Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
JAMA Netw Open. 2020 Aug 3;3(8):e2012749. doi: 10.1001/jamanetworkopen.2020.12749.
Although the heart team approach is recommended in revascularization guidelines, the frequency with which heart team decisions differ from those of the original treating interventional cardiologist is unknown.
To examine the difference in decisions between the heart team and the original treating interventional cardiologist for the treatment of patients with multivessel coronary artery disease.
DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional study, 245 consecutive patients with multivessel coronary artery disease were recruited from 1 high-volume tertiary care referral center (185 patients were enrolled through a screening process, and 60 patients were retrospectively enrolled from the center's database). A total of 237 patients were included in the final virtual heart team analysis. Treatment decisions (which comprised coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy) were made by the original treating interventional cardiologists between March 15, 2012, and October 20, 2014. These decisions were then compared with pooled-majority treatment decisions made by 8 blinded heart teams using structured online case presentations between October 1, 2017, and October 15, 2018. The randomized members of the heart teams comprised experts from 3 domains, with each team containing 1 noninvasive cardiologist, 1 interventional cardiologist, and 1 cardiovascular surgeon. Cases in which all 3 of the heart team members disagreed and cases in which procedural discordance occurred (eg, 2 members chose coronary artery bypass grafting and 1 member chose percutaneous coronary intervention) were discussed in a face-to-face heart team review in October 2018 to obtain pooled-majority decisions. Data were analyzed from May 6, 2019, to April 22, 2020.
The Cohen κ coefficient between the treatment recommendation from the heart team and the treatment recommendation from the original treating interventional cardiologist.
Among 234 of 237 patients (98.7%) in the analysis for whom complete data were available, the mean (SD) age was 67.8 (10.9) years; 176 patients (75.2%) were male, and 191 patients (81.4%) had stenosis in 3 epicardial coronary vessels. A total of 71 differences (30.3%; 95% CI, 24.5%-36.7%) in treatment decisions between the heart team and the original treating interventional cardiologist occurred, with a Cohen κ of 0.478 (95% CI, 0.336-0.540; P = .006). The heart team decision was more frequently unanimous when it was concordant with the decision of the original treating interventional cardiologist (109 of 163 cases [66.9%]) compared with when it was discordant (28 of 71 cases [39.4%]; P < .001). When the heart team agreed with the original treatment decision, there was more agreement between the heart team interventional cardiologist and the original treating interventional cardiologist (138 of 163 cases [84.7%]) compared with when the heart team disagreed with the original treatment decision (14 of 71 cases [19.7%]); P < .001). Those with an original treatment of coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy, 32 of 148 patients [22.3%], 32 of 71 patients [45.1%], and 6 of 15 patients [40.0%], respectively, received a different treatment recommendation from the heart team than the original treating interventional cardiologist; the difference across the 3 groups was statistically significant (P = .002).
The heart team's recommended treatment for patients with multivessel coronary artery disease differed from that of the original treating interventional cardiologist in up to 30% of cases. This subset of cases was associated with a lower frequency of unanimous decisions within the heart team and less concordance between the interventional cardiologists; discordance was more frequent when percutaneous coronary intervention or medication therapy were considered. Further research is needed to evaluate whether heart team decisions are associated with improvements in outcomes and, if so, how to identify patients for whom the heart team approach would be beneficial.
重要性：虽然血管重建指南推荐采用心脏团队的方法，但心脏团队的决策与最初治疗的介入心脏病专家的决策差异尚不清楚。
目的：检查心脏团队与最初治疗的介入心脏病专家在多血管冠状动脉疾病治疗方面的决策差异。
设计、地点和参与者：在这项横断面研究中，从 1 家高容量三级转诊中心招募了 245 例多血管冠状动脉疾病连续患者（185 例通过筛选过程招募，60 例从中心数据库中回顾性招募）。最终有 237 例患者纳入虚拟心脏团队分析。治疗决策（包括冠状动脉旁路移植术、经皮冠状动脉介入治疗和药物治疗）由 3 月 15 日至 2014 年 10 月 20 日期间的最初治疗介入心脏病专家做出。然后，使用 10 月 1 日至 2018 年 10 月 15 日之间的结构化在线病例介绍，由 8 名盲法心脏团队成员对这些决策与团队汇总多数治疗决策进行了比较。心脏团队的随机成员由 3 个领域的专家组成，每个团队包含 1 名非侵入性心脏病专家、1 名介入心脏病专家和 1 名心血管外科医生。当所有 3 名心脏团队成员意见不一致时，或者发生手术不一致时（例如，2 名成员选择冠状动脉旁路移植术，1 名成员选择经皮冠状动脉介入治疗），在 2018 年 10 月进行面对面心脏团队审查以获得团队汇总多数决策。数据分析于 2019 年 5 月 6 日至 2020 年 4 月 22 日进行。
主要结果和措施：心脏团队的治疗建议与最初治疗介入心脏病专家的治疗建议之间的 Cohen κ 系数。
结果：在可获得完整数据的 237 例患者中的 234 例（98.7%）中，平均（SD）年龄为 67.8（10.9）岁；176 例（75.2%）为男性，191 例（81.4%）有 3 个心外膜冠状动脉狭窄。心脏团队与最初治疗的介入心脏病专家之间发生了 71 次（30.3%；95%CI，24.5%-36.7%）治疗决策差异，Cohen κ 为 0.478（95%CI，0.336-0.540；P=0.006）。当心脏团队的决定与最初治疗的介入心脏病专家的决定一致时，心脏团队的决定更有可能是一致的（163 例中的 109 例[66.9%]），而不一致的情况（71 例中的 28 例[39.4%]）较少；P<0.001）。当心脏团队同意原始治疗决策时，心脏团队介入心脏病专家与最初治疗的介入心脏病专家之间的一致性更高（163 例中的 138 例[84.7%]），而当心脏团队不同意原始治疗决策时，一致性较低（71 例中的 14 例[19.7%]）；P<0.001）。对于最初接受冠状动脉旁路移植术、经皮冠状动脉介入治疗和药物治疗的患者，心脏团队建议进行不同治疗的患者分别为 32 例（148 例中的 22.3%）、32 例（71 例中的 45.1%）和 6 例（15 例中的 40.0%），与最初治疗的介入心脏病专家的建议不同；这 3 组之间的差异具有统计学意义（P=0.002）。
结论和相关性：多血管冠状动脉疾病患者的心脏团队推荐治疗与最初治疗的介入心脏病专家的治疗差异高达 30%。这种情况与心脏团队内一致决策的频率较低以及介入心脏病专家之间的一致性较低有关；当考虑经皮冠状动脉介入治疗或药物治疗时，不一致的情况更为常见。需要进一步研究以评估心脏团队决策是否与改善结局相关，如果是，如何确定心脏团队方法有益的患者。
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