Structure and functioning of the Heart Team: primum non nocere

Clinical discussion within multidisciplinary teams has been shown to improve the quality of patient care in many fields of medicine. A pivotal example is the ‘tumour board’, proposed in the 1960s. A multidisciplinary discussion strategy in the field of oncology was associated with improved survival and more consistent survival rates between different hospitals and with increased treatment conformity to clinical practice guidelines [ 1 ]. In the field of myocardial revascularization, the Heart Team concept was introduced through randomized trials during the last decade, with the aim of facilitating a balanced evidence-based decision process, minimizing specialty bias and preventing self-referral from interfering with optimal patient care [ 2 ]. Of note, the decision-making process in a Heart Team appears to be largely reproducible [ 3 ]. The need for a multidisciplinary strategy is underscored by evidence showing underuse of revascularization procedures in up to 40% of patients with coronary artery disease [ 4 ] as well as inappropriate use of revascularization strategies and lack of clinical case discussions [ 5 ]. In addition, the heterogeneity in percutaneous coronary interventions (PCIs) to coronary artery bypass grafting ratios between European countries with similar health care systems has raised concerns on the appropriate selection of revascularization strategies [ 6 ]. The recently released guidelines on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) provide a Class I, level C recommendation to the Heart Team, recognizing its relevance in current clinical practice [ 7 ]. In this issue of the Journal, the Joint Working Group of the British Cardiovascular Society (BCS), Society for Cardiothoracic Surgery in Great Britain and Ireland (SCTS) and British Cardiovascular Intervention Society (BCIS) reports a document that aims to provide guidance on the structure and function of the Heart Team [ 8 ]. This high-quality document includes an extensive overview on needs for a Heart Team in clinical practice and elaborates detailed recommendations on its structure and organization. Several important aspects of the document should be mentioned. Firstly, the composition of the Heart Team recommended by the Joint Working Group of the BCS/BCIS/SCTS is in line with the guidelines on myocardial revascularization of the ESC/EACTS [ 7 ]. Specifically, a clinical/non-invasive cardiologist, an interventional cardiologist and a cardiac surgeon should be included. Extending, on a regular basis, the Heart Team to additional specialists—such as general practitioners, anaesthesiologists, diabetologists, geriatricians, nephrologists or intensivists—is impractical, but may be useful on a case-by-case basis depending on patients' comorbid conditions. Secondly, the Joint Working Group of the BCS/BCIS/SCTS recommends that Heart Team meeting frequency should suffice the demands of the local clinical service. Therefore, in line with the ESC/EACTS guidelines, the document recommends to adapt frequency and duration of meetings to institutional needs. Thirdly, the document underscores the importance of communicating with patients, carers and families. Heart Team meetings are by necessity technical, explicit discussions about risks and prognosis based on the available evidence as well as the experience of involved specialists individually and as a group. It is, therefore, impracticable for patients and carers to attend Heart Team meetings. However, the Heart Team should accommodate patient's wishes in any decision-making process. Fourthly, it is noteworthy that the working group emphasizes the educational value of Heart Team meetings by encouraging junior physicians to attend. Indeed, education to multidisciplinary discussions is of paramount importance for future leaders in the field of cardiovascular medicine. The value and quality of the document is high. Nevertheless, a few issues deserve consideration. The recent ESC/EACTS guidelines on myocardial revascularization recommend the development by the Heart Team of evidence-based institutional protocols to implement the appropriate revascularization strategy for common case scenarios in accordance with guidelines (Class I, level C) [ 7 ]. Of note, these protocols should include but not be limited to emergency clinical cases. While stating that the Heart Team discussion should be focused on those patients in whom the possibility of any form of revascularization is considered, the document of the Joint Working Group of the BCS/BCIS/SCTS does not explicitly refer to institutional protocols. This issue is critical since establishing institutional protocols may facilitate the Heart Team work in common case scenarios, avoiding time-consuming systematic case-by-case discussions and potential treatment delays. Another important consideration is that the Joint Working Group of the BCS/BCIS/SCTS document is largely based on expert consensus rather than clinical evidence. The same is true for Heart Team recommendations of the ESC/EACTS myocardial revascularization guidelines, all of which are based on a level of evidence C. It is undoubtedly reasonable that expert consensus plays a key role in guiding clinical practice, particularly when robust evidence is not available. However, physicians should always interpret recommendations that are based on expert consensus according to their clinical experience. Last but not least, it needs to be underscored that the Joint Working Group of the BCS/BCIS/SCTS document addresses the need for Heart Team standardization in the UK, in response to a national survey indicating variations in Heart Team practice across the country. The national nature of the document limits its generalizability to other countries with different settings and resources. Overall, the Joint Working Group of the BCS/BCIS/SCTS should be congratulated for having completed such an important document. While applying the document recommendations in clinical practice, it should always be kept in mind that the Heart Team is a pivotal instrument to improve patient care but should never represent an administrative barrier determining treatment delays, since ‘the physician must have two specific objectives in view with regard to disease, namely to do good and to do no harm’ [ 9 ].