What’s happened in 2007 and why?What’s happened in 2007 and why?

Mark de BelderMark de BelderPresidentPresident

British Cardiovascular Intervention SocietyBritish Cardiovascular Intervention Society

12691216

77,373

73,612

0

200

400

600

800

1000

1200

1400

1600

1800

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

PC

I pe

r m

illio

n

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

PC

I P

roce

dure

Num

bers

PCI per million

PCI Procedures

PCI activity to 2007 (UK)PCI activity to 2007 (UK) 2007 data: Ludman

Aggregate forms

NSF

PCIPCI’s’s (all) per million inhabitants per year (all) per million inhabitants per year 2007 2007Widimsky P, ESC 2008Widimsky P, ESC 2008

0

500

1000

1500

2000

2500

3000

3500

4000

PCI / million / year

D

IZR

A

B

I

SLO

PL

NL

CZ

NO

CH

S

DK

FIN

H

E

UK

TR

HR

SRB

BG

SK

RO

PCI vs Isolated CABG Rates (UK)PCI vs Isolated CABG Rates (UK)Estimated 5 year growth: 2002Estimated 5 year growth: 2002

0

20000

40000

60000

80000

100000

120000

140000

'91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08

SCTSBCIS

All revasc:>2700 pm3.3:1 PCI:CABGPCI >2000 pm

PCI vs Isolated CABG Rates (UK)PCI vs Isolated CABG Rates (UK)Estimated 5 year growth: 2002Estimated 5 year growth: 2002

0

20000

40000

60000

80000

100000

120000

140000

'91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08

SCTSBCISSCTS actualBCIS actual

All revasc:>2700 pm3.3:1 PCI:CABGPCI >2000 pm

Actual in 2007: All revascularisation 1685pm; PCI 1269pm; CABG 416pm3.1:1 PCI:CABG

Influences on requirements/deliveryInfluences on requirements/delivery

PositivePositive• Growth in infrastructureGrowth in infrastructure• More interventional More interventional

cardiologistscardiologists• Primary PCIPrimary PCI• NICE ACS Guidelines 2009?NICE ACS Guidelines 2009?

– Equity of accessEquity of access• NSF and established interface NSF and established interface

between primary and secondary between primary and secondary carecare– RACPCsRACPCs– Appropriate investigation of Appropriate investigation of

IHDIHD– NICE AP guidelines NICE AP guidelines

2009/2010?2009/2010?• New evidence?New evidence?• Work of the CVC?Work of the CVC?

NegativeNegative• Lack of infrastructureLack of infrastructure• Too few interventional (and Too few interventional (and

other) cardiologistsother) cardiologists• Belief in thrombolysisBelief in thrombolysis• ICTUS believersICTUS believers• COURAGE and the impact of COURAGE and the impact of

secondary preventionsecondary prevention• Concerns about DESConcerns about DES• Smoking banSmoking ban• Healthier lifestyles (diet, Healthier lifestyles (diet,

exercise)exercise)• Changes in air pollutantsChanges in air pollutants• Global warming?Global warming?• New evidence?New evidence?• Economic downturn?Economic downturn?• Work of the CVC?Work of the CVC?

Hospitalized STEMI treatment in Europe.Hospitalized STEMI treatment in Europe.

National registries dataNational registries data ((**estimates of national opinion leaders)estimates of national opinion leaders)

95

05

92

17

85

0

15

75

12

13

75

5

20

74

18

8

72

2

26

70

20

10

70

15

15

68

6

26

60

12

28

59

14

27

50

15

35

45

40

15

45

16

39

40

40

20

39

26

35

35

40

25

19

44

37

17

21

62

14.9

61.4

23.7

13

26

61

9

50

41

8

29

62

4

50

46

5

15

80

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

NL CZ SLO NO DK B PL CH HR S H D IL FIN I E SK A P SRB UK BG GR TR RO RU

P-PCI TL No reperfusion* * ** *** * **

Clinical SyndromeClinical Syndrome

2007 data: Ludman

CCAD

46.8

53.2

0

10

20

30

40

50

60

70

80

2005 2006 2007

% PCI Performed for

each Indication

Stable

Unstable

13.24%

1.18%

40.48%

45.10%

StableNSTEMI / UASTEMIOther

Indication for PCIIndication for PCI

2007 data: Ludman

CCAD

PCI for STEMIPCI for STEMI

5866

8153

3930

5902

1936

2581

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

All STEMI Primary PCI Rescue

2001

2002

2003

2004

2005

2006

2007

2007 data: Ludman

CCAD

Variation in patients with STEMI treated with Variation in patients with STEMI treated with lysis or no reperfusion undergoing angiographylysis or no reperfusion undergoing angiography

MINAP dataMINAP datapersonal communication – John Birkheadpersonal communication – John Birkhead

Hosps Median % Percentile 25 Percentile 75

2006 214 63% 43% 81%

2007 210 63% 48% 78%

2008 205 67% 48% 80%

Issues relating to Non-STEMI ACSIssues relating to Non-STEMI ACS

• ESC & US guidelines support early ESC & US guidelines support early angiography with a view to early (within angiography with a view to early (within 72hrs) revascularisation by either PCI or 72hrs) revascularisation by either PCI or CABG in higher risk subsetsCABG in higher risk subsets

• Rates of angiography and revascularisation Rates of angiography and revascularisation vary considerably across England (MINAP vary considerably across England (MINAP - John Birkhead, personal communication)- John Birkhead, personal communication)

