment is always a moving target, as science and cardiology evolve better and better. Say what you may, but PCI is a very reasonable alternative for patients with complex CAD but whose Syntax Score is <32. This was the recommendation after Syntax 3 years. Now after Syntax 4 years, I will be happy to offer PCI to patients with complex CAD whose Syntax score is <22. It will be terrible ( in my opinion ) to open someone's chest for 3 discrete stenosis, when in 1 hour, and 3 stents, I can take care of the symptoms and be as good as CABG.
In the current scheme of things, this will be my strategy.