Coronary Scoring Systems

A Historical Perspective Merril Knudtson, MD Background

The coronary artery reporting system adopted by APPROACH ! between 1995 and 2008 was based upon the graphic tool known as Heartview ! with modifications from the literature to increase the tools precision.1 A new graphic coronary anatomy and intervention reporting tool called CARAT ! (Coronary Artery Reporting and Archiving Tool) has been developed for use by APPRAOCH to achieve, inter alia, the following anatomical reporting goals: 1. To capture greater patient-level detail 2. To develop a clinically relevant expression of lesion severity 3. To present a credible expression of the size and location of the myocardial bed supplied by diseased arteries 4. To abandon the historic three-region (anterolateral, lateral and posterolateral) LV model in favour of the 17-segment model currently adopted by most cardiac imaging systems.2 This document summarizes observations from literature reports that influenced the design of CARAT ! with summary comments concerning how this information was used.

Classifying Lesion Severity Whats in a number?

Although attempts have been made to create more complicated and granular lesion severity grading systems, none of these have improved upon the early lesion severity categorization of Oberman et al (1972)3. These clinically important severity ranges are explained below (see also Figure below): <50% diameter reduction. Lesions in this range are very unlikely to have hemodynamic and clinical significance based upon severity alone and further severity subdivisions within this range have no proven value. >50% and <70% diameter reduction. Lesions in this range are of borderline hemodynamic and clinical significance but 35% were found to have a compromised hyperemic response in one large series4. This is an important range to capture from a clinical perspective for interventions on lesions in this range would benefit from confirmation of their 1

hemodynamic significance by prior non-invasive testing or by FFR assessment at the time of angiography. >70% but <100%. Almost all lesions in this range are hemodynamically significant, thus seeking supplementary confirmation of hemodynamic significance is not warranted in most cases. Further there is no established benefit to assigning a more precise stenosis grade within this range. Gould5-7 has shown that the hyperemic response falls off geometrically in the 65-85% diameter reduction range, a range that Gensini refers to as the resistance elbow. In this range, angiography simply lacks adequate discriminating power. Lesions >85% may demonstrate reduced flow at rest, the apparent justification for the addition of a 90-99% category by some investigators8-11, but it is not clear whether this category is clinically useful. 100%. A separate category for completely occluded vessels is warranted for multiple clinical and therapeutic reasons.

10 20 30 40 50 60 70 80 90 100 >70% 50-70% <50%

10 20 30 40 50 60 70 80 90 100
Luminal Diameter Reduction (%)

If a single threshold for clinical significance were adopted, the literature is divided on whether this threshold should be 50% 3, 8, 12-14 or 75%1, 9, 15, 16. Clearly the 70% cutoff has the greatest physiologic support 7, 15 and has been labeled the gold standard threshold for clinical significance7. Rather than accepting a fixed threshold for significance, several investigators have assigned a lesion score that is graded by lesion severity 13, 16-19. This graded value is then used alone, or used as a multiplier along with some expression of myocardial territory at risk, with the belief that a graded valuation and/or a

combined score is a more sensitive and reliable outcome predictor than a binary designation of significance. The 7 published lesion-weighting systems are listed below with the score shown in bold print beside the severity ranges used: 1 = <50%; 2= 50-90% single lesion; 3=50-90% multiple lesions; 4=90%; 5=100% 20 1=Trivial; 2=<50%; 3=50-75%; 4=75-90%; 5=100% 3 1=<50%; 2=50-75%; 3=75-99%; 4=100% 17, 19, 21, 22 0.2=<50%; 0.4=50-75%; 0.6=75-90%; 0.8=90-99%; 1.0=100% 1=70-90%; 3=90-99%; 5=100% 18 1=25-50%; 2=50-75%; 4=75-90%; 8=90-99%; 16=100% 10 0=<50%; 2=50-99%; 5=100% 13

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The lesion range weighting scores above lack appropriate validation and face validity. For example, it is not clear why a 100% occlusion, usually associated with collateral support and frequently associated with an area of prior infarction, should be given a consistently higher weighting than more vulnerable lesions in the 70-90% range. APPROACH has not adopted a weighting system based upon diameter severity and will employ the single threshold stenosis value of 75% (50% for LM). As 50%, 70% and 100% luminal diameter obstruction thresholds have clinical utility and a strong evidence base, is there clinical value in including other intermediate severity levels in a clinical scoring system? It has been shown that simple visual estimates of severity, particularly in more severe lesions, have a stronger correlation with baseline exercise test performance than automated quantitative techniques 23. One may conclude from this that there be value in providing 60, 80 and 90% options to angiographers in order to allow expression of their clinically integrated impressions of lesion severity. A 60% designation, for example, may be selected as a cautionary statement of borderline severity. There is no value in attempting to sub-classify lesion severity in the <50% range; a simple statement of the existence of angiographically identifiable disease should suffice19. Also, a strategy of intervening on lesions <50% has been discredited24.

