Introduction Cardiologists are generally the gatekeepers of coronary artery disease and have been much criticised for not discussing all patients being considered for revascularisation therapy at an MDT (multi-disciplinary team) meeting or not referring patients with traditional “surgical disease” for CABG. At the Freeman Hospital (FRH), a large cardiothoracic unit in the North of England, patients are typically referred for PCI or CABG by cardiologists working within the Newcastle upon Tyne Trust or from district general hospitals within the network. Patients are not routinely discussed at MDT but can be brought to the weekly meeting at the discretion of the referrer. The recently reported SYNTAX study allows objective quantification of the degree of coronary disease and facilitates an evidence based decision between CABG and PCI. This gives us the opportunity to examine whether elective revascularisation is being performed appropriately at our institution.
Methods We performed a retrospective analysis at the Freeman Hospital. 200 patients who had elective revascularisation between April 2009 and April 2010 were selected. This included 100 cases of CABG and 100 of PCI. Half of each were referrals from other hospitals. Patients' SYNTAX scores were calculated using pre-procedure angiograms. MDT meeting records and patients' notes were reviewed.
Results The average SYNTAX score for patients undergoing elective PCI was 15, compared to 29 for those undergoing CABG. 84% of patients undergoing elective PCI had SYNTAX scores less than 22. 35% of all patients referred for elective CABG had scores greater than 33. The average SYNTAX score for CABG referrals from outside the trust was lower (25) than from within the trust (31).
Discussion The majority of patients undergoing PCI at the FRH have SYNTAX scores in the lowest tertile. There is no difference in the SYNTAX scores in patients having PCI from referral bases within the centre or from outside. In total almost one quarter of all patients undergoing CABG have a SYNTAX score in the lowest tertile. And this rises to almost one third in those patients referred from district general hospitals. Only a small number of these patients have an additional clear indication for CABG over PCI. Furthermore we found that a significant proportion of these do not go through MDT planning. These results may indicate that cardiologists are more likely to bring patients to MDT meetings than surgeons and, according to SYNTAX scoring, more patients are inappropriately having CABG than are inappropriately having PCI. Based on this data in our institution discussing all patients at an MDT and the use of SYNTAX scoring at point of referral would be more likely to increase PCI revascularisation rates.