Hobson’s Choice

Thomas Hobson was a livery stable owner in Cambridge, England, in the 17th century who had an extensive stable of over 40 horses and ran a thriving horse rental business. His customers believed that, on entry, they would be given their choice of mounts, when in fact he offered them no choice: Hobson required that all his customers choose the horse in the stall closest to the door or have no horse at all. Literally, they had no choice but Hobson’s choice. Similarly, in percutaneous coronary intervention (PCI), adjunctive pharmacotherapy with platelet inhibitors and anticoagulant regimes have improved clinical outcomes through a reduction in ischemic events, including stent thrombosis,1–3 albeit at the expense of increased bleeding complications.4 Although the delivery of antiplatelet agents and anticoagulant regimes can be personalized at an individual patient level in an attempt to balance the reduction in ischemic risk while minimizing the increased risk of major bleeding, like Hobson’s choice in the 17th century, there is currently no option to avoid these agents altogether in PCI in patients with high bleeding risk. Thus, in general, it is either antiplatelet inhibition or no PCI—a 21st century interventional cardiologist’s manifestation of Hobson’s choice.See Article by Groves et al Thrombocytopenia is not uncommon in patients undergoing PCI with a reported prevalence of around 6% in a pooled analysis of the ACUITY trial (Acute Catheterization and Urgent Intervention Triage Strategy) and HORIZONS-AMI trial (The Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction),5 with ≤7% of elective patients6 and 13% of patients with acute coronary syndrome (ACS) developing new thrombocytopenia during their hospitalization.7 Patients with thrombocytopenia tend to be older,5 …