Meaningful Treatments In The Battle Against Coronary Disease

Tue, 01/17/2012 - 4:32am
Eric Van De Graaff, MD

I saw a patient in my office this week who had received a stent from one of my partners last month. The man was highly satisfied with his experience—the procedure was tolerable, the recovery short, and the nurses were pretty (he specifically made a point of this, presumably because the post-hospitalization customer surveys don’t include what seemed to him to be the most important feedback metric)—but his wife had a different opinion. She was upset (and not about the nurses).

“Why did he get only one stent?”

The cardiac catheterization had apparently revealed the presence of at least a couple of blockages. The 99% narrowing—the one that was stented—was the clear cause of his chest tightness, and fixing this one had dramatically improved the patient’s ability to get from the couch to the refrigerator without gasping for breath and clutching his chest. Another coronary vessel tapered to 70%, the cardiologist estimated, but that artery received no stent. I pulled up the images from the procedure and saw that other minor disease was present but none that impinged on the vessel by more than 20 or 30%.

The concern from the patient’s wife is valid. Why not put a stent in the 70% vessel while you’re in there? The question implies the underlying logic that a 70% blockage, while perhaps not yet critical, will progress over time and eventually cause a heart attack: Let’s just put in a stent now and prevent future problems. This same line of reasoning applies to so many other things we deal with. Take cars, for example. If three of my tires are bald and the fourth is 70% bald, wouldn’t it make sense to replace them all? I know for a fact that my own mechanic has squeezed me for plenty of cash by successfully applying this logic to brake pads, filters, belts, etc.

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