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Page 4 of 16 Riojas et al. Vessel Plus 2024;8:6 https://dx.doi.org/10.20517/2574-1209.2023.122

team to discuss revascularization is the 2021 ACC/AHA/SCAI Guideline for Coronary Artery
Revascularization [1,35] . In the 2021 report, the recommendation for a Heart team was given a Class 1
recommendation based on Level B-NR evidence, and recommends representatives from interventional
cardiology, cardiac surgery, and clinical cardiology, as well as other specialists that may be involved in the
care of the patient. The Heart team must continue to stand on the pillars of commitment to excellence in
patient care, mutual respect amongst medical providers, and fair and equitable decision making for all
patients. In addition to discussing the complex coronary artery disease, the team should consider comorbid
conditions that may affect the revascularization strategy, and other clinical or social factors that may impact
the desired outcome [Table 1] . Ideally, this collaborative approach will provide patients with evidence-
[35]
based and unbiased treatment choices. Furthermore, these options should involve a shared decision-making
process with the patients and align with their personal values and preferences. The patient-centric model of
including the patients and their support system in the decision-making process is also a Class I
[1]
recommendation .

Soon after the 2014 guideline recommendations for a heart team, a working group on behalf of the British
Cardiovascular Society (BCS), Society for Cardiothoracic Surgery in Great Britain and Ireland (SCTS), and
British Cardiovascular Intervention Society (BCIS) developed guidance on how their heart teams should
function. In addition to a designated chairperson and attendance by cardiologists and surgeons, the BCS/
SCTS/BCIS also recommended administrative and management involvement. They also recommend that
patients’ and caregivers’ input should be considered. In Europe, the EUROSCORE or EUROSCORE II is
used for surgical risk calculation. Interestingly, there was a strong recommendation that centers without
surgical capability should invite cardiac surgeons and interventional cardiologists with experience in
complex PCI to participate via teleconference in an open format to promote transparency and to ensure
discussion of all available treatment options . It should be noted that there are several differences between
[9]
European and American guidelines for the evaluation and management of patients with coronary artery
disease, and these may impact how patients are ultimately treated [36,37] .

WHICH PATIENTS SHOULD BE PRESENTED TO THE HEART TEAM
It remains unclear which patients should be discussed by the heart team. One approach in the UK and
similarly in the Netherlands was to hold daily meetings and discuss all patients with coronary artery disease
potentially requiring intervention [38,39] . Another approach is to focus on patients with complex coronary
anatomy. An early study by Sanchez et al., defined complex coronary artery disease (CAD) in patients with
one of the following: (1) unprotected left main CAD; (2) three-vessel CAD; (3) proximal single vessel LAD
in patients with diabetes mellitus; and (4) any other cases where the treating physician felt that
[4]
revascularization could reasonably be approached with either percutaneous or surgical strategies . The
authors concluded that whereas most patients met appropriate use criteria, the heart team approach can be
used to account for both angiographic and clinical criteria in a multidisciplinary setting. In general, patients
with significant left main coronary artery disease, complex coronary anatomy, intermediate or high
SYNTAX scores, chronic total occlusions, multivessel disease, and disease at major bifurcations should be
considered for discussion. The 2021 ACC/AHA/SCAI Guideline states that a Heart Team approach is
recommended for patients for whom the optimal treatment strategy is unclear [Table 1]. Furthermore, more
recent data has shown that medical management may be equivalent to an invasive strategy in stable
ischemic coronary disease . The heart team may be able to help delineate which patients will benefit from
[40]
optimal medical management versus an intervention.

Additional reasons to discuss patients may include factors not captured with risk scores. Although risk score
calculations such as the SYNTAX, Society of Thoracic Surgery - Predicted Risk of Mortality (STS-PROM),