Adherence of Catheterization Laboratory Cardiologists to American College of Cardiology/American Heart Association Guidelines for Percutaneous Coronary Interventions and Coronary Artery Bypass Graft Surgery

Outcomes Following Percutaneous Coronary Intervention in Patients With Multivessel Disease Who Were Recommended for But Declined Coronary Artery Bypass Graft Surgery

BACKGROUND

Patients may prefer percutaneous coronary intervention (PCI) over coronary artery bypass graft (CABG) surgery, despite heart team recommendations. The outcomes in such patients have not been examined. We sought to examine the results of PCI in patients who were recommended for but declined CABG.

METHODS AND RESULTS

Consecutive patients with stable ischemic heart disease and unprotected left main or 3-vessel disease or Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery score >22 who underwent PCI after heart team review between 2013 and 2020 were included. Patients were categorized into 3 groups according to heart team recommendations on the basis of appropriate use criteria: (1) PCI-recommended; (2) CABG-eligible but refused CABG (CABG-refusal); and (3) CABG-ineligible. The primary end point was the composite of death, myocardial infarction, or stroke at 1 year. The study included 3687 patients undergoing PCI (PCI-recommended, n=1718 [46.6%]), CABG-refusal (n=1595 [43.3%]), and CABG-ineligible (n=374 [10.1%]). Clinical and procedural risk increased across the 3 groups, with the highest comorbidity burden in CABG-ineligible patients. Composite events within 1 year after PCI occurred in 55 (4.1%), 91 (7.0%), and 41 (14.8%) of patients in the PCI-recommended, CABG-refusal, and CABG-ineligible groups, respectively. After multivariable adjustment, the risk of the primary composite outcome was significantly higher in the CABG-refusal (hazard ratio [HR], 1.67 [95% CI, 1.08-3.56]; P=0.02) and CABG-ineligible patients (HR, 3.26 [95% CI, 1.28-3.65]; P=0.004) groups compared with the reference PCI-recommended group, driven by increased death and stroke.

CONCLUSIONS

Cardiovascular event rates after PCI were significantly higher in patients with multivessel disease who declined or were ineligible for CABG. Our findings provide real-world data to inform shared decision-making discussions.

Safety and feasibility of a real-time electronic heart team decision-making approach in patients with complex coronary artery disease: a protocol for a randomised controlled trial (EHEART trial)

INTRODUCTION

The implementation of a heart team still faces many challenges which may be facilitated with advanced communication technology. There is a knowledge gap to support the use of an electronic real-time heart team decision-making approach based on communication technology in the real clinical practice and evaluate its safety and feasibility in patients with complex coronary artery disease (CAD).

METHODS AND ANALYSIS

The EHEART (Electronic HEArt team with Real-Time decision-making) trial is a prospective, multicentre, two-arm, randomised controlled trial that will randomise 490 patients with complex CAD to either an electronic real-time heart team group or conventional heart team group. For patients allocated to the real-time electronic group, heart team meetings will be initiated during the coronary angiography and guided by a supporting system based on communication technology to help with information synchronisation, real-time communication between specialists, meeting process recording and assistance and joint decision-making with patients' families. The primary and safety endpoint is a composite of all-cause death, myocardial infarction, stroke, revascularisation or re-angina hospital admission at 1 year. The primary secondary outcome is the time interval from the coronary angiography to the final treatment, which is the major indicator of feasibility. We will also compare the practical feasibility from the specialist's and patient's perspectives (for example, specialist's workload and patient's decision results) between the two groups.

ETHICS AND DISSEMINATION

The study was approved by the Institutional Review Board (IRB) of Fuwai Hospital (no. 2022-1749). Informed consent will be obtained from all participants. The results of this trial will be disseminated through manuscript publication and national/international conferences, and reported in the trial registry entry.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT05514210).

