Arq Bras Cardiol abc Arquivos Brasileiros de Cardiologia Arq. Bras. Cardiol. 0066-782X 1678-4170 Sociedade Brasileira de Cardiologia - SBC Zn6G8ZRhZjsXFbkLnT4bCCh S0066-782X2017001400497 10.5935/abc.20170156 Letter to the Editor Association between SYNTAX Score and Coronary Collateral Circulation Cerit Levent 1 Near East University Nicosia Cyprus Near East University - Nicosia - Cyprus Mailing Address: Levent Cerit Near East University. 07100, Nicosia - Cyprus. E-mail: drcerit@hotmail.com, drcerit@yahoo.com 11 2017 109 5 497 498 16 02 2017 20 04 2017 20 04 2017 This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Keywords: Myocardial Infarction Coronary Circulation / physiopathology Coronary Angiography Coronary Artery Disease Probability

Dear Editor,

I have read the article entitled “Which Coronary Lesions Are More Prone to Cause Acute Myocardial Infarction?” by Sen et al. with great interest, recently published in journal. The investigators reported that more than 70% of the patients with acute myocardial infarction (MI) had coronary collateral circulation (CCC) with Rentrop scores of 1-3 during primary coronary angiography. This shows that most cases of acute MI in our study originated from underlying high-grade stenosis, challenging the common believe. Higher serum triglycerides levels, greater mean platelet volume, and increased white blood cell and neutrophil counts were independently associated with impaired development of collateral vessels.1

Synergy between percutaneous coronary intervention with Taxus and cardiac surgery (SYNTAX) score is the angiographic scoring system and is widely used to evaluate the severity and complexity of coronary aretry disease.2 SYNTAX score (SS) predicts not only possible peri-procedural difficulties but also indicates the pattern of atheroma including length, thrombosis, and calcification of the lesion.3 Association between multi-vessel disease and CCC has been reported by several studies.4,5 Börekçi et al.4 reported that higher SS in patients with poor CCC. Cetin et al.5 observed that in the poor CCC group, SS were significantly higher compared to good CCC group.

In this context, considering association between SS and CCC, correlation of this study’s result with SS may shed light on further studies.

References 1 Sen T, Astarcioglu MA, Beton O, Asarcikli LD, Kilit C. Which coronary lesions are more prone to cause acute myocardial infarction? Arq Bras Cardiol. 2017;108(2):149-153. doi: 10.5935/abc.20170003. Sen T Astarcioglu MA Beton O Asarcikli LD Kilit C Which coronary lesions are more prone to cause acute myocardial infarction? Arq Bras Cardiol 2017 108 2 149 153 10.5935/abc.20170003 2 Sianos G, Morel MA, Kappetein AP, Morice MC, Colombo A, Dawkins K, et al. The SYNTAX score: an angiographic tool grading the complexity of coronary artery disease. EuroIntervention. 2005;1(2):219-27. PMID: 19758907. Sianos G Morel MA Kappetein AP Morice MC Colombo A Dawkins K The SYNTAX score: an angiographic tool grading the complexity of coronary artery disease EuroIntervention 2005 1 2 219 227 19758907 3 van Gaal WJ, Ponnuthurai FA, Selvanayagam J, Testa L, Porto I, Neubauer S, et al. The Syntax score predicts peri-procedural myocardial necrosis during percutaneous coronary intervention. Int J Cardiol. 2009;135(1):60-5. doi: 10.1016/j.ijcard.2008.03.033. van Gaal WJ Ponnuthurai FA Selvanayagam J Testa L Porto I Neubauer S The Syntax score predicts peri-procedural myocardial necrosis during percutaneous coronary intervention Int J Cardiol 2009 135 1 60 65 10.1016/j.ijcard.2008.03.033 4 Börekçi A, Gür M, Seker T, Baykan AO, Özaltun B, Karakoyun S, et al. Coronary collateral circulation in patients with chronic coronary total occlusion; its relationship with cardiac risk markers and SYNTAX score. Perfusion. 2015;30(6):457-64. doi: 10.1177/0267659114558287. Börekçi A Gür M Seker T Baykan AO Özaltun B Karakoyun S Coronary collateral circulation in patients with chronic coronary total occlusion; its relationship with cardiac risk markers and SYNTAX score Perfusion 2015 30 6 457 464 10.1177/0267659114558287 5 Cetin MS, Ozcan Cetin EH, Balci KG, Aydin S, Ediboglu E, Bayraktar MF, et al. The association between whole blood viscosity and coronary collateral circulation in patients with chronic total occlusion. Korean Circ J. 2016;46(6):784-90. doi: 10.4070/kcj.2016.46.6.784. Cetin MS Ozcan Cetin EH Balci KG Aydin S Ediboglu E Bayraktar MF The association between whole blood viscosity and coronary collateral circulation in patients with chronic total occlusion Korean Circ J 2016 46 6 784 790 10.4070/kcj.2016.46.6.784 Reply Sen Taner

Dear editor

I have read the letter to the editor about my study entitled “Which Coronary Lesions Are More Prone to Cause Acute Myocardial Infarction?” with great interest. The author proposed that high Syntax score might be correlated with poor coronary collateral development.

