Treatment Recommendations for Patients With Multivessel Coronary Artery Disease—There Is No “I” in Heart Team, But Is the Heart Team Better Than the I? | Acute Coronary Syndromes | JAMA Network Open | JAMA Network
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Invited Commentary
Cardiology
August 10, 2020

Treatment Recommendations for Patients With Multivessel Coronary Artery Disease—There Is No “I” in Heart Team, But Is the Heart Team Better Than the I?

Author Affiliations
  • 1Heart Institute, Department of Cardiology, Geisinger Medical Center, Danville, Pennsylvania
  • 2Department of Cardiology, University of New Mexico, Albuquerque, New Mexico
JAMA Netw Open. 2020;3(8):e2013098. doi:10.1001/jamanetworkopen.2020.13098

Tsang et al1 report the results of a well-designed study that compares treatment received by 234 patients with multivessel coronary artery disease (CAD) between 2012 and 2014 vs treatment recommended by virtual heart teams between 2017 and 2018. Eight heart teams, each consisting of a surgeon, an interventional cardiologist, and a noninvasive cardiologist, reviewed clinical and angiographic data of each patient asynchronously. In the 13% of cases in which all 3 of the heart team members disagreed about treatment strategy or in cases in which heart team specialists recommended a treatment different than the one the patient received, a larger 7-member heart team convened for a face-to-face meeting to produce a definitive heart team recommendation.

Tang et al1 report some fascinating results. Overall, 30% of patients would have received different treatment if the treatment strategy had been decided by the heart team. Different treatment was recommended by the heart team for 22% of patients who received coronary artery bypass grafting (CABG), 45% of patients who received percutaneous coronary intervention (PCI), and 40% of patients who received medical therapy.

The total number of patients receiving each treatment vs the number of patients recommended by the heart team to receive that treatment substantially differed only for medical therapy: 63% of patients received CABG, 31% of patients received PCI, and 6% of patients received medical therapy, while the heart team recommended treatment with CABG for 60% of patients, treatment with PCI for 26% of patients, and treatment with medical therapy for 15% of patients.

Heart team specialists indicated a numeric but statistically insignificant bias toward the procedure of their specialty. Heart team interventional cardiologists recommended PCI for 32% of cases (vs 27% of cases recommended by heart team surgeons), and heart team surgeons recommended CABG for 61% of cases (vs 52% of cases recommended by the heart team interventional cardiologist). All 3 members of the heart team more frequently favored medical therapy (12% of cases recommended by the heart team surgeon, 16% of cases recommended by the heart team interventional cardiologist, and 12% of cases recommended by the heart team noninvasive cardiologist vs 6% of cases recommended by the original treating interventional cardiologist).

The original treating interventional cardiologist recommended PCI for 30.3% of patients, while the heart team interventional cardiologist recommended PCI for 31.6% of patients, which is contrary to what would be expected if the original treating interventional cardiologist had been motivated by personal gain from performance of the procedure or by patient preferences for PCI.

Although the study was carefully designed, it has limitations. First, important studies published during this period may have changed treatment strategies between the interval when treatment decisions were made (2012-2014) and the interval when the heart teams convened (2017-2018).2 Second, it is unclear whether the study measured the treating interventional cardiologist’s recommendation or the actual treatment received. The authors state that “the original treatment decisions were documented at the time of the angiogram” but throughout the article, they refer to treatment received by the patients rather than treatment recommended by the interventional cardiologist. Clinical treatment decisions were made by the original treating interventional cardiologist, but the reader may wonder whether an informal real-time heart team helped to select the treatment received. The heart team approach was a class 1 recommendation in the 2011 American College of Cardiology/American Heart Association guidelines for patients with CABG, in the 2011 American College of Cardiology/Society for Cardiovascular Angiography and Interventions guidelines for patients with PCI, and in the 2012 American College of Cardiology/Society for Cardiovascular Angiography and Interventions guidelines for patients with stable ischemic heart disease. The tradition of multispecialty consultation for complex cases has been standard practice for decades. Thus, it is possible that this study compared treatment provided after consultation with an informal heart team with treatment recommendations from a formal heart team. Third, the virtual heart team approach excluded consideration of patient preference in the 9% of cases in which patient preference was considered by the treating interventional cardiologist to be an important factor in decision-making. Fourth, as the authors state, this study does not suggest that the formal heart team approach produces better outcomes than those made by treating physicians.

