Primary PCI for STEMI 2008 Data from NHS Centres

BCIS Audit Returns Adult Interventional Procedures

Jan 2008 to Dec 2008

Peter F Ludman BCIS National Audit Lead On behalf of British Cardiovascular Intervention Society

Bournemouth October 2009 Contents 2008 data: Ludman • Structure – Multi-vessel treatment – New centres – Additional interventional techniques – Total PCI numbers – Arterial access – No of procedures per unit • complications – PCI pmp and by country • DTB times – PCI Operators • Process of care – Surgical cover – Delays to treatment NSTEMI – Day case activity – Delays to treatment Primary PCI – Primary PCI units • DTB times by unit • PCI Procedure specific data • CTB times by unit – CCAD data completeness • Non coronary intervention – Demographics – HOCM septal ablation – Ethnicity – Mitral valuloplasty • Appropriateness – Other adult structural intervention – indication for PCI / Clinical syndrome – Transcutaneous Aortic Valves – Circadian activity for PPCI • Outcome – Stents (BMS and DES) – MACCE – Adjunctive therapy – Outcome by syndrome – LV support – Outcome by lesion subset – Shock – Risk adjusted outcomes Structure 2007 data: Ludman Angiography Centres 2008

New Centres 2008 data: Ludman Maidstone (restarts) Peterborough District Hospital West Suffolk Hospital Ipswich Hospital

Centres ceasing activity St James’s University Hospital Western General (Bristol) Bristol Spire Droitwich Spa PCI Centres 2008

2008 data: Ludman

PCI becomes Angio only Southend PCI Centres 2008

New PCI Centres 2008 data: Ludman Frenchay Hospital (Bristol) Kettering General Hospital

PCI centres from existing angiography units Kent and Sussex Hospital Darrent Valley Kings Mill Hospital (Mansfield) Lincoln County Hospital Worcester Royal Hospital UK Centres 2008

2008 data: Ludman PCI Angio only

120 105 98 91 100

80 90 85 81 60 40 No. of Centres of No. 20

0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2008

Angiography (81)

PCI (105) PCI Centres in 2008 UK Countries

2008 data: Ludman

Scotland NHS 7→5 Private 1 England NHS 76 Private 16 N Ireland 3 Wales 2 Total 105 PCI Data Sources

2008 data: Ludman

All UK England Wales Angio Only Aggregate PCI Audit form Audit form partial Northern Ireland Scotland (via MINERVA upload) CCAD UK Interventional and Diagnostic centres

2008 2008 data: Ludman

No. No No Caths PCIs cath PCI (% of total) (% of total) data data NHS 88 0 0 Interventional Private 17 1 1 Interventional Diagnostic 81 2 na only TOTAL 186

Aggregate forms UK Interventional and Diagnostic centres

2008 2008 data: Ludman

No PCINo. data:No No Caths PCIs cath PCI (% of total) (% of total) London dataIndependentdata Hospital NHS 88 0 0 Interventional Private 17 1 1 Interventional Diagnostic 81 2 na only TOTAL 186

Aggregate forms UK Interventional and Diagnostic centres

2008 2008 data: Ludman

No angiographyNo. No Nodata: Caths PCIs University Hospitalcath PCI of(% Hartlepool of total) (% of total) Princess ofdata Walesdata Hospital, Bridgend NHS 88 0 0 Interventional Private 17 1 1 Interventional Diagnostic 81 2 na only TOTAL 186

Aggregate forms UK Interventional and Diagnostic centres

2008 2008 data: Ludman

No. No No Caths PCIs cath PCI (% of total) (% of total) data data NHS 88 0 0 166,454 78,077 Interventional Private 17 11 7,026 2,254 Interventional Diagnostic 81 2na 56,548 na only TOTAL 186 230,028 80,331

Aggregate forms PCI activity to 2008 (UK) 2008 data: Ludman

PCI per million PCI Procedures 1800 90000 80,331 1600 77,373 80000 73,612 1400 1308 70000 1269 1216 1200 60000

1000 50000

800 40000

600 30000 PCI per million

400 20000 PCI Procedure Numbers

200 10000

0 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Aggregate forms Rate of increase in PCI numbers pmp

2008 data: Ludman

5 Rate of Increase (%) Increase of Rate

0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Aggregate forms PCI per Angiogram ratio

2008 data: Ludman 40 35 30 25 % 20 15 10 5 0

8 9 0 1 2 3 4 5 06 07 08 199 199 200 200 200 200 200 200 20 20 20

Aggregate forms PCI per Angiogram ratio By Individual PCI Units

2008 data: Ludman

100

60 % 40

0 0 1000 2000 3000 Number of PCI procedures Total PCIs in the UK Countries by Type of Institution

Total No.s of PCI 2008 data: Ludman

70000 2000 60000 2001 50000 2002 40000 2003 2004 30000 2005 20000 2006 10000 2007 2008 0 England England Scotland Scotland N. Ireland Wales NHS Private NHS Private Aggregate forms Total PCIs in the UK Countries by Type of Institution

Total No.s of PCI 2008 data: Ludman

10000 9000 2000 8000 2001 7000 2002 6000 2003 5000 2004 4000 2005 3000 2006 2000 2007 1000 2008 0 England England Scotland Scotland N. Ireland Wales NHS Private NHS Private Aggregate forms Population estimates

Mid 2008 2008 data: Ludman Total UK: 61.4 m Scotland 5.169 m

Northern Ireland 1.775 m

England 51.446 m est: Welsh Rx in England 0.8 m Total Rx in England 52.3 m

Wales 2.99 m est: Rx in Wales: 2.2 m PCIs/million UK Countries

2008 data: Ludman 1800 1626 1600 2000 1400 1302 1339 2001 1143 1200 2002 2003 1000 2004 800 2005 600 2006 400 2007 200 2008 0 England Scotland N. Ireland Wales

Aggregate forms PCI vs Isolated CABG Numbers (UK) 1991 to 2008

2008 data: Ludman

90000 80000 70000 PCI 60000 CABG 50000 40000 30000 20000 10000 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Note: CABG data for financial yr Aggregate forms PCI vs Isolated CABG Ratio (UK) 2000 to 2008

2008 data: Ludman

4 3.1 3.1 3.24 3 3 2.5 2.1 Ratio 2 1.8 1.6 1.3 1

001 2000 2 2002 2003 2004 2005 2006 2007 2008

Aggregate forms Number of PCIs performed in 2008 (per NHS Centre)

Mean = 908 2008 data: Ludman

3500 3000 2500 2000 1500 1000 Numberof PCIs 500 0 Individual Centres 26 Centres performing < 400 cases (25%)

Data from: all NHS centres Aggregate forms Number of PCIs performed in 2008

7 Centres performing < 200 procedures 2008 data: Ludman

Whipps Cross (2005)

Kings Mill (2008)

Darent Valley (2008)

Lincoln County (2008)

QE Woolwich (2007)

Kent and Sussex (2008)

Worcester Royal (2008)

0 20 40 60 80 100 120 140 160 180 200 PCI program start date Number of PCIs performed in 2008

19 Centres performing 200 to 400 procedures 2008 data: Ludman Sunderland Royal (2006) Wexham Park (2006) Birmingham City (< 2003) North Hampshire (2003) Worthing (2006) Derbyshire Royal (2005) Torbay (2004) Great Western (2006) East Surrey (2006) William Harvey (2006) Lister (2006)l Eastbourne (2006) Bradford Royal (2005) St Peter's (2003) Conquest (2007) Kettering General (2008) Frenchay (2008) Wigan Royal (2007) Hemel Hempstead (2005)

0 50 100 150 200 250 300 350 400 PCI program start date No. of Interventional Consultants (NHS centres)

2008 data: Ludman 700 40 591 600 547 35 519 30 500 441 424 25 400 362 Total 312 20 % 300 292 Increase 15 Number 200 10 100 5 0 0 2001 2002 2003 2004 2005 2006 2007 2008

Note: if work at two NHS centres will be counted twice Includes cardiologists and radiologists No. of Interventional Consultants (NHS centres 2008)

