Optimising care through the heart team approach


By David Holmes

What are the goals of a heart team approach?

The therapeutic options available to patients for a wide variety of cardiovascular disorders continue to grow. Furthermore, deciding which option to choose is based on scientific information that is expanding greatly—often to extent that it has outstripped the ability of medical care systems and individuals to keep up to date. Different medical specialties often have different experiences and approaches and biases towards the same medical setting. In an era of patient-centric care, it is incumbent on the medical care team to offer information on the different therapeutic and diagnostic options, and then provide the best care. Team-based care optimises the chance that patients will be informed about the different options (ie, the risks and benefits associated with them) so that they can make informed decisions about their care.

Why is a heart team approach important in interventional cardiology?

In interventional cardiology, there are two major approaches to revascularisation—a percutaneous approach with stent implantation and a surgical approach with bypass grafting. There is a growing body of scientific information about both approaches. They both have risks and benefits that may be different. In educating the patient about the different options available, it is desirable to have the experts in each approach.

How would an ideal TAVI heart team differ from an ideal coronary revascularisation heart team?

Depending on the specific situation, the composition of the heart team varies. In the setting of aortic stenosis and transcatheter aortic valve implantation (TAVI) considerations, the heart team should include cardiovascular surgeons, interventional cardiologists, and imaging specialists, the referring [general] cardiologist, and members of allied health teams for making recommendations. For coronary revascularisation, the team is smaller. It includes the cardiovascular surgeon, interventional cardiologist and the referring cardiologist.

Renal denervation is an emerging field in interventional cardiology. Should a heart team approach be used in this setting?

The issue of renal denervation is an important one, but there is less information available on that. The team should include an interventionalist (sometimes that will be an interventional cardiologist, sometimes a vascular radiologist, or sometimes even an electrophysiologist) and an expert in hypertension.

What are the potential difficulties of a heart team approach?

Potential difficulties are real. Scheduling patients to be seen by the multiple members of the team may be problematic. Collaborative discussion is important but may be difficult if members of the team are not amenable to free and open discussion while minimising the issues of bias as much as possible. After discussion by multiple physicians, the patients may become confused. Some patients just would like the physician to decide on what is best. In some settings that may be appropriate, while in many or even most settings, the goal should be to give information on the risk/benefit ratio for the specific procedure being contemplated, in such a way that the patient can be as fully informed as possible so as to make the decision that best fits their needs and goals.

David Holmes is the lead author of a paper on heart teams in the Journal of American College of Cardiology