U.K. ROLL-OUT OF DRUG-ELUTING STENTS

JIM McLENACHAN,

YORKSHIRE HEART CENTRE,

LEEDS.ADVANCED ANGIOPLASTY

17th JANUARY, 2003

WHAT DRIVES ‘ROLL-OUT’?

PERCEIVED CLINICAL PROBLEM

RANDOMISED STUDIES

GUIDELINES

WHAT DRIVES “ROLL-OUT’’?

DEATHQ WAVE MINON-Q WAVE MICABGREPEAT 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;346:1773-80

Stenting and procedures for restenosis

(2000 data from 40 centres)

0

10

20

30

40

50

60

70

80

90

'92 '93 '94 '95 '96 '97 '98 '99 '00

Year

%

0

2

4

6

8

10

12

14

%

% Stent

% Restenosis

BCIS AUDIT

CARDIAC EVENTS AT ONE YEARRAVEL STUDY

EVENT SIROLOMUS 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;346:1773-80

REPEAT PCI IN RAVEL

50556065707580859095

100

0 30 60 90 120 150 180 210 240 270 360

CYPHERBARE

EventFreeSurvival (%)

Days after implantation

N Engl J Med 2002;346:1773-80

TIMIMG OF EVENTS IN RAVEL

50556065707580859095

100

0 30 60 90 120 150 180 210 240 270 360

CYPHERBARE

EventFreeSurvival (%)

Days after implantation

N Engl J Med 2002;346:1773-80

REPEATANGIOGRAPHY

CURRENT DES UPTAKE

NO. OF PCI IN LAST YEAR

NO. WITH DES

PROJECTED % WITH DES

AGREED PROTOCOL WITH PURCHASERS

WESTERN,

EDINBURGH 700 1-2 ? NOWESTERN,

GLASGOW 800 ZERO ? NOCARDIFF 430 1 ? NOMANCHESTER

ROYAL 970 20% 20% YESLEEDS 1800 ZERO ZERO NO

PATTERNS OF UPTAKE OF DRUG-ELUTING STENTS

MANCHESTER MODEL- 20% usage

- specific lesions- <2.5 mm

diameter - >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

NHSTech

nolo

gy A

pp

rais

al G

uid

an

ce -

No.1

2

Cost Per Life savedTherapiesTherapies CostCost

CABG Left Main Bypass2

Abciximab (Elect Stent, Full Cost)3

Cervical Cancer Screening4

Noenatal Intensive Care4

Abciximab (All PCI, Full Cost)3

Kidney Transplant4

t-PA vs. SK5

Hemodialysis fo Chronic Renal Failure2

Heart Transplant4

7,000

9,316

12,000

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