Professor Roger Boyle CBE National Director for Heart Disease and Stroke Department of Health

1. PCI in the UK: Fit for service? A view from the Department of Health Professor Roger Boyle CBE National Director for Heart Disease and Stroke Department of Health

2. CONFLICTS OF INTEREST I work for the Department of Health!

3. Acknowledgement I have drawn on Peter Ludman’s work quite extensively

5. SAVING LIVES I A T H Target achieved five years ahead of schedule Health Improvement Analytical Team Immortality guaranteed by 2026 Monitoring Unit Circulatory Disease Mortality TargetDeath rates from All Circulatory Disease in England 1993-2006 and targetPersons under 75 Death rate per 100,000 population Progress since baseline: A fall of 40.3% 141.0 Target: 40% minimum reduction from 1995-97 baseline rate 84.2 84.6 3 year average baseline Progress target Rates are calculated using the European Standard Population to take account of differences in age structure. ICD9 data for 1993 to 1998 and 2000 have been adjusted to be comparable with ICD10 data for 1999 and 2001 onwards. Source: ONS (ICD9 390-459; ICD10 I00-I99)

7. 69 in English NHS 16 private

17. BCIS Peer Review System • New PCI centres should be subject to BCIS peer review BEFORE starting • Minimum number of cases should be 200 per year with clear plans to increase to 400 per year • Minimum of three operators • Arrangements for surgical cover • Network agreement to the service

19. England – Total Waiters – by SHA – April 2004 – August 2008 - Angiography Last 3 years 5 months

20. England – Total Waiters – by SHA – April 2004 – August 2008 - PCI PCI Last 3 years 5 months

23. Rationale for NIAP • Need for test of feasibility in NHS • Need for cost-effectiveness data relevant to NHS

24. PPCI Lysis No Reperfusion

25. NIAP and National Guidance launch event • Key issues • General acceptance of direction of travel • Debate regarding the proportion of the population that would still require thrombolysis • DH estimate that we can reach 97% of population, others more like 80% • Other issues • Some pushback regarding our statement advising against hybrid models

26. Lord Voldemort of Worthing

27. Peter WeissbergMedical Director BHF “We must not replace a first class thrombolysis service, which is proven to save lives, with a second class angioplasty service, which might not.”

28. MINAP data

30. Sunday Mirror Mail on Sunday

32. Reperfusion ServicesNHS Improvement Survey – November 2008

33. Future Network Plans • 10 networks have full 24/7 PPCI service • 6 networks have a business case for PPCI Of these: • 3 networks plan to have 24/7 PPCI by March 2009 • 1 network will commence in Jan 2010 • 12 in the process of developing business case Some hybrid service due to travel times and 120 minute window

34. Results from ALKK P for trend 0.004 Zahn et al Heart 2008; 94: 329-35

35. 18,504 consecutive patients in US Adjusted odds ratio of adverse CV events by volume per operator Moscucci et al, JACC 2005; 46:625-632

36. Paris PCI registry Spaulding et al European Heart J 2006; 27: 1054-1060

37. MINAP – STEMI IN HOURS & OUT OF HOURS – 2007 Per Week (average) - By SHA of Admission Missing Data London Chest Based on 55% In Hours / 45% Out of Hours AVE PER WEEK

38. Consensus event 24th September • One fifth of England’s cardiologists present • General agreement that Networks were the right building blocks for planning purposes for angioplasty services • General agreement that BCIS had a major role in setting standards and continuing peer review visits • General agreement that we should move to reporting and publishing outcome data • Less consensus as to how and where PCI services should be provided • Also doubts about minimum numbers for PPCI

39. Lord Voldemort of Worthing

40. Cardiac Networks