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Objective The aim of this study was to evaluate SYNTAX score role in guiding the choice of optimal revascularization strategies in patients with complex coronary artery disease.Methods 361 consecutive patients with de novo leftrnainor three-vessel coronary artery disease (CAD) who underwentpercutaneous coronary intervention (PCI) with drug-eluting stent (n =191) or coronaryartery bypass grafting (CABG) (n =170) between Jan.2008 and Dec.2008 were prospectively studied.Their angiograms were scored according to the SYNTAXscore.The patientswere divided into three groups according to the SYNTAX score; the lowest SYNTAX score (SYNTAX score ≤22),intermediate SYNTAX score (SYNTAX score of 23 to 32), and the highest SYNTAX score (SYNTAX score ≥33).The primary end point of this studywere defined as the rate of major adverse cardiac and cerebrovascular events (MACCE) at 2years.The MACCE-free survival curves were estimated bythe Kaplan-Meier method.Propensityscore analysis was performed using a stratified Coxregression with treatment strategy (PCI vs.CABG) as a fixed dummy covariate.Results The overall SYNTAX score ranged from 5 to 65 with mean ± standard deviation of 29.8±11.7.The rate of MACCE at 2 years in the PCI group was significantly higher than that in CABG group (15.7% vs.10.0%, P =0.038).Patients with the lowest or intermediate scores in two groups had similar rate of 2-year MACCE, whereas among patients with the highest scores, the event rate was significantly increased in the PCI group (28.1% vs.11.1%, P =0.011).Conclusion The overall rate of 2-year MACCE in the PCI group was significantly higher compared with CABG.The rate of 2-year MACCE was similar between the two treatment groups for patients with the lowest or intermediate SYNTAX scores.Among patients with highest SYNTAX scores, those in the PCI group had a significantly higher 2-year MACCE rate than those in the CABG group.