Cardiac surgeons defy guidelines for severe disease

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PCI when experts recommend CABG

Gathering evidence over recent years has shown that multidisciplinary teams can improve overall outcomes in many clinical scenarios, Dr. M. Sertac Cicek said in his commentary (J. Thorac. Cardiovasc. Surg. 2014 [doi:10.1016/j.jtcvs.2014.12.008]). He cited a 2012 study that showed an 18% lower mortality at 5 years when multidisciplinary teams got involved in the treatment of breast cancer, compared with cases that did not involve team consultation (BMJ 2012;344:e2718).

Dr. M. Sertac Cicek

Cardiovascular disease is a specialty that demands teamwork, but controversy still surrounds the role of surgery vs. PCI for patients with severe coronary disease, despite the evidence supporting CABG as the “gold standard,” Dr. Cicek said. The data presented by Dr. Yates and his colleagues, Dr. Cicek said, “simply confirm once again how far we are away from providing the optimal care to our patients, raising the question: ‘Are guidelines there to be disrespected?’ ”

A key factor in implementing the multidisciplinary approach involves educating patients and accepting them as members of the heart team during decision-making, Dr. Cicek noted. “It seems increasingly evident that multidisciplinary teams clearly strengthen our ability to provide higher quality and more efficient care; so much so that it may not come as surprise to anyone in the practice if in the very near future practicing ‘medicine without teamwork’ were declared and added to the Seven [Social] Sins of Mahatma Gandhi as the eighth [social] sin,” Dr. Cicek wrote.

Dr. Cicek is professor of cardiovascular surgery at the Anadolu Medical Center in Kocaeli, Turkey.




Although expert committees spend hours developing guidelines for best practices, clinicians on the front line of care can be somewhat hesitant to adopt them, as a recent study evaluating the use of guidelines for treatment of heart attack patients at three major cardiothoracic centers in London revealed.

The study, published in the Journal of Thoracic and Cardiovascular Surgery (J. Thorac. Cardiovasc. Surg. 2014 [doi:10.1016/j.jtcvs.2014.10.110]) , found that surgeons more often than not flaunted the Joint European Society of Cardiology and European Association for Cardiothoracic Surgery (ESC/EACTS) guidelines that call for a multidisciplinary “Heart Team” to discuss each case of severe coronary artery disease before treatment.

The investigators looked at January-to-June periods in 2010 (before the guidelines) and 2012 (after the guidelines had been in place for 18 months) and found identical 17% rates of multidisciplinary team discussions before treatment. Both samples involved patients who had percutaneous coronary interventions (PCI). The 621 cases in the 2010 sample and 686 cases in the 2012 group comprise “a significant proportion of the coronary revascularization workload” of the National Health Service (NHS) hospitals in London, Dr. Martin T. Yates of St. George’s Hospital, University of London, and coauthors reported. The other participating centers were Barts Health NHS Trust and King College Hospital.

The ESC/EACTS guidelines (Eur. Heart J. 2010;31:2501-55) determined that PCI at the same catheterization session as the diagnostic angiogram and elective PCI are inappropriate for patients with severe coronary artery disease, defined as proximal left-anterior descending, left-main stem or three-vessel disease. The guidelines state that these patients should be considered for surgery first.

In a previous single-center study a year after the guidelines were adopted, Dr. Yates and his colleagues reported that almost a third of all elective PCI (29%) were carried out on patients who may have benefited more from coronary artery bypass grafting (CABG) (J. Thorac. Cardiovasc. Surg. 2014;147:606-10). Of those cases, the multidisciplinary team again discussed only 17% of cases before PCI.

Dr. Yates and his colleagues intimated that the rush to PCI might be circumventing in-depth discussions about more appropriate CABG for patients with severe coronary artery disease. “Furthermore, despite the guidelines suggesting that ad hoc PCI is inappropriate in the elective setting, this practice continues,” they said. “Although this is convenient for the patient and more cost effective, it does not allow time for Heart Team discussions prior to intervention.”

In the current study, the 2010 group included 187 patients with severe coronary artery disease who had treatment without a multidisciplinary team consultation, and less than half (44%) achieved complete revascularization. The 2012 group included 225 patients with severe heart disease, and precisely half achieved complete revascularization.

In both groups, a considerable majority of patients with three-vessel disease had PCI without the multidisciplinary team discussion: 76% in 2010 and 64% in 2012.

Dr. Yates and his associates noted that this is not a problem specific to London cardiac centers. They cited variations in the use of PCI and CABG in a large study of the New York State Registry, which showed that only 53% of patients suitable for CABG, according to the American College of Cardiology/American Heart Association guidelines, actually had the procedure (Circulation 2010;121:267-75). They cited similar results in a Canadian study (CMAJ 2012;184;179-86).

One way to get cardiac surgeons to adhere to guidelines is to tie payment to treatment – an approach that may work better in the United States than in Canada or the United Kingdom. “This may be easier to implement in countries with payment linked to insurance systems as opposed to those with a nationalized service,” Dr. Yates and his associates wrote.

The authors reported no financial disclosures.

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