Heart team often opposes treating interventionalist’s strategy for multivessel CAD
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An analysis of the team approach to decision-making for multivessel CAD indicated that the consensus of a heart team was discordant with patients’ original treating interventionalist in nearly one-third of cases, researchers reported.
According to findings published in JAMA Cardiology, heart teams consisting of a noninvasive cardiologist, an interventional cardiologist and a cardiac surgeon who disagreed with the treating interventional cardiologist on the management of multivessel CAD were also more likely to be in disagreement among themselves.
“This study represents one building block step to understanding what the implications of heart team decision making are for patients with multivessel CAD,” Michael B. Tsang, MD, MSc, assistant professor in the division of cardiology at McMaster University in Ontario, Canada, told Healio. “While we still do not know whether it improves outcomes, many centers have already adopted the model in some form. I think what this study suggests is that the heart team would make the largest impact among those cases where divergent opinions are expected, when there is a therapeutic dilemma.”
For this analysis, researchers enrolled 237 patients (mean age, 68 years; 75% men) from a single high-volume tertiary care referral center who presented with multivessel CAD from March 15, 2012, to Oct. 20, 2014. Treatment decisions that included CABG, PCI or medication therapy made by the original treating interventionalist were compared with pooled recommendations of eight masked heart teams from October 2017 to Oct. 15, 2018.
The primary endpoint was the Cohen’s kappa coefficient between the treatment recommendation from the heart team and the treatment decision of the treating interventional cardiologist.
The recommendation of the heart team compared with that of the treating clinician differed in 30.3% of cases (95% CI, 24.5-36.7; Cohen’s kappa = 0.478; 95% CI, 0.336-0.540; P = .006), according to the study.
In cases when the heart team agreed with the treating physician, the recommendation was also more frequently unanimous among the three members of the team (66.9%; P < .001).
Moreover, when the team recommendation was concordant with the treating physician, the heart team interventionalist and the treating interventionalist were more often in agreement, as well (84.7%; P < .001).
When in disagreement with the treating physician, the heart team chose differing recommendations for 22.3% of patients who underwent CABG, 45.1% of patients who underwent PCI and 40% of patients who received medications therapy (P = .002).
“While this study does suggest that the heart team model has an impact on decision making, we do need further studies to determine whether this model would improve patient outcomes,” Tsang said in an interview. “Furthermore, if heart team confers a benefit, we need to be able to develop tools to a priori select for the patients where heart team decision making would make the largest impact. Lastly, consensus decision making is often the standard for many heart teams. For our study it was an asynchronous pooled majority decision for the most part. Further research into the advantages and disadvantages of various heart team decision making mechanics is also definitely needed.”
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