150 “Heart Team” decision making in the management of patients with coronary artery disease; structure, outcomes and reproducibility
Notice bibliographique
Résumé
Introduction Contemporary national and international guidelines recommend that patients with stable angina and acute coronary syndromes (ACS) with multi-vessel disease are discussed by a multidisciplinary “Heart Team” (HT) to facilitate optimal evidence-based management. However, there is a paucity of data describing the workings of a HT, actioning of it's recommendations and reproducibility of decisions. Methods We have utilised a HT approach since 2005, meeting twice weekly with our HT database managed by a dedicated co-ordinator. We analysed the data for 2010 and describe the HT process. A random sample of cases were scrutinised to identify whether the HT decision had been implemented. Additionally, cases were re-presented to the HT after 1 year to determine consistency and reproducibility of decision making. The HT panel for the review process did not include members involved in the original discussion. Results During 2010, 108 meetings were held, attended by a median of 3 interventional cardiologists, 1 non-interventional cardiologist and 2 cardiac surgeons. A total of 1454 cases were discussed (mean 13.5 cases per meeting). 854 cases (58.7%) were from our own unit and 600 (41.3%) from referring hospitals. 356 (24.5%) were current inpatients and 1098 (75.5%) were outpatients. 1340 (92.2%) were patients with stable coronary artery disease (CAD) or ACS. The HT recommendation was for coronary artery bypass grafting (CABG) ± valve surgery in 429 (32%) cases, percutaneous coronary intervention (PCI) in 303 (22.6%), and optimised medical therapy (OMT) in 264 (19.7%). In the remaining 344 cases (25.7%) further investigation was advised before a HT decision was made; the most frequent recommendation was for a pressure wire study, in 151 cases (43.9%). 117 randomly selected cases were analysed to determine whether the HT recommendation had been actioned. This occurred in 101 (86.3%) cases. In the remaining 16 cases, deviation from the initial plan was due to the patient declining revascularisation (CABG 3, PCI 1), development of new co-morbidity (2) or revascularisation of different vessels (6). The reason for deviation was unclear in four cases. 50 cases were re-presented after 1 year with the original HT recommendation being the same in 38 cases (76%). Different decisions in the remaining 12 (24%) included seven cases (14%) in which further investigation had initially been suggested, and re-vascularisation was recommended on re-presentation. Conclusions A well-structured HT allows a large number of cases to be evaluated while interdisciplinary discussion facilitates consensus with evidence-based and individualised advice. There is a prominent role for pressure wire assessment in the further evaluation of equivocal CAD. The HT approach appears robust and reproducible in the majority of cases. Variation in decision making reflects the equipoise between suitability of CABG, PCI and OMT in many cases.
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,420 | 0,646 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,001 |
| Méta-épidémiologie (sens large) | 0,001 | 0,002 |
| Bibliométrie | 0,008 | 0,007 |
| Études des sciences et des technologies | 0,002 | 0,007 |
| Communication savante | 0,007 | 0,004 |
| Science ouverte | 0,003 | 0,007 |
| Intégrité de la recherche | 0,002 | 0,002 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,002 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».