A study comparing recommendations from a heart team versus those of an interventional cardiologist for the treatment of patients with multivessel coronary artery disease (CAD) has found differing recommendations in up to one-third of cases.
According to the author of the study published in JAMA: Network Open Michael B Tsang (Department of Medicine, McMaster University, St Catharines, Canada), this subset of cases was associated with a greater number of divergent opinions between interventional cardiologists and within the heart team.
The study enrolled 245 consecutive patients with multivessel CAD from a high-volume tertiary care referral centre, 185 of whom were patients were enrolled through a screening process, and 60 patients were retrospectively enrolled from the centre’s database. A total of 237 patients were included in the final virtual heart team analysis.
Treatment decisions—which comprised coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy—were made by the original treating interventional cardiologists between March 15 2012 and October 20 2014. These decisions were then compared with pooled-majority treatment decisions made by eight blinded heart teams using structured online case presentations between October 1 2017, and October 15 2018.
The randomised members of the heart teams comprised experts from three domains, with each team containing one non-invasive cardiologist, one interventional cardiologist, and one cardiovascular surgeon.
Cases in which all three of the heart team members disagreed and cases in which procedural discordance occurred were discussed in a face-to-face heart team review in October 2018 to obtain pooled-majority decisions. Data were analysed from May 6 2019 to April 22 2020.
Among 234 of 237 patients (98.7%) in the analysis for whom complete data were available, the mean age was 67.8 (10.9) years, 176 patients (75.2%) were male, and 191 patients (81.4%) had stenosis in three epicardial coronary vessels. A total of 71 differences (30.3%; 95% CI, 24.5%‒36.7%) in treatment decisions between the heart team and the original treating interventional cardiologist occurred, with a Cohen κ of 0.478 (95% CI, 0.336-0.540; p=0.006).
The heart team decision was more frequently unanimous when it was concordant with the decision of the original treating interventional cardiologist (109 of 163 cases [66.9%]) compared with when it was discordant (28 of 71 cases [39.4%]; p<0.001). When the heart team agreed with the original treatment decision, there was more agreement between the heart team interventional cardiologist and the original treating interventional cardiologist (138 of 163 cases [84.7%]) compared with when the heart team disagreed with the original treatment decision (14 of 71 cases [19.7%]); p<0.001), Tsang and colleagues found.
Those with an original treatment of coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy, 32 of 148 patients [22.3%], 32 of 71 patients [45.1%], and 6 of 15 patients [40.0%], respectively, received a different treatment recommendation from the heart team than the original treating interventional cardiologist; the difference across the three groups was statistically significant (p=0.002).
Tsang and colleagues conclude that the heart team’s recommended treatment for patients with multivessel coronary artery disease differed from that of the original treating interventional cardiologist in up to 30% of cases. This subset of cases, they note, “was associated with a lower frequency of unanimous decisions within the heart team and less concordance between the interventional cardiologists; discordance was more frequent when percutaneous coronary intervention or medication therapy were considered.”
Tsang and colleagues add that Further research is needed to evaluate whether heart team decisions are associated with improvements in outcomes and, if so, how to identify patients for whom the heart team approach would be beneficial.