Building and Optimizing the Interdisciplinary Heart Team

A multidisciplinary care team model, or Heart Team approach, has become a central tenet of cardiovascular care. Though initially applied to the management of heart transplantation and subsequently complex coronary artery disease, the Heart Team is now utilized broadly across cardiovascular medicine, including in the treatment of valvular disease, pulmonary embolism, cardiogenic shock, high-risk pregnancies in patients with pre-existing cardiovascular disease, and adult congenital heart disease. The Heart Team model improves interdisciplinary collaboration among specialties, adherence to societal guidelines, and shared decision-making with patients and families. In this review, we highlight the development and rationale supporting the Heart Team model, address the challenges of implementing a multidisciplinary care team, and discuss the optimal methods to continue to build, optimize, and implement this approach.

[Myocardial revascularization in chronic coronary artery disease. State of art]

The review addresses debatable issues of myocardial revascularization in chronic forms of ischemic heart disease, shows major differences between percutaneous coronary intervention and coronary artery bypass grafting in terms of long-term prognosis, and the dependence of the results on the clinical profile of the disease. The review of current publications demonstrates advantages of open surgery in long-term survival and prevention of adverse outcomes in target groups of patients.

Methods for assessing guideline adherence for invasive procedures in the care of chronic coronary artery disease: a scoping review

OBJECTIVES

In the care of coronary artery disease (CAD), evidence questions the adequate application of guidelines for cardiovascular procedures, particularly coronary angiographies (CA) and myocardial revascularisation. This review aims to examine how care providers' guideline adherence for CA and myocardial revascularisation in the care of chronic CAD was assessed in the literature.

DESIGN

Scoping review.

DATA SOURCES

PubMed and EMBASE were searched through in June 2021 (rerun in September 2022).

ELIGIBILITY CRITERIA

We included studies assessing care providers' adherence to evidence-based guidelines for CA or myocardial revascularisation in the care of chronic CAD. Studies had to list the evaluation of guideline adherence as study objective, describe the evaluation methods used and report the underlying guidelines and recommendations.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers used standardised forms to extract study characteristics, methodological aspects such as data sources and variables, definitions of guideline adherence and quantification methods and the extent of guideline adherence. To elucidate the measurement of guideline adherence, the main steps were described.

RESULTS

Twelve studies (311 869 participants) were included, which evaluated guideline adherence by (1) defining guideline adherence, (2) specifying the study population, (3) assigning (classes of) recommendations and (4) quantifying adherence. Thereby, primarily secondary data were used. Studies differed in their definitions of guideline adherence, where six studies each considered only recommendation class I/grade A/strong recommendations as adherent or additionally recommendation classes IIa/IIb. Furthermore, some of the studies reported a priori definitions and allocation rules for the assignment of recommendation classes. Guideline adherence results ranged from 10% for percutaneous coronary intervention with prior heart team discussion to 98% for coronary artery bypass grafting.

CONCLUSION

Due to remarkable inconsistencies in the assessment, a cautious interpretation of the guideline adherence results is required. Future efforts should endeavour to establish a consistent understanding of the concept of guideline adherence.

Pathophysiology and Outcomes of Endothelium Function in Coronary Microvascular Diseases: A Systematic Review of Randomized Controlled Trials and Multicenter Study

BACKGROUND

Coronary macrovascular disease is a concept that has been well-studied within the literature and has long been the subject of debates surrounding coronary artery bypass grafting (CABG) vs. Percutaneous Coronary Intervention (PCI). ISCHEMIA trial reported no statistical difference in the primary clinical endpoint between initial invasive management and initial conservative management, while in the ORBITA trial PCI did not improve angina frequency score significantly more than placebo, albeit PCI resulted in more patient-reported freedom from angina than placebo. However, these results did not prove the superiority of the PCI against OMT, therefore do not indicate the benefit of PCI vs. the OMT. Please rephrase the sentence. We reviewed the role of different factors responsible for endothelial dysfunction from recent randomized clinical trials (RCTs) and multicentre studies.

METHODS

A detailed search strategy was performed using a dataset that has previously been published. Data of pooled analysis include research articles (human and animal models), CABG, and PCI randomized controlled trials (RCTs). Details of the search strategy and the methods used for data pooling have been published previously and registered with Open-Source Framework.

