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.