2008 data: Ludman

25 Mean 20 2000 5.5 2001 6.1 Number of 15 2002 6.5 Interventional Consultants 10 2003 6.7 2004 7.4 5 2005 7.0 2006 6.9 0 Individual Centres 2007 6.9 2008 6.8

Note: if work at two NHS centres will be counted twice No. of Consultant in each unit (NHS Centres 2008)

2008 data: Ludman

30 Mean 25 2000 5.5 20 Number of 2001 6.1 Consultants in 15 2002 6.5 each unit 10 2003 6.7 2004 7.4 5 2005 7.0 0 2006 6.9 0 500 1000 1500 2000 2500 3000 3500 2007 6.9 Total PCIs in each Unit 2008 6.8

Note: if work at two NHS centres will be counted twice No. of PCIs per Consultant (NHS Centres 2008)

2008 data: Ludman 300

250

200

150

100

50 PCIs per Consultant

0 Individual Centres

Note: Data from institutional volume divided by No operators per institution Some consultants work in multiple institutions PCI per Consultant Unit case number / Number of operators

150 2008 data: Ludman 145 140 135 129 130 125 120 115 Number of PCIs Number 110 105 100 2000 2001 2002 2003 2004 2005 2006 2007 2008 No. of PCIs per Consultant (NHS Centres 2008)

2008 data: Ludman

350 300 250 Total PCIs / 200 Number of 150 Consultants 100 50 0 0 500 1000 1500 2000 2500 3000 3500 Total PCIs in each Unit

Note: Data from institutional volume divided by No operators per institution Some consultants work in multiple institutions On v Off Site Surgery All Centres (NHS and private)

2008 data: Ludman

100% Off Site 28 On Site 80% 38 45 53 60% 49.5 % 40% 55 53 53 52 20%

0% 2005 2006 2007 2008

Aggregate forms On v Off Site Surgery NHS Centres only

2008 data: Ludman

100% Off Site On Site 80% 26 37 42 50 60%

40% 43% 38 38 39 20% 38

0% 2005 2006 2007 2008

Aggregate forms Surgical Cover (2008 - all 88 NHS centres)

2008 data: Ludman

Off site On Site

3500 3000 2500 PCIs per 2000 Mean Centre 1500 1532 1000 500 458 0 Individual Centres

Aggregate forms Surgical Cover (all 105 NHS and Private Centres)

2008 data: Ludman

On site Off site No of centres 52 53 (49.5%) (50.5%) No. of PCI (% of total) 57,127 23,204 (71%) (29%) Mean No. PCI per centre (all) 1143 438 Mean No. PCI per centre (NHS) 1532 458

Aggregate forms Day Case PCI

• 54 of 87 Units performing day case PCI 2008 data: Ludman

12000 25 11087

10000 20 8589 8000 15 Number 6000 5780 13.8 % % of all PCI

Number 4603 11 10 4000 3018 7.8 2492 5 2000

0 0 2003 2004 2005 2006 2007 2008

Data from: 87 of 105 centres Day Case PCI Total DC PCI against all PCI activity

2008 Data from 87 of 105 centres 2008 data: Ludman

1400 1200 1000 Number of 800 Day Case PCIs 600 400 200 0 0 500 1000 1500 2000 2500 3000 3500 Number of PCI procedures Day Case PCI As Percentage of all PCI activity

2008 Data from 87 of 105 centres 2008 data: Ludman

80 70 60 50 % 40 30 20 10 0 0 500 1000 1500 2000 2500 3000 3500 Number of PCI procedures Primary PCI Routine Rx for STEMI

2008 data: Ludman Working Hours 24/7

100% 100% 25 80% 80% 43

60% 60%

40% 61 40% 50 52 38 43 28 32 20% 20% 28 32 18 22 13 13 5

Percentage of NHS Centres Percentage of 0% 0%

7 06 8a 09 8a 09 0 08b 2004 2005 20 200 20 2004 2005 2006 2007 20 200 2008b 20 20 Number of centres 86 NHS Centres only (Glasgow Royal and Western no PPCI after March 08) Working Hrs includes all 24/7 sites Primary PCI Routine Rx for STEMI

2008 data: Ludman • Discrepancies in 2008 information about centres – Glasgow Royal and Western moved activity to Golden Jubilee in March 2008 • these 2 units not counted in No of centres in 2008 slide • CCAD includes such activity as occurred before switch (so data from all 3 hospitals) – Daytime only (in describing activity in 2008) • Belfast: – in 2007 return said y, in 2008 return said n • City Stoke, Mayday, Freeman: – in 2007 return said n, in 2008 return said y – 24/7 (in describing activity in 2008) • Walsgrave : – in 2007 return said n, in 2008 return said y • Torbay, Sunderland, Torbay, Freeman: – in 2007 return said y, in 2008 return said n Contents 2008 data: Ludman • Structure – Multi-vessel treatment – New centres – Additional interventional techniques – Total PCI numbers – Arterial access – No of procedures per unit • complications – PCI pmp and by country • DTB times – PCI Operators • Process of care – Surgical cover – Delays to treatment NSTEMI – Day case activity – Delays to treatment Primary PCI – Primary PCI units • DTB times by unit • PCI Procedure specific data • CTB times by unit – CCAD data completeness • Non coronary intervention – Demographics – HOCM septal ablation – Ethnicity – Mitral valuloplasty • Appropriateness – Other adult structural intervention – indication for PCI / Clinical syndrome – Transcutaneous Aortic Valves – Circadian activity for PPCI • Outcome – Stents (BMS and DES) – MACCE – Adjunctive therapy – Outcome by syndrome – LV support – Outcome by lesion subset – Shock – Risk adjusted outcomes Procedure Specific Analysis Participation in CCAD

2008 data: Ludman Total No. of Data to Participation Centres CCAD England NHS 75 76* 99% Private 16 5 31% Wales 2 2 100% N Ireland 3 1 33% Scotland NHS 7 7 via link 100% Private 1 0 0%

*QE Woolwich not yet linked ‘Front end’ Database used

2008 2008 data: Ludman

2 11 1 BCIS 5 Tomcat 5 23 other 5 PATS Lotus Notes 7 Carddas Datacam Medcon Minerva 8 15 Infoflex Cardex 10 Cardiobase 13 Prism Data Quantity CCAD data 2008 data: Ludman UK PCI data in CCAD as % of Reported Totals

Castle Hill Hospital (Hull and East Yorkshire NHS Trust) Yorkshire Heart Centre Wigan Royal Infirmary (Wrighton WiganRoyal Leigh Cornwall NHS trust,Hospital Royal RochdaleRoyal Brompton Infirmary, HospitalSilver Heart and Unit Harefield Penine NHS Acute Trust, Hospital Brompton Trust Albert EdwardSandwell Infirm District ary General Hospital London Chestsite Hospital, Barts and the London Walsgrave Hospital (University Hospital Coventry) Worcester Royal Hospital St Thomas'Torbay HospitalHospital St Peter's Hos pital Southampton General Hospital QueenNinewells Elizabeth HospitalHospital Lister Hospital Kettering General Hospital Royal Brompton Hospital and Harefield NHSDarent Trust, Valley Harefield Hospital site Eastbourne Hospital Cheltenham General Hospital Royal BournemouthConquest Hospital Hospital Royal Berkshire and Battle Hospital Liverpool Cardiothoracic Centre James Cook University Hospital NorthBirmingham Hampshire City Hospital Frenchay Hospital Hemel Hempstead General Frimley Park HospitalNottingham NHSWycombe Foundation City HospitalHospital Trust, PortsmouthBristol Road, Royal Infirmary UniversityDerriford Hospital Hospitalof Wales Derbys hire Royal Infim ary Mayday University Hospital William Harvey Hospital, East KentWexham Hospitals Park HospitalNHS Trust Heart Hospital (UCLH) Morris ton Hos pital Whipps Cross University Hospital JohnFreeman Radcliffe HospitalHospital Wythenshawe Hospital Glenfield Hospital BirminghamSunderland Heartlands Royal HospitalHospital Aberdeen Royal Infirmary Manchester Royal Infirmary Hull Royal Infirmary (Hull and EastEdinburgh Yorkshire Heart NHS Centre Trust) Great Western Hospital, Wiltshire Cardiac Centre Kent and Sussex Hospital Queen AlexandraVictoria Hospital Hospital Royal Devon & Exeter Hospital Royal Free Hospital Golden Jubilee National Hospital (formerly HCI) NorthwickDorset County Park Hospital Worthing Hospital Northern General Hospital NorfolkCity & GeneralNorwich HospitalHospital Papworth Hospital New Cross Hospital HammersmithCraigavon HospitalHospital Lincoln County Hospital St George's Hospital Royal BradfordSussex County Royal Infirmary Hospital Kings College Hospital Royal United Hospital St Mary's Hospital Basildon and Thurrock UniversityHairmyres Hospitals, Hospital Essex East Surrey Hospital, Surrey and Sussex NHS trust CardiothoracicTaunton Centre & Somerset QueenRoyal Elizabeth Victoria Hospital Belfas t Trus t City Hos pital