RESULTS

The roles of nitric oxide (NO), endothelium-derived contracting factors (EDCFs), and vasodilator prostaglandins (e.g., prostacyclin), as well as endothelium-dependent hyperpolarization (EDH) factors, are crucial for the maintenance of vasomotor tone within the coronary vasculature. These homeostatic mechanisms are affected by sheer forces and other several factors that are currently being studied, such as vaping. The role of intracoronary testing is crucial when determining the effects of therapeutic medications with further studies on the horizon.

CONCLUSION

The true impact of coronary microvascular dysfunction (CMD) is perhaps underappreciated, which supports the role of medical therapy in determining outcomes. Ongoing trials are underway to further investigate the role of therapeutic agents in secondary prevention.

Variations in Coronary Revascularization Practices and Their Effect on Long-Term Outcomes

Background

The degree of hospital‐level variation in the ratio of percutaneous coronary interventions to coronary artery bypass grafting procedures (PCI:CABG) and the association of the PCI:CABG ratio with clinical outcome are unknown.

Methods and Results

In a multicenter population‐based study conducted in Ontario, Canada, we identified 44 288 patients from 19 institutions who had nonemergent diagnostic angiograms indicating severe multivessel coronary artery disease (2013–2017) and underwent a coronary revascularization procedure within 90 days. Hospitals were divided into tertiles according to their adjusted PCI:CABG ratio into low (0.70–0.85, n=17 487), medium (1.01–1.17, n=15 275), and high (1.18–1.29, n=11 526) ratio institutions. Compared with low PCI:CABG ratio hospitals, hazard ratios (HRs) for major adverse cardiac and cerebrovascular events were higher at medium (HR, 1.19; 95% CI, 1.14–1.25) and high ratio (HR, 1.21; 95% CI, 1.15–1.27) hospitals during a median 3.3 (interquartile range 2.1–4.6) years follow‐up. When interventional cardiologists performed the diagnostic angiogram, the odds of the patient receiving PCI was higher (odds ratio, 1.37; 95% CI, 1.23–1.52) than when it was performed by noninterventional cardiologists, after accounting for patient characteristics. Having the diagnostic angiogram at an institution without cardiac surgical capabilities was independently associated with a higher risk of major adverse cardiac and cerebrovascular events (HR, 1.07; 95% CI, 1.02–1.11), death (HR, 1.09; 95% CI, 1.02–1.18), and myocardial infarction (HR, 1.10; 95% CI, 1.03–1.17).

Conclusions

Patients undergoing diagnostic angiography in hospitals with higher PCI:CABG ratio had higher rates of adverse outcomes, including major adverse cardiac and cerebrovascular events, myocardial infarction, and repeat revascularization. Presence of on‐site cardiac surgery was associated with better survival and lower major adverse cardiac and cerebrovascular events.

The extended heart: cardiac surgery serving more hospitals

The Heart Team is becoming ever more central in delivering cardiovascular care, embodying a modern aspect of medical practice, designed to place the patient at the 'center' of a team with different specialists, all contributing to the definition of the most appropriate therapeutic actions. We prospectively analyzed 200 consecutive patients (2015-2017). Patients were evaluated independently by a cardiologist and a cardiac surgeon, each deciding the most appropriate therapeutic action. At a later time, the same patient, was evaluated by the Heart Team. For the first 100 patients the rate of concurrence between cardiologist and cardiac surgeon as well as among each specialist and the Heart Team, was relatively low (51 and 42% respectively). For the following 100 patients the concurrence rate was significantly higher (75 and 70% respectively). The systematic and collegial discussion of the patients in the contest of the Heart Team, steered toward an evolution of each specialist in the group settings. The Electronic Heart Team (e-Heart Team) employing video conference support, applied to the first 65 patients with promising results, represent a further advancement in the delivery of care, by reducing the distance from the 'Hub' center, and the specialist in the 'Spoke' facility, who from simple source of the patient, now becomes an essential part of the therapeutic decision process. The Heart Team environment can deeply affect patients management and improve treatment results, by sharing the expertise and overcoming the limitations of the individual disciplines, thus reaching the common goal of the patient's best available treatment.