Myocardial Jeopardy A critical dimension

From the earliest days of angiography, estimations of the amount of myocardium supplied by diseased coronary vessels and the impact of these estimates on treatment and outcome have received close study20, 25 Initially these estimates were based upon a simple statement of the number of diseased major epicardial vessels8, but the lack of precision of this approach soon became evident and 3

adjustments were made for the dominant influence of proximal LAD and LM disease8, 26. In the later part of the 1970s standardized myocardial templates were developed and used in natural history studies, but the wide anatomic variability seen between individual patients in clinical practice pointed to the obvious deficiencies in these over simplified models. Unfortunately precise measurement of the relative amounts of LV myocardium supplied by each major epicardial artery is available from a single pathologic study, that of Kalbfleisch and Hort (1977)27. The following table indicates the percentage of the LV volume assigned to each major epicardial artery in five classic clinical studies as well as the landmark pathology measurements of Kalbfleisch and Hort. The variable size of LCx and RCA distributions in these studies is not surprising due to the wide variability in the source of blood supply the posterolateral LV free wall.

Alderman et al (1992) Gensini (1975)17 Brandt (1977)16 Jenkins (1978)21 Dash (1977)14 Kalbfleisch & Hort (1977)27

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LAD
48 42 47 43 50 49-53

LCx
28 42 40 29 33 18-27

RCA
24 16 13 28 17 18-33

The table below indicates the percentage of the LV volume attributed to the septum as well as the anterior, lateral and posterolateral free wall territories in three clinical models along with the pathological work of Kalbfleisch and Hort.

Brandt (1977) Dash (1977)14 Graham (2006)1 Fulton (1952)28 Lorenz (1999)29 Kalbfleisch & Hort (1977)27

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Anterior Lateral Inferolateral

13 17 20 27-32 20 17 19 18-27 20 17 19 9-22

Septum
47 49 42 31 34 34 (2/3 LAD) Assumed

Challenges in quantifying septal coronary flow

Recent imaging studies are consistent with pathologic studies over the last 80 years that the septum accounts for 31-34% of the LV mass28, 30, 31. Unfortunately, it is equally clear that the relative contribution of LAD and PDA septal perforators to septal blood flow is highly variable and remains difficult to measure or estimate due to their large number and variable size and location. Based upon an autopsy series of 31 patients, James et al (1958) reported that the LAD provided 60-70% of septum in 23% of patients, 70-80% of patients in 29% and 80-90% of patients in 48%.32 (Although this report did not give individual anatomic detail, one would suspect that the third group included patients with a Type 3 LAD or a septal arcade variant.) A Canadian autopsy series of 12 human hearts reported that the LAD supplied 50% of the septum in half of the specimens and 2/3 of the septum in the remaining half.33 The review of Smith (1962) stated that the LAD contribution to septal blood flow was twothirds30, and this estimate continues to receive wide support. Assigning relative contributions of LAD and PDA perforator flow to this substantial and functionally important part of the LV myocardium remains a challenge. Alderman et al (1992) in the angiographic methods used by the BARI study assigned 3 of the 5 septal points (60%) to the LAD, 2 of these points to the largest perforator.12

Toward an optimal myocardium-focused coronary reporting tool

The reporting strategies summarized in this document have had modest value in evaluating group behavior in clinical trails and epidemiologic investigations, but they all lack precision and have significant shortcomings in capturing individual patient variability. The following features are desirable in a reporting tool: 1. Variability in the number, size and location of LV free wall branches should be provided for with dynamic adjustment of the amount and regional location of myocardium assigned to each1, 12, 16. 2. Allow for variation in length of distal LAD (Types 1-3)1. 3. Characterize the geometry and size of LV segments in the 17-segment model. Currently jeopardy calculations in CARAT assume a size of 6% for each segment. This value could be easily substituted for by actual CMR measurements in normal hearts, when they are available. 4. Capture the variations in RCA and LCx supply of posterolateral LV. 5. Allow for anomalous coronary origins and pathways.