0 50 100 150 200 As July 09 CCAD data 2008 data: Ludman UK PCI data in CCAD as % of Reported Totals

Castle Hill Hospital (Hull and East Yorkshire NHS Trust) Yorkshire Heart Centre Wigan Royal Infirmary (Wrighton WiganRoyal Leigh Cornwall NHS trust,Hospital Royal RochdaleRoyal Brompton Infirmary, HospitalSilver Heart and Unit Harefield Penine NHS Acute Trust, Hospital Brompton Trust Albert EdwardSandwell Infirm District ary General Hospital London Chestsite Hospital, Barts and the London Walsgrave Hospital (University Hospital Coventry) Worcester Royal Hospital St Thomas'Torbay HospitalHospital St Peter's Hos pital Southampton General Hospital QueenNinewells Elizabeth HospitalHospital Lister Hospital Kettering General Hospital Royal Brompton Hospital and Harefield NHSDarent Trust, Valley Harefield Hospital site Eastbourne Hospital Cheltenham General Hospital Royal BournemouthConquest Hospital Hospital Royal Berkshire and Battle Hospital < 90% Liverpool Cardiothoracic Centre James Cook University Hospital NorthBirmingham Hampshire City Hospital Frenchay Hospital Hemel Hempstead General Frimley Park HospitalNottingham NHSWycombe Foundation City HospitalHospital Trust, PortsmouthBristol Road, Royal Infirmary 2007: 17 Centres UniversityDerriford Hospital Hospitalof Wales Derbys hire Royal Infim ary Mayday University Hospital 2008: 12 Centres William Harvey Hospital, East KentWexham Hospitals Park HospitalNHS Trust Heart Hospital (UCLH) Morris ton Hos pital Whipps Cross University Hospital JohnFreeman Radcliffe HospitalHospital Wythenshawe Hospital Glenfield Hospital BirminghamSunderland Heartlands Royal HospitalHospital Aberdeen Royal Infirmary Manchester Royal Infirmary Hull Royal Infirmary (Hull and EastEdinburgh Yorkshire Heart NHS Centre Trust) Great Western Hospital, Wiltshire Cardiac Centre Kent and Sussex Hospital Queen AlexandraVictoria Hospital Hospital Royal Devon & Exeter Hospital Royal Free Hospital Golden Jubilee National Hospital (formerly HCI) NorthwickDorset County Park Hospital Worthing Hospital Northern General Hospital NorfolkCity & GeneralNorwich HospitalHospital Papworth Hospital New Cross Hospital HammersmithCraigavon HospitalHospital Lincoln County Hospital St George's Hospital Royal BradfordSussex County Royal Infirmary Hospital Kings College Hospital Royal United Hospital St Mary's Hospital Essex CardiothoracicHairmyres Hospital Centre East Surrey Hospital Taunton & Somerset Royal VictoriaQE Woolwich Hospital Belfas t Trus t City Hos pital

0 50 100 150 200 As July 09 CCAD data 2008 data: Ludman PCI data in CCAD as % of Reported Totals Centres with < 90% of their activity in CCAD

Lincoln County Hospital St George's Hospital Bradford Royal Infirmary Royal Sussex County Hospital Kings College Hospital Royal United Hospital St Mary's Hospital Hairmyres Hospital Essex Cardiothoracic Centre East Surrey Hospital Taunton & Somerset Royal Victoria Hospital QE Woolwich Belfast Trust City Hospital

0 20 40 60 80 100 As Sept 08 CCAD data 2008 data: Ludman UK PCI data in CCAD as % of Reported Totals

0 50 100 150 200 As July 09 CCAD data 2008 data: Ludman UK PCI data in CCAD as % of Reported Totals

Castle Hill Hospital (Hull and East Yorkshire NHS Trust) Yorkshire Heart Centre Wigan Royal Infirmary (Wrighton WiganRoyal Leigh Cornwall NHS trust,Hospital Royal RochdaleRoyal Brompton Infirmary, HospitalSilver Heart and Unit Harefield Penine NHS Acute Trust, Hospital Brompton Trust Albert EdwardSandwell Infirm District ary General Hospital London Chestsite Hospital, Barts and the London Walsgrave Hospital (University Hospital Coventry) Worcester Royal Hospital UK E&W E, W&S St Thomas'Torbay HospitalHospital St Peter's Hos pital Southampton General Hospital QueenNinewells Elizabeth HospitalHospital Lister Hospital Kettering GeneralPCIs Hospital 80,331 70,549 77,469 Royal Brompton Hospital and Harefield NHSDarent Trust, Valley Harefield Hospital site Eastbourne Hospital Cheltenham General Hospital Royal BournemouthConquest Hospital Hospital Royal Berkshire and Battle Hospital Liverpool Cardiothoracic Centre 73,421 66,595 72,843 James Cook UniversityIn HospitalCCAD NorthBirmingham Hampshire City Hospital Frenchay Hospital Hemel Hempstead General Frimley Park HospitalNottingham NHSWycombe Foundation City HospitalHospital Trust, 6,910 3,954 4,626 PortsmouthBristol Road, RoyalMissing Infirmary UniversityDerriford Hospital Hospitalof Wales Derbys hire Royal Infim ary Mayday University Hospital William Harvey Hospital, East KentWexham Hospitals Park HospitalNHS Trust Heart Hospital (UCLH) Morris ton Hos pital Whipps Cross University% HospitalMissing 8.6% 5.6% 6.0% JohnFreeman Radcliffe HospitalHospital Wythenshawe Hospital Glenfield Hospital BirminghamSunderland Heartlands Royal HospitalHospital Aberdeen Royal Infirmary Manchester Royal Infirmary Hull Royal Infirmary (Hull and EastEdinburgh Yorkshire Heart NHS Centre Trust) Great Western Hospital, Wiltshire Cardiac Centre Kent and Sussex Hospital Queen AlexandraVictoria Hospital Hospital Royal Devon & Exeter Hospital Royal Free Hospital Golden Jubilee National Hospital (formerly HCI) NorthwickDorset County Park Hospital Worthing Hospital Northern General Hospital NorfolkCity & GeneralNorwich HospitalHospital Papworth Hospital New Cross Hospital HammersmithCraigavon HospitalHospital Lincoln County Hospital St George's Hospital Royal BradfordSussex County Royal Infirmary Hospital Kings College Hospital Royal United Hospital St Mary's Hospital Basildon and Thurrock UniversityHairmyres Hospitals, Hospital Essex East Surrey Hospital, Surrey and Sussex NHS trust CardiothoracicTaunton Centre & Somerset QueenRoyal Elizabeth Victoria Hospital Belfas t Trus t City Hos pital

0 50 100 150 200 As July 09 Data Quality Risk Stratified Outcome A D Grayson et al Heart 2006;92:658–663

• NWQIP risk adjustment model % Completeness 12 fields required for risk adjusted outcome NWQIP

Top score potential = 1200 2006 2007 2008 Demographics

2008 data: Ludman

2007 2008 Age (mean) 64.3 yrs 64.4 yrs Sex (male) 73.6% 73.8% Diabetic 17.5% 18.0% Previous CABG 8.5% 9.1% Previous PCI 18.6% 21.1% Previous MI 29.5% 30.2%

