Tom Treasure Weblog

As the end of the year approaches it is time to plan for next year. I have just attended a series of meetings about meetings. ESTS Council met in Paris to plan the May 2006 Cluj-Napoca meeting, EACTS discussed the Stockholm meeting in Windsor and in London we are setting the programme for the Summer meeting of our Cardiothoracic Section of the Royal Society of Medicine. For 23rd June 2006 the subject at the RSM is The Cardiac Multidisciplinary Team. This is the notion that the cardiologist and surgeon work together to decide the coronary management plan. Perhaps the public think that happens already but evidently not. Read David Taggart (Professor of Cardiovascular Surgery in the University of Oxford). Taggart reasons that “A multidisciplinary approach is essential” (BMJ 2nd April 2005). More often in my experience the patient is shown a coned-in view of a narrowed coronary artery, there is some physicianly body language in the form of head shaking, brow furrowing and sucking in through the teeth, and then, hey presto, have I got the stent for you! The solitary man with a hammer sees a nail and knows what he has to do - but from the wider perspective of a multidisciplinary team, each intervention is only one step on the patient’s life journey in which a single step driven by the occulo-stenotic reflex might just be a step in the wrong direction. Surely that first step should not be made without consideration of the route ahead and the ultimate destination. For many patients now receiving percutaneous coronary interventions (PCI) if all aspects were properly considered “best evidence favours surgery over percutaneous intervention” writes Taggart and he ably defended his argument in debate at EACTS (Barcelona September 2005) and again in the correspondence columns of the British satirical magazine Private Eye.

Life defining decisions about coronary interventions are important enough to be made in a Multidisciplinary Team Meeting.

Surgeons joke about the occulo-stenotic reflex and yet the most eminent cardiologists use before and after slides to make their point, as they have done since the first PTCA. Now it’s a video clip rather than grainy stills but this salesman’s “now you see it now you don’t” approach is surely demeaning to a senior audience who deserve data. To make a decision we need statistically sound results in hundreds and thousands of patients, and to know relative benefits in terms of years and decades, in comparisons with other or with no intervention. You can hear more from David Taggart along these lines at meetings to come - and it should be worth hearing. Meanwhile he is adding to high quality evidence with his brain child the Arterial Revascularisation Trial (ART) (http://www.csm-oxford.org.uk/index.asp?o=1121) which compares single versus double mammary artery grafting. Multivariate analysis, however brilliant the analyst, will not resolve whether the claimed long term benefits are attributable to the second mammary graft itself or the potential confounders which are its selected application in better patients and the higher degree of skill required for a surgeons to be comfortable with this choice. The point is that an RCT is the only way to find out. It is hoped that Taggart’s ART trial will answer the question; it has already recruited about 700 patients!

The management of coronary disease is a remarkable international success story which I have seen unfold in my professional lifetime. It has been both a technical and public health triumph. Soon after the Argentinian surgeon Favaloro visited London in 1970 and demonstrated his coronary operation, I assisted Donald Ross with some of the first coronary operations in England. Through the 1980s I supported our cardiologists as they replicated the angioplasty work of the Swiss radiologist Gruntzig and into the 1990s I participated in the British RITA trials. Very many patients have been helped by these interventions but the down turn in the coronary disease epidemic which we are now seeing has been gained neither by surgery nor PCI. It is due to substantial changes in consumption of fat and dairy products, cholesterol lowering by diet and pharmacology, and because smoking is going out of fashion. Those benefits gained in populations, also inform the multidisciplinary team (MDT) approach which plans not only the interventions but drives metabolic and life style change for the individual.

For the thoracic surgeon the equivalent epidemic has been lung cancer where the incidence is also turning down thanks to a public health mission against smoking but for the many lung cancer patients we will continue to see, multidisciplinary working is the norm. In the UK the MDT is now the standard of care. We have at our disposal chemotherapy, radiotherapy, surgery and a range of palliative strategies and the challenge is to employ whatever combination will give the patient the best prospect of relief and longevity. And that is what we do. I am pleased to have been brought up and to have trained within a health service where we do not compete to treat and bill (pace Dr Replogle’s blog “Blind Faith and Choice 27th November). There is an important and unstated difference however between the pulmonologist and the cardiologist. The pulmonologist is the usual first point of contact for lung cancer patients, the “gatekeeper” and, in our team at Guy’s Hospital, he is the leader. But the respiratory physician does not “treat” the cancer, in most instances. Clinical management – chemotherapy, radiotherapy, surgery or any combination - is in the hands of other members of the team. This is in marked contrast to angina where the cardiologist is not only the gate keeper but prescribes all the drugs, adjudicates on all the tests, performs the angiogram and, like the man with a hammer to whom everything looks like a nail, the cardiologist can and will perform the PCI. Surgery tends to be a last resort when all else has failed.

For coronary disease there is a whole other context which is the management of acute coronary events, particularly evolving infarction. Howard Swanton recent President of the British Cardiac Society presented the evidence for the relative merits of PCI and thrombolysis at the Evan Jones Memorial Lecture at St Thomas’ Hospital (November 2005). Just as the elective management of angina has been completely transformed in my lifetime, so have the options for acute ischaemia. In the 1960s patients with infarcts were put to bed and kept there. In 1967 I remember presenting such a patient to an austere physician and had the misfortune to use the phrase “coronary thrombosis”. He had a gaze that shrivelled medical students and turning it on me he asked “Where do you learn your medicine, Treasure? In the Reader’s Digest?” for it had been proven and was well known to him and apparently the rest of the world in the 1960s that infarction was not caused by thrombosis in the coronary artery. That was before GISSI, ISIS2 and the benefits of chewing an aspirin rescued the thrombus theory from being a figment of my imagination to its now central role. Also it turns out that the sooner you restore blood flow, the more likely you are to live and the more myocytes you will have with which to enjoy life - hardly a surprising “discovery”.

Early in my career, emergency surgery was tried and set to one side. Now if my anterior descending coronary were to occlude and I could get to Dr Swanton, or even someone half as skilled, that’s what I would want: acute PCI. I had the pleasure to work with him between 1982 and 1990. In those years the emphasis was that the emerging technology of angioplasty should be “safe” and always be backed up by surgery. Attention was focused on stable angina and the “culprit lesion”. Infarction is often the very first manifestation of coronary disease and it is the mild stenosis, that fissures and occludes, that may well be the fatal one (Lancet 1991; 338:1379-80). The occulo-stenotic reflex produces an undue emphasis on stenoses. Which will be the one to occlude and when, we cannot predict. When a vessel occludes, the culprit has declared itself and the object is clear – to reopen it to save heart muscle and to save life – and 24/7 catheter laboratory availability will be needed to deliver that service. On the other hand, for an elective case, a planned surgical strategy of complete revascularisation including arterial grafts may be a better strategy for life than picking off one stenosis after another in the catheter laboratory. That is a decision that deserves an MDT.