Treatment Decision Making in Multivessel Coronary Artery Diseas

Multivessel coronary artery disease patients may be treated with coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or optimal medical therapy. Randomized trials and observational analyses have demonstrated risk and benefit tradeoffs between treatment strategies. This thesis examines the decision making processes that occur when determining treatments for multivessel coronary artery disease patients. Study 1 investigates clinical outcomes of multivessel coronary artery disease patients receiving ad-hoc compared to delayed PCI in a procedural registry. There was no significant difference in mortality or repeat revascularization between ad-hoc PCI and delayed PCI in the full cohort. Among three vessel disease patients, ad-hoc PCI resulted in higher rates of repeat revascularization compared to delayed PCI. The second study assessed healthcare provider's attitudes about multivessel treatment options using a survey with three clinical vignettes. Treatment choice was significantly associated with patient vignette and participant type, demonstrating patient characteristics and provider type play a role in treatment choice. Cardiologists were most likely to choose multiple treatments (CABG and PCI) as appropriate options. Surgeons were most likely to choose only CABG as an appropriate treatment option. Study 3 used qualitative semi-structured interviews to document clinicians' experience with decision making and patient engagement with current multivessel disease practice patterns. Direct content analysis resulted in three themes describing clinicians' frustrations with multivessel treatment decision making: 1) Multivessel coronary artery disease treatment decisions are multifaceted due to the number of factors and clinicians involved; 2) Clinician-to--clinician communication is inadequate because clinicians lack formalized pathways and roles; and 3) Patient communication time is not in the clinical workflow and suffers from patients' little prior knowledge of coronary artery disease. By studying the decision points in the multivessel pathway this thesis has elucidated trade-offs among treatment strategies, identified a lack of congruence among clinicians about appropriate treatment options, and documented workflow and communication barriers that prevent clinicians and patients from optimal decision making.