CCAD Demographics - Age

Male: mean = 63.2 2008 data: Ludman Female: mean = 67.9

20000

15000

No. PCIs 10000 Male 07 Male 08 5000 Female 07 Female 08 0 >90 <=30 31-40 41-50 51-60 61-70 71-80 81-90 Age (yrs) CCAD Demographics - Age

2008 data: Ludman

60 Mean Age(yrs)

0 1000 2000 3000 4000 Number of PCI procedures Demographics

2008 data: Ludman

Ethnic Origin Year 2007 2008 n 43,929 48,581 Caucasian 92.3% 92.0% Asian 6.7% 7.1% Black 0.83% 0.72% Oriental 0.2% 0.17%

CCAD Demographics

2008 data: Ludman

Ethnic Origin Year 2007 2008 n 43,929 48,581 Caucasian 92.3% 92.0% Asian 6.7% 7.1% Black 0.83% 0.72% Oriental 0.2% 0.17%

CCAD Age at PCI by Ethnicity

• Age (mean) 2008 data: Ludman

70 64.5 64.7 64.4 64.7 60.2 60.4 60.4 61 60 50

40 Asian 30 European 20 10 0 2005 2006 2007 2008 Sex by Ethnicity

• Sex (male %) 2008 data: Ludman

90 75.7 76.7 77.8 77.6 80 73.1 73.4 73.9 73.3 70 60 50 Asian 40 European 30 20 10 0 2005 2006 2007 2008 Diabetes by Ethnicity

• Diabetes 2008 data: Ludman

50 45.5 44.6 44.4 45 42.7 40 35 30 Asian 25 European 20 16.1 14.9 15.6 15.8 15 10 5 0 2005 2006 2007 2008 BMI by Ethnicity 2008

• BMI 30 2008 data: Ludman 27.1 27.9

Asian 15 European

0 BMI Smoking by Ethnicity

2008 data: Ludman • Smoking - current 30 24.4 25.2 25 22.7 21.9 19.9 20 17.1 17.5 15.1 Asian 15 European 10

0 2005 2006 2007 2008 Smoking by Ethnicity

2008 data: Ludman • Smoking - never 70 59.4 60 57.6 55.9 57.7 50

40 34 35.4 33.7 34 Asian 30 European 20 10 0 2005 2006 2007 2008 Presentation by Ethnicity

2008 data: Ludman • % Acute 70 60 50

40 Asian % 30 European 20 10 0 2005 2006 2007 2008 Total Adverse Markers for outcome

S. Asian European

Older Diabetes Smokers Acute More females Contents 2008 data: Ludman • Structure – Multi-vessel treatment – New centres – Additional interventional techniques – Total PCI numbers – Arterial access – No of procedures per unit • complications – PCI pmp and by country • DTB times – PCI Operators • Process of care – Surgical cover – Delays to treatment NSTEMI – Day case activity – Delays to treatment Primary PCI – Primary PCI units • DTB times by unit • PCI Procedure specific data • CTB times by unit – CCAD data completeness • Non coronary intervention – Demographics – HOCM septal ablation – Ethnicity – Mitral valuloplasty • Appropriateness – Other adult structural intervention – indication for PCI / Clinical syndrome – Transcutaneous Aortic Valves – Circadian activity for PPCI • Outcome – Stents (BMS and DES) – MACCE – Adjunctive therapy – Outcome by syndrome – LV support – Outcome by lesion subset – Shock – Risk adjusted outcomes Appropriateness 2008 data: Ludman

100%

80%

Under analysis

60%

73426

40% Accepted as appropriate

20%

0% All Cases Appropriateness 2008 data: Ludman

100%

80% 33309

60%

73426

40%

40117 Acute 20%

0% All Cases Stable / Acute Appropriateness 2008 data: Ludman

Of Stable Cases 100% 100%

80% 33309 80% 4 3 60% 60% 2 1 0 40% 40% UnK 40117 20% 20%

0% 0% CCS All Cases Stable / Acute Appropriateness 2008 data: Ludman

Of Stable Cases 100% 100%

80% 33309 80% 4 3 60% 60% 2 1 0 40% 40% UnK 40117 20% 20%

0% 0% CCS All Cases Stable / Acute Appropriateness 2008 data: Ludman Of Stable of CCS 0 or 1

100% 100% 189

1070

80% 80% 33309 3. MPI 910 60% 2. ETT 60% Unk 1. Rest ECG 0. No UnK 40% 1887 40%

40117 20% 20% 944 0% 0% Non All Cases Stable / CCS Invasive Acute Appropriateness 2008 data: Ludman Of Stable of CCS 0 or 1

100% 100% 189

1070

80% 80% 33309 3. MPI 910 60% 2. ETT 60% Unk 1. Rest ECG 0. No UnK 40% 1887 40%

40117 20% 20% 944 0% 0% Non All Cases Stable / CCS Invasive Acute Appropriateness 2008 data: Ludman Of Stable, CCS 0/1, no non invasive testing

100% 100% 144

80% 80% 33309 60% IVUS/FFR Remainder 2435 60% Unk UnK 40%

40% 20%

40117 93 20% 0%

0% All Cases Stable / CCS Non Inva IVUS / FFR Acute Appropriateness 2008 data: Ludman Of Stable, CCS 0/1, no non invasive testing

100% 100% 144

80% 80% 33309 60% IVUS/FFR Remainder 2435 60% Unk UnK 40%

40% 20%

40117 93 20% 0%

0% All Cases Stable / CCS Non Inva IVUS / FFR Acute Appropriateness 2008 data: Ludman

• Stable 100% • CCS 0/1 • no non invasive testing • no invasive testing for ischaemia

80% 33309 Number % ? Inappropriate 2435 3.3 % 60% Unk Unknown 6587 8.8 % 73426

40%

40117 20%

0% All Stable / CCS Non Inv Invas Cases Acute Clinical Syndrome

2008 data: Ludman

80 70 60 54.6 50 % PCI 45.4 Stable Performed for 40 Unstable each Indication 30 20 10

0 2005 2006 2007 2008

CCAD Clinical Syndrome

• % PCI in patients with Acute 2008 data: Ludman syndromes by unit volume

100

% Acute cases 20

0 1000 2000 3000 4000 Number of PCI procedures Indication for PCI

2008 data: Ludman Stable 37.95% NSTEMI / UA STEMI 16.31% Other

1.35%

44.38%

CCAD Indication for PCI

2008 data: Ludman

Stable Other NSTEMI / UA STEMI 1.2 Other 37.95% 1

16.31% 0.8 0.6 1.35% % 2007 0.4 2008 0.2 44.38% 0 SAT Hybrid Staged Bailout

CCAD Indication for PCI

2008 data: Ludman

Stable STEMI NSTEMI / UA STEMI 12 Other 10 37.95% 8 16.31% % 6 1.35% 4 2007 2008 2 44.38% 0 Primary Rescue Facilitated

CCAD PCI for STEMI

2008 data: Ludman 14000 11784 12000 2001 9224 2002 10000 8513 2003 8000 2004 5902 2005 6000 2006 4000 25812560 2007 2000 2008

0 All STEMI Primary PCI Rescue

CCAD Primary PCI for STEMI 2008 data from NHS Centres

Total 9224 procedures 2008 2008 data: Ludman

1000 900 800 700 Number of 600 procedures 500 400 300 200 100 0

CCAD Primary PCI for STEMI

2008 data: Ludman 2004 2005 2006 2007 2008

1000 900 800 700 Number of 600 procedures 500 400 300 200 100 0

Hospitals Primary PCI for STEMI Absolute number PPCI 2008 data: Ludman

1000 900 800 700 600 500 400 300 200

Number of PPCI cases 100 0

0 1000 2000 3000 Number of any type of PCI procedure Primary PCI for STEMI % PPCI of total activity 2008 data: Ludman

40 35 30 25 20 15 10

% of Total PCI Activity PCI Total of % 5 0 0 1000 2000 3000 Number of any type of PCI procedure Primary PCI UK Countries

Total Number of PPCI 2008 data: Ludman

9000 8170 8000 7000

6000 4784 5000 2007 4000 2008 3000 2000 616 935 1000 74 103 0 England Scotland Wales