6. Capture the variable contribution of anterior septals from LAD (variation from 50 90%) and inferior septals from PDA (variation from 10 to 33%) to the interventricular septum. There is no literature that would help in making this decision.

Diffuseness of Coronary Disease Is it measurable?

Although pathologic studies have consistently shown a strong correlation between the endothelial extent of atherosclerosis and the severity of lipid disorders and other risk factors19, 34, attempts to develop clinically useful measures of diffuseness of atherosclerosis continue to be disappointing10.

Literature Summary
Parker et al (1966) Kingston, Ontario 25
o Purpose Correlate angiographic severity with prior MI, symptoms and resting ECG changes o Coronary Score Lesion Grade (Variable) Grade 1 - <50% area stenosis; Grade 2 - >50% area stenosis but <100%; Grade 3 100% LV Extent Number of major vessels with > Grade 2 lesions o Conclusions 100% occlusion correlated with prior MI Presence of symptoms and resting ECG changes correlated with severe multi-vessel disease No correlation of variable lesion grade with outcome Historical importance this Canadian centre was the first to report association of CAD extent and clinical status

Friesinger et al (1970) Vanderbilt 20

o Purpose Establish a coronary scoring system that will permit anatomy correlation with outcome o Coronary Score Lesion Grade (Variable) 0 no disease; 1 lesions <50% area stenosis; 2 single lesion >50% but <90%; 3 multiple lesions >50% but <90%; 4 90%; 5 100%. 6

LV Extent Three regions: LAD, LCx and RCA Score calculation Friesinger Score - Sum of most severe lesion grade 1 to 5) for each of 3 regions o Maximum score total is 15. o Conclusions The coronary score was a stronger predictor of mortality than all measured clinical factors

Manuscript does not validate lesion grading system used

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Oberman et al (1972) Birmingham

o Purpose Establish correlation between lesion severity and subsequent mortality o Coronary Score Lesion Grade (Variable) 1 trivial disease; 2 lesions < 50% diameter reduction; 3 50 75%; 4 75 90%; 5 100%

LV Extent LAD, RCA and LCX divided into proximal and distal segments and graded separately. LM treated as 1 segment. Total segments possible 7. Number of diseased vessels Score calculation Oberman Score - Sum of lesion grade for each of the 7 individual segments. (A LM lesion is given the sum of scores for LAD plus LCx.) o Maximum score is 35 Number of diseased major vessels with diameter stenosis >50% (0-3) o Conclusions Confirms correlation of 2 and 3-vessel disease with mortality, but minor effect with 1 vessel disease. There was a mortality multiplying effect if CHF present. Of note, the Oberman Score described above was not used in the analysis, only the number of diseased vessels.

Bruschke et al (1973) Cleveland 8

o Purpose Correlate mortality over 4 years with number of diseased vessels in patients not treated with CABG o Coronary Score Lesion Grade (Fixed) Diameter reduction >50% defines significant disease Grading system: normal, <30%, 30-50%, 50-90%, >90% and 100% LV Extent Number of major vessels (0-3) o Conclusions Mortality increases with number of diseased vessels. Single vessel disease mortality not significantly influenced by lesions <50% in other vessels.

 Brymer et al (1974) Ann Arbor, Michigan 26

o Purpose Correlate coronary anatomy with outcome o Coronary Score See Friesinger Score Also - number of diseased vessels (>50% area reduction) with and without LAD involvement o Conclusions Significant influence of proximal LAD disease on mortality when added to number of diseased vessels or to Friesinger score.

