By: Faisal Latif, MD, FSCAI and Suresh Mulukutla, MD, FSCAI

The Revascularization Heart Team: Take Patient-Centered Care to Heart

The Heart Team Concept has been gathering momentum over the last few years. While the Heart Team can encompass many diseases and conditions, this edition of the SCAI-QIT Tip-of-the-Month will focus on the Revascularization Heart Team.

Why? The ACCF/AHA/SCAI Guidelines advocate for a Heart Team approach in revascularization decisions for patients with complex coronary disease. The management of patients with complex CAD is difficult, and old paradigms are being challenged with the advent of more sophisticated tools, an explosion of clinical data, increased scrutiny over appropriateness, and greater focus on patient-centered care. A Heart Team approach can offer a balanced approach to shared decision making, capitalizing on the collective experience of the team. The Heart Team can be the bedrock of multidisciplinary, patient-centric, cardiovascular care and among the most intellectually rewarding clinically-driven programs.

Who? For decisions regarding coronary revascularization, the Heart Team is made up of primarily general and interventional cardiologists and cardiovascular surgeons. However, their respective teams are augmented by cardiac anesthesiologists, nurses, nurse practitioners, physician assistants, and other healthcare providers.

How? Strategies for implementation of a Heart Team must be tailored to your environment, but a suggested implementation protocol is outlined:

• Build the roster: Identify the multidisciplinary team members who are willing to commit energy and time towards the Heart Team.
• Establish a process: Having all team members present every day is impractical. However, devise a process by which all stakeholder groups are adequately represented so each patient case gets a unique roster of individuals that make up his/her Team. While there may be different individual physicians on any given day, every patient will benefit from a team-based evaluation. In this way, a daily meeting is possible in order to prevent delays in therapies and to avoid disruption in the flow of clinical care.
• Identify cases: Since not every case needs to be discussed in this format, define the types of cases that should be discussed routinely during Heart Team meetings. Invite others to refer cases for team-based evaluation. Include cases referred to cardiologists as well as cardiac surgeons. Discuss cases even if patients were already given a therapy to help the entire team understand other perspectives.
• Pre-discussion data collection: Collect key data points in advance of Heart Team meetings
   • Patient history, presentation, risk factors, comorbidities
   • Cardiac risk scores (e.g., SYNTAX, STS, PCI risk estimates)
• Heart Team discussion and recommendations: Collaboratively discuss cases and include risk assessment for specific outcomes (mortality, quality of life, repeat procedures, stroke, overall recovery). Explore with the Team how recommendations are made (i.e., deliberate until consensus vs. majority opinion vs. recording number of individuals favoring a particular therapeutic choice).
• Communication to patients and referring physicians: Devise mechanisms to communicate recommendations to patients and other physicians, understanding that these recommendations may be trumped by patient preferences. Several tools exist now that may help facilitate communication to patients:
   • http://med.stanford.edu/hsr/cabg-pci/
   • http://shareddecisions.mayoclinic.org/pci-choice/
• Post-discussion data collection: Prospectively record Heart Team recommendations, how frequently those were followed, why they may not have been followed, and outcomes of patients.

References

1. Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2011;124:e574–e651.
2. Holmes DR, Rich JB, Zoghbi WA, Mack MJ. The Heart Team of Cardiovascular Care. J Am Coll Cardiol. 2013;61(9):903–907.
3. Sanchez CE, Badhwar V, Dota A, Schindler J, Chu D, Smith AJ, Lee JS, Khandhar S, Toma C, Marroquin OC, Schmidhofer M, Bhama J, Wei L, Scolieri S, Esper S, Lee A, Mulukutla SR. Practical implementation of the coronary revascularization heart team. Circ Cardiovasc Qual Outcomes. 2013 Sep 1;6(5):598–603.