| Part Ⅰ: Derivation of a 17 myocardial segmentation(CatLet)angiographic scoring systemObjectives: The current study aimed to devise a new scoring system,the 17 myocardial segmentation(CatLet)angiographic scoring system,to grade the severity and complexity of the acquired coronary artery diseases according to the importance of a blood vessel,and to collect the treatment information on lesions.In addition,this scoring system can be used to describe the anatiomical characteristics of the native coronary artery trees.Methods and Results: Based on the 17 myocardial segment model,combined with law of competitive myocardial blood supply,law of flow conservation,and the invariable global value of 17.0,we developed a new angiographic scoring system.There are clearly 3 anatomical landmarks(anterior inter-ventricular sulcus,posterior inter-ventricular sulcus,and obtuse marginal border)on the left heart surface consistently dividing the left heart into 3 areas: the septal area,the diagonal-obtuse marginal area and the inferior wall.Considering the tremendous variability of coronary artery,coronary artery circulation system is divided into 6 types based on the supply territory of right coronary artery(RCA): PDA zero,PDA only,Small RCA,Average RCA,Large RCA and Super RCA;coronary artery circulation system is divided into 3 types based on the supply territory of left anterior descending(LAD)(excluding diagonals): short,average,and long LAD;coronary artery circulation system is divided into 3 types based on the supply territory of diagonals: small,intermediate,and large diagonals.Thus,we make up a total of 54 types of coronary artery circulations.Three major epicardial coronary arteries compete for the blood supply to the left ventricle and we assign a weighting factor to each blood vessel based on the number of segments the blood vessel supplies.For coronary lesions,we multiply the weightage of the diseased vessel by the multiplication factor(completely occluded lesion × 5,stenosis 50-99% × 2)to obtain the initial score.Within one segment,direct scoring will overestimate the severity of coronary artery disease in the presence of significant side branches(SB,>1.5 mm in diameter)preceding the main branch(MB)lesion regardless of their normal or diseased status.Thus,lesion scoring should be modified.The sum of individual scores can be added to get the total score.For those non-stenotic characteristics of the lesion,wedo not score,but only record them objectively.Conclusions: Based on the 17 myocardial segmentation model,we devised a new coronary lesion scoring system,CatLet angiographic scoring system,which can used to grade the severity and complexity of the acquired coronary artery diseases and to collect coronary artery tree information.Part Ⅱ: Predictive value of CatLet angiographic scoring system in acute myocardial infarction patientsObjective: This study aimed to validate the utility of the CatLet angiographic scoring system on long-term outcome predictions in patients with acute myocardial infarction undergoing primary PCI.Methods: A total of 434 consecutive patients undergoing emergency coronary angiography suspect of myocardial infarction were retrospectively enrolled from the Chest pain center,the First Affiliated Hospital of Soochow University,from January 01,2012 to January 31,2013.After excluding those patients who did not meet the inclusion criteria,we enrolled a total 308 patients in our study.Medical history,laboratory examination,ultrasonic echocardiography and coronary angiograms were collected,and CatLet and Syntax scores were calculated seperately based on coronary angiography.All patients were followed up for 4 years.We recorded all adverse cardiovascular and cerebrovascular events(including all-cause death,cardiac death,non-fatal myocardial infarction,stroke or transient ischemic attack,and ischemic event-driven blood transfusion)and the time of all events.Tertiles for CatLet score were defined as lowest tertile ￡14,intermediate tertile 14-22,highest tertile 322.And we analyzed the differences between those tertiles in baseline characteristics and clinical outcome.Kaplan-Meier(K-M)curve,log-rank test,trend test and Cox regression model were used to analyzed the regressive relationship between the 3 groups in different score models.We used Harrell’s C index to assess the ability of CatLet score in predicting long-term clinical outcome.Statistical analyses were completed with STATA 13.0.Two-tailed P < 0.05 was considered to be statistically significant.Results: 1.A total of 308 cases with 651 lesions were studied in this study.On average,each patient had 2.11 ± 1.21 lesions.Catlet score ranged from 3 to 81,with a mean ± SD of 20.1 ± 12.1,Syntax score ranged from 2 to 52,with a mean ± SD of 12.5 ± 7.5.Spearman rank correlation analysis showed that there was correlation between the two scores(r = 0.794,P <0.001).2.1)K-M curves for all endpoints of 4-year show a gradual decline in survival with time. In the Cox regression analysis,there was a higher incidence of major adverse cardiac cerebralvascular events(MACCE)(37.25% vs 7.26%)in the highest tertile of CatLet score than the lowest tertile at 4 years.And the Hazard ratio(HR)and 95% confidence interval were: 6.38(3.08-13.19).Compared to lowest tertile of Catlet score,the hazard ratio(HR)of intermediate tertile was 3.01(1.34-6.75)and the trend test P <0.001.And there were similar results in terms of 4-year all-cause death and cardiac death.When the confounding factors were adjusted,the highest tertile still had a higher event rate than lowest tertile in all study endpoints.But there was no statistically significant differences in event rate and HR between lowest tertile and intermediate tertile.2)The Harrell’s C indexes of CatLet score in isolation were over 0.7 in terms of all study endpoints.And Hosmer-Lemeshow goodness-of-fit test showed a good calibration.After adjusting the non-stenotic vessel factors,the C indexes had no significant differences of each endpoint of the CatLet score model when compared with CatLet score in isolation,but the calibration worsened.When the clinical factors were adjusted,C indexes significantly improved,but the calibration were apparently worensed.3)Compared with the Syntax score,CatLet scores had a higher C index and a better calibration in terms of all study endpoints at 1-and 4-year respectively,but the differences were not statistically significant.Conclusions: The utility of the CatLet angiographic scoring system was first validated in terms of its long-term outcome predictions in AMI patients undergoing primary PCI.And the CatLet score seems to perform better than the Syntax score in 1-and 4-year outcome predictions.The prognostic value of the CatLet angiographic scoring system in coronary heart diseases warrants further confirmation. |
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