It's the FFR!:It's the FFR!:It's the FFR!:It's the FFR!:Functional Syntax Score Functional Syntax Score Functional Syntax Score Functional Syntax Score
vs. Syntax Scorevs. Syntax Scorevs. Syntax Scorevs. Syntax Score
Keimyung University Dongsan medical center, Daegu, Korea
Chang Wook Nam MD PhDChang-Wook Nam MD, PhD
80 YO ♀ Angina, HTN Hx
Bifurcation lesion
Multivessel diseaseBifurcation lesion
Multifocallesion
Intermediate lesion
Diffuse lesion
Intermediate lesion
CTO
VS.CABG PCI c DESVS.CABG PCI c DES
TAXUS (N=546)CABG (N=549)
3 Year Results in 3 VD subset3 Year Results in 3 VD subsetOutcomeOutcome
TAXUS (N=546) (%
)
40Death/CVA/MIDeath/CVA/MI
(%) 40
CVACVA
3-Year Results in 3 VD subset3-Year Results in 3 VD subset
P=0.04 14 8%e Ev
ent R
ate
20
40Before 1 year*
6.6% vs 8.0%P=0.39
1-2 years*
1.8% vs 3.7%P=0.07
2-3 years*
2.5% vs 4.4%P=0.10
P 0 64 2 9%Even
t Rat
e
Before 1 year*
1.9% vs 0.7%P=0.09
1-2 years*
0.4% vs 0.8%P=0.69
2-3 years*
0.6% vs 0.8%P=1.0020
10.6%
14.8%
0Cum
ulat
ive 20 P=0.64
2.6%2.9%
0Cum
ulat
ive
0 12 36240
Months Since Allocation0 12 3624
(%)
Repeat revasc.Repeat revasc. (%)
MACCEMACCE
Months Since Allocation0 12 3624
19 4%Even
t Rat
e 40Before 1 year*
5.5% vs 14.6%P<0.001
1-2 years*
2.8% vs 3.9%P=0.35
2-3 years*
2.5% vs 3.0%P=0.63
pp
28 8%Even
t Rat
e 40 Before 1 year*
11.5% vs 19.2%P<0.001
1-2 years*
4.4% vs 7.0%P=0.08
2-3 years*
4.6% vs 7.4%P=0.06
P<0.001 19.4%
10.0%
mul
ativ
e E 20
Repeat CABG: 1.0% vs 3.8%, P=0.003Repeat PCI: 9 5% vs 16 7% P=0 0003
P<0.001
28.8%
18.8%m
ulat
ive
E 20
2010 TCTCumulative KM Event Rate ± 1.5 SE; log-rank P value; *Binary rates
0Cu
0 12 3624Months Since Allocation
Repeat PCI: 9.5% vs 16.7%, P=0.0003 0Cu
0 12 3624Months Since Allocation
ITT population
The Selection of Patients with M lti l CAD I O t
MACCE to 3 Years by SYNTAX Score Tertile
Multi-vessel CAD can Improve Outcomes%
)
%)
31 4%%)
PCICABG
P=0.4525.8%
nt R
ate
(% 40
30 P=0.003
29.4%
nt R
ate
(% 40
30P=0.004
31.4%
nt R
ate
(% 40
30
22.2%
ativ
e Ev
en
20
10 16 8%lativ
e Ev
en20
10 17.9%lativ
e Ev
e
20
10
M th Si All tiM th Si All ti
Cum
ula
0 12 240
10
36M th Si All ti
16.8%
M th Si All ti
Cum
ul
0 12 240
10
36M th Si All ti
Cum
ul
0 12 240
10
36Months Since AllocationMonths Since Allocation Months Since AllocationMonths Since Allocation Months Since Allocation
Low Scores (0-22)
Intermediate Scores (22-33)
High Scores (33≤)
TCT 2010
(0-22) (22-33) (33≤)
Multivessel disease
Current Guidelines for MVDCurrent Guidelines for MVD
Wijns W, EHJ 2010;31:2501–2555.
Multivessel disease
SYNTAXSYNTAXSYNTAX SYNTAX scorescore
SYNTAX score
38
MVD in FAMEMVD in FAMEP<0 001
FFRFFR--GuidedGuided
tent
P<0.001
AngioAngio--GuidedGuided
mbe
r of s
730 days730 days4.5%4.5% N
um
FFR-guided PCI
Angio-guided PCI
Angio Less
Angio Better FFR Better
Less Costly
QALY
FFR Less Costly
QALY
Tonino PA, NEJM 2009;360:213-24Pijl NH, JACC 2010;56:177-84
Fearon WF, Circ 2010;29USD
Courtesy to Dr William Wijns17
The Selection of Patients with Multi-vessel CAD can Improve Outcomes
Current Guidelines for MVDCurrent Guidelines for MVD
Multi vessel CAD can Improve Outcomes
If we can addIf we can add
functional functional
information for information for
decision making…decision making…
Wijns W, EHJ 2010;31:2501–2555.
