U.K. ROLL-OUT OF DRUG-ELUTING STENTS JIM McLENACHAN, YORKSHIRE HEART CENTRE, LEEDS. ADVANCED ANGIOPLASTY 17 th JANUARY, 2003

WHAT DRIVES ‘ROLL-OUT’? PERCEIVED CLINICAL PROBLEM RANDOMISED STUDIES GUIDELINES

WHAT DRIVES “ROLL-OUT’’? DEATH Q WAVE MI NON-Q WAVE MI CABG REPEAT PCI -for symptoms -for angiographic restenosis increasing ‘softness” of end-point

RESTENOSIS “additional revascularisation procedures were performed within one year in 21% of patients who had undergone stenting” N Engl J Med 2002;346:

Stenting and procedures for restenosis (2000 data from 40 centres) BCIS AUDIT

CARDIAC EVENTS AT ONE YEAR RAVEL STUDY EVENTSIROLOMUS STENT (n=120) STANDARD STENT (n=118) DEATH 2 2 Q WAVE MI 2 1 NON Q WAVE MI 2 4 CABG 1 1 N Engl J Med 2002;346:

REPEAT PCI IN RAVEL Event Free Survival (%) Days after implantation N Engl J Med 2002;346:

TIMIMG OF EVENTS IN RAVEL Event Free Survival (%) Days after implantation N Engl J Med 2002;346: REPEAT ANGIOGRAPHY

CURRENT DES UPTAKE NO. OF PCI IN LAST YEAR NO. WITH DES PROJECTED % WITH DES AGREED PROTOCOL WITH PURCHASERS WESTERN, EDINBURGH ?NO WESTERN, GLASGOW 800ZERO ?NO CARDIFF 4301 ?NO MANCHESTER ROYAL 97020% YES LEEDS 1800ZERO NO

PATTERNS OF UPTAKE OF DRUG-ELUTING STENTS MANCHESTER MODEL -20% usage -specific lesions - 28 mm length -restenotic lesions -diabetic patients -up and running -agreed with purchasers

PATTERNS OF UPTAKE OF DRUG-ELUTING STENTS SCOTTISH MODEL -attempted national roll-out -scoring system -not yet agreed with purchasers

PATTERNS OF UPTAKE OF DRUG-ELUTING STENTS CARDIFF MODEL -would like to use DES -no agreement with purchasers

PATTERNS OF UPTAKE OF DRUG-ELUTING STENTS LEEDS MODEL -no usage -‘underwhelmed’ by data -K.B.O. approach

PATTERNS OF UPTAKE OF DRUG-ELUTING STENTS COVENTRY MODEL -completely illogical to choose specific lesions for DES -more logical to choose specific patients for DES

WHAT DRIVES ‘ROLL-OUT’? PERCEIVED PROBLEM RANDOMISED STUDIES GUIDELINES

National Institute for Clinical Excellence NHS Technology Appraisal Guidance - No.12

Cost Per Life saved TherapiesCost CABG Left Main Bypass 2 Abciximab (Elect Stent, Full Cost) 3 Cervical Cancer Screening 4 Noenatal Intensive Care 4 Abciximab (All PCI, Full Cost) 3 Kidney Transplant 4 t-PA vs. SK 5 Hemodialysis fo Chronic Renal Failure 2 Heart Transplant 4 7,000 9,316 12,000 18,000 19,000 32,000 35,000 54,000

SUMMARY ROLL-OUT OF D.E.S. IS PIECEMEAL USE VARIES FROM 0% TO 40 % NICE GUIDELINES WILL BE EVEN MORE IMPORTANT THAN IN OTHER AREAS (eg. Stents, IIb/IIIa inhibitors) NEED FOR VIGILANCE ABOUT LONGER- TERM FOLLOW-UP