MINAP records 8099 E&W calendar yr 2008 (98%) CCAD Primary PCI UK Countries

Overall UK = 150 pmp 2008 data: Ludman PPCI pmp

200 181 180 156.2 160 140 120 2007 100 2008 80 60 46.8 40 20 0 England Scotland Wales CCAD Primary PCIs pmp

Data source: www.escardio.org/EAPCI Europe

Average: 448 Switzerland Austria

1,000 Poland

Czech Rep 900 Sweden

800 Hungary

Slovakia 700 Denmark

600 Israel

Lithuania 500 Italy

400 Belgium

Spain 300 UK

200 Bulgaria

PCIs (per million inhabitants per year) PCIs (per million Serbia 100 Greece 0 Turkey European countries Data source: www.escardio.org/EAPCI Romania

Primary PCI for STEMI

‘Balloon’ time in 24/7 units 2008 data: Ludman

2hr = 2.00 to 3.00 am etc Primary PCI for STEMI

‘Balloon’ time in day time only units 2008 data: Ludman Stents Procedures using Stents

2008 data: Ludman

94.7 92 100 90 80 70 60 % of 50 Procedures 40 30 20 10 0 '92 '94 '96 '98 '00 '02 '04 '06 '08 Year

aggregate data up to 2007, CCAD for 2008 Procedures using Stents

Mean = 92% 2008 data: Ludman

100

% PCI with 60 stent 40

0 0 1000 2000 3000 Number of PCI procedures Drug Eluting Stent cases

Mean of % use by Centres 2008 data: Ludman

80 62 63.5 70 55 57 60 53 50 40 30 17 20

% DES cases 10 ? 0 4 8 02 0 05 06 0 0 0 0 2 2003 20 2 2 2007 20

NHS and private Procedures using DES

Mean = 57% 2008 data: Ludman

100

% PCI with 60 DES 40

0 0 1000 2000 3000 Number of PCI procedures Drug Eluting Stent cases NHS % PCI with DES

2008 data: Ludman

100 2003 90 2004 80 2005 70 2006 60 2007 50 2008 ccad 40 2008 agg 30 20 10 0 Scotland England Wales N. Ireland Country Stents per Case

• Mean number of stents per case 2008 data: Ludman

2 1.8 1.63 1.62 1.55 1.6 1.53 1.4 1.2 1 0.8 0.6 0.4 0.2 0 2005 2006 2007 2008

CCAD Mean Stents per Case (by PCI unit) 2008 data: Ludman

2.5

1.5 Stents per case

1 0 1000 2000 3000 4000 Number of PCI procedures BMS and DES use V PCI for Restenosis

2008 data: Ludman

100 14 90 12 80 70 10 60 8 % Stent 50 %DES % Restenosis 40 6 30 4 20 2 10 0 0 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08

PCI for re-stenosis from CCAD Procedures for Restenosis % by total unit activity

2008 data: Ludman

16 14 12 10 % PCI for restenosis 8 6 4 2 0

0 1000 2000 3000 Number of PCI procedures Adjunctive therapy Use by Type

2007 2008 2008 data: Ludman 40 32 30 28 25 % of 21.1 Procedures 20

10 4.9 4.9 2 1.6 1.3 0.6 0

tag b e n n n id a a ima ib x f lirudi Ia iro II ifibat pt T Ib/ Abci E Biva y I An NB Bivalirudin data: agg 2007, CCAD 2008 GP IIb/IIIa Antagonists Use by Presentation

100 2008 data: Ludman 90 74 % Procedures 80 with any GP IIb/IIIa blocker 70 2005 60 2006 50 2007 40 31.6 2008 30 20.3 20 11.9 10 0 I I le A C b U M a PP St STE N CCAD LV Support

2008 data: Ludman Data for circulatory support available for 66,910 procedures

LV Support Number % Inotropes 359 0.54 % IABP 1085 1.62 % LV Support % IABP use by total unit activity

2008 data: Ludman

7 6 5 4 3 2 % used IABP 1 0 0 1000 2000 3000 Number of PCI procedures Cardiogenic Shock % Cases with shock by PCI unit

Shock in 1.4% of cases (1064 of 74,250) 2008 data: Ludman % Shock Cases Treated with IABP support by total PCI unit activity

Mean = 53.6% 2008 data: Ludman

100

80 60 40 20

0 % Shock and IABP used 0 1000 2000 3000 Number of PCI procedures % Shock Cases Treated with IABP support by total PCI unit activity for shock

Mean = 53.6% 2008 data: Ludman

100

% Shock and IABP used and Shock % 0 0204060 Number of PCI s for Shock LV Support 2008 data: Ludman

• Mortality (in hosp) v IABP use in shock – Classification of shock is subjective

40 37

Mortality 30 % 21.7 (to Dx) 20

0 IABP used No IABP used LV Support % cases using IABP v LV function

• Total cases 74,250 2008 data: Ludman • Data from 33,915 cases

14 12.1 12 10 8 % 6 4 2.7 2 0.52 0 Good LV Moderate Poor Multi-vessel Disease Multi-vessel Treatment

2008 data: Ludman 100 78.5 80.1 80 2006 % of all 60 PCIs 2007 40 2008 18.3 20 17 2.9 2.6 0 123 Vessels Treated per case Multi-Lesion Treatment

2008 data: Ludman 100 80 67.8 2006 % of all 60 2007 PCIs 40 2008 23.2 20 6.8 2.3 0 123>3 Number of Lesions treated per case Multi-Lesion Treatment

2008 data: Ludman 1.7

1.6

1.5 1.51

1.4 Lesions per case % Vessels per case 1.3 1.23 1.2

1.1

1 2006 2007 2008 Multi-vessel Treatment

By centre - 2008 2008 data: Ludman

2 Lesions / Case Vessels / Case 1.8 1.6

Ratio 1.4 1.2 1 0 1000 2000 3000 Number of PCI procedures Additional Interventional Coronary Techniques

2008 data: Ludman

∆ % cf Max Units No Mean* 2007 Cases Rotablation 45 1118 +32% 25 81 Laser 11 145 +77% 13 49 Cutting balloon 66 986 -6% 15 137 Thrombectomy 64 3749 +153 % 59 385

Distal protection 63 650 -12% 10 60

*Mean number in units using the technique Aggregate data Rotational Atherectomy

2008 data: Ludman

6 5 4 3 2 1

% of Cases using Rota using % of Cases 0 0 1000 2000 3000 Total Number of PCI procedures Other Diagnostic Techniques

2008 data: Ludman

Max Units No ∆ cf 2007 Mean Cases IVUS 63 2836 +37% 45 469

Press wire 88 5406 +39% 61 318 IVUS and Pressure Wire

2008 data: Ludman

IVUS PW 30 25 20 15 10 5

% Cases with device Cases% with 0 0100020003000 Total Number of PCI procedures Radial Artery Access

2008 data: Ludman • Overall use • Use in different presenting syndromes • Complications – Bleeding – Stroke • Door to Balloon times Radial Artery Access

2008 data: Ludman

35 34.61

30 28.1 25 21.3 % Cases 20 using Radial 15.7 Access 15 10 10.2

0 2004 2005 2006 2007 2008 Radial Artery Access

2006 2007 2008 2008 data: Ludman

100 90 80 70 % Cases 60 using 50 Radial Access 40 30 20 10 0 Individual Centres

CCAD Radial Artery Access

2008 data: Ludman

100 90 80 70 60 50 40 30 20 10 % Cases using radial access radial Cases using % 0 0 500 1000 1500 2000 2500 3000 3500 Number of PCI procedures Radial Artery Access Clinical Syndrome

2008 data: Ludman

40 37.3 34.6 35 33 32.7 30

% Cases 25 using Radial 20 Access 15 10 5 0 All Stable ACS not PPCI STEMI Complication by Access route

Complications to hospital Dx: False aneurysm 2008 data: Ludman Haemorrhage (retroperitoneal, delay Dx, surgery) Art occlusion / dissection Any need for surgery

