Drug-eluting stents: NICE guidelines and the reality

The National Institute for Clinical Excellence (NICE) stent appraisal (2003) defined criteria for the use of drug-eluting stents (DES) on the basis of lesion length, vessel diameter and the absence of recent myocardial infarction or intra-luminal thrombus. The appraisal suggested that as many as one third of all stents may need to be DES.
In order to determine the requirement for DES and adherence to these guidelines, we assessed 1,673 consecutive patients undergoing coronary intervention over a 17-month period. A total of 2,513 stents were implanted, of which 50.1% were DES. In all, 77.4% of patients fulfilled NICE criteria for at least one DES. A further 7.3% of patients were excluded because of either a recent (< 24 hours) myocardial infarct or visible intra-luminal thrombus. A total of 33.4% of patients who did fulfil NICE criteria for DES deployment inappropriately received a bare-metal stent (BMS) whilst 5.7% patients inappropriately received a DES. These results would suggest that NICE have grossly underestimated the need for DES in ‘real world’ practice. Despite our centre using a high volume of DES, significant numbers of patients were inappropriately treated with BMS, with a smaller number inappropriately treated with DES, according to NICE criteria.