12 The heart team in acute cardiac care

The complexity of acute cardiac care today makes it necessary that patients are looked after by more than one health care professional. Complex tasks require complex systems. Teamwork is essential for minimizing adverse events caused by miscommunication and misunderstanding about roles and responsibilities, and it can have an immediate and positive impact on the patient. The increasing complexity and specialization of care of the cardiac patient in the acute setting, combined with an ever increasing number of therapeutic options, make it necessary to coordinate teams of doctors for each specialty area. Multidisciplinary decision making optimizes care and is mandatory in light of evolving options and improvement of quality of care and will lead to more efficiency.

Medical practice has traditionally put the individual physician in the centre of the organization, rather than the patient. Medical training programmes have emphasized technical proficiency and produced well-educated, highly skilled, self-sufficient, individually responsible care providers. The physician was exclusively responsible for patient care and would only consult with other physicians, if deemed necessary. Knowledge of physicians authorized the power to the most senior person, rather than that of team. The importance of teamwork, however, is increasing not only due to increasing comorbidities of patients and increasing complexity and specialization of care, but also due to the restriction of working hours and financial resources. Furthermore, the number of therapeutic options is rapidly increasing as is seen, for instance, with transcatheter repair and replacement of heart valves as additional options to surgical interventions. Given all these circumstances, even the brightest, most diligent, and punctilious clinician will frequently choose a suboptimal diagnostic and treatment strategy. The corporate knowledge of multiple people brainstorming for solutions is more likely to resolve difficulties and reduce errors than one person thinking alone. Most mistakes in health care are attributed to the lack of organization and dysfunctional, or non-existent, teamwork and leadership [1].

The benefits of a systemic approach has been proven in aviation, an industry in which mistakes can result in unacceptable loss and which has been at the forefront of risk reduction through teamwork training. Error rates have steadily decreased and are now several orders of magnitude below the rates in health care. Of course, patients are not airplanes, and therefore you cannot learn from them by copying what they do, but we can learn from these successes and translate these principles into the medical environment. Reframe the experience so that it fits the situation whether it is in cardiac surgery or in cardiology. The parallels between the aviation industry and emergency cardiac care are remarkable. Both require rapid, accurate decision making under conditions of uncertainty. Both require groups of professionals from different disciplines to work together for effective operation.

An effective heart team should be composed of people with complementary skills and expertise who work well together. For different patients and distinctive scenarios, the composition of the team will vary. Cardiologists, both interventional and non-interventional, cardiac surgeons, and anaesthesiologists will, in most instances, form the basis of the heart team. However, other specialists (e.g. intensivists, geriatricians), nursing staff, allied health providers, and the patient’s primary care team may also be part of the heart team.

The heart team is considered important, and multiple guidelines of the European Society of Cardiology (ESC) and the European Association for Cardio-thoracic Surgery (EACTS) including the guidelines for coronary revascularization, heart failure and heart valve pathology [2, 3, 4] and the 2012 ACC 2012 Appropriate use criteria for coronary revascularization [5] both list the heart team as a class I indication for treatment. The new 2017 ESC/EACTS guidelines on valvular heart disease stress the importance of specialized expertise centers, named Heart Valve Centers. These centers consist of a team of specialists with extensive experience and specialized training required to do interventions or surgery on multiple valves. Furthermore, by centralization of these procedures, the case volume in each center will rise, which, in theory, will result in a higher procedural success rate [16]. Unfortunately, there is limited direct evidence from studies to show the benefits of the heart team, and therefore it is based on expert opinion (class C evidence) [6] Studies on the incremental effect of Heart Teams start to emerge now, and although the results are promising, evidence is still scarcely available[7].

Although patients are not commonly regarded as being part of the team, they are the most important members of a clinical team. More recently, clinical decision making has increasingly been regarded as a collaborative process involving shared, parallel decision making with patients and teams of health professionals. Evidence-based criteria for the choice of diagnostic and/or therapeutic procedures have been stressed upon, but a lack of specificity in accurate risk prediction for an individual patient, as well as different patient expectations and estimated life expectancy or expected quality of life improvement, make recommendations for the individual patient extremely difficult. Patients and their families need to be educated about different risk–benefit ratios with several treatment options so that their expectations can be met as fully as possible. Although patients should be actively involved in their care, the mental or physical capability for participation can be difficult in the acute setting.