1.2 1.1 1 0.9

0.8 0.6 2007 % of all cases 0.6 0.5 2008 0.4

0.2

0 Femoral Radial Complication by Access route (including bleeding)

Complications to hospital Dx: 2008 data: Ludman Arterial complications 1 to 11 inclusive: False aneurysm Haemorrhage (retroperitoneal, delay Dx, surgery) Art occlusion / dissection Any need for surgery

PCI hospital outcomes: 5. arterial complication 13. Blood Tx 17. Platelet Tx Complication by Access route (including bleeding)

2008 data: Ludman 1.4 1.2 % Cases 1.2 with 1 Complication 0.76 0.8

0.6

0.4

0.2

0 Femoral Radial

561 of 46,699 188 of 24,719 Complication by Access route CVA

0.2 2008 data: Ludman

% Cases 0.15 with CVA

0.1 0.09

0.06

0.05

0 Femoral Radial

43 of 46,851 13 of 23,444 Door to Balloon time Femoral v Radial

2008 data: Ludman • Methodology – 2008 data – all centres with default STEMi Rx PPCI • 24/7 and day time only – direct admission only • (to avoid problems with D1 or D2) – Primary, no shock – radial v femoral – data cleaning • ignored times > 240 min and negative DTB time Femoral v Radial

2008 data: Ludman Results

FA RA p Cases 2,511 976 Mean 66.02 63.16 0.08 Median 57 54 Femoral closure devices

• % PCI via FA using closure device 2008 data: Ludman FA closure (PCI from FA) 2006 = 39.6% 2007 = 50.7% 2008 = 53.6%

100 90 80 70 60

% 50 40 30 20 10 0 0 500 1000 1500 2000 2500 3000 3500 Number of PCI procedures Contents 2008 data: Ludman • Structure – Multi-vessel treatment – New centres – Additional interventional techniques – Total PCI numbers – Arterial access – No of procedures per unit • complications – PCI pmp and by country • DTB times – PCI Operators • Process of care – Surgical cover – Delays to treatment NSTEMI – Day case activity – Delays to treatment Primary PCI – Primary PCI units • DTB times by unit • PCI Procedure specific data • CTB times by unit – CCAD data completeness • Non coronary intervention – Demographics – HOCM septal ablation – Ethnicity – Mitral valuloplasty • Appropriateness – Other adult structural intervention – indication for PCI / Clinical syndrome – Transcutaneous Aortic Valves – Circadian activity for PPCI • Outcome – Stents (BMS and DES) – MACCE – Adjunctive therapy – Outcome by syndrome – LV support – Outcome by lesion subset – Shock – Risk adjusted outcomes Dataset Updates to 5.4.4

2008 data: Ludman Data point added Data point Jan 09 added June 08 Door 1

Door 2 Symptom Call

Door 1 Balloon Home Time fields Data completeness For Healthcheck 08/09

BCIS Patients treated for STEMI by MINAP Field Field No. Primary PCI No. 2.07 Date/time of symptom onset 3.01 2.08 Date/time of arrival at first hospital 3.06 5.26 Date/time of arrival at PCI hospital 3.26 Date/time of first balloon inflation 3.09 4.04 Discharge date 4.01 > 90% completeness in each Time fields Data completeness

2008 data: Ludman Time fields Data completeness

2008 data: Ludman Time fields Data completeness 2008 data: Ludman Time fields Data completeness

2008 data: Ludman Time fields Data completeness

2008 data: Ludman PCI for Acute Sx

Four admission scenarios 2008 data: Ludman

Admitted from Already the community in hospital

Admission to Non-PCI centre

Direct admission Transfer Hospital is a Hospital is a to PCI centre to PCI centre PCI centre Non-PCI centre PCI for Acute Sx

Four admission scenarios 2008 data: Ludman

Admitted from Already the community in hospital

Admission to Non-PCI centre

Direct admission Transfer Hospital is a Hospital is a to PCI centre to PCI centre PCI centre Non-PCI centre Scheduled reporting

2008 data: Ludman NSTEMI NSTEMI / UA / Convalescent STEMI Direct admission v IHT - 2008

2008 data: Ludman

Time Units Wtd mean of units’ median times Direct: Door to PCI 2.96 Days

IHT: Door 1 to Door 2 3.2 Days Door 2 to PCI 1.0 Days NSTEMI / UA / Convalescent STEMI

Direct admission - 2008 2008 data: Ludman Mean Door to PCI = 2.96 days NSTEMI / UA / Convalescent STEMI

IHT - 2008 2008 data: Ludman Mean D1 to D2 = 3.2 days NSTEMI / UA / Convalescent STEMI

IHT - 2008 2008 data: Ludman Mean D2 to PCI = 1.01 days Primary PCI Primary PCI 2008: Routine Rx for STEMI (NHS centres)

Day only or 24/7: 50 centres 2008 data: Ludman

AMG. Wycombe General Hospital HAM. Hammersmith Hospital RFH. Royal Free Hospital BAL. Barts and the London HH. Harefield Hospital RSC. Royal Sussex County Hospital BAT. Royal United Hospital Bath HHH. Hemel Hempstead General Hospital SAN. Sandwell District General Hospital BHR. Royal Berkshire and Battle Hospital KCH. King's College Hospital SCM. James Cook University Hospital BOU. Royal Bournemouth General Hospital LGI. Yorkshire Heart Centre SGH. Southampton General Hospital BRD. Bradford Royal Infirmary LIS. Lister Hospital STH. St Thomas' Hospital BRI. Bristol Royal Infirmary MOR. Morriston Hospital STM. St Mary's Hospital CHN. Nottingham City Hospital MRI. Manchester Royal Infirmary STO. North Staffordshire Hospital CRG. Craigavon Area Hospital NCR. New Cross Hospital SUN. Sunderland Royal Hospital DGE. Eastbourne DGH NGS. Northern General Hospital TOR. Torbay Hospital DUD. City Hospital NHB. Royal Brompton Hospital UCL. University College Hospital EBH. Birmingham Heartlands Hospital NHH. North Hampshire Hospital UHW. University Hospital of Wales ERI. Royal infirmary of Edinburgh NPH. Northwick Park Hospital VIC. Victoria Hospital ESU. East Surrey Hospital QAP. Queen Alexandra Hospital WAL. Walsgrave Hospital GEO. St George's Hospital QEB. Queen Elizabeth Hospital Edgbaston WIG. Glasgow Western Infirmary GRI. Glasgow Royal Infirmary RAD. John Radcliffe Hospital WYT. Wythenshawe Hospital GRL. Glenfield Hospital RDE. Royal Devon & Exeter Hospital Primary PCI 2008: Routine Rx for STEMI (NHS centres)

24/7: 28 centres 2008 data: Ludman

BAL. Barts and the London NCR. New Cross Hospital BRD. Bradford Royal Infirmary NGS. Northern General Hospital BRI. Bristol Royal Infirmary NHB. Royal Brompton Hospital DUD. City Hospital RAD. John Radcliffe Hospital EBH. Birmingham Heartlands Hospital RDE. Royal Devon & Exeter Hospital ERI. Royal infirmary of Edinburgh RFH. Royal Free Hospital GEO. St George's Hospital SAN. Sandwell District General Hospital GRI. Glasgow Royal Infirmary SCM. James Cook University Hospital HAM. Hammersmith Hospital STH. St Thomas' Hospital HH. Harefield Hospital STM. St Mary's Hospital HHH. Hemel Hempstead General Hospital UCL. University College Hospital KCH. King's College Hospital WAL. Walsgrave Hospital LGI. Yorkshire Heart Centre WIG. Glasgow Western Infirmary MRI. Manchester Royal Infirmary WYT. Wythenshawe Hospital Primary PCI 2008: Routine Rx for STEMI (NHS centres)

Anomalies 2008 data: Ludman • > 20 cases but “not” PPCI centre – Fre. Freeman

• Doing PPCI but < 5 cases in CCAD

BRD. Bradford Royal Infirmary no cases in ccad ERI. Royal infirmary of Edinburgh no cases in ccad CHN. Nottingham City Hospital no cases in ccad GRI. Glasgow Royal Infirmary no cases in ccad DGE. Eastbourne DGH no cases in ccad WIG. Glasgow Western Infirmary no cases in ccad ESU. East Surrey Hospital 1 case NGS. Northern General Hospital no cases in ccad NHB. Royal Brompton Hospital 1 case NPH. Northwick Park Hospital 3 cases STM. St Mary's Hospital no cases in ccad VIC. Victoria Hospital 2 cases Primary PCI 2008: Routine Rx for STEMI (NHS centres)