Impact of non-respect of SYNTAX score II recommendation for surgery in patients with left main coronary artery disease treated by percutaneous coronary intervention: an EXCEL substudy

OBJECTIVES

The SYNTAX score II (SSII) was developed from the SYNTAX trial to predict the 4-year all-cause mortality after left main or multivessel disease revascularization and to facilitate the decision-making process. The SSII provides the following treatment recommendations: (i) coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) (equipoise risk), (ii) CABG preferred (excessive risk for PCI) or (iii) PCI preferred (excessive risk for CABG). We sought to externally validate SSII and to investigate the impact of not abiding by the SSII recommendations in the randomized EXCEL trial of PCI versus CABG for left main disease.

METHODS

The calibration plot of predicted versus observed 4-year mortality was constructed from individual values of SSII in EXCEL. To assess overestimation versus underestimation of predicted mortality risk, an optimal fit regression line with slope and intercept was determined. Prospective treatment recommendations based on SSII were compared with actual treatments and all-cause mortality at 4 years.

RESULTS

SSII variables were available from EXCEL trial in 1807/1905 (95%) patients. For the entire cohort, discrimination was possibly helpful (C statistic = 0.670). SSII-predicted all-cause mortality at 4 years overestimated the observed mortality, particularly in the highest-risk percentiles, as confirmed by the fit regression line [intercept 2.37 (1.51-3.24), P = 0.003; slope 0.67 (0.61-0.74), P < 0.001]. When the SSII-recommended treatment was CABG, randomized EXCEL patients treated with PCI had a trend towards higher mortality compared with those treated with CABG (14.1% vs 5.3%, P = 0.07) in the as-treat population. In the intention-to-treat population, patients randomized to PCI had higher mortality compared with those randomized to CABG (15.1% vs 4.1%, P = 0.02), when SSII recommended CABG.

CONCLUSIONS

In the EXCEL trial of patients with left main disease, the SSII-predicted 4-year mortality overestimated the 4-year observed mortality with a possibly helpful discrimination. Non-compliance with SSII CABG treatment recommendations (i.e. randomized to PCI) was associated with higher 4-year all-cause mortality.

Disparities in Access to Revascularization: Evidence from New York

Purpose: To quantify and compare citywide disparities in the performance of coronary revascularization procedures in New York residents diagnosed with ischemic heart disease (IHD) by the characteristics of the patients and their neighborhood of residence in 2000–2002 and 2011–2013.

Methods: We identify the number of hospitalizations for patients with diagnoses of IHD and/or congestive heart failure (CHF) and the number of revascularization procedures performed on the population 45 years and older, relying on hospital administrative data for New York City, by area of residence, from the Statewide Planning and Research Cooperative System (SPARCS). We conduct multiple logistic regressions to analyze the factors associated with revascularization for hospitalized patients admitted with IHD and CHF over the two time periods.

Results: Despite any decline in population health status, both the age-adjusted rates of inpatient hospital discharges for acute myocardial infarction, for IHD and for CHF, decreased as did the rates of revascularization procedures. Racial and ethnic disparities were much smaller in the later period than those documented earlier. However, there were persistent gender, insurance status, and neighborhood-level disparities in the treatment of heart disease.

Conclusions: With the declines in rates of heart disease, our findings point to the need for more clinical and population-based research to improve the understanding of why race/ethnicity, gender, insurance status, and neighborhood-level disparities persist in the treatment of heart disease.

