1. What’s happened in 2007 and why? Mark de Belder President British Cardiovascular Intervention Society

2. PCI activity to 2007 (UK) 2007 data: Ludman Aggregate forms NSF

3. PCI’s (all) per million inhabitants per year 2007 Widimsky P, ESC 2008

4. PCI vs Isolated CABG Rates (UK) Estimated 5 year growth: 2002 All revasc:>2700 pm 3.3:1 PCI:CABG PCI >2000 pm

5. PCI vs Isolated CABG Rates (UK) Estimated 5 year growth: 2002 All revasc:>2700 pm 3.3:1 PCI:CABG PCI >2000 pm Actual in 2007: All revascularisation 1685pm; PCI 1269pm; CABG 416pm 3.1:1 PCI:CABG

6. Influences on requirements/delivery Positive Growth in infrastructureGrowth in infrastructure More interventional cardiologistsMore interventional cardiologists Primary PCIPrimary PCI NICE ACS Guidelines 2009?NICE ACS Guidelines 2009? –Equity of access NSF and established interface between primary and secondary careNSF and established interface between primary and secondary care –RACPCs –Appropriate investigation of IHD –NICE AP guidelines 2009/2010? New evidence?New evidence? Work of the CVC?Work of the CVC? Negative Lack of infrastructure Too few interventional (and other) cardiologists Belief in thrombolysis ICTUS believers COURAGE and the impact of secondary prevention Concerns about DES Smoking ban Healthier lifestyles (diet, exercise) Changes in air pollutants Global warming? New evidence? Economic downturn? Work of the CVC?

7. Hospitalized STEMI treatment in Europe. National registries data (*estimates of national opinion leaders) **********

8. Clinical Syndrome 2007 data: Ludman CCAD

9. Indication for PCI 2007 data: Ludman CCAD

10. PCI for STEMI 2007 data: Ludman CCAD

11. Variation in patients with STEMI treated with lysis or no reperfusion undergoing angiography MINAP data personal communication – John Birkhead HospsMedian %Percentile 25Percentile 75 2006 21463%43%81% 2007 21063%48%78% 2008 20567%48%80%

12. Issues relating to Non-STEMI ACS ESC & US guidelines support early angiography with a view to early (within 72hrs) revascularisation by either PCI or CABG in higher risk subsetsESC & US guidelines support early angiography with a view to early (within 72hrs) revascularisation by either PCI or CABG in higher risk subsets Rates of angiography and revascularisation vary considerably across England (MINAP - John Birkhead, personal communication)Rates of angiography and revascularisation vary considerably across England (MINAP - John Birkhead, personal communication)

13. Non-STEMI ACS patients

14. Variation in patients with nonSTEMI ACS undergoing angiography MINAP data personal communication – John Birkhead HospsMedian %Percentile 25Percentile 75 2006 21260%40%82% 2007 20757%41%75% 2008 20363%47%78%

15. Stable patients

16. Non-STEMI ACS patients

17. Changing case mix - JCUH

19. Angiography (85) PCI (98) 2007 Where is the work being done?

20. PCI per Consultant Unit case number / Number of operators 2007 data: Ludman

21. Surgical Cover Surgical Cover (2007 - all 81 NHS centres) 2007 data: Ludman 420 1471 Mean Aggregate forms

22. Surgical Cover (all 98 NHS and Private Centres) On site Off site No of centres 53(54%)45(46%) No. of PCI (% of total) 59,455(77%)17,918(23%) Mean No. PCI per centre (all) 1122398 Mean No. PCI per centre (NHS) 1471420 2007 data: Ludman Aggregate forms

23. Development of off-site centres Positives Increased access to careIncreased access to care Provides local careProvides local care Main drive historically was to provide service when regional tertiary centre could not provide appropriate level of activityMain drive historically was to provide service when regional tertiary centre could not provide appropriate level of activityNegatives Smaller infrastructure, fewer support staffSmaller infrastructure, fewer support staff Smaller teams, smaller volumes of activitySmaller teams, smaller volumes of activity May be harder to liase between interventional and surgical colleaguesMay be harder to liase between interventional and surgical colleagues International literature shows potential for worse outcomesInternational literature shows potential for worse outcomes

24. Effect of New Centres 2007 data: Ludman Brighton

25. Effect of New Centres 2007 data: Ludman Worthing Eastbourne Hastings Brighton

26. Effect of New Centres 2007 data: Ludman

27. Effect of New Centres 2007 data: Ludman

28. Downsizing of larger units

29. Numbers of PCIs needed NSF 2000NSF 2000 –1500 revascularisations pmp –750 PCI / 750 CABG BCS Workforce document 2005BCS Workforce document 2005 –2200-3000 PCI pmp DoH Stocktake exercise 2007DoH Stocktake exercise 2007 –1900, 2200, 2500 revascularisations pmp –3:1 ratio PCI:CABG –~1400, 1650, 1900 PCIs pmp “Services are saturated” versus “We’re clearly under-providing”“Services are saturated” versus “We’re clearly under-providing”

30. Conclusions Growth in activity is likely to depend on growth in PPCI and angioplasty for non-STEMI ACS patientsGrowth in activity is likely to depend on growth in PPCI and angioplasty for non-STEMI ACS patients Considerable regional differences are likely to be ironed outConsiderable regional differences are likely to be ironed out –Updated guidelines Delivery of services should be determined by a review of the changing epidemiology and evidence base for PCIDelivery of services should be determined by a review of the changing epidemiology and evidence base for PCI –Importance of the Clinical Network and SHA We’re moving from a “cold” to a “hot” serviceWe’re moving from a “cold” to a “hot” service Should all PCI centres be 24/7 services?Should all PCI centres be 24/7 services?