Gould et al (1974, 1974 and 2009) - Houston 5-7

o Purpose Animal work correlating diameter stenosis to reduction in flow

o Conclusions o 50-85% diameter stenosis defines threshold for clinical significance (Hyperemic response starts to diminish >50% ldr with resting flow reduced when ldr is >85%) o Propose >70% as the gold standard for defining a single significant clinical endpoint o 65-95% diameter stenosis needed to see impaired flow, but angiographic measurement limitations do not allow finer discrimination within this range

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 Gensini G.G. (1975) Syracuse 17

o Purpose Description of a Coronary Artery Disease Scoring and Retrieval System (Cardscores). The system was intended to take into account: (1) Geometrically increasing severity of lesions 25, 50, 75, 90, 99 and 100% diameter reduction; (2) cumulative effect of multiple lesions; (3) lesion location; (4) influence of collaterals; (b) vessel graftability. o Coronary Score Severity score With each step in the 25 50 75 90 99 100% diameter reduction progression, the impact on flow doubles in accordance with Poiseuilles law. As a result severity scores for lesions in this progression were assigned the values 1 2 4 8 16 32. Region multiplying factors for coronary segments were designated to express the relative amount of myocardium supplied by a diseased segment (see diagram)

11

Collateral factor The severity score adjustment for collaterals is indicated on the right side of the table below. The adjustment is reduced by the extent of disease in the vessel that is the source of collaterals (left column).

Gensini Score Calculation: severity score X the segment location multiplying factor X Collateral adjustment factor

Brandt et al (1977) Auckland, NZ16

o Purpose Propose a flexible myocardial reporting and scoring model o Scoring System Grade of Stenosis severity (x-sectional area) 100 % - Correction value = 1.0 90-99% - Correction value = 0.8 75-90% - Correction value = 0.6 50-75% - Correction value = 0.4 <50% - Correction value = 0.2 Myocardial Value The Green Lane Model was loosely based upon the definitions of WG Austen et al 35 and the 15 point scoring system of GC Friesinger et al 20, modified by a 5-region diagram used by Auckland radiologists to diagram coronary anatomy. The regions are LAD septum, PDA septum, diagonal region, marginal region and posterolateral region and the percentage of LV myocardium assigned to each region is listed below: o LAD septum -30% (Value 5) o PDA septum -17% (Value 2) o Diagonals -13% (Value 2) o Marginals -20% (Value 3) o Posterolaterals -20% (Value 3)

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The angiographer draws the location of LV free wall branches on a template of the above 5 regions and the percentage area of each region supplied by each diseased vessel is estimate visually (see diagram below). Myocardial Score - The myocardial value of each diseased artery is multiplied by the Stenosis Severity Correction value and is then summed to obtain the Myocardial Score. This is an expression of the combined influence of jeopardized myocadial area and stenosis severity. The LV myocardium percentages specified above are similar to Kalbfleish and Hort (1977) and Dash (1977), but perhaps undervalue the PDA and overvalue the circumflex contributions. o Conclusions Rationale for specified stenosis grading not given in paper An elegant but operator dependent scoring system

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 Kalbfleisch and Hort 1977 - Marburg an der Lahn, Germany 27

This is an elegant and landmark pathologic study of the amount of myocardium supplied by the left anterior descending, circumflex and right coronary arteries in 171 human hearts. The hearts were categorized by vascular type: left coronary type with LCA supplying all of LV (left dominant system); RCA type with RCA supplying only the posteriorseptal wall (co-dominant system); and three normal types in which the RCA and LCx both supply variable portions of the posterior wall (right dominant systems). Based upon this data, the following regional LV mass calculations can be reasoned for the five Green Lane regions. The LADPDA septum division was calculated using the Green Lane 64:36 split of LAD and PDA blood supply to the septum. o LAD (Anterior septum and adjacent Ant. Wall) -32% o PDA (Inferior septum and adjacent PL wall) -18% o Diagonals -15% o Marginals -18% o Posterolaterals -17%

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 Dash et al (1977) Harvard

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o Purpose ! Coronary anatomy - LV function correlation ! Does the development and extent of ischemic cardiomyopathy correlate with coronary anatomy? o Coronary Score ! Lesion Grade (Fixed) Primary threshold level - Significant defined as Area reduction >70% ! LV Extent Two points are assigned to each of 6 specified segments with a significant proximal stenosis (see diagram below). The territory assignments are clear except dLAD (1) is unspecified but is likely a combination of anterior wall and septum.

o Conclusions
!

An angiographic scoring system grade based upon myocardial volume at risk is a better predictor of ischemic cardiomyopathy development than a 1, 2 or 3 vessel disease classification. Paper does not specify the basis for the jeopardy scoring system but is very similar to Kalbfleisch and Hort (1977)

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 Proudfit et al (1978) Cleveland 11

o Purpose - Explore association of clinical and angiographic variables with 5-9 year survival in a cohort of 600 non-surgical patients. o Coronary Score ! Lesion grade - diameter reduction < 30% 30-50% 50-90% - Primary threshold level Subtotal 100% o Conclusions ! Mortality increases with the number of vessels with diameter lesions > 50% ! In patients with 2 and 3 vessel disease who are referred for surgery, complete revascularization is associated with a better survival than patients incompletely revascularized

Jenkins et al (1978) Victoria, Australia 21

!

