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Tsang MB, Schwalm JD, Gandhi S, Sibbald MG, Gafni A, Mercuri M, Salehian O, Lamy A, Pericak D, Jolly S, Sheth T, Ainsworth C, Velianou J, Valettas N, Mehta S, Pinilla N, Yanagawa B, Zhang L, Chu V, Parry D, Whitlock R, Dyub A, Cybulsky I, Semelhago L, Ioannou K, Hameed A, Wright D, Mulji A, Darvish-Kazem S, Gupta N, Alshatti A, Natarajan MK. Comparison of Heart Team vs Interventional Cardiologist Recommendations for the Treatment of Patients With Multivessel Coronary Artery Disease. JAMA Netw Open 2020; 3:e2012749. [PMID: 32777060 PMCID: PMC7417969 DOI: 10.1001/jamanetworkopen.2020.12749] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
IMPORTANCE Although the heart team approach is recommended in revascularization guidelines, the frequency with which heart team decisions differ from those of the original treating interventional cardiologist is unknown. OBJECTIVE To examine the difference in decisions between the heart team and the original treating interventional cardiologist for the treatment of patients with multivessel coronary artery disease. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, 245 consecutive patients with multivessel coronary artery disease were recruited from 1 high-volume tertiary care referral center (185 patients were enrolled through a screening process, and 60 patients were retrospectively enrolled from the center'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 8 blinded heart teams using structured online case presentations between October 1, 2017, and October 15, 2018. The randomized members of the heart teams comprised experts from 3 domains, with each team containing 1 noninvasive cardiologist, 1 interventional cardiologist, and 1 cardiovascular surgeon. Cases in which all 3 of the heart team members disagreed and cases in which procedural discordance occurred (eg, 2 members chose coronary artery bypass grafting and 1 member chose percutaneous coronary intervention) were discussed in a face-to-face heart team review in October 2018 to obtain pooled-majority decisions. Data were analyzed from May 6, 2019, to April 22, 2020. MAIN OUTCOMES AND MEASURES The Cohen κ coefficient between the treatment recommendation from the heart team and the treatment recommendation from the original treating interventional cardiologist. RESULTS Among 234 of 237 patients (98.7%) in the analysis for whom complete data were available, the mean (SD) age was 67.8 (10.9) years; 176 patients (75.2%) were male, and 191 patients (81.4%) had stenosis in 3 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 = .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 < .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 < .001). 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 3 groups was statistically significant (P = .002). CONCLUSIONS AND RELEVANCE 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 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. 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.
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Affiliation(s)
- Michael B. Tsang
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - J. D. Schwalm
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sumeet Gandhi
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Trillium Health Partners, Mississauga, Ontario, Canada
| | - Matthew G. Sibbald
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amiram Gafni
- Center for Health Economics and Policy Analysis, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mathew Mercuri
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Omid Salehian
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andre Lamy
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Dan Pericak
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sanjit Jolly
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Tej Sheth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Craig Ainsworth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - James Velianou
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nicholas Valettas
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Shamir Mehta
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Natalia Pinilla
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Bobby Yanagawa
- Division of Cardiovascular Surgery, St Michael’s Hospital, Toronto, Ontario, Canada
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Li Zhang
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Victor Chu
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Dominic Parry
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Dunedin Hospital, Otago, New Zealand
| | - Richard Whitlock
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Adel Dyub
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Irene Cybulsky
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Lloyd Semelhago
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kostas Ioannou
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Oakville Trafalgar Memorial Hospital, Oakville, Ontario, Canada
| | - Adnan Hameed
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Douglas Wright
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amin Mulji
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Saeed Darvish-Kazem
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Brampton Civic Hospital, William Osler Health System, Brampton, Ontario, Canada
| | - Nandini Gupta
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ahmed Alshatti
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Madhu K. Natarajan
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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