Angioplasty and Stents to Treat Coronary Artery Disease - 2008

The number of PCIs in the UK was 1,269 per million population (pmp). These numbers are less than in most other developed European countries. The number of angiograms and PCI procedures are also less than that recommended by the British Cardiovascular Society (BCS), but both exceed

the numbers expected by the National Service Framework (NSF) for Coronary Heart Disease. For PCIs, the NSF target in 2000 was 750 pmp, and the BCS 2003 target was 1,400 pmp, with expectations that the level might need to be 2-3,000 pmp.

Although there has again been an increase in PCI activity in all the UK countries, there remain large differences between these countries, with the poorest provision in Wales at 1031 pmp compared with the highest in Northern Ireland at 1648 pmp.

For the past 2 years the rate of increase in overall number of PCI procedures performed remains at the lowest level since records began in 1992.

Centre size: there is evidence that suggests improved outcomes for patients being treated in higher volume PCI centres, particularly those that perform at least 400 procedures pa. This forms part of the recommendations of the Joint Working Group on PCI of BCIS and the British Cardiovascular Society. In 2007 the majority of units were performing considerably more than the recommended minimum. Of the 29 units performing less than 400 cases pa, the majority were new units undertaking a gradually increasing volume of work.

The National Institue for Health and Clinical Excellence (NICE) recommend that "Stents should be used routinely where PCI is the clinically appropriate procedure for patients with either stable or unstable angina or with acute myocardial infarction".The great majority of procedures do now involve stent insertion (95 per cent), suggesting that this aspect of good practice is being met.

Following concerns about the safety of drug eluting stents in September 2006, there was a fall in their use to 55 per cent across the UK. These concerns have now been recognised to be mainly invalid and early indications are for a return to higher percentage use. The National Institute for Health and Clinical Excellence (NICE) has produced updated guidelines for the use of these stents, that are largely unchanged from its original guidance. They again recommended that drug eluting stents should be used if "the target artery to be treated has less than a 3-mm calibre or the lesion is longer than 15 mm." Research suggests that compliance with the NICE guidance on use of such stents would result in about 70 to 80 per cent of patients being treated with a drug eluting stent, which is in keeping with the rates observed in this audit prior to the down turn induced by concerns about possible long-term safety.

The overall rate of death before discharge from hospital following PCI has gradually risen over the past few years.This is due to a change in case mix. There has been no evidence of a change in the outcomes when patients in similar clinical presentations are compared. For patients with unstable angina or NSTEMI, the in hospital mortality is less than 1 per cent. For patients with STEMI the mortality is higher at about 5 per cent.