Optimal Heart Team Protocol to Improve Revascularization Decisions in Patients with Complex Coronary Artery Disease: A Sequential Mixed Method Study

Abstract

Aims Current guidelines recommend a heart team in the decision making for patients with complex coronary artery disease (CAD). However, the decision-making stability of these teams has not been evaluated and the optimum protocol is unknown. We assessed inter-team agreement for revascularization decision-making and influencing factors to inform the development of a heart team protocol. Methods and results This sequential, explanatory mixed methods study included (1) a cross-sectional quantitative study to assess inter-team agreement on treatment strategy for retrospectively enrolled complex CAD patients and (2) a qualitative study that used semi-structured interviews with heart team members to identify factors influencing decision-making discrepancy. We randomly selected 101 complex CAD patients. Sixteen specialists were randomly assigned to 4 heart teams to make decisions for these patients. The primary outcome kappa of inter-team decision-making agreement was moderate (kappa 0.58). Factors influencing decision-making were generated through inductive thematic analysis and were summarized by 3 themes (specialist quality, team composition, meeting process) and 10 subthemes. Recommendations of heart team implementation were generated based on qualitative and quantitative data at 5 levels: specialist selection, specialist training, team composition, team training, and meeting process. A detailed protocol on the integration of guidelines, previous experience and recommendations was generated to establish and deploy a qualified heart team. Conclusions Agreement between heart teams for revascularization decision-making in complex CAD patients was moderate. Potential factors associated with decision discrepancies were summarized and recommendations were generated. A detailed heart team protocol was designed and should be validated in future.

Epidemiology and current management of cardiovascular disease in China

“…A study analyzed the data from 165 patients' coronary CT angiography (680 vessels and 1505 segments). [30] The average post-processing and interpretation times of AI was 2.3 ± 0.6 min per case, reduced by 76%, 72%, 69% compared with low/ intermediate/ high experience readers (all P < 0.001), respectively. On a per-patient, pervessel and per-segment basis, with invasive coronary angiography as reference standard, the AI overall diagnostic sensitivity for detecting obstructive CAD was 90.5%, 81.4%, 72.9%, the specificity was 82.3%, 93.9%, 95.0%, with the corresponding AUC of 0.90, 0.90, 0.87, respectively.…”

Effect of a standardised heart team protocol versus a guideline-based protocol on revascularisation decision stability in stable complex coronary artery disease: rationale and design of a randomised trial of cardiology specialists using historic cases

“…Several studies reported that on re-discussion of the same patient data 9–12 months later, nearly 20%–24% of decisions differed from the original heart team recommendations 7 8. In our previous work, the agreement between heart teams for revascularisation decision-making was just moderate (kappa=0.58) 9…”

“…Eligible specialists randomised to this group will establish 12 heart teams and conduct heart team meetings based on the standardised heart team protocol9 (figure 2).…”

“…7 8 In our previous work, the agreement between heart teams for revascularisation decision-making was just moderate (kappa=0.58). 9 Clinical guidelines and previous practice experience from different centres have summarised several critical principles in heart team implementation. [10][11][12] Guidelines recommend the composition should be at least a cardiac surgeon, an interventional cardiologist and a noninterventional cardiologist.…”

The Utility of the SYNTAX Score II and SYNTAX Score 2020 for Identifying Patients with Three-Vessel Disease Eligible for Percutaneous Coronary Intervention in the Multivessel TALENT Trial: A Prospective Pilot Experience

“…Recently, Ma et al . [ 19 ] have reported the agreement between heart teams for revascularization decisions in patients with complex coronary artery disease and the potential factors behind discrepancies. Despite the fact that the Heart teams were in possession of the key factors for the selecting the mode of revascularization (e.g., SYNTAX score, STS score etc…), the primary outcome kappa for the level of agreement for inter-team decision-making was moderate (kappa = 0.58), at variance with the randomized SYNTAX III trial in which the kappa for agreement for inter-team decision-making based on Invasive Conventional Cine Angiography (ICA) or Computerized Tomographic Angiography (CTA) was “almost perfect” (kappa = 0.82) [ 18 ].…”