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Not Quite Common Sense

Posted Aug 24 2008 9:52pm

A conversation after I perform a coronary angiogram:

Me: You have a blockage in your artery.

Patient: So you put in a stent?

Me: No.

Patient: You didn't open the blockage?

Me: No. You will do better with medicine.

Patient: The blockage is still there?

Me: Yes. But it was a complicated blockage, and putting a stent in it just wouldn't be the right thing to do. Medication is a better way to treat this.

Patient: Medicine? For a blockage?

It seems intuitive -- Find blockage, open blockage, patient all better. It doesn't quite work that way. In fact, there's a trial published last year called the COURAGE trial that found that many patients with stable coronary disease do better with medicines than with angioplasty. There are definitely situations where angioplasty is the right thing to do, but there are others where medicines or surgery are better options.

Further, any time we place wires, balloons, and stents in a coronary artery, there is a risk. We could tear the artery. We could puncture a hole in the artery, causing blood to accumulate in the pericardium, the sac around the heart. And the dye that we use can cause injury to the kidneys. These are just some of the many possible life-threatening complications.

I'm sure there may be a few unscrupulous cardiologists out there who would be willing to put a stent in just about anything. The patient knows the blockage is open and does well, perhaps just as well as if no stent had been deployed, and yet an unnecessary risk has been taken.

Maybe it's a hard sell to say that there's a blockage and it's better not to open it. But, often it's the best thing to do.
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