External Validation of the SYNTAX Score II 2020

Hironori Hara, Hiroki Shiomi, David van Klaveren, David M. Kent, Ewout W. Steyerberg, Scot Garg, Yoshinobu Onuma, Takeshi Kimura, Patrick W. Serruys*

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

28 Citations (Scopus)


Background: The SYNTAX score II 2020 (SSII-2020) was derived from cross correlation and externally validated in randomized trials to predict death and major adverse cardiac and cerebrovascular events (MACE) following percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with 3-vessel disease (3VD) and/or left main coronary artery disease (LMCAD). Objectives: The authors aimed to investigate the SSII-2020's value in identifying the safest modality of revascularization in a non-randomized setting. Methods: Five-year mortality and MACE were assessed in 7,362 patients with 3VD and/or LMCAD enrolled in a Japanese PCI/CABG registry. The discriminative abilities of the SSII-2020 were assessed using Harrell's C statistic. Agreement between observed and predicted event rates following PCI or CABG and treatment benefit (absolute risk difference [ARD]) for these outcomes were assessed by calibration plots. Results: The SSII-2020 for 5-year mortality well predicted the prognosis after PCI and CABG (C-index = 0.72, intercept = −0.11, slope = 0.92). When patients were grouped according to the predicted 5-year mortality ARD, <4.5% (equipoise of PCI and CABG) and ≥4.5% (CABG better), the observed mortality rates after PCI and CABG were not significantly different in patients with lower predicted ARD (observed ARD: 2.1% [95% CI: −0.4% to 4.4%]), and the significant difference in survival in favor of CABG was observed in patients with higher predicted ARD (observed ARD: 9.7% [95% CI: 6.1%-13.3%]). For MACE, the SSII-2020 could not recommend a specific treatment with sufficient accuracy. Conclusions: The SSII-2020 for predicting 5-year death has the potential to support decision making on revascularization in patients with 3VD and/or LMCAD.

Original languageEnglish
Pages (from-to)1227-1238
Number of pages12
JournalJournal of the American College of Cardiology
Issue number12
Publication statusPublished - 21 Sept 2021

Bibliographical note

Funding Information:
Dr Hara has received a grant for studying overseas from Japanese Circulation Society, a grant-in-Aid for JSPS Fellows, and a grant from Fukuda Foundation for Medical Technology. Dr Shiomi has received personal fees from Abbott Vascular, Boston Scientific, and Daiichi-Sankyo, outside of the submitted work. Dr Serruys has received personal fees from Biosensors, Micel Technologies, Sinomedical Sciences Technology, Philips/Volcano, Xeltis, and HeartFlow, outside of the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Publisher Copyright:
© 2021 American College of Cardiology Foundation


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