Minimally invasive coronary artery bypass grafting

Minimally invasive cardiac surgery (MICS)-CABG is a technique that at its core has patient comfort, early return to routine activities, meeting patient expectations for less invasive options, and maintaining the highest possible standards of care and outcomes. The technique requires not only surgical dexterity but also integration of significant technological advancements in patient care. At a time when percutaneous interventions are often prescribed on the pretext of increased patient comfort and demand, minimally invasive myocardial revascularization becomes even more relevant. Minimally invasive myocardial revascularization is ever evolving and encompasses both small-incision open techniques as well as endoscopic-assisted procedures. The success of the procedure depends not only on the learning curve and familiarity with the technology but also on appropriate patient selection. Mere feasibility of the technique is not sufficient, and the results have to be comparable with the long-established techniques of conventional coronary artery bypass grafting both in terms of early morbidity and mortality as well as long-term outcomes. In this review, we discuss patient selection and technical aspects of minimally invasive coronary artery bypass grafting. We also provide an evidence-based comparison to early and long-term outcomes with conventional coronary artery bypass grafting. Finally, we review the uptake and outcomes of minimally invasive revascularization in the Indian subcontinent.

A review of hybrid coronary revascularization

Purpose

Hybrid coronary revascularization is an emerging treatment strategy for coronary artery disease. We will review the reasons for the development of this strategy, describe surgical techniques, and review outcomes. Finally, we will discuss the future of hybrid revascularization and explain why it will grow as a treatment modality.

Methods

For this review, we conducted an unstructured review of the literature for articles related to hybrid coronary revascularization, bypass surgery, and percutaneous coronary interventions.

Results

Hybrid coronary revascularization has been shown in large series to have excellent results. These include fast recovery time, low mortality and rates of complications, and excellent surgical graft patency. There may be increased need for revascularization over conventional bypass surgery.

Conclusions

The combination improved surgical techniques including a robotic surgery platform, as well as the ever-improving efficacy and durability of coronary stents have made hybrid coronary revascularization an attractive option for many patients. It offers a minimally invasive approach to surgery while avoiding the poor patency of saphenous vein grafts. In appropriately selected patients, this may be an ideal treatment strategy that minimizes risks and maximizes short- and long-term benefits.

Impact of treatment strategies on outcomes in patients with stable coronary artery disease and type 2 diabetes mellitus according to presenting angina severity: A pooled analysis of three federally-funded randomized trials

BACKGROUND AND AIMS

The impact of treatment strategies on outcomes in patients with stable coronary artery disease (CAD) and type 2 diabetes mellitus (T2DM) according to presenting angina has not been rigorously assessed.

METHODS

We performed a patient-level pooled-analysis (n = 5027) of patients with stable CAD and T2DM randomized to optimal medical therapy [OMT], percutaneous coronary intervention [PCI] + OMT, or coronary artery bypass grafting [CABG] + OMT. Endpoints were death/myocardial infarction (MI)/stroke, post-randomization revascularization (both over 5 years), and angina control at 1 year.

RESULTS

Increasing severity of baseline angina was associated with higher rates of death/MI/stroke (p = 0.009) and increased need for post-randomization revascularization (p = 0.001); after multivariable adjustment, only association with post-randomization revascularization remained significant. Baseline angina severity did not influence the superiority of CABG + OMT to reduce the rate of death/MI/stroke and post-randomization revascularization compared to other strategies. CABG + OMT was superior for angina control at 1 year compared to both PCI + OMT and OMT alone but only in patients with ≥ Class II severity at baseline. Comparisons between PCI + OMT and OMT were neutral except that PCI + OMT was superior to OMT for reducing the rate of post-randomization revascularization irrespective of presenting angina severity.

CONCLUSIONS

Presenting angina severity did not influence the superiority of CABG + OMT with respect to 5-year rates of death/MI/stroke and need for post-randomization revascularization. Presenting angina severity minimally influenced relative benefits for angina control at 1 year.

NOBLE and EXCEL: The debate for excellence in dealing with left main stenosis

Left main coronary artery (LMCA) disease is associated with increased morbidity and mortality. Coronary artery bypass grafting surgery (CABG) has always been the standard revascularization strategy for this group of patients. However, with the recent developments in stents design and medical therapy over the past decade, several trials have been designed to evaluate the safety and efficacy of percutaneous coronary intervention (PCI) as an alternative to CABG surgery in patients with LMCA disease. Recently, the results of two major trials, EXCEL and NOBLE, comparing CABG versus PCI in this patient population have been released. In fact, the results of both trials might appear contradictory at first glance. While the EXCEL trial showed that PCI was non-inferior to CABG surgery, the NOBLE trial suggested that CABG surgery is a better option. In the following review, we will discuss some of the similarities and contrasts between these two trials and conclude with lessons to be learned to our daily practice.

