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Key Points Question Do treatments recommended by a heart team differ from those recommended by an original treating interventional cardiologist for patients with multivessel coronary artery disease? Findings In this cross-sectional study of 245 patients with multivessel coronary artery disease, heart team treatment recommendations indicated moderate agreement (with discordance in 30% of cases) with the original treating interventional cardiologist. Unanimous decisions within the heart team and agreement between the heart team interventional cardiologist and the original treating interventional cardiologist were less frequent in this subset of cases, while interventional cardiologist recommendations for angioplasty and medication therapy were more frequent. Meaning The study’s findings indicated that heart team recommendations differed from those of the original treating interventional cardiologist in approximately one-third of cases; this subset of cases was associated with a greater number of divergent opinions between interventional cardiologists and within the heart team., Importance Although the heart team approach is recommended in revascularization guidelines, the frequency with which heart team decisions differ from those of the original treating interventional cardiologist is unknown. Objective To examine the difference in decisions between the heart team and the original treating interventional cardiologist for the treatment of patients with multivessel coronary artery disease. Design, Setting, and Participants In this cross-sectional study, 245 consecutive patients with multivessel coronary artery disease were recruited from 1 high-volume tertiary care referral center (185 patients were enrolled through a screening process, and 60 patients were retrospectively enrolled from the center’s database). A total of 237 patients were included in the final virtual heart team analysis. Treatment decisions (which comprised coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy) were made by the original treating interventional cardiologists between March 15, 2012, and October 20, 2014. These decisions were then compared with pooled-majority treatment decisions made by 8 blinded heart teams using structured online case presentations between October 1, 2017, and October 15, 2018. The randomized members of the heart teams comprised experts from 3 domains, with each team containing 1 noninvasive cardiologist, 1 interventional cardiologist, and 1 cardiovascular surgeon. Cases in which all 3 of the heart team members disagreed and cases in which procedural discordance occurred (eg, 2 members chose coronary artery bypass grafting and 1 member chose percutaneous coronary intervention) were discussed in a face-to-face heart team review in October 2018 to obtain pooled-majority decisions. Data were analyzed from May 6, 2019, to April 22, 2020. Main Outcomes and Measures The Cohen κ coefficient between the treatment recommendation from the heart team and the treatment recommendation from the original treating interventional cardiologist. Results Among 234 of 237 patients (98.7%) in the analysis for whom complete data were available, the mean (SD) age was 67.8 (10.9) years; 176 patients (75.2%) were male, and 191 patients (81.4%) had stenosis in 3 epicardial coronary vessels. A total of 71 differences (30.3%; 95% CI, 24.5%-36.7%) in treatment decisions between the heart team and the original treating interventional cardiologist occurred, with a Cohen κ of 0.478 (95% CI, 0.336-0.540; P = .006). The heart team decision was more frequently unanimous when it was concordant with the decision of the original treating interventional cardiologist (109 of 163 cases [66.9%]) compared with when it was discordant (28 of 71 cases [39.4%]; P, This cross-sectional study examines the differences in treatment decisions between a heart team and an original treating interventional cardiologist for patients with multivessel coronary artery disease.

Apical hypertrophic cardiomyopathy (AHCM), first described by Sakamoto et al (1), is typically characterized by ‘giant negative T waves’ (larger than 10 mm), particularly in the precordial leads, asymmetrical left ventricular (LV) apical hypertrophy on echocardiogram and spade-shaped LV configuration on left ventriculography (2). An asymptomatic 55-year-old woman had repolarization abnormalities noted on a routine preoperative electrocardiogram (Figure 1A). The initial echocardiogram was normal, with no evidence of LV hypertrophy or segmental wall motion abnormalities. Subsequent investigations, including coronary catheterization and cardiac magnetic resonance imaging, led to the diagnosis of AHCM with LV apical aneurysm (Figures 1B and ​and1C1C). Figure 1) A Resting 12-lead electrocardiogram demonstrating voltage criteria for left ventricular hypertrophy and negative T waves of 2 mm to 4 mm in leads II, III, aVF and V3 to V6. B Left ventricular angiogram demonstrating apical aneurysm. C Left ventricular ... The present case illustrates that although the electrocardiogram and echocardiogram are commonly used in clinical practice, these tests may not be sufficient to exclude the diagnosis of AHCM. Further investigations, including cardiac magnetic resonance imaging, are essential to the diagnosis of this rare condition (3,4). The second point illustrated by the present case is that patients with AHCM are at risk of developing an aneurysm at the LV apex, which can potentially lead to increased incidence of embolic complications, arrhythmias and congestive heart failure (5).