Revascularization heart team recommendations as an adjunct to appropriate use criteria for coronary revascularization in patients with complex coronary artery disease

Abstract

Objectives To evaluate how a comprehensive evidence‐based clinical review by a multidisciplinary revascularization heart team on treatment decisions for revascularization in patients with complex coronary artery disease using SYNTAX scores combined with Society of Thoracic Surgeons‐derived clinical variables can be additive to the utilization of Appropriate Use Criteria for coronary revascularization. Background Decision‐making regarding the use of revascularization for coronary artery disease has come under major scrutiny due to inappropriate overuse of revascularization. There is little data in routine clinical practice evaluating how a structured, multidisciplinary heart team approach may be used in combination with the Appropriate Use Criteria for revascularization. Methods From May 1, 2012 to January 1, 2015, multidisciplinary revascularization heart team meetings were convened to discuss evidence‐based management of 301 patients with complex coronary artery disease. Heart team recommendations were adjudicated with the Appropriate Use Criteria for coronary revascularization for each clinical scenario using the Society for Cardiovascular Angiography and Interventions' Quality Improvement Toolkit (SCAI‐QIT) Appropriate Use Criteria App. Results Concordance of the Heart Team to Appropriate Use Criteria had a 99.3% appropriate primary indication for coronary revascularization. Among patients who underwent percutaneous revascularization, 34.9% had an inappropriate or uncertain indication as recommended by the Heart Team. Patients with uncertain or inappropriate percutaneous coronary interventions had significantly higher SYNTAX score (27.3 ± 6.6; 28.5 ± 5.5; 19.2 ± 6; P < 0.0001) and Society of Thoracic Surgeons‐Predicted Risk of Mortality (6.1% ± 4.7%; 8.1% ± 6.3%; 3.7% ± 4.1%; P < 0.0081) compared to appropriate indications, frequently had concomitant forms of advanced comorbidities and frailty in the setting of symptomatic coronary artery disease. Conclusions A formal, multidisciplinary revascularization heart team can provide proper validation for clinical decisions and should be considered in combination with the Appropriate Use Criteria for coronary revascularization to formulate revascularization strategies for individuals in a patient‐centered fashion. © 2015 Wiley Periodicals, Inc.

2018 ESC/EACTS Guidelines on myocardial revascularization

“…190 This was driven by a significant risk reduction in 30 day all-cause mortality by the culprit lesion-only strategy compared with immediate multivessel PCI (43.3 vs. 51.6%; HR 0.84, 95% CI 0.72-0.98, P = 0.03). These findings need to be interpreted in light of a low 12.5% (43 out of 344 patients) crossover rate from culprit lesion-only to immediate multivessel PCI based on physicians' judgment.…”

“…49 Several reports from different centres have established that the treatment recommendations made in multidisciplinary Heart Team discussions are reproducible and implemented in the vast majority of cases (93-95%). 50,51 Interdisciplinary institutional protocols should be developed for common case scenarios to avoid the need for systematic caseby-case review of all diagnostic angiograms. However, complex cases-defined by the protocols-should be discussed individually.…”

Revascularization following non‐ST elevation myocardial infarction in multivessel coronary disease

“…An important implication of this real‐world analysis is that a multidisciplinary heart team approach should be considered in cases of MVCAD with NSTEMI. Our group has previously demonstrated the utility of a multidisciplinary revascularization heart team as a means to support and validate clinical decisions in an individual patient‐centered approach 21 . In fact, joint guidelines from the American College of Cardiology and the AHA provide a class I recommendation for a heart team approach to revascularization in patients with complex MVCAD 22 …”

The criteria for choice of myocardial revascularization method in patients with stable coronary artery disease in routine clinical practice

“…Зіставлення даних РКД і реєстрів має велике значення для кінцевого рішення щодо ендоваскулярного чи хірургічного варіантів відновлення міокардіального кровоплину [6]. При цьому варто зважати не лише на анатомічні особливості ураження вінцевого русла, а й на весь спектр клінічних характеристик пацієнта, рівень якості життя (ЯЖ), а також особливості локальної клінічної практики [7]. Вивчення цих аспектів здійснюється як шляхом аналізу суцільних популяцій пацієнтів зі стабільною ІХС, яким виконана реваскуляризація міокарда [6], так і селективних вибірок, сформованих за заздалегідь визначеними критеріями.…”