Outcome and selection of revascularization strategy in left main coronary artery stenosis

OBJECTIVES

To investigate clinical outcome in unselected real-life patients with unprotected left main coronary artery (ULMCA) stenosis and determine factors associated with selection of revascularization strategy.

DESIGN

Consecutive patients with ULMCA stenosis at our institution in 2009-2013 (n = 308) were retrospectively analyzed with propensity score adjusted Cox proportional hazards models for outcome. Baseline characteristics in relation to selection of revascularization strategy were analyzed with multivariate logistic regression.

RESULTS

Patients that underwent PCI (n = 94) had a higher risk of major adverse cardiac and cerebrovascular events (MACCE; adjusted HR 2.13 [95% CI 1.08-4.19]) than patients that had CABG surgery but there was no difference in the combination of death and MI (adjusted HR 1.17 [95% CI 0.50-2.75]). Later year of index angiography, age, Euroscore II and angiographer favoring PCI was associated with PCI as revascularization strategy. Higher SYNTAX score, higher systolic blood pressure and angiographer favoring CABG was associated with CABG.

CONCLUSIONS

In consecutive patients with ULMCA stenosis PCI is associated with higher MACCE rates than CABG but there is no difference in death and MI. Later year of index angiography, higher age, lower systolic blood pressure, higher predicted per-procedural surgical risk, less complex coronary anatomy and angiographer favoring PCI increased the probability of revascularization with PCI instead of CABG.

Treatment Strategies in Symptomatic Intermediate, Low-Risk, and Asymptomatic Patients With Severe Aortic Stenosis

Survival of symptomatic patients with severe aortic stenosis (AS) is very poor, with an average mortality reaching up to 2% per month. Approach to diagnosis and treatment of patients with AS was conservative; patients were referred to surgery only if the AS-induced symptoms become apparent and significantly limit the quality of patient' life. In the past 15 years, the novel treatment strategy in subgroups of symptomatic patients with AS have been the subject of extensive research, starting from introduction of transcatheter aortic valve implant (TAVI) in inoperable symptomatic patients with severe AS and continuing further to patients with very high and high operative risk. In the past few years, the focus has further shifted toward the patients with lower operative risk, as well as to asymptomatic patients with severe AS. In the former group, the question relates to whether TAVI is beneficial when compared to SAVR in intermediate- to low-risk patients with symptomatic AS. In the latter group, the main issue is if and when the SAVR should be performed. This article analyzes current status and evidences regarding treatment strategies in symptomatic high, intermediate, low-risk, and asymptomatic patients with isolated severe AS.

Rationale and design of the Coronary Computed Tomographic Angiography for Selective Cardiac Catheterization: Relation to Cardiovascular Outcomes, Cost Effectiveness and Quality of Life (CONSERVE) trial

Although coronary computed tomography angiography (CCTA) has shown promise as a "gatekeeper" to invasive coronary angiography (ICA) in longitudinal cohort studies, it remains unknown whether the strategy of selective ICA by initial performance of CCTA is either safe or effective when compared with a direct ICA strategy in patients with an American Heart Association (AHA)/American College of Cardiology (ACC) guideline-directed indication for ICA.

OBJECTIVES

The CONSERVE trial is a prospective randomized multicenter trial to determine the clinical effectiveness of "selective catheterization" vs "direct catheterization" strategies for stable patients with suspected but without known coronary artery disease, who meet AHA/ACC guideline indication for ICA.