Despite these limitations, this is an important study. As the authors point out, guideline recommendations for the heart team approach are all based on level C evidence, or expert consensus. The evidence base supporting the advantages of a heart team approach is scant. This study did, however, indicate that a formal heart team approach may produce different recommendations than those arrived at clinically. These differences may represent an opportunity for improvement.

Another important finding of this study is that a virtual, asymmetric heart team approach is feasible. Heart team members virtually assessed patients, were able to alter their assessments based on the opinions of other heart team members, and evaluated cases in which the heart team members initially disagreed, in most situations without the need for face-to-face interaction between heart team members. These asynchronous assessments may provide a faster decision-making process for busy clinicians who find it difficult to schedule face-to-face meetings, and they may become the new normal in the post–COVID-19 virus era.

An interesting aspect of this study is that it provides reassuring insight into biases that sometimes play a role in complex decision-making. For example, the availability bias increases the likelihood that a clinician will choose the treatment with which he or she is most familiar3; thus, surgeons might choose CABG, and interventional cardiologists might choose PCI. In this study, a numerical association with availability bias was found, but it was statistically insignificant. Second, self-interest bias might motivate the clinical interventional cardiologist to recommend PCI more often than would the heart team interventional cardiologist,4 but, in fact, the clinical interventional cardiologist and heart team interventional cardiologist recommended PCI with similar frequency in this study. Third, this study did identify 1 possible bias: the action bias, which is the tendency of clinicians to intervene rather than follow a conservative treatment strategy when encountering a patient with a problem.5 The clinical interventional cardiologist chose revascularization (action) over medical therapy (often perceived as inaction) more frequently than did heart team members, perhaps owing to this bias.

In summary, this study confirms that a virtual heart team can function effectively and, in this institution, was able to recommend treatment that differed from that chosen in 30% of cases. Whether this formal heart team approach is associated with better outcomes than clinical decisions made by individual physicians remains to be examined in future studies.

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Article Information

Published: August 10, 2020. doi:10.1001/jamanetworkopen.2020.13098

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Blankenship JC et al. JAMA Network Open.

Corresponding Author: James C. Blankenship, MD, MAcc,Department of Cardiology 27-75, 100 N Academy Avenue, Geisinger Medical Center, Danville, PA 17822 (jblankenship@geisinger.edu).

Conflict of Interest Disclosures: None reported.

References
1.
Tsang  MB, Schwalm  JD, Gandhi  S,  et al.  Comparison of heart team vs interventional cardiologist recommendations for the treatment of patients with multivessel coronary artery disease.   JAMA Netw Open. 2020;3(8):e2012749. doi:10.1001/jamanetworkopen.2020.12749Google Scholar
2.
Al-Lamee  R, Thompson  D, Dehbi  H-M,  et al; ORBITA investigators.  Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial.   Lancet. 2018;391(10115):31-40. doi:10.1016/S0140-6736(17)32714-9 PubMedGoogle ScholarCrossref
3.
Cho  I, Bates  DW.  Behavioral economics interventions in clinical decision support systems.   Yearb Med Inform. 2018;27(1):114-121. doi:10.1055/s-0038-1641221 PubMedGoogle ScholarCrossref
4.
Kesternich  I, Schumacher  H, Winter  J.  Professional norms and physician behavior: homo oeconomicus or homo hippocraticus?   J Public Econ. 2015;131:1-11. doi:10.1016/j.jpubeco.2015.08.009 Google ScholarCrossref
5.
Foy  AJ.  Don’t just do something, stand there! Intervention bias in medical decision making.   J Am Phys Surg. 2013;18(1):17-21.Google Scholar
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