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Myocardial revascularisation in complex patients: does it happen as prescribed by the heart team?
Montasir Ali1, Adrian Ionescu2, Abdul R A Bakhsh3
1Specialist Registrar in Cardiology.
Insights
The heart team (HT) approach for myocardial revascularisation decisions is implemented in nearly 90% of complex cases. Ischaemia testing is key for these crucial cardiac interventions.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiovascular Surgery
Background:
- Clinical guidelines advocate for heart team (HT) decision-making in complex myocardial revascularisation cases.
- Limited data exist on the practical application and outcomes of the HT approach in real-world settings.
Purpose of the Study:
- To evaluate the implementation rate and outcomes of heart team recommendations for myocardial revascularisation.
- To identify the primary investigations driving HT decisions in complex cardiac patients.
Main Methods:
- Retrospective analysis of an electronic heart team database for patients evaluated for myocardial revascularisation.
- Data extraction included clinical questions, HT recommendations, and decision implementation status.
- Patient demographics, interventions, and outcomes (including mortality) were analyzed.
Main Results:
- 154 patients were analyzed, with 91% of clinical questions concerning coronary artery bypass graft (CABG) versus percutaneous coronary intervention (PCI).
- Heart team recommendations were implemented in 89% of cases, with a mean decision-to-implementation time of 80.5 days.
- Ischaemia testing was the most frequent further investigation required (32% of cases needing more data).
Conclusions:
- The heart team approach demonstrates high decision implementation rates (89%) for myocardial revascularisation in complex patients.
- Ischaemia testing is a critical component guiding heart team decisions.
- Current clinical practice appears to lag behind recent evidence questioning the efficacy of certain revascularisation strategies.
Abstract:
Guidelines recommend decision- making using the heart team (HT) in complex patients considered for myocardial revascularisation, but there are little data on how this approach works in practice. We data-mined our electronic HT database and selected patients in whom the clinical question referred to revascularisation, and documented HT recommendations and their implementation. We identified 154 patients (117 male), mean age 68.9 ± 11.4 years, discussed between February 2019 and December 2020. The clinical questions were coronary artery bypass graft (CABG) versus percutaneous coronary intervention (PCI) (141 cases, 91%), and medical treatment versus revascularisation by PCI (eight cases, 6%) or by CABG (five cases, 3%). HT recommended CABG in 55 cases (35%), PCI in 43 (28%), medical treatment in 15 (10%), and equipoise in seven (5%) and further investigations in 34 (22%): non-invasive imaging for ischaemia in 11 (32%), invasive coronary physiology studies in eight (24%), further clinical assessment in seven (20%), structural imaging for five (15%), invasive coronary angiography in two (6%), and an electrophysiology opinion in one case (3%). Decisions were implemented in 135 cases (89%). The average time between the HT and the implementation of its decision was 80.5 ± 129.3 days. There were 17 deaths: 10 cardiac, six non- cardiac and one of unknown cause. Patients who survived were younger (68.6 ± 11.3 years) than those who died (73.8 ± 10.0 years, p = 0.03). In conclusion, almost 90% of the decisions of the HT on myocardial revascularisation are implemented, while ischaemia testing is the main investigation required for decision- making. Recent data on the futility of such an approach have not yet permeated clinical practice.