Coronary collateral vessels serve as conduit between proximal site of occluded coronary artery and its distal parts.1 The most important triggered effect of the collateral vessel development is the shear stress due to occlusion. 20-25% of normal humans have coronary collateral circulation but it is weak and small and it cannot be seen during coronary angiography. Pressure gradient after occlusion or severe stenosis of a coronary artery lead to endotelial stimulation and arteriogenesis and also enlargement of preexisting collateral vessels.2

In the study performed by Borekci et al.3 they found that patients with poorly developed collateral coronary circulation had higher SYNTAX scores compared with the well-developed coronary collateral group. However, multivariate analysis revealed that there was no relationship between SYNTAX score and coronary collateral flow. So far, there has not been a specific study addressing this issue. In our study, we did not calculate the SYNTAX score because it was not the aim of the study. I think that other specific trials addressing this issue are needed to determine if there is any relationship between the SYNTAX score and the coronary circulation or not. In addition, the possible mechanism of this relationship has to be explained.

Taner Sen 1 Pitt B. Interarterial coronary anastomoses: occurrence in normal hearts and in certain pathologic conditions. Circulation. 1959,20:816-822. PMID: 14433299. Pitt B Interarterial coronary anastomoses: occurrence in normal hearts and in certain pathologic conditions Circulation 1959 20 816 822 14433299 2 Seiler C. The human coronary collateral circulation. Eur J Clin Invest. 2010; 40(5):465-76. doi: 10.1111/j.1365-2362.2010.02282.x. Seiler C The human coronary collateral circulation Invest 2010 40 5 465 476 10.1111/j.1365-2362.2010.02282.x 3 Börekçi A, Gür M, Şeker T, Baykan AO, Özaltun B, Karakoyun S, et al. Coronary collateral circulation in patients with chronic coronary total occlusion; its relationship with cardiac risk markers and SYNTAX score. Perfusion. 2015;30(6):457-64. doi: 10.1177/0267659114558287. Börekçi A Gür M Şeker T Baykan A Özaltun B Karakoyun S Coronary collateral circulation in patients with chronic coronary total occlusion; its relationship with cardiac risk markers and SYNTAX score Perfusion 2015 30 6 457 464 10.1177/0267659114558287 Carta ao Editor Associação entre o Escore SYNTAX e a Circulação Coronária Colateral Cerit Levent 2 Near East University - Nicosia - Chipre Correspondência: Levent Cerit Near East University. 07100, Nicosia - Chipre. E-mail: drcerit@hotmail.com, drcerit@yahoo.com Palavras-chave Infarto do Miocárdio Circulação Coronária / fisiopatologia Angiografia Coronária Doença da Artéria Coronariana Probabilidade

Prezado editor,

Li com grande interesse o artigo intitulado "Quais lesões coronárias são mais propensas a causar infarto agudo do miocárdio?" por Sen et al.,1 recentemente publicado no jornal. Os pesquisadores relataram que mais de 70% dos pacientes com infarto agudo do miocárdio (IAM) tiveram circulação colateral coronária (CCC) com escores de Rentrop de 1-3 durante a angiografia coronária primária. Isso mostra que a maioria dos casos de IAM em nosso estudo originou-se de estenoses de alto grau subjacentes, desafiando a crença comum. Níveis mais elevados de triglicerídeos no soro, maior volume médio de plaquetas e aumento da contagem de glóbulos brancos e neutrófilos foram associados de forma independente ao desenvolvimento reduzido de vasos colaterais.1

A sinergia entre a intervenção coronária percutânea com Taxus e escore da cirurgia cardíaca (SYNTAX) é o sistema de pontuação angiográfica e é amplamente utilizado para avaliar a gravidade e a complexidade da doença coronariana.2 O escore SYNTAX (SS) prevê não apenas possíveis dificuldades periprocedimentais, mas também indica o padrão de ateroma, incluindo comprimento, trombose e calcificação da lesão.3 A associação entre doença de múltiplos vasos e CCC tem sido relatada por vários estudos.4,5 Börekçi et al.4 relataram esse maior SS em pacientes com CCC pobre. Cetin et al.5 observaram que no grupo CCC pobre, SS foram significativamente maiores em comparação com o grupo CCC bom.

Neste contexto, considerando a associação entre SS e CCC, a correlação do resultado deste estudo com SS pode esclarecer estudos futuros.

Carta-resposta Sen Taner

Prezado Editor

Li com grande interesse a carta ao editor sobre o meu estudo intitulado “Quais lesões coronárias são mais propensas a causar infarto agudo do miocárdio?”. O autor propôs que o Escore de Sintax pode estar correlacionado com um desenvolvimento coronário colateral deficiente.

Os vasos colaterais coronários servem como canal entre o local proximal da artéria coronária ocluída e suas partes distais.1 O efeito desencadeado mais importante do desenvolvimento dos vasos colaterais é o estresse de cisalhamento devido à oclusão. 20-25% dos humanos normais têm circulação colateral coronária, mas é fraca e pequena e não pode ser vista durante a angiografia coronariana. O gradiente de pressão após oclusão ou estenose grave de uma artéria coronária levam à estimulação endotelial e à arteriogênese e também ao aumento dos vasos colaterais preexistentes.2

No estudo realizado por Borekci et al.,3 eles acharam que os pacientes com circulação coronária colateral mal desenvolvida tinham escores SYNTAX mais altos em comparação com o grupo colateral coronário bem desenvolvido. No entanto, a análise multivariada revelou que não houve relação entre o escore SYNTAX e o fluxo colateral coronariano. Até agora não houve um estudo específico tratando dessa questão. Em nosso estudo, não calculamos o escore SYNTAX porque não era o objetivo do estudo. Eu acho que outros ensaios específicos que tratem desta questão são necessários para definir se há alguma relação entre a escore SYNTAX e a circulação colateral coronária ou não. Além disso, o possível mecanismo dessa relação deverá ser explicado.

Taner Sen