Heartbeat: shared decision making in care of patients with cardiovascular disease

Shared decision making (SDM) has become a central tenet in our care of patients with cardiovascular disease. However, the effectiveness of SDM for improving patient centered outcomes is uncertain. In this issue of Heart, Mitropoulou and colleagues report a metaanalysis of 18 randomised controlled trials of SDM, with measurement of at least one outcome measure. In these 4419 patients, increased use of SDM, compared with standard care, reduced decisional conflict and increased patient knowledge (figure 1). The areas for SDM in these studies included evaluation of chest pain for coronary artery disease, anticoagulation for atrial fibrillation, cardiac devices and advanced treatment options. In the accompanying editorial, Lauck and Lewis summarise the principles of optimal SDM (figure 2) and point out that “patients who experience shared decisionmaking report an increased sense of control in managing their illness and improved communication with their healthcare providers, and are more likely to engage in their care and treatment.” Even so, there are many barriers to increased use of SDM in clinical practice. They conclude that “based on the inclusion of shared decisionmaking in multiple international guidelines, it is no longer a matter of ‘if ’ but rather ‘when’ and ‘how’ clinicians will adopt what is increasingly seen as a best practice in cardiac care.” In patients with left ventricular hypertrophy due to aortic stenosis (AS) and no obstructive coronary artery disease (CAD), myocardial perfusion remains adequate at rest due to a compensatory increase in resting coronary blood flow as nicely demonstrated by Paolisso and colleagues based on CT measurement of myocardial mass and invasive measurement of coronary flow by thermodilution (figure 3). Although rest flow was higher, hyperaemic flow was similar in AS patients compared with controls, so that coronary flow reserve and microvascular resistance reserve were significantly lower in AS patients. The authors suggest that these findings “raise significant concern over the reliability of invasive functional assessment of CAD in patients with significant AS, at least in the absence of a thorough investigation of the coronary microvascular status.” Carberry, Ang and Berry comment that this analysis “underlines the diagnostic challenges when assessing coronary artery disease in aortic stenosis and highlights the potential use of microvascular physiology as a marker for prognostication and therapeutic decisionmaking in the management of aortic stenosis.” In patients with an aortic root aneurysm being considered for valvesparing aortic root replacement, a detailed assessment of leaflet and cusp anatomy is needed to determine the feasibility of retaining the native aortic valve and to plan the surgical procedure. Ehrlich and colleagues examined the aortic cusp pathology in 582 patients with a trifleafet aortic valve who were undergoing root replacement, either for aortic root aneurysm (40%) or secondary aortic regurgitation (60%). Most patients were men (78%) with a mean age of 56.8±15.4