• Final Funnel analysis 2008 data: Ludman – all units that described as using PPCI as default Rx for STEMI and have cases in CCAD – plus: • FRE. Freeman • No time data from – GEO. St George’s Hospital – NPH. Northwick Park Hospital

Note: – Call time only mandatory from Jan 2009 – Door 1 and Door 2 times mandatory from Aug 2008 Primary PCI 2008: Routine Rx for STEMI (NHS centres)

2008 data: Ludman Direct admission to PCI unit only Exclusions: cardiogenic shock and pre-procedure ventilation • Door to Balloon – Mean 53.8 min – 81.3% of all patients < 90 min

• Call to Balloon – Mean 116.6 min – 78.8 % of all patients < 150 min Primary PCI Door to Balloon time (min) 2008 data: Ludman

Mean = 53.8 Primary PCI

Door to Balloon Time (%<90 min) 2008 data: Ludman

Mean 81.3%

solid points = no A&E on site Data not Primary PCI mandatory in 2008 Call to Balloon time (min) 2008 data: Ludman

Mean = 116.6

solid points = no A&E on site Data not mandatory Primary PCI in 2008 Call to Balloon time (%<150 min) 2008 data: Ludman

Mean = 78.8%

solid points = no A&E on site PPCI for STEMI

Direct admission - 2008 2008 data: Ludman Mean PCI to Discharge or transfer = 2.6 days PPCI for STEMI Direct admission to PCI centre - 2008

All units treating > 5 cases by PPCI 2008 data: Ludman (not just those with default PPCI strategy)

Time Units Wtd mean of units’ median times Symptom to arrival 1.9 Hours n=3631 Door to Balloon 53.8 Min n=3662 Call to Balloon 111.3 Min n=2159 PCI to discharge 2.59 Days n=4229 Contents 2008 data: Ludman • Structure – Multi-vessel treatment – New centres – Additional interventional techniques – Total PCI numbers – Arterial access – No of procedures per unit • complications – PCI pmp and by country • DTB times – PCI Operators • Process of care – Surgical cover – Delays to treatment NSTEMI – Day case activity – Delays to treatment Primary PCI – Primary PCI units • DTB times by unit • PCI Procedure specific data • CTB times by unit – CCAD data completeness • Non coronary intervention – Demographics – HOCM septal ablation – Ethnicity – Mitral valuloplasty • Appropriateness – Other adult structural intervention – indication for PCI / Clinical syndrome – Transcutaneous Aortic Valves – Circadian activity for PPCI • Outcome – Stents (BMS and DES) – MACCE – Adjunctive therapy – Outcome by syndrome – LV support – Outcome by lesion subset – Shock – Risk adjusted outcomes Alcohol Mediated Septal Ablation

∆ cf Units No Mean Max 2008 data: Ludman 2007 Septal ablation 12 62 +27% 5 15

16 14 12 10 8 2008 6 4

Number of Procedures of Number 2

0 Individual Centres Adult non coronary intervention

2008 data: Ludman

∆ cf Max Units No. Mean 2007 Cases MV plasty 24 97 -37% 5 12 AV plasty 17 177 +581% 10 33 PV plasty 12 38 +41% 3.2 10 TV plasty 110% 1 1 PDA 15 72 -27% 4.8 21 ASD 33 615 +7% 19 58 PFO 37 874 +10% 24 87 Adult non coronary intervention

2008 data: Ludman

∆ cf Units No Mean Max 2007 VSD congen 818-14% 62 VSD post MI 617-10% 39 LAA occlusion 00 0 0 Paravalvular leak 817 2 5 closure Adult great vessel intervention

2008 data: Ludman

∆ cf Units No Mean Max 2007 Coarct / Re-coart 12 73 -11% 615 Carotid 5 119 +95% 24 98 Aorta 3 106 +71% 35 82 Pulm art 5 16 -45% 3.6 7 World wide TAVI

2008 data: Ludman 4000 3500 3000 2500 Corevalve 2000 Edwards 1500 Total 1000 500 Number of Procedures 0 2007 2008 Year Transcatheter Valves

2008 data: Ludman

Max Units No Mean Cases Transcatheter Aortic Valve Implantation (TAVI) CoreValve: Femoral 10 165 17 24 CoreValve: Subclavian 5 10 2 4 Edwards: Femoral 8 51 6.4 16 Edwards: Apical 9 66 7.3 23 Total = 292 UK TAVI

• TAVI Dataset agreed 2008 data: Ludman – Collection via CCAD – Web browser interface – Version: 3.7 (Sept 2009)

https:// www.ncasp.org.uk UK TAVI 2008 data: Ludman Implanted devices in CCAD as % of activity Bristol Freeman Leeds Liverpool London Chest Manchester Oxford Plymouth Southampton St Georges Wolverhampton Brighton Brompton Leicester Wythenshawe Kings Health St Marys Papworth Blackpool Stoke Birmingham 0 20406080100 As Sept 09 UK TAVI 2008 data: Ludman Implanted devices in CCAD as % of activity Bristol Freeman Leeds Liverpool London Chest Manchester Oxford Plymouth Southampton St Georges Wolverhampton Brighton Brompton Leicester Wythenshawe Kings Health St Marys Papworth Blackpool Stoke Birmingham 0 20406080100 As Sept 09 UK TAVI 2008 data: Ludman Implanted devices in CCAD as % of activity Bristol Freeman Leeds Liverpool London Chest Manchester Oxford Plymouth Southampton St Georges Wolverhampton Brighton Brompton Leicester Wythenshawe Kings Health St Marys Papworth Blackpool Stoke Birmingham 0 20406080100 As Sept 09 Percutaneous Valves

2008 data: Ludman

∆ % cf Units No Mean Max 2007

Pulmonary Valve 5 62 +107% 12 23 Percutaneous Valves

2008 data: Ludman

∆ % cf Max Units No Mean 2007 Cases Mitral Valve Repair Mitra-clip 2 3 1.5 2 Viacor 0 Carillon 0 Monarch 0 Total = 3 Contents 2008 data: Ludman • Structure – Multi-vessel treatment – New centres – Additional interventional techniques – Total PCI numbers – Arterial access – No of procedures per unit • complications – PCI pmp and by country • DTB times – PCI Operators • Process of care – Surgical cover – Delays to treatment NSTEMI – Day case activity – Delays to treatment Primary PCI – Primary PCI units • DTB times by unit • PCI Procedure specific data • CTB times by unit – CCAD data completeness • Non coronary intervention – Demographics – HOCM septal ablation – Ethnicity – Mitral valuloplasty • Appropriateness – Other adult structural intervention – indication for PCI / Clinical syndrome – Transcutaneous Aortic Valves – Circadian activity for PPCI • Outcome – Stents (BMS and DES) – MACCE – Adjunctive therapy – Outcome by syndrome – LV support – Outcome by lesion subset – Shock – Risk adjusted outcomes Outcome Data sources 2008 data: Ludman

• Success, Mortality CVA and Emergency CABG – CCAD – No data from aggregate forms (Some England pp, some NI)

• QMI – CCAD – Denominator: Total PCI procedures except PCI for STEMI (only tiny numbers of STEMI treated in units not submitting to CCAD) • NQMI – CCAD – Denominator: Total PCIs for stable symptoms MACE - All PCIs 2008 data: Ludman NQMI Em Procedure QMI CVA Mortality Year Success (stable) CABG % (%) (%) (%) (%) (%) 1997 92 1.2 1.1 0.89 1998 92 0.8 0.7 0.80 1999 90 0.57 0.48 0.61 2000 92 0.6 0.4 0.64 2001 94 0.5 0.4 0.75 2002 92 0.57 0.28 0.54 (51 of 64) (49 of 64) (53 of 64) (53 of 64) 2003 92 0.36 0.29 0.53 (62 of 73) (56 of 73) (64 of 73) (64 of 73) 2004 93.5 0.30 0.21 0.56 (63 of 78) (57 of 78) (64 of 78) (66 of 78) 2005 90.2 0.24 0.12 0.59 2006 95.5 0.15 0.74 0.09 0.74 2007 92.1 0.14 0.62 0.08 0.89 2008 91.8 0.25 0.51 0.07 0.08 1.03 Adverse Outcomes - Death

