A Dutch perspective on the ESC/EACTS guidelines on myocardial revascularisation

The guidelines state a class III level of evidence (LoE) B recommendation against percutaneous coronary intervention (PCI) in patients with left main disease with a high SYNTAX score (> 32) and three-vessel disease with intermediate (23–32) and high SYNTAX scores. There appears to be insufficient evidence to support this recommendation, given the fact that this is based on only one trial (SYNTAX) in which first-generation drug-eluting stents (DES) were used, which are currently no longer used as they have been superseded by next-generation DES that proved to be superior in terms of repeat revascularisation, stent thrombosis, myocardial infarction and even death [3, 4]. The fact that the guideline advocates assigning PCI or coronary artery bypass grafting (CABG) based upon the purely anatomical SYNTAX score foregoes other important clinical and functional factors that are considered by the typical heart team in the Netherlands. The importance of functional lesion assessment using coronary pressure or flow is not taken into account by the current recommendation. The FAME trials clearly demonstrated the usefulness of fractional flow reserve (FFR)-guided revascularisation in patients with multi-vessel disease [5]. An opportunity to deliver the important message that interrogation, with FFR, of all PCI targets in multi-vessel disease results in better patient outcome is therefore missed. Interrogation of all target stenoses with FFR is also important because it allows calculation of the functional SYNTAX score, which has been shown to be superior to the standard SYNTAX score in terms of risk stratification of patients with multi-vessel coronary artery disease undergoing PCI [6]. Specifically, by only counting lesions that are FFR-positive towards the total of the SYNTAX score, patients can often be assigned To the editor,