Purpose - Correlate serum cholesterol with angiographic extent of disease o Coronary Score ! Lesion Grade 1 - <50% luminal diameter reduction 2 50-75% 3 75-99% 4 100% ! LV Extent 8 proximal coronary segments analyzed ! Gensini score sum of lesion grade for each of 8 segments

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o Conclusions ! Serum lipids correlate with extent of coronary disease

Harris et al (1980) Duke 9

o Purpose - To determine the incremental influence of 50% lesions on survival in 1183 medically treated patients with 1, 2 or 3 vessels (lesions greater than 75% luminal diameter reduction) o Coronary Score ! Lesion grade - diameter reduction <25% 25% 50% - Secondary threshold level 75% - Primary threshold level 90% 100% o Conclusions ! The presence of one or more lesions of 50% severity was not associated with an increased mortality in patients with 1, 2 or 3 vessels with 75% lesions.

Lee et al 1981 - Duke 36

o Purpose Study of 18 autopsy human hearts confirming the correlation of relative infarction size and vessel distribution area. o Results ! The ischemic bed sizes by major coronary region were: Circumflex -30% (varied from 21% to 43%) RCA -32% (varied from 24% to 37%) LAD -44% (varied from 29% to 66%) o Conclusions ! Although this is a small study that does not provide enough detail to arrive at a 5-region breakdown of myocardial mass, the study presents an important confirmation that infarct size correlates closely with the regional LV mass.

Leaman et al (1981) Rotterdam 18

o Purpose ! To fashion a coronary scoring system that takes into account lesion severity and distribution area. ! To evaluate the score as a means to predict symptoms and LV function

17

o Coronary Score ! Lesion grade diameter reduction 70-90% 90-99% 100% ! LV Weighing Factor see diagram after Gensini (1975) ! Leaman Score Calculation - Multiply lesion score by weighting factor for each segment !

o Conclusions\ ! Symptoms and LV function do not correlate with this score. ! No supporting comments on the validity of magnifying the LV weighting factor by the lesion severity.

White et al (1984) Iowa City37

o Purpose Does lesion angiographic severity predict maximum hyperemic response o Methodology ! Correlate caliper-assistant diameter measurements with hyperemic flow Doppler measurements 18

o Conclusions ! Poor correlation between angiographic lesion severity and physiologic maximal hyperemic response as measured by flow Doppler

Reardon et al (1985) Victoria, Australia 19

o Purpose - Correlate lipid concentrations with coronary severity o Coronary Score Gensini score (See Jenkins et al (1978) ! Lesion grade 1 - <50% luminal diameter reduction 2 50-75% 3 75-99% 4 100% ! LV Extent 8 Segment method o Conclusion ! 22% of the variation in coronary severity can be accounted for by lipid concentrations

Califf et al (1985) Duke 38

o Purpose ! Prognostic value of Jeopardy score ! Incremental value of score over coding number of diseased arteries o Coronary Score ! Lesion grade Diameter stenosis >75% considered significant (rather than >50% used in work of Harris et al (1978) ! LV Extent Uses the Dash et al (1977) 6-segment grading system ! Score Calculation

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o Conclusions ! Jeopardy score is an improvement over classifying CAD severity on basis of number of diseased arteries ! Further refinement needed, in particular paying more attention to pLAD disease and other anatomic factors

Hamsten et al (1986) Stockholm, Sweden 10

o Purpose ! Correlate lipoprotein risk factors with angiographic score ! Score designed to capture disease diffuseness/extent o Coronary Score ! Segments 15 proximal segments (AHA) ! Diffuseness score Hamsten Score Multiply Extension by Mean plaque size score (maximum 9) for each of 15 segments

Stenosis score (Modified Gensini score) 0 - <25% luminal diameter reduction 1 25-50% 2 50-75% 4 75-90% 8 90-99% 16 100% ! Jenkins et al (1978) Score o Conclusion Poor correlation between extent of lipid disorder and coronary severity and diffuseness measures !

