PCI vs Isolated CABG Numbers (UK) Data from BCIS and SCTS Registry

1. PCI vs Isolated CABG Numbers (UK)Data from BCIS and SCTS Registry Ratio PCI:CABG 1.3 1.5 ? 1.7

2. PCI and CABG rates per million(Europe 2000) Ratio PCI:CABG 2.3 3.3 5.4 2.4 4.1 3.0 1.7 1.4 2.8 2.0 0.9 4.2 1.3 1.8 1.4 2.0 0.7

3. The problem of restenosis Results from ARTS trial, NEJM 2001 Survival Event free survival excluding target vessel revascularisation Event free survival including target vessel revascularisation

4. Issues of Drug Elution • Is drug elution effective? • Is the effect sustained? • Are there any adverse effects? • Are there other down sides? • Is it being used in most patients? If not, why? • Can it be used in all patients? • Are there subgroups where it should be avoided?

5. Is Drug Elution Effective?

6. TAXUS IV

7. TAXUS IV

8. Issues of Drug Elution  • Is drug elution effective? • Is the effect sustained? • Are there any adverse effects? • Are there other down sides? • Is it being used in most patients? If not, why? • Can it be used in all patients? • Are there subgroups where it should be avoided?

9. Is this effect sustained or merely delayed? Virmani et al. Heart 2003 Neointimal growth with bare metal stents Neointimal growth with drug eluting stents

16. Issues of Drug Elution  • Is drug elution effective? • Is the effect sustained? • Are there any adverse effects? • Are there other down sides? • Is it being used in most patients? If not, why? • Can it be used in all patients? • Are there subgroups where it should be avoided? 

17. BCIS Website Sept ‘03

18. UK report of 3 cases of Cypher stent thrombosis

21. Subacute Thombosis Data from >100,000 patients

22. Drug Eluting StentsOther potential down sides! • More prolonged use of anti-platelet therapy • Addition of clopidogrel for 3-6 months in line with trend in anti-platelet therapy for ACS • Cost • Cost analysis flawed • Patients have different perspective on cost versus benefit • Ability to treat many more lesions with DES • Impact in reducing need for surgical revascularisation – long term cost benefit issues

23. Issues of Drug Elution  • Is drug elution effective? • Is the effect sustained? • Are there any adverse effects? • Are there other down sides? • Is it being used in most patients? If not, why? • Can it be used in all patients? • Are there subgroups where it should be avoided?   

24. Southampton Usage - 2003 93% 73%

25. League Table

26. Reasons for bare metal stent usage • Limited availability of different types of stent • Deliverability • Limitation on available lengths and sizes • Lesion suitability • Graft disease • NICE guidance

27. NICE Guidance – Drug Eluting Stents

28. TAXUS IV

29. TAXUS IV

30. TAXUS IV

31. Cypher stents in AMI • 96 patients with ST elevation AMI • 12 patients with cardiogenic shock • Primary PCI in 89 (92.7%) • TIMI 3 flow in 93.3% • 1 patient with reinfarction and TLR • Follow up mean of 218 (+ 75) days • 1 death during follow up Saia et al. Circulation 2003

32. Cypher stents in AMI

33. Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) Registry • 508 consecutive patients treated with Sirolimus eluting stent • Compared to preceding 450 patients with bare metal stents • SES group had more patients with multivessel disease, more type C lesions, more bifurcation lesions and received more stents Serruys group – Circulation, NEXT week

34. RESEARCH Registry 30 day outcome

35. RESEARCH Registry1 year outcome

36. Issues of Drug Elution  • Is drug elution effective? • Is the effect sustained? • Are there any adverse effects? • Are there other down sides? • Is it being used in most patients? If not, why? • Can it be used in all patients? • Are there subgroups where it should be avoided?      

37. Drug Eluting Stents Q. Use them in all patients? A. Use them on all patients!