NICE Technology Appraisal

Drug-eluting stents

Keith Jackson, National Chairman

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  While from time to time the Association is invited to participate in appraisals that the National Institute for Health and Clinical Excellence NICE is carrying out, I cannot recall a time when such an action has been reported to members through the Journal.

  However, it would seem appropriate to report on a recent decision taken by NICE.

  Early in August NICE made a preliminary decision not to recommend drug-eluting stents as treatment for coronary heart disease on the basis of cost effectivencess. This is despite a ruling in 2003 that approved their use in patients that are at particular risk of restenosis (re-narrowing of arteries), the fact they are now used in up to 60% of angioplasty procedures, and that they have improved the quality of life for hundreds of thousands of patients. If these recommendations are reflected in NICE’s final decision, this will have a profound impact on patients and on the NHS.

  Coronary heart disease, CHD, is the UK’s biggest killer, accounting for 117,500 deaths annually in the UK. Coronary artery disease or the narrowing of arteries is the major cause of CHD.

  There are two types of revascularisation procedure that treat this condition:

  • invasive open heart surgery (eg CABG); or
  • a percutaneous coronary intervention, also known as angioplasty.

  Angioplasty involves widening the artery using metal stents. It is a less invasive procedure and now accounts for more than three quarters of all revascularisations due to patient preference (as it means less recovery time and decrease in morbidity) and on the basis of cost (an angioplasty procedure costs half as much as open heart surgery).

  Drug-eluting stents were developed to help prevent restenosis that can affect angioplasty patients. If the NICE recommendation becomes a final decision, patients would only be treated with the older technology – bare metal stent – which would represent a complete reversal in the treatment of heart disease.

  Treatment using only bare-metal stents will mean thousands of patients will have to undergo unnecessary repeat procedures as they develop restenosis. Moreover, clinicians will refer many more patients to open heart surgery, as the risk of restenosis within certain patient subgroups, such as diabetics, is so high (24.9%). This will impact on patient’s quality of life, recovery times, and on patient choice.

  Furthermore, the NHS will be put under enormous strain and forced to absorb extra costs. If many more patients go back to hospital for repeat procedures, this will mean much greater costs to the NHS in the long-term. Additionally, if the trend towards more treatment through angioplasty rather than open-heart surgery is reversed, the NHS will have to cover the bill for this more expensive procedure and associated hospital stays. This could also mean an increase in waiting lists and put at risk the considerable achievement the NHS has made in meeting the 2000 National Service Framework targets on heart disease. The NHS simply will not have the capacity to deal with more repeat procedures and substantially greater numbers of open-heart surgery cases. None of these points were taken into consideration during the NICE review.

  These recommendations have come as a shock to many clinicians and those in the medical world. It represents a huge step backwards for the NHS and condemns patients to an outdated technology. It will have a considerable impact on patient care and overall cost for the NHS. Drug eluting stents are widely used in most other healthcare systems in developed countries around the world and their ban in the UK would send a very unhelpful message to those involved in developing the latest technologies and therapies.

  It may be that you would wish to write to the Secretary of State for Health* asking him to ask NICE to look again at this technology and the available evidence. It is inconceivable that a technology that has been used so widely and with such enthusiasm in the NHS by clinicians, and benefitted so many patients should be withdrawn.

* Rt Hon Alan Johnson MP, Secretary of State for Health, Richmond House, 79 Whitehall, London SW1A 2NS Tel: 020 7210 4850 Website:

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