{"id":1344,"date":"2009-11-29T09:05:01","date_gmt":"2009-11-29T14:05:01","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/return-to-poba\/"},"modified":"2011-07-19T17:45:31","modified_gmt":"2011-07-19T21:45:31","slug":"return-to-poba","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2009\/11\/29\/return-to-poba\/","title":{"rendered":"Return to POBA?"},"content":{"rendered":"

We almost never do plain old balloon angioplasty in our place anymore. To many, that technique seems\u00a0so<\/em> last century. We have moved on to better procedures\u00a0that\u00a0have\u00a0made restenosis\u00a0a relatively rare occurrence.<\/p>\n

We have even changed the name of the procedure. If an intern on rounds\u00a0utters the word “angioplasty,” we quickly correct him or her, using the opportunity\u00a0to teach the meaning of “percutaneous coronary intervention.”\u00a0 Angioplasty, we say,\u00a0derives from Greek words meaning “molding of the vessel”\u00a0— whereas PCI involves more than molding,\u00a0often the implantation of\u00a0a stent.<\/p>\n

The problem with stenting is that we have exchanged\u00a0a\u00a0higher risk of restenosis, an annoying but generally non-life-threatening event, for a lower risk of stent thrombosis, an often abrupt, often catastrophic closure of the vessel that can result in AMI and death. The stent thrombosis risk can be mitigated with dual antiplatelet therapy —\u00a0aspirin and a thienopyridine\u00a0— but\u00a0only if\u00a0the patient can purchase the pills and take them.<\/p>\n

During\u00a0the last two weeks, experiences with several of my patients who received stents\u00a0for the treatment of\u00a0AMI had me reflecting on our progress. As their hospitalizations came to a close, it became clear that they could not afford clopidogrel and had few options. The\u00a0price\u00a0of\u00a0the antiplatelet drugs, in addition to the other medications their care required,\u00a0represented a heavy burden for these individuals. Pharmaceutical company assistance programs\u00a0require at least a month and\u00a0a lot of\u00a0paperwork.\u00a0And\u00a0cost is not the only problem;\u00a0some of my patients have developed contraindications to dual antiplatelet therapy during hospitalization, putting them in an especially difficult position.<\/p>\n

I know that one of my patients, despite all\u00a0pleading and\u00a0efforts to make the pills affordable, will almost certainly not buy and take them. He is an undocumented resident who has lived in our area for 14 years. He occasionally finds work as a painter and has a loving family and many friends. He has a warm smile, even\u00a0though he has just survived a devastating MI with many complications\u00a0— including a retroperitoneal bleed requiring multiple transfusions\u00a0— which only makes our\u00a0discharge instructions\u00a0more difficult to give.<\/p>\n

Would he have been better off with a POBA and the risk of restenosis? If so, could we have known that in advance?<\/p>\n

I worry that for some patients,\u00a0we have set up a dangerous situation in our attempts to do good and provide the most advanced care.<\/p>\n","protected":false},"excerpt":{"rendered":"

We almost never do plain old balloon angioplasty in our place anymore. To many, that technique seems\u00a0so last century. We have moved on to better procedures\u00a0that\u00a0have\u00a0made restenosis\u00a0a relatively rare occurrence. We have even changed the name of the procedure. If an intern on rounds\u00a0utters the word “angioplasty,” we quickly correct him or her, using the […]<\/p>\n","protected":false},"author":211,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1,9],"tags":[],"class_list":["post-1344","post","type-post","status-publish","format-standard","hentry","category-general","category-interventional-cardiology"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/1344","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/211"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=1344"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/1344\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=1344"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=1344"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=1344"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}