Non-STEMI ACS patientsNon-STEMI ACS patients

25941

2987533009

0

5000

10000

15000

20000

25000

30000

35000

40000

2005 2006 2007

Procedures performed for

non-STEMI ACS

Variation in patients with nonSTEMI ACS Variation in patients with nonSTEMI ACS undergoing angiographyundergoing angiography

MINAP dataMINAP datapersonal communication – John Birkheadpersonal communication – John Birkhead

Hosps Median % Percentile 25 Percentile 75

2006 212 60% 40% 82%

2007 207 57% 41% 75%

2008 203 63% 47% 78%

Stable patientsStable patients

39280 3795136211

0

5000

10000

15000

20000

25000

30000

35000

40000

2005 2006 2007

Procedures performed for stable angina

Non-STEMI ACS patientsNon-STEMI ACS patients

25941

2987533009

36211

0

5000

10000

15000

20000

25000

30000

35000

40000

2005 2006 2007

Non-STEMI

Stable

Procedure urgency 2000 to 2007

0

100

200

300

400

500

600

700

800

2000 2001 2002 2003 2004 2005 2006 2007

Urgent

Elective

Emergency

Changing case mix - JCUHChanging case mix - JCUH

Changing case mix - JCUHChanging case mix - JCUH

0

10

20

30

40

50

60

70

80

90

100

2003 2004 2005 2006 2007 2008

%

STEMI

Non-STEMI ACS

Stable

Angiography (85)

PCI (98)

2007Where is the workWhere is the work

being done?being done?

PCI per ConsultantPCI per ConsultantUnit case number / Number of operatorsUnit case number / Number of operators

100105110

115120125130135

140145150

2000 2001 2002 2003 2004 2005 2006 2007

Nu

mb

er

of

PC

Is

2007 data: Ludman

0

500

1000

1500

2000

2500

3000

3500

PCIs per Centre

Individual Centres

Off site On Site

Surgical CoverSurgical Cover (2007 - all 81 NHS centres)

2007 data: Ludman

420

1471

Mean

Aggregate forms

Surgical CoverSurgical Cover(all 98 NHS and Private Centres)(all 98 NHS and Private Centres)

On siteOn site Off siteOff siteNo of centresNo of centres 5353

(54%)(54%)

4545(46%)(46%)

No. of PCI No. of PCI (% of total)(% of total) 59,45559,455(77%)(77%)

17,91817,918(23%)(23%)

Mean No. PCI per centre (all) Mean No. PCI per centre (all) 11221122 398398

Mean No. PCI per centre (NHS)Mean No. PCI per centre (NHS) 14711471 420420

2007 data: Ludman

Aggregate forms

Development of off-site centresDevelopment of off-site centres

PositivesPositives• Increased access to careIncreased access to care• Provides local careProvides local care• Main drive historically was to provide service when Main drive historically was to provide service when

regional tertiary centre could not provide appropriate level regional tertiary centre could not provide appropriate level of activityof activity

NegativesNegatives• 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 May be harder to liase between interventional and surgical

colleaguescolleagues• International literature shows potential for worse outcomesInternational literature shows potential for worse outcomes

Effect of New CentresEffect of New Centres

2007 data: Ludman

Brighton

Effect of New CentresEffect of New Centres

2007 data: Ludman

Worthing

Eastbourne

Hastings

Brighton

Effect of New CentresEffect of New Centres

0

200

400

600

800

1000

1200

1400

1600

1800

2000

2002 2003 2004 2005 2006 2007

CGH. ConquestHospital

W RG. W orthingHospital

DGE. Eastbourne

RSC. Royal SussexCounty Hospital

2007 data: Ludman

Effect of New CentresEffect of New Centres

0

500

1000

1500

2000

2500

3000

3500

2002 2003 2004 2005 2006 2007

BOU. RoyalBournemouthGeneral Hospital

SGH. SouthamptonGeneral Hospital

2007 data: Ludman

Downsizing of larger unitsDownsizing of larger units

0

500

1000

1500

2000

2500

3000

3500

BAL PAP STH GEO FRE RAD RSC NGS HH KCH SCM NHB WYT PLY STM QEB STO WAL BRI UCL

2003

2004

2005

2006

2007

Numbers of PCIs neededNumbers of PCIs needed

• NSF 2000NSF 2000– 1500 revascularisations pmp1500 revascularisations pmp– 750 PCI / 750 CABG750 PCI / 750 CABG

• BCS Workforce document 2005BCS Workforce document 2005– 2200-3000 PCI pmp2200-3000 PCI pmp

• DoH Stocktake exercise 2007DoH Stocktake exercise 2007– 1900, 2200, 2500 revascularisations pmp1900, 2200, 2500 revascularisations pmp– 3:1 ratio PCI:CABG3:1 ratio PCI:CABG– ~1400, 1650, 1900 PCIs pmp~1400, 1650, 1900 PCIs pmp

• ““Services are saturated” versus Services are saturated” versus “We’re clearly under-providing”“We’re clearly under-providing”

ConclusionsConclusions• Growth in activity is likely to depend on growth in Growth in activity is likely to depend on growth in

PPCI and angioplasty for non-STEMI ACS PPCI and angioplasty for non-STEMI ACS patientspatients

• Considerable regional differences are likely to be Considerable regional differences are likely to be ironed outironed out– Updated guidelinesUpdated guidelines

• Delivery of services should be determined by a Delivery of services should be determined by a review of the changing epidemiology and review of the changing epidemiology and evidence base for PCIevidence base for PCI– Importance of the Clinical Network and SHAImportance 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?