While a Heart Team is important for deciding the best treatment for patients with life-threatening CAD, this subgroup probably represents about a quarter of all patients who need revascularization treatment, Dr. Smith said. The remaining three quarters need revascularization for symptom relief, and while CABG also works well for this purpose, most patients in this category would also benefit from PCI, which may be the preferred choice, he added.
This new approach will probably not have a big impact of the volume of U.S. PCIs performed, predicted Dr. James C. Blankenship, vice-chairman of the PCI guidelines committee and an interventional cardiologist practicing in Danville, Pa. "On the complex end, I doubt that many PCIs today are done in super complex patients. On the low end, there has been a big shift in recognizing coronary lesions that need PCI," using tools that identify ischemia-causing lesions such as intravascular ultrasound and measuring fractional flow reserve. "Most interventionalists have shifted to this paradigm. For any who haven’t, the guidelines emphasize the importance of this approach," Dr. Blankenship said in an interview.
The call for Heart Teams by the new guidelines raises the issue whether enough U.S. teams exist to handle the volume of appropriate patients. Dr. Smith said there are, although they may not have a formal Heart Team designation.
"I think surgeons and cardiologists collaborate on this more than people think. They may not even realize they are doing it. To a large extent today it is not a formal process, but cardiologists and surgeons have multiple encounters with each other over their patients and they develop a sense of where to go, and when it is a close call [on how to manage a patient] they get together," Dr. Smith said
"It may not be a Heart Team as defined in the SYNTAX study. It can be any cardiac surgeon, and any interventional cardiologist," said Dr. Blankenship.
But, Dr. Smith noted, "the average cardiologist doesn’t calculate a SYNTAX score. We hope [the new guidelines] will lead to a resetting of the thought process."
And there are undoubtedly cardiologists today do not consult with surgeons as often as they should, said Dr. Blankenship. "For many cardiologists it’s routine, but some cardiologists may be more aggressive about using PCI and less aggressive about getting surgical input." The new guidelines "set it forth as standard, and codify it by making the SYNTAX score a surrogate for disease complexity."
Dr. Levine said that he had no disclosures. Dr. Smith said that he has been a consultant to Eli Lilly and Baxter BioSurgery. Dr. Blankenship said that he has received research support from Abiomed, AstraZeneca, Boston Scientific, Conor Medsystems, Kai Pharmaceuticals, and Schering-Plough.