We almost never do plain old balloon angioplasty in our place anymore. To many, that technique seems so last century. We have moved on to better procedures that have made restenosis a relatively rare occurrence.
We have even changed the name of the procedure. If an intern on rounds utters the word “angioplasty,” we quickly correct him or her, using the opportunity to teach the meaning of “percutaneous coronary intervention.” Angioplasty, we say, derives from Greek words meaning “molding of the vessel” – whereas PCI involves more than molding, often the implantation of a stent.
The problem with stenting is that we have exchanged a higher 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 – aspirin and a thienopyridine – but only if the patient can purchase the pills and take them.
During the last two weeks, experiences with several of my patients who received stents for the treatment of AMI 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 price of the antiplatelet drugs, in addition to the other medications their care required, represented a heavy burden for these individuals. Pharmaceutical company assistance programs require at least a month and a lot of paperwork. And cost is not the only problem; some of my patients have developed contraindications to dual antiplatelet therapy during hospitalization, putting them in an especially difficult position.
I know that one of my patients, despite all pleading and efforts 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 though he has just survived a devastating MI with many complications – including a retroperitoneal bleed requiring multiple transfusions – which only makes our discharge instructions more difficult to give.
Would he have been better off with a POBA and the risk of restenosis? If so, could we have known that in advance?
I worry that for some patients, we have set up a dangerous situation in our attempts to do good and provide the most advanced care.