AnatomySYNTAX Score Angiographic Mapping
Lesion Burden
Number of Lesions (≥50% stenosis)
1
Complexity Factors
Bifurcations
0
Trifurcations
0
Calcification
0
Thrombus Presence
0
Severe Tortuosity
0
Diffuse Disease (>20mm)
0
Aortic Ostial
0
Left Main
0
Awaiting Angio Profile
Quantify the lesion burden and complexity factors from the coronary angiogram to generate the anatomical score.
Guidelines & Evidence
Verified
Last Review: 2026
When to Use
When to Use the SYNTAX Score
Multivessel coronary artery disease (CAD) requiring revascularization decision — de novo lesions only (no in-stent restenosis, no prior CABG)
Left main coronary artery disease (any stenosis ≥ 50%, isolated or with multivessel disease)
Complex CAD (three-vessel disease, bifurcations, chronic total occlusions, heavy calcification, tortuous vessels, diffuse disease)
PCI vs. CABG decision-making (Class I recommendation in AHA/ACC/ESC guidelines for complex CAD with SYNTAX score > 22)
Risk stratification for adverse outcomes post-PCI (mortality, MI, repeat revascularization, stent thrombosis)
Clinical trial inclusion criteria (many trials use SYNTAX score to define complexity strata: low ≤ 22, intermediate 23-32, high ≥ 33)
Pre-procedural planning for PCI (identifies high-risk lesions that may require advanced techniques: rotational atherectomy, IVUS/ OCT guidance, two-stent bifurcation techniques, CTO crossing)
Patient counseling (communicates complexity and risk: "Your SYNTAX score is 38, which means your disease is very complex. CABG is strongly recommended and has better long-term outcomes with lower mortality and repeat revascularization.")
Heart team discussion (standardized language for comparing revascularization strategies across interventional cardiology and cardiac surgery)
Current Guidelines Recommendations (2024-2025 Update)
| Guideline (Year) | Low SYNTAX (≤ 22) | Intermediate SYNTAX (23-32) | High SYNTAX (≥ 33) | Left Main Multi- Vessel (LM + CAD) | Strength of Recommendation |
|---|---|---|---|---|---|
| ESC/EACTS Myocardial Revascularization (2024) | PCI and CABG both acceptable | Heart team decision; PCI acceptable in selected | CABG preferred | LM + low SYNTAX (≤ 22): PCI Class I; LM + intermed/high: CABG Class I | Level of evidence A (multiple RCTs) |
| AHA/ACC Chronic Coronary Disease (2023) | PCI may be reasonable for multivessel | Heart team required; PCI if surgical risk high | CABG recommended | LM + low SYNTAX (≤ 22) PCI Class IIa; LM + high SYNTAX (≥ 33) CABG Class I | Level of evidence B-R (moderate) |
| NICE (UK) (2022) | Offer either PCI or CABG | Discuss options at heart team; consider patient preference | Offer CABG | Offer CABG for LM with SYNTAX > 32 | Guideline (strong) |
SYNTAX Score Limitations (What It Does NOT Account For)
Left ventricular ejection fraction (LVEF) — severe LV dysfunction (EF < 35%) worsens prognosis regardless of SYNTAX score; SYNTAX II score adds LVEF
Patient age, frailty, comorbidities (diabetes, CKD, COPD, PAD, prior stroke) — SYNTAX I is pure angiographic; SYNTAX II integrates clinical factors
Lesion physiology (ischemia) — anatomical stenosis ≥ 50% may not be ischemic (FFR < 0.80). FFR-guided PCI (FAME trials) reduces unnecessary stenting in intermediate lesions (50-70% stenosis) especially in low SYNTAX range
In-stent restenosis (ISR) — SYNTAX score derived for de novo lesions only; ISR requires different treatment (drug-coated balloons, repeat stenting, surgery)
Prior CABG (saphenous vein grafts) — scoring system not validated for graft disease or native vessel progression post-CABG
Chronic total occlusion (CTO) scoring is complex (weighted heavily but does not account for collaterals or viability — J-CTO score better for procedural planning)
Small vessel disease (< 2.5 mm diameter) — increases technical difficulty but not well captured (treated medically or with small drug-eluting stents)
Operator skill and center volume — high SYNTAX (> 32) lesions can be successfully stented by high-volume operators with advanced techniques, but outcomes still inferior to CABG in large RCTs
Last Comprehensive Review: 2026