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Taking the multidisciplinary decision

ESC Congress News 2016 - Rome, Italy

Interventionist William Wijns and surgeon Philippe Kolh support the concept of the heart team.



THE LEVEL OF CARE in medicine can be improved and made more consistent with the use of multidisciplinary teams to recommend the most optimal treatment. For example, pretreatment multidisciplinary discussion in tumour boards, introduced as early as the 1960s, has been shown to improve survival and to reduce hospital-variations in rates.

Multidisciplinary heart teams have been developed for the treatment of heart failure, congenital heart disease, aortic and mitral valve interventions, and myocardial revascularisation. The creation of a heart team, consisting of a clinical or non-invasive cardiologist, an interventional cardiologist and a cardiac surgeon, serves the purpose of a balanced multidisciplinary decision process. Additional input may be needed from general practitioners, anaesthesiologists, geriatricians, intensivists, or other specialists involved with the care of the patient (‘extended’ heart team).1
In the field of myocardial revascularisation (MR), while decision-making for patients with acute indications or less complex CAD may be straightforward, European and American guidelines strongly advocate the implementation of heart team decisions for patients with stable and complex CAD as class of recommendation I (level of evidence C).2,3 Meetings of the heart team should be organised according to local needs: heart team discussions may be scheduled daily, weekly, or at various intervals, as suitable.

The benefit a heart team decision is convincingly presented throughout the literature. Interestingly, some studies have shown that re-discussing the same patients after one year leads to different discussions in about 25% of the cases.4 This underscores the fact that, in some CAD patients, both treatment modalities – PCI or CABG – might be appropriate. Also, including other clinical specialists into this conference might lead to a significant proportion of treatment recommendations other than MR (eg, medical therapy, heart transplantation, ventricular assist device, or valve surgery).

Despite being strongly recommended in the guidelines, the heart team concept has probably not been yet sufficiently implemented. As an example, the OECD (Organization for Economy Cooperation and Development) reports an average rate of 218 coronary revascularisation procedures per 100,000 population, with an average PCI proportion of 72% performed in 2013.5 There is, however, a high variation in these figures across countries, which may partly be the consequence of physician-related factors - and these have raised concerns about overuse, underuse and inappropriate selection of revascularisation.

Heart teams can initiate patient discussions using the treatment algorithms as outlined in the guidelines - however, as doctors, clinical decision making typically requires a more comprehensive understanding of the unique characteristics of the individual patient. For patient-focused care, each specialty needs to hear the other colleague’s viewpoint. When this fails to happen, we need to remain cognizant of the fact that it is the patient who ultimately loses from dysfunctional interactions - market share is not the issue. And remember that cardiologists and cardiac surgeons are on the same team – the Heart Team.

Click here to read other scientific highlights in the full edition of the Congress news.

References

  1. Wijns W, Kolh P, Danchin N, et al. Guidelines on myocardial revascularization. Eur Heart J 2010; 31: 2501-2555.
  2. Windecker S, Kolh P, Alfonso F, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: Eur Heart J 2014; 35: 2541-2619.
  3. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol 2012; 60: e44-e164.
  4. Yates MT, Soppa GK, Valencia O, et al. Impact of European Society of Cardiology and European Association for Cardiothoracic Surgery Guidelines on Myocardial Revascularization on the activity of percutaneous coronary intervention and coronary artery bypass graft surgery for stable coronary artery disease. J Thorac Cardiovasc Surg 2014; 147: 606-610.
  5. OECD (2015), Health at a Glance 2015: OECD Indicators, OECD Publishing, Paris. 2016.

Notes to editor

To access all the scientific resources from the sessions during the congress, visit ESC Congress 365.  

About the European Society of Cardiology

The European Society of Cardiology brings together health care professionals from more than 120 countries, working to advance cardiovascular medicine and help people lead longer, healthier lives.

About ESC Congress 2016

ESC Congress is the world’s largest gathering of cardiovascular professionals contributing to global awareness of the latest clinical trials and breakthrough discoveries. ESC Congress 2016 takes place 27 to 31 August at the Fiera di Roma in Rome, Italy. The full scientific programme is here.