In this issue of Heart Bagust and colleagues¹ report on their view of the cost effectiveness of the drug eluting stents (DES) in the UK. The remarkable conclusion of this manuscript appears to be that DES should only be used in 4% of patients on economic grounds. Previous National Institute for Health and Clinical Excellence (NICE) guidelines² supported DES use in small vessels (< 3 mm) and longer lesions (> 15 mm) and it was anticipated this would result in a 30% use per lesion. The conclusions of the current paper are highly controversial and deserve further comment.

SINGLE CENTRE STUDY

The Bagust paper is based on a 12 month audit from a single centre in the UK, the Cardiothoracic Centre-Liverpool. The main outcome measured was the potential reduction in risk of repeat revascularisation produced by the use of DES rather than bare metal stents within 12 months of an index procedure. A proportional hazard model for the risk of repeat revascularisation within 12 months was used to identify factors associated with restenosis. In elective patients calcification, angulation > 45°, treatment of restenotic lesions, and triple vessel disease were identified and in non-elective patients, only vessel diameter of < 2 mm and prior coronary artery bypass grafting. Based on these data the Liverpool group conclude that in elective patients DES are only cost effective (based on the usually quoted UK cost effectiveness threshold of £30 000 per quality of life-year (QUALY) gained) when two or more of the identified factors were present. In non-elective patients DES are only effective if they are placed in vein grafts of < 2 mm in diameter (that is, both risk …