METHODS

Patients being referred for clinically indicated nonemergent ICA with an AHA/ACC class II guideline indication for ICA will be randomized to either direct catheterization or selective catheterization strategy. Patients in the direct catheterization arm will proceed directly to ICA as planned, whereas patients in the select catheterization arm will undergo initial CCTA, followed by ICA at the discretion of the site physician. All CCTAs and ICAs will be interpreted on site. Follow-up testing and/or therapy after CCTA or ICA will be at the discretion of the site physician.

RESULTS

This trial will report a primary clinical end point of noninferiority rates of major adverse cardiac events, as defined by the composite of death, nonfatal myocardial infarction, unstable angina, stroke, urgent or emergent coronary revascularization, or cardiac hospitalization.

CONCLUSION

The CONSERVE trial will determine whether selective catheterization strategy, based on initial CCTA in patients being referred to ICA, is safe and effective.

Why surgery won the SYNTAX trial and why it matters

The Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) trial cause of death analysis shows that cardiac death due to myocardial infarction is 10 times higher with percutaneous coronary intervention than coronary artery bypass grafting in the higher-risk patients. There was a clear advantage for surgery in the prevention of death in both the intermediate and high SYNTAX score groups with 3-vessel disease and in the high SYNTAX score group with left main disease, and that incremental advantage is statistically significant and widening with time, which should be transparently communicated to patients.

Revascularization in stable coronary artery disease: a combined perspective from an interventional cardiologist and a cardiac surgeon

It is now half a century since the start of coronary bypass graft surgery (CABG) with the first percutaneous coronary intervention (PCI) following just over a decade later. The relative merits of PCI vs. CABG for stable coronary artery disease (stable-CAD) have continued to be debated ever since and have been the focus of around 20 randomized trials and numerous registry studies, systematic reviews, and meta-analyses. The aim of this review is to identify areas of agreement, disagreement, and uncertainties in the role of PCI and CABG in patients with stable-CAD.

Multiple procedures and cumulative individual radiation exposure in interventional cardiology: A long-term retrospective study

INTRODUCTION

Various studies address discrepancies between guideline recommendations for coronary angiographies and clinical practice. While the issue of the appropriateness of recurrent angiographies was studied focusing on the role of the cardiologist, little is known about individual patients' histories and the associated radiation exposures.

METHODS

We analyzed all patients with coronary artery disease (CAD) in an academic teaching practice who underwent at least one angiography with or without intervention between 2004 and 2009. All performed angiographies in these patients were analyzed and rated by three physicians for appropriateness levels according to cardiology guidelines. Typical exposure data from the medical literature were used to estimate individual radiation exposure.

RESULTS

In the cohort of 147 patients, a total of 441 procedures were analyzed: between 1981 and 2009, three procedures were performed per patient (range 1-19) on average. Appropriateness ratings were 'high/intermediate' in 71%, 'low/no' in 27.6% and data were insufficient for ratings in 1.4%. Procedures with 'low/no' ratings were associated with potentially avoidable exposures of up to 186 mSv for single patients.

CONCLUSIONS

Using retrospective data, we exemplify the potential benefit of guideline adherence to decrease patients' radiation exposures.

KEY POINTS

• A cohort study of 147 patients showed 27.6% low appropriateness procedures. • Potentially avoidable radiation exposure cumulated up to about 186 mSv for single patients. • Predisposing factors were prior bypass surgery and first treatment in a tertiary centre. • 7.5% of the patients received 58% of the potentially avoidable radiation exposure. • The benefits of guideline adherence in decreasing patient radiation exposure are exemplified.

Continued expansion of the Heart Team concept

ABSTRACT 

The concept of a multidisciplinary Heart Team approach to treating cardiovascular disease has garnered increasing interest in recent years. This team-based approach has been a cornerstone of practice in other medical fields, such as oncology and solid organ transplantation. Advances in technology and new therapeutic strategies now offer multiple treatment options to patients with complex coronary artery or valvular heart disease, making therapeutic decision-making more challenging. There is a growing literature that use of a Heart Team for management of these complex cardiovascular diseases has demonstrated great merit. While the composition and implementation of Heart Team will vary, this multidisciplinary team-based approach will become the standard of care in cardiovascular medicine in the future.