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 Sulllivan et al (1990) Sydney, Australia 22

o Purpose ! Correlate lipoprotein risk factors with angiographic score ! Score designed to reflect the amount of endothelial surface area involved with atheroma o Coronary Score ! Vessel score number of vessels with stenosis >70% luminal diameter reduction ! Stenosis score 1 - <50% luminal diameter reduction 2 50-75% 3 75-99% 4 100% ! Gensini Score - Sum the severity score above for each of the 8 segments (maximum score 32) ! Extent score Novel score in this study. The following is a list of hypothesized percent distribution of coronary artery endothelial surface area: LM 5% LAD 20% Main diagonal 10% Septal perforator 5% Left circumflex 20% OM and PL vessels 10% RCA 20% PDA 10% o Conclusions ! Age and lipid profile correlates with the Extent Score

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 Alderman et al (1992) Stanford 12

o Purpose ! Describe definitions used by the BARI Trial o LV free wall branch sizes

o Coronary Score ! Lesion grade Significant if diameter reduction is >50% ! BARI coronary map

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BARI Myocardial Territory Units

Score Calculation Lesion jeopardy unit score divided by the Global left ventricular territory unit score o Conclusions ! Advantages: flexibility in branch sizing and numbers and adjusting for coronary dominance ! Jeopardy expressed as % of total LV ! Problems: No value assignment to inferoseptal area PDA relative size appears to be too small at 8% Excessive points given to branched side branches !

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 Seller et al (1993) - Houston39

o Purpose - Establish mathematical relationship between epicardial vessel length and amount of myocardium supplied o Method ! Radiolabelled microsphere injection into in vivo and PM hearts with measurement of LV mass and summed epicardial 1st, 2nd and 3rd generation coronary branch length o Conclusions ! Summed length of epicardial vessel length is closely and linearly related to the size of the myocardial bed !

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 Sianos et al (2005) Rotterdam 13

o Purpose - Create a single numerical score that captures CAD complexity (including the number and location of lesions) o Coronary Score

Lesion grade Segment modifiers <50% - 0 50-99% - score 2 100% - score 5 LV Extent 16 segments as per ARTS modification of AHA Segment Weighting Factors (Leamon et al (1981) o PDA 1 o PL 0.5 o LM 5 o Proximal, Mid and apical LAD 3.5 / 2.5 / 1 o D1 and D2 1 / 0.5 o RI 1 o OM and Distal LCx 1 / 0.5

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Adverse Features Score

Score Calculation Summation of lesion and adverse feature scores for each of 16 segments

Graham et al (2006) Alberta 1

o Purpose ! Correlate APPROACH Jeopardy score with mortality in patients subsequently treated with CABG, PCI or no intervention in first year ! Compare APPROACH Jeopardy score with those of Dash et al (1977) and Alderman et al (1992) o Coronary Score ! Lesion grade significance threshold >70% diameter reduction, but >50% for LM lesions

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LV Extent Named free-wall branches: small = 1; medium=2; large = 3. Myocardial territories (and relative sizes) specified as per the diagram below. Small-unnamed diagonal branches supply the LAD Anterolateral Region and similar small branches of the PDA supply the PDA Posterolateral Region.

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Score Calculation (APPROACH Jeopardy Score) For free-wall LV branches: 44 X Diseased Branch size/summed score of all branches For LAD: 33 for proximal LAD lesion; 22 for mid LAD and 11 for distal LAD, plus a portion of the apical value of 5 depending upon the LAD type. For the PDA: 18 for a proximal PDA lesion, 12 for mid lesion and 6 for distal lesion PLUS 5 for the apex with a Type 1 small LAD. o Conclusions ! Log mortality odds by treatment group for each Scoring system. PCI risk lower than Medical group. Surgery mortality, higher than PCI for lower Jeopardy Scores and lower than PCI and Medical for higher Scores !

APPROACH C-statistic highest, but not by much

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 Torino et al (2009)15 and (2010)4 FAME Study

o Purpose ! Assess physiologic importance as a function of diameter stenosis ! Randomized trial of FFR-guided versus angiographic-guided PCI (FAME) o Coronary Score ! Lesion grade Lesions < 50% diameter excluded 50 70% diameter reduction >70% diameter reduction o Conclusions ! FFR < 0.8 in 35% of 50-70% lesions and 82% of >70% lesions ! FFR-guided intervention better event-free survival

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