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SYNTAX: No change to clinical practice so what is the value of the trial?


Clinical practice has been largely unchanged by trials such as SYNTAX. Given the expense and the Herculean energies involved, what are your thoughts on the value of such trials? Do we really need them?

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Well, I am not so sure the Syntax will not change clinical practice, truth is that it has already affected our way of thinking. Where we thought we (interventional cardiologists) were doing as good as CABG at least terms of hard endpoints, i.e. complex 3-vessel disease, turned out not to be the case really as the trend disfavouring PCI with that respect is worrisome. To the other side, the left main disease where many of us were not even thinking to tackle with PCI, it seems actually that there is room for doing even better than CABG provided the complexity of remaining disease is not extensive. The syntax score is probably the true real novelty of this trial and this may help guiding the best revascularization approach in the single patient. But we need far more data to validate the score.
Posted by Marco Valgimigli, Mar 12, 2009 Publié le Marco Valgimigli, 03.12.2009

Dar Dr Topol,

Your question regarding the real merit of Syntax like trials seems to be a bit early. A good year has elapsed since the evaluation of the trial, and one  can see fundamental benefits on either modality. The chance for evaluation a given status of the coronaries simultaneously by the cardiologist and surgeon is a great breakthrough. This might be a great achievement and may serve the patients very well.

As a surgeon, I wish to note, that while the basic surgical practice (CABG) has not changed since the Green procedure (LIMA to LAD, 1970) and more and more arteries are being used for bypass surgery, in PCI practice one can observe an ever changing methodology (DES with different substances, bioabsorbable stents,etc) and also very serious complications: early, late thrombosis, clopidogrel resistency.

The effect of the SYNTAX trial will come a bit later, I think.


Posted by Ferenc I. TARR, Mar 20, 2009 Publié le Ferenc I. TARR, 03.20.2009
It is important to realize that not all clinical trials, no matter how extensive, will lead to changes in clinical practice. Research and clinical trials must go on if we are to avoid homeostasis. To observe the credo of, "first do no harm," do we have the luxury of not pursuing clinical trials?
Posted by Errol Prasad, Mar 20, 2009 Publié le Errol Prasad, 03.20.2009

 

 The important aspect of the Syntax trial is to define the hitherto guessed "risk" for PCI in complex morphologies with the Syntax Score.

Interventional cardiologists have been doing this for a while by intuition and such a score adds to the decision making process.

 

The second aspect is that CABG vs PCI for Left main with 1 vessel disease was evaluated and it appears that this subsection can be safely treated with PCI at the same complication and outcome rates as CABG.  This might move Left main PCI from a classIII indication to Class 2b for a select subsect of patients.

 


Posted by S Kumar, Mar 31, 2009 Publié le S Kumar, 03.31.2009

    

Dear Dr.Topol :

                     I am clinical cardiology and I think that  the syntax trial don´t change my choice in the clinical practice  because the guide to the decision is only anatomical and i think it  should be more functional . Finally i note the ausence of the clinical decision in this trial.

                           thanks


Posted by antonio gentile M.D., Jul 09, 2009 Publié le antonio gentile M.D., 07.09.2009

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