Another aspect of involving patients during their care is that patients can provide important safety information. Short interviews with patients can identify process failures and can report many serious events that are not recorded in medical records. It is much more appropriate to view patients as partners with an active role, depending on the nature and complexity of the treatment.

The heart team can only be effective when the team members share a common goal, have specific roles, and perform interdependent tasks [8]. Everyone is aware of their role and wants to deliver the best care for the patient. The team should be composed of people with complementary skills who work well together. A heart team is a wonderful example of how complementary skills can enhance the team’s success in patient care. It is essential that members of the team trust and respect each other. Channels of communication must be open to inform the different team members. A lack of communication leads to arguments, misinterpretations, and a lack of interest in team concerns. Furthermore, with the complexity of some patients, the heart team provides a basis for ‘creative solutions’ that are not necessarily comprised within guidelines, but are considered the best possible treatment in specific circumstances for an individual patient and include novel and compassionate use treatments.

In emergency circumstances, every person in the team knows his designated role ahead of time. The aim is to stabilize the patient in minutes, collect essential information, and triage the patient to definitive care. Each team member is committed to the mission and therefore to each other. Everyone trusts that the other puts in the maximum effort for the patient’s best interests.

In the setting of acute cardiac care, this is a so-called ‘contingency team’. These teams are formed for emergent or specific and time-limited events (e.g. cardiac arrest team, disaster response teams, rapid response teams) and are composed of team members drawn from a variety of core teams.

The most important question for the future of health care is how we will deliver care in teams. Traditional, hierarchical, and organizational structures are increasingly being replaced with teams. Education systems in medicine have focused on teaching clinical skills to individuals. However, this does not guarantee effective team performance, and effective teamwork does not spontaneously happen when individuals work together. Physicians are trained largely to be self-sufficient and individually responsible for their actions, and training programmes to improve team skills are new concepts in medicine. Early in their career, students and residents, but also the more experienced clinicians who are used to work individually need to understand the importance of teamwork in health care and learn how to become an effective team player. Online learning tools are available such as the TeamSTEPPS^® programme which can be found at <http://www.ahrq.gov/qual/teamstepps>. Moreover, a solid implementation of regular heart team meetings is essential for the continuous education and tuition of residents and doctors in multidisciplinary decision making.

Teams share certain characteristics, but each member will have a specific role, and together they interact to achieve a common goal. The heart team is a multidisciplinary care team that comes together to plan, coordinate, and take decisions about the patient’s care. The care is organized around the patient (and relatives) and tailored to his or her health care needs and usually involves the input from a (interventional) cardiologist, a cardiac surgeon, intensivist, and an anaesthesiologist. However, if further expertise is required, other members (e.g. geriatrician) can be consulted (see Figure 12.1).

For the heart team to be effective, the members should coordinate directly and repeatedly with each other to ensure proper and timely clinical task execution. Daily meetings, or at least 3 times per week, are essential to make a team effective. Local protocols may stipulate which patients need to be discussed in the heart team. Work coordination and administration can be done by a secretary, for example, who ensures that the decisions taken at meetings are followed by action points. Administrative personnel can ensure the referring physician is informed about the heart team’s decisions (see Figure 12.2).

Ideally, the heart team should be able to review all relevant information and involve the patient in decision making (see also Chapters 47 and 48) , however in acute cardiac care, there is less time for elaborate decision making which leads to more rapid responses and less analytical approaches [9]. Early risk stratification by the acute cardiac care team is essential for the selection of medical, as well as interventional, treatment strategies for patients with for instance Non-ST-segment elevation myocardial infarction (NSTEMI). This group is heterogeneous and has a highly variable prognosis. In patients at high risk and in whom the differential diagnosis of other acute clinical situations is unclear, coronary angiography should be performed urgently to define the anatomy. It is recommended to schedule an informal ‘time out’ to allow surgical consultation in the catheterization laboratory; this concept could therefore accelerate the decision-making process in patients with acute coronary syndrome (ACS) while still maintaining some degree of a multidisciplinary discussion. Subsequently, an invasive strategy can be chosen, depending on the anatomy and other risk factors [4]. The team should weigh the benefits of early intervention with percutaneous coronary intervention (PCI) vs the benefits of a delayed coronary artery bypass grafting (CABG) several days after the patient has been stabilized. In specific subsets of patients, the decision might be even more complex, e.g. in patients with diabetes and coronary disease, and not guided by level A (or B) evidence. Currently, CABG is favoured over PCI, and an individually tailored, collaborative approach, guided by a multidisciplinary heart team, should be employed [10]. In most cases of an acute myocardial revascularization, PCI is the treatment of choice. However, when the coronary artery disease (CAD) is too complex for PCI, CABG in the acute setting can be considered. In these cases, consultation of the heart team is essential.

