National Angioplasty Audit - 2009

The number of PCIs in the UK was 1,308 per million population (pmp). These numbers remain 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.

There has been an increase in PCI activity in all the UK countries except N. Ireland. Wales has seen the greatest increase, but still has the poorest provision at 1143 pmp compared with the highest in Northern Ireland at 1626 pmp.

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 2008 25% of PCI units were performing 400 or less cases pa, but the majority of these were new units undertaking a gradually increasing volume of work.

The National Institute 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. Data from 2008 suggest a gradual increase in their use now that safety issues are better understood. These levels still fall short of what might be expected from the National Institute for Health and Clinical Excellence (NICE) updated guidelines.

Research suggests that compliance with the NICE guidance 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 stable elective patients, in hospital mortality is less than 0.2%, 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.