What the cardiothoracic surgeon wants to know from the radiologist: from X-ray reporting to imaging consultancy and Heart Team membership

In the early days of cardiac surgery, the pretreatment multidisciplinary discussion involved a presentation of the case history and diagnostic imaging by the clinical cardiologist. At this time, most, if not all, cardiac imaging techniques were in the hands of the cardiologist. If the radiologist made a report, this was done relatively late in the clinical process and only concerned the perioperative radiographs. In recent years, multidisciplinary decision-making in the context of a Heart Team has gained an increasingly important role in the process of decision-making with regard to the available therapy options in individual patients. Nevertheless, the concept of the Heart Team is still evolving. The minimal requirements for the Heart Team include the presence of the attending cardiologist, an interventional cardiologist and a cardiac surgeon. Those members of the Heart Team should be aware of the local possibilities, should correctly make conclusions about the available data and should put this information into the clinical context and preference of the patient. In addition, in areas where expertise in cardiac imaging such as CT and MRI is relevant, this would explicitly require expertise of the Heart Team in these specific areas, most often by involving a radiologist, to provide the optimal joint treatment strategy recommendation.

Interventions for coronary artery disease (surgery vs angioplasty) in diabetic patients

Patients with diabetes develop more widespread and more severe atherosclerotic coronary artery disease than patients without diabetes. Medical management of this coronary disease is inferior to revascularization for more complex or more widespread disease. Revascularization by percutaneous intervention (PCI) for patients with diabetes is associated with high mortality and complication rates. Surgical revascularization by coronary artery bypass grafting, yields superior results to PCI for patients with diabetes and coronary artery disease. Patients with diabetes benefit from the same medical management of their coronary artery disease and secondary risk modification as patients without diabetes.

How does the 'Heart Team' decision get enacted for patients with coronary artery disease?

OBJECTIVES

A heart team approach has been recommended for managing patients with coronary artery disease. Although this seems to be a new concept, we have been developing such a practice for over 8 years. In this report, the enactment of the heart team decision is reviewed and possible improvement is discussed.

DESIGN

Review of 1000 heart team decisions over a 1-year period for patients with coronary artery disease. These decisions were recorded contemporaneously at the time of the team discussion. Thereafter, patient's notes were reviewed 6 months following the heart team meeting to assess whether the decision was enacted and, if not, what were the reasons for aberration.

RESULTS

The heart team decision was enacted in 95.5% of patients. The reasons for aberration in the remaining 45 patients included patient's choice (refusal), unrecognised comorbidities at the time of the heart team discussion, change in patient's clinical condition requiring urgent intervention and death while awaiting procedure, among others.

CONCLUSIONS

The decision of a well set-up heartteam meeting is carried out for most patients. Aberration is uncommon and usually due to unknown factors at the time of the discussion. The heart team approach ensures that patients receive best available care (most likely evidence-based), and demonstrates transparency.

The heart team approach to coronary revascularization--have we crossed the lines of evidence-based medicine?

Evidence-based medicine demands considerable time and decision-making skills to navigate through the proliferating data. A hierarchical "pyramid of evidence" has been formulated to help categorize data quality. The hierarchical data are processed into recommendations in Practice Guideline statements. Recently, both American College of Cardiology/American Heart Association/Society for Cardiac Angiography and Interventions and European Society of Cardiology guidelines for percutaneous coronary intervention embraced a new "heart team approach" as the preferred method to optimize revascularization decision making in cases of complex coronary anatomy. This extrapolation of a research method to the broad clinical practice has potential limitations. We suggest that both the need for a new method to optimize patient triage for the various revascularization strategies and the method to optimize decision making should be discussed. Published data suggest only minor deviations from guideline-based indications. Furthermore, traditional clinical judgment may result in a better patient outcome than arbitrary treatment assignment by rigid set of criteria. In conclusion, the need for a new decision-making process in the choice of revascularization strategy should be further explored and supported by scientific evidence.