Patients with acute heart failure is another subgroup of patients where urgent intervention is often required and multidisciplinary consultation is advisable. Initially, treatment will usually start with optimal medical therapy (e.g. vasodilators, inotropes, diuretics etc.), but if a patient continues to decline other means of therapy might be considered (e.g. extracorporeal membrane oxygenation (ECMO), LVAD implantation etc.). It is important to discuss these situations upfront, and specify the responsibility of each team member. Since the emergence of percutaneous ECMO cannulation there is considerable inter-hospital variation: in some hospital cannulation is performed by an intensivist while in others this is done by an interventional cardiologist, whereas in other hospitals it is strictly performed by a cardiac surgeon [11]. The prognostic value of traditional and also new risk scores is limited [12], therefore a careful consideration by all specialists involved is vital, while also contemplating the long-term clinical- (e.g. possible recovery, LVAD implantation) and cost-effectiveness, but also discussing the possibility to refrain from treatments of curative intent if deemed not useful. Other examples of acute situations preferably discussed in a multidisciplinary team are massive pulmonary embolisms (e.g. saddle embolus) and active bacterial endocarditis complicated with cerebral emboli.

Risk–benefit analysis is particularly important when different treatment options are available. Currently, with the evolution of transcatheter valve repairs or replacements and the treatment of end-stage heart failure with LVADs, the number of pathologies where multiple treatments are available is substantial. As with myocardial revascularization with either PCI or CABG, severe aortic stenosis can be treated with either Surgical Aortic Valve Replacement (SAVR) or Transcatheter Aortic Valve Replacement (TAVR). It is therefore important to perform an analysis where expected benefits (e.g. survival, health outcomes: symptoms, functional status and quality of life) are compared with possible negative aspects of the different procedures. CABG, for instance, is associated with a lower long-term major adverse cardiac and cerebrovascular event (MACCE) rate, compared to PCI among patients with three-vessel coronary artery disease, mainly driven by a lower repeat revascularization rate, and, in subsets of patients, it is even associated with lower mortality. On the other hand, surgery is related to post-operative cognitive impairment and a higher early stroke rate, longer hospitalization, and post-operative pain. The trade-off that physicians and patients face in choosing between the benefits of CABG vs those of PCI (or medical treatment) requires complex risk–benefit modelling including time-dependent risk analyses. Clinical and anatomical risk scores that are used for decision making have notable inter- and intra-observer variability and are more accurate when calculated by a team, rather than by an individual [6]. The contemporary risk models for cardiac surgery, such as the STS-PROM and EuroScore II, do take into account the emergency of the procedure, but have important limitations as a predictor for coronary revascularization and TAVR surgical risk [13, 14], However, the SYNTAX II score [15], that aims to help in deciding which patients should undergo CABG or PCI, is derived from a population of stable CAD patients and is therefore not applicable in the acute coronary care setting.

Although data from trials demonstrating a direct patient benefit to the heart team approach are lacking, the rational arguments that teamwork is essential in complex modern health care are compelling. Furthermore, risk models in (acute) cardiac care setting are definitely an area for improvement that could help to distinguish which patients benefit from the heart team’s decision making.

In an era with an aging population with evermore comorbidities, accompanied by a continuous evolution in the number of diagnostic and therapeutic options, it is essential to teach clinicians to behave as true team members and thereby ameliorate patient care and the performance of a department. Since the predictive value of risk scores is often not comprehensive, multidisciplinary discussions of patient cases are an important tool in the prevention of medical errors and to optimize decision making both clinically and economically.