Editorial
The Heart Team Approach to Coronary Revascularization—Have We Crossed the Lines of Evidence-Based Medicine?

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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.

Section snippets

From Evidence-Based Medicine to the Heart Team Approach

Clinical judgment is based on both available relevant data and the decision-making process. The shift in recent decades to “evidence-based medicine” demands considerable time to navigate through the proliferating data. The need to identify and categorize data that influence clinical decision making has become a Sisyphean struggle for the practicing physician. As a result, a hierarchical “pyramid of evidence” has been formulated to help categorize data quality (Figure 1).1 To further assist and

Is There a Need to Optimize the Revascularization Decision-Making Process?

In the last decade, “the PCI era”, PCI has evolved into the most common in hospital procedures followed by a dramatic reduction in mortality in CAD, mostly in patients with acute myocardial infarction.

Two retrospective analyses of large registries have examined adherence by current methods of decision making to PGs. Anderson et al,9 in a retrospective analysis of 412,617 PCIs in the ACC National Cardiovascular Registry, found that only 8% of the PCIs were performed in class 3 indication whereas

Is the Heart Team Approach Supported by the Contemporary Science of Decision Making?

As for the optimal method for decision making, the complex issue of optimal decision making and judgment under uncertainty, for which the solution of the heart team approach was proposed, has been studied extensively in the last 4 decades.

In 2002, Daniel Kahneman was awarded the Nobel Prize for his landmark studies on human biases in judgment and decision making. His seminal work, together with the late Amos Tversky, illuminated the way that inherent and consistent patterns of cognition lead to

Disclosures

The authors have no conflicts of interest to disclose.

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Cited by (14)

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    2022, American Journal of Cardiology
    Citation Excerpt :

    With the advent of the HT, we have potentially crossed the line of evidence-based medicine. Currently, it is an extrapolation of a research method of patient recruitment that is being brought into broad clinical practice.5 The current evidence for the use of HT comes from multidisciplinary teams in cancer care.

  • Identification of candidates for coronary artery bypass grafting admitted with STEMI and Multivessel Disease

    2018, Cardiovascular Revascularization Medicine
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    The higher residual SYNTAX score in the left coronary artery, and the lower infarct-related SYNTAX when the RCA is the culprit vessel may define this population as possible ideal candidates for CSR after provisional percutaneous revascularization without stent implantation, provided that the surgical risk is not high and an ad-hoc heart team has agreed that this approach is the best for the affected patient. Since surgical risk scores have limited accuracy to predict outcomes after CABG, especially when a percutaneous intervention has been previously performed [27], we simulated a heart-team after the patient was treated (post hoc heart-team) [28]. We discussed what would have been our treatment choice after the patient had the culprit vessel opened, before stent implantation, and if the patient had been in a stable setting.

  • Implementation and consistency of Heart Team decision-making in complex coronary revascularisation

    2016, International Journal of Cardiology
    Citation Excerpt :

    Although the HT concept has now been widely accepted by the scientific community, data for its adoption and implementation in every day practise are scarce. Studies that evaluate its pros and cons and especially the reproducibility of its results are important in order to validate its concept [24–25]. The purpose of this study was to evaluate the implementation and consistency of coronary HT decisions in a tertiary cardiac centre.

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Drs. Rosenschein and Nagler contributed equally to this work.

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