SYNTAX Analysis Demonstrates Need for Optimal Medical Therapy With Revascularization

April 7, 2015—At 5-year follow-up, the SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) trial investigators found that the use of optimal medical therapy (OMT) remains low in patients with complex coronary disease who require revascularization with percutaneous coronary intervention (PCI), and it is even lower in patients treated with coronary artery bypass graft surgery (CABG). Because lack of OMT is associated with adverse clinical outcomes, targeted strategies are warranted to improve OMT use in postrevascularization patients, concluded the investigators. Javaid Iqbal, MD, et al published these findings from the SYNTAX study in Circulation (2015; 131:1269–1277).

The background of the study is that there is a paucity of data on the use of OMT in patients with complex coronary artery disease undergoing revascularization with PCI or CABG and its long-term prognostic significance.

As summarized in Circulation, the SYNTAX trial is a multicenter, randomized, clinical trial of patients (n = 1,800) with complex coronary disease randomized to revascularization with PCI or CABG. Detailed drug history was collected for all patients at discharge and at 1-month, 6-month, 1-year, 3-year, and 5-year follow-up. 

OMT was defined as the combination of at least one antiplatelet drug, statin, beta blocker, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. Five-year clinical outcomes were stratified by OMT and non-OMT. 

The SYNTAX investigators reported that OMT was underused in patients treated with coronary revascularization, especially CABG, and that OMT was an independent predictor of survival. Additionally, OMT was associated with a significant reduction in mortality and composite endpoint of death/myocardial infarction/stroke at 5-year follow-up. The treatment effect with OMT was greater than the treatment effect of revascularization strategy. 

On stratified analysis, all the components of OMT were important for reducing adverse outcomes regardless of revascularization strategy, stated the investigators in Circulation.