Implementation and consistency of Heart Team decision-making in complex coronary revascularisation

Abstract

Background

A multidisciplinary team (MDT) approach for decision-making in patients with complex coronary artery disease (CAD) is now a class IC recommendation in the European and American guidelines for myocardial revascularisation. The aim of this study was to evaluate the implementation and consistency of Heart Team HT decision-making in complex coronary revascularisation.

Methods

We prospectively evaluated the data of 399 patients derived from 51 consecutive MDT meetings held in a tertiary cardiac centre. A subset of cases was randomly selected and re-presented with the same clinical data to a panel blinded to the initial outcome, at least 6 months after the initial discussion, in order to evaluate the reproducibility of decision-making.

Results

The most common decisions included continued medical management (30%), coronary artery bypass grafting (CABG) (26%) and percutaneous coronary intervention (PCI) (17%). Other decisions, such as further assessment of symptoms or evaluation with further invasive or non-invasive tests were made in 25% of the cases. Decisions were implemented in 93% of the cases. On re-discussion of the same data (n = 40) within a median period of 9 months 80% of the initial HT recommendations were successfully reproduced.

Conclusions

The Heart Team is a robust process in the management of patient with complex CAD and decisions are largely reproducible. Although outcomes are successfully implemented in the majority of the cases, it is important that all clinical information is available during discussion and patient preference is taken into account.

Introduction

A team-based approach to decision-making has been widely adopted in several medical fields; most notably in oncology and organ transplantation [1], [2], [3], [4]. In cardiovascular medicine, the continuously evolving treatment options and strategies, along with the proliferating amount of scientific information from randomized control trials (RCTs) and large registries, and the need for input from various specialties or subspecialties make decision-making in complex cases difficult [5]. Furthermore, the effort to include patient preference in a shared decision process regarding their treatment requires moving away from the single physician-centric model to a multidisciplinary approach, where clinicians group themselves around the patient as a multidisciplinary team which can better disclose both the pros and cons of available therapies [6]. Thus, Heart Teams (HTs) have been developed for the management of congenital heart disease, heart failure and more recently for the treatment of aortic and mitral valve disease [7], [8], [9], [10], [11]. In the management of patients with complex coronary artery disease (CAD), the significant variability in revascularisation decisions and delivery of care [12], [13], [14], the need for evidence based and up-to-date decision making and reports of inappropriate use [15], [16], [17], but also underuse of revascularisation indicate the need for a multidisciplinary team (MDT) approach [18], [19]. The coronary HT concept was more widely adopted after the publication of the SYNTAX (SYNergy Between PCI [percutaneous coronary intervention] With TAXUS and Cardiac Surgery) trial. In the SYNTAX trial, the concept of multidisciplinary decision-making was emphasized and formally implemented. In order to enrol a patient in the study interventional cardiologists and cardiac surgeons should come together in consensus [20].

The most recent guidelines for myocardial revascularisation published by the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery and also the guidelines for percutaneous coronary intervention (PCI), published by the American College of Cardiology Foundation, American Heart Association and the Society for Cardiovascular Angiography and Interventions have embraced the HT approach and assigned a class IC recommendation for decision-making in complex CAD [21], [22]. The British Cardiovascular Society (BCS), British Cardiovascular Intervention Society (BCIS) and the Society for Cardiothoracic Surgery in Great Britain and Ireland (SCTS) have recently published official recommendations for the structure and functioning of HTs in the United Kingdom [23]. Although the HT concept has now been widely accepted by the scientific community, data for its adoption and implementation in every day practise are scarce. Studies that evaluate its pros and cons and especially the reproducibility of its results are important in order to validate its concept [24], [25]. The purpose of this study was to evaluate the implementation and consistency of coronary HT decisions in a tertiary cardiac centre.