Revisit FAMERevisit FAMERevisit FAMERevisit FAME
Functional SYNTAX ScoreFunctional SYNTAX Scorefor Risk Assessmentfor Risk Assessment
Functional SYNTAX ScoreFunctional SYNTAX Scorefor Risk Assessmentfor Risk Assessmentfor Risk Assessment for Risk Assessment
in Multiin Multi--vessel Coronary Artery Diseasevessel Coronary Artery Diseasefor Risk Assessment for Risk Assessment
in Multiin Multi--vessel Coronary Artery Diseasevessel Coronary Artery DiseaseFFR-guided “Functional SYNTAX score (FSS)”
y yy yy yy y
would predict 1-year clinical outcome better than the “classic SYNTAX score (SS)” in patients with multi-vessel coronary artery disease undergoing percutaneous coronary intervention
Patient with stenoses ≥ 50% in at least 2 of the 3 major
FLOW CHART
Indicate all stenoses ≥ 50%
epicardial vessels
Indicate all stenoses ≥ 50% considered for stenting
A i h id d PCI FFR guided PCI
Randomization
Angiography-guided PCI FFR-guided PCI
Measure FFR in all indicated stenoses
Stent only thoseStent all indicated stenoses
Stent only those stenoses with FFR ≤ 0.80
1-year follow-up
SYNTAX score
FFR 0.92
FFR 0.90
FFR 0.92
FFR 0.86
FFR 0 86FFR 0.86
FFR 0.90FFR 0.90
Functional SYNTAX score
Comparison of Outcomesp<0.001p=0.001
CI
SS
p=0.02P<0.001
%)
guid
ed P
C
d PC
I
h SS SS H
igh
F S
FSS
year
(%
BG
PCI
Ang
io-g
R-g
uide
d
Hig
h
Med
ium
Med
ium
F
E at
1-y
CA
B
FF
Low
to
Low
to
MA
CE
SYNTAX
N=163
N=334
N=101
N=396
SYNTAX FAMENam CW, Interv Cardiol 2011:3:695–704
Different Fate of Risk Group
Low riskMedium risk P<0.01High risk
101(62%)
SYNTAX scoreSYNTAX score
37(23%)25
(15%)
( %)
CE
(%)
69
( )
year
MA
C
98(59%)
(41%) 1-y
Functional SYNTAX scoreFunctional SYNTAX score
32%Remained
in High riskMoved to Lower risk
32% Nam CW, JACC 2011;58:1211–8Nam CW, Interv Cardiol 2011:3:695–704
Comparison of Outcomes
Nam CW, JACC 2011;58:1211–8Nam CW, Interv Cardiol 2011:3:695–704
Functional SYNTAX score1.0
0.790.91
0.840.79
1.0
0 710.71
18
RCA CTO intervention
LCX Evaluation and Treatment
Bifurcation lesion
Multivessel disease
Multifocallesion
Multivessel disease
I t di t l ilesion Intermediate lesion
Diffuse lesion
CTO
PCI in intermediate lesion: FFR PCI in intermediate lesion: FFR vsvs IVUSIVUS
Nam CW, et al. JACC interv 2010:3:812
Intermediate lesion
56 5
6
45
VA 3.74mm²
VA 5.95mm²LA 4.37mm²
Plaque Burden 26.5%
12
34
MLA 2.87mm²Plaque Burden 50.0%
Plaque Burden 26.5%
0 841
VA 7.09mm²LA 2 75 ²
0.84
12
LA 2.75mm²Plaque Burden 61.3% 3
2
VA 5.43mm²LA 2.0 mm²
VA 12.46mm²LA 4.78mm²
Plaque Burden 61.7% VA 11.58mm²LA 2.88mm²
Plaque Burden 75.1%
Plaque Burden 63.1%
LAD Evaluation and Treatment
Bifurcation lesion
Multivessel disease
Bifurcation lesion
I t di t l i
Multivessel diseaseMultifocal
lesion
Intermediate lesion
Diffuse lesion
CTO
Multifocal & Diffuse long lesion
0 911.00.79
0.91
0.71 0.79 0.91
1.0
0.71
Post interventional evaluation
0 850.85
0.80
0.76 0.80 0.851.01.0
0 760.76
Post interventional evaluation
0.97
0.89 0.97 1.01.0
0.89
FFR-guided 3VD PCI
ConclusionConclusionIf FSS is applicable in the patients with multi-vessel CAD, the number of low- and medium-riskvessel CAD, the number of low and medium risk patients who usually are recommended PCI can be dramatically increased.be dramatically increased. CABG could be highly recommendable in the high risk patients with multi vessel CAD classifiedhigh-risk patients with multi-vessel CAD classified by FSS to hopefully improve outcomes.Therefore, the selection of target vessels, the method for revascularization, and the determination of prognosis in patients with multi-vessel CAD are improved by FFR-guided risk in daily practice.