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150 “Heart Team” decision making in the management of patients with coronary artery disease; structure, outcomes and reproducibility
  1. L D Tapp,
  2. J Thekkudan,
  3. E Morris,
  4. H Luckraz,
  5. M S Norell
  1. New Cross Hospital, Birmingham, UK

Abstract

Introduction Contemporary national and international guidelines recommend that patients with stable angina and acute coronary syndromes (ACS) with multi-vessel disease are discussed by a multidisciplinary “Heart Team” (HT) to facilitate optimal evidence-based management. However, there is a paucity of data describing the workings of a HT, actioning of it's recommendations and reproducibility of decisions.

Methods We have utilised a HT approach since 2005, meeting twice weekly with our HT database managed by a dedicated co-ordinator. We analysed the data for 2010 and describe the HT process. A random sample of cases were scrutinised to identify whether the HT decision had been implemented. Additionally, cases were re-presented to the HT after 1 year to determine consistency and reproducibility of decision making. The HT panel for the review process did not include members involved in the original discussion.

Results During 2010, 108 meetings were held, attended by a median of 3 interventional cardiologists, 1 non-interventional cardiologist and 2 cardiac surgeons. A total of 1454 cases were discussed (mean 13.5 cases per meeting). 854 cases (58.7%) were from our own unit and 600 (41.3%) from referring hospitals. 356 (24.5%) were current inpatients and 1098 (75.5%) were outpatients. 1340 (92.2%) were patients with stable coronary artery disease (CAD) or ACS. The HT recommendation was for coronary artery bypass grafting (CABG) ± valve surgery in 429 (32%) cases, percutaneous coronary intervention (PCI) in 303 (22.6%), and optimised medical therapy (OMT) in 264 (19.7%). In the remaining 344 cases (25.7%) further investigation was advised before a HT decision was made; the most frequent recommendation was for a pressure wire study, in 151 cases (43.9%). 117 randomly selected cases were analysed to determine whether the HT recommendation had been actioned. This occurred in 101 (86.3%) cases. In the remaining 16 cases, deviation from the initial plan was due to the patient declining revascularisation (CABG 3, PCI 1), development of new co-morbidity (2) or revascularisation of different vessels (6). The reason for deviation was unclear in four cases. 50 cases were re-presented after 1 year with the original HT recommendation being the same in 38 cases (76%). Different decisions in the remaining 12 (24%) included seven cases (14%) in which further investigation had initially been suggested, and re-vascularisation was recommended on re-presentation.

Conclusions A well-structured HT allows a large number of cases to be evaluated while interdisciplinary discussion facilitates consensus with evidence-based and individualised advice. There is a prominent role for pressure wire assessment in the further evaluation of equivocal CAD. The HT approach appears robust and reproducible in the majority of cases. Variation in decision making reflects the equipoise between suitability of CABG, PCI and OMT in many cases.

  • Heart team
  • coronary artery disease
  • revascularisation

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