Does not incorporate patient comorbidities (see SYNTAX II)
Section 4
Next Steps
Low Score (0–22)
PCI-first strategy reasonable for fit patients
Single or staged procedures likely sufficient
Standard dual-antiplatelet therapy and follow-up
Intermediate Score (23–32)
Heart team involvement strongly recommended
Consider CABG if excellent graft targets; PCI if good left main reserve
Patient values/preferences should heavily influence decision
High Score (>32)
CABG strongly preferred in most guidelines
PCI should be reserved for inoperable or very high-risk surgical candidates
If PCI pursued: multistage approach, newest-generation stents, aggressive antiplatelet/anticoagulation
Left main involvement almost always warrants CABG unless patient refusal
Complementary Calculators
FFR Calculator
iFR Calculator
DAPT Score
Duke Treadmill Score
GRACE ACS Risk Score
Section 5
Evidence Appraisal
Primary Studies
The SYNTAX Score: an angiographic tool grading the complexity of coronary artery disease.
Sianos G et al. • EuroIntervention.. 2005;219–227. The original validation paper.
Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease.
SYNTAX Trial Investigators. • NEJM.. 2009;961–972. The landmark clinical trial.
Section 6
Literature
Development
Developed collaboratively by interventional cardiologists led by Guy Sianos (Thoraxcentrum, Netherlands) for the SYNTAX trial. Published in 2005 as an angiographic grading system to standardize assessment of coronary complexity and guide left main and multivessel CAD treatment decisions.