• % of all cases with in-hospital death 2008 data: Ludman – Overall mean = 1.03

3 2.5 2

% 1.5 1 0.5 0 0 1000 2000 3000 Number of PCI procedures Adverse Outcomes - CVA

• % of all cases with CVA (not TIA) 2008 data: Ludman – Overall mean = 0.08

0.6 0.5 0.4

% 0.3 0.2 0.1 0

0 1000 2000 3000 Number of PCI procedures Adverse Outcomes – CABG

• % of all cases needing emergency CABG 2008 data: Ludman – Overall mean = 0.07

0.6 0.5 0.4

% 0.3 0.2 0.1 0

0 1000 2000 3000 Number of PCI procedures Adverse Outcome Death and emergency CABG

3.0 2008 data: Ludman

2.5

2.0 Mortality % 1.5 em CABG 1.0

0.5

0.0

2 6 2 6 '91 '9 '93 '94 '95 '9 '97 '98 '99 '00 '01 '0 '03 '04 '05 '0 '07 '08 Outcome 2008

Elective Patients 2008 data: Ludman No. Partial Fail no Em All as % Success Re-PCI QMI Death cases success comp CABG Stable SV 19,128 95.3 3.3 0.11 0.13 0.07 0.1 (no CTO)

MV 5179 92.8 5.8 0.90 0.23 0.30 0.05 0.25 (no CTO)

SV CTO 2942 68.5 28.9 0.20 0.07 0.14 0.14

MV CTO 778 72.4 23.8 3.5 0.13 0.26 0 0 Overall Stable ALL 29,372 91.5% 0.14 0.16 0.07 0.13 Outcome 2008

2008 data: Ludman

Partial Fail no Re- Em No. Success QMI Death All as % success comp PCI CABG NSTEMI / UA 26,264 no shock 93.4 2.5 3.3 0.3 0.4 0.07 0.62 All STEMI 10,766 93.6 1.9 2.4 0.6 0.07 2.0 no shock

Primary PCI 8513 91.2 2.1 2.6 0.7 0.08 4.1

Rescue PCI 2129 91.0 2.2 2.2 0.6 0.05 4.7

Shock 1040 62.7 3.9 3.2 1.4 0 29.7 Summary: Mortality Risk Stratified by Syndrome

6 2008 data: Ludman 4.8 4.3 4.7 5 4.1 2003 4 2004 2005 % 3 2006 2 2007 0.89 1.03 0.61 2008 1 0.14 0.62 0.13 0 All Elective UA / Primary Rescue NSTEMI PCI Mortality by Syndrome

40 2008 data: Ludman 35 30 2003 25 2004 2005 % 20 2006 15 2007 10 2008 5 0 All Elective UA / Primary Rescue Shock NSTEMI PCI Primary PCI Mortality v Volume Funnel 2008 data: Ludman Bypass grafts PCI of SVG and Arterial 2008

2008 data: Ludman

Partial Fail no Re- Em No. Success QMI Death All as % success comp PCI CABG Bypass Grafts 4308 91.0 3.2 5.2 0.3 0.16 0.02 0.56 Bypass Grafts (all types - SVG and IMA etc)

2008 data: Ludman • Distal protection in 10.4%

100% 402

80%

60% Distal protection used 3465 No distal protection 40%

20%

0% Bypass graft Rx Chronic Total Occlusions 2008

2008 data: Ludman

Partial Fail no Re- Em No. Success QMI Death All as % success comp PCI CABG Chronic Total Occlusion 5949 67.6 8.0 21.7 0.3 0.4 0.13 1.1 Unprotected LMS 2008

2008 data: Ludman

Partial Fail no Re- Em No. Success QMI Death All as % success comp PCI CABG Unprotected LMS 1084 83.9 5.3 2.6 0.6 0.46 0.5 8.0

N.B. Includes all clinical presentations (including shock) In hospital outcome Models

2008 data: Ludman

• Shared risk factors – Age – Gender – Urgency – Shock – LMS treatment Age and Syndrome v Mortality

2008 data: Ludman 20 all 18 <40 16 <50 14 <60 Mortality 12 <70 (%) in 10 hospital <80 8 <90 6 4.06 4 <99 2 0.82 0.15 0 stable acs not stemi stemi Age and Syndrome v Mortality

2008 data: Ludman all 20 18 <40 16 <50 14 <60 Mortality 12 (%) in <70 10 hospital <80 8 <90 6 4.06 4 <99 0.82 2 0.15 0 stable acs not stemi stemi Gender v Mortality

In Hospital Mortality 2008 data: Ludman

6 5 4 Male % 3 Female 2 1.36 0.95 1 0 Overall Stable STEMI Gender v Mortality

In Hospital Mortality 2008 data: Ludman

6 5.44 5 4 3.58 Male % 3 Female 2 1.36 0.95 1 0.14 0.16 0 Overall Stable STEMI Risk adjusted outcome Assessment of unit specific performance

• 2007 + 2008 data 2008 data: Ludman • Data monitoring committee – assessed Cumulative funnels for each unit • Plots of each unit’s overall risk adjusted outcome Observed MACCE

Predicted MACCE

+3 σ +2 σ -2 σ -3 σ Observed MACCE

Predicted MACCE ? +3 σ +2 σ -2 σ -3 σ Babu Kunadian, Joel Dunning, Anthony P Roberts, Robert Morley, Darragh Twomey, James A Hall, Andrew G C Sutton, Robert A Wright, Douglas F Muir and Mark de Belder BMJ 2008;336:931-4 Babu Kunadian, Joel Dunning, Anthony P Roberts, Robert Morley, Darragh Twomey, James A Hall, Andrew G C Sutton, Robert A Wright, Douglas F Muir and Mark de Belder BMJ 2008;336:931-4 Outcome MACCE for 2007 and 2008

After all PCIs for 2007 and 2008 2008 data: Ludman

Observed MACCE

Predicted MACCE Outcome MACCE for 2007 and 2008

After all PCIs for 2007 and 2008 2008 data: Ludman

Risk Adjusted MACCE (for unit x) =

Observed MACCE Observed MACCE (all cases) X (for unit x) Predicted MACCE Outcome 2008 data: Ludman Data for 2007 and 2008

Observed MACCE = 1.4%

Units with >50% PCIs in CCAD Outcome 2008 data: Ludman Data for 2007 and 2008

Units with >50% PCIs in CCAD Potential Problems

2008 data: Ludman

• Possible under reporting of MACCE – what happens after patient leaves lab – Rx and transfer – Data collection issues – Outperforming the model Potential Problems

2008 data: Ludman

• Risk Models – Shock – Heavy weighting – Subjective assessment Developments

• Regular reports 2008 data: Ludman

Cumulative Funnel report

1. Satisfactory 2. Possible under reporting of MACCE 3. Possible higher than predicted MACCE

• Development of a mortality only model • Peer assessment of outlying case mix? Developments

• Revalidation 2008 data: Ludman – Unit specific data – Operator specific data • GMC number to be added to dataset • Private units - CCAD Summary 2008

• 105 PCI centres in UK • 1,308 PCI pmp in UK • Smaller increase in PCI continues • Radial access related to less complications • Early analysis of PPCI timings encouraging • Risk adjusted outcomes appear good • Plans – Improve reporting of syndromes and outcomes – Develop mortality model (ONS validation) – Potential role in revalidation – Call to balloon times mandatory from Jan 2009

• Additional data on the web site The End

Acknowledgments • Andrew Donald – Programmer at CCAD • Peter Nightingale – Statistician University Hospital Birmingham • Tony Roberts and Robert Morley – Statistical process control chart development • Owen Nicholas – Statistician at NICOR