NYT

January 6, 2009

Personal Health

More Isn’t Always Better in Coronary Care

By JANE E. BRODY

Ira’s story is a classic example of invasive cardiology run amok.
Ira, of Hewlett, N.Y., was 53 when he had an exercise stress test as part of an insurance policy application. Though he lasted the full 12 minutes on the treadmill with no chest pain, an abnormality on the EKG led to an angiogram, which prompted the cardiologist to suggest that a coronary artery narrowed by atherosclerosis be widened by balloon angioplasty, with a wire-mesh tube called a stent inserted to keep the artery open.

The goal, he was told, was to prevent a clot from blocking the artery and causing a heart attack or sudden cardiac death.

Wanting to avoid an invasive procedure, Ira decided to pursue a less drastic course of dieting, weight loss and cholesterol-lowering medication. But three years later, the specter of a stent arose again. An abnormal reading on a presurgical EKG led to another angiogram, which indicated that the original narrowing had worsened. Cowed by the stature of the cardiologist, Ira finally agreed to have not one but three coronary arteries treated with angioplasty and drug-coated stents, making him one of about a million Americans who last year underwent angioplasties, most of whom had stents inserted.

Being Treated While HealthyFor patients in the throes of a heart attack and those with crippling chest pain from even minor exertion, angioplasty and stents can be lifesaving, says Dr. Michael Ozner, a Miami cardiologist and the author of “The Great American Heart Hoax” (Benbella Books, $24.95). But, Dr. Ozner said in an interview, such “unstable” patients represent only a minority of those undergoing these costly and sometimes risky procedures.

Most stent patients are healthy like Ira, who was experiencing no chest pain or cardiac symptoms of any sort. Yet Ira was afraid not to follow the doctor’s advice, despite the fact that no study has shown that these procedures in otherwise healthy patients can reduce the risk of heart attacks, crippling angina or sudden cardiac death. “We’ve extended the indications for surgical angioplasty and stent placement without any data to support the procedures in the vast majority of patients — stable patients with blockages in their arteries,” Dr. Ozner said.

What the studies do show, Dr. Ozner said, is that putting stents in such patients is no more protective than following a heart-healthy lifestyle and taking medication and, if necessary, nutritional supplements to reduce cardiac risk. The studies have also shown that stents sometimes make matters worse by increasing the chance that a dangerous clot will form in a coronary artery, as noted in 2006 by an advisory panel to the Food and Drug Administration.
Dr. Ozner, medical director of the Cardiovascular Prevention Institute of South Florida, is one of many prevention-oriented cardiologists vocal about the overuse of “interventional cardiology,” a specialty involving invasive coronary treatments that have become lucrative for the hospitals and doctors who perform them.

Even some interventional cardiologists have expressed concern about the many patients without symptoms who are treated surgically. “The only justification for these procedures is to prolong life or improve the quality of life,” said Dr. David L. Brown, an interventional cardiologist and chief of cardiology at Stony Brook University Medical Center, “and there are plenty of patients undergoing them who fit into neither category.”

Mistaken AssumptionsThe treatments — coronary artery bypass surgery, angioplasty and the placement of drug-coated stents — cost about $60 billion a year in the United States. Though they are not known to prevent heart attacks or coronary mortality in most patients, they are covered by insurance. Counseling patients about diet, exercise and stress management — which is relatively inexpensive and has been proved to be life-extending — is rarely reimbursed. In other words, procedure-oriented modern cardiology is pound wise and penny foolish. And in these economic times, it makes great sense to reconsider the approaches to reducing morbidity and mortality from the nation’s leading killer.

Most people mistakenly think of coronary artery disease as a plumbing problem. Influenced by genetics, diet, diabetes, hypertension, smoking and other factors, major arteries through which oxygen-rich blood flows to the heart gradually become narrowed by deposits of cholesterol-rich plaques until blood can no longer pass through, resulting in a heart attack. In coronary bypass surgery, a blood vessel taken from elsewhere in the body is reattached to a clogged coronary artery to bypass the narrowed part.

However, as Dr. Ozner points out in his book, “three major studies performed in the late 1970s and early 1980s clearly proved that for the majority of patients, bypass surgery is no more effective than conservative medical treatment.” The exceptions — patients whose health and lives could be saved — were those with advanced disease of the left main coronary artery and those with severe crippling, or unstable, angina.

Bypass surgery does relieve the pain of angina, though recent studies suggest this may happen because pain receptors around the heart are destroyed during surgery.
“The studies on angioplasty delivered even worse news,” Dr. Ozner wrote. “Unless the patient was in the midst of a heart attack, the opening of a blocked coronary artery with a balloon catheter resulted in a worse outcome compared to management through medication.” In fact, one trial, published in 2003 in The Journal of the American College of Cardiology, found that balloon angioplasty, which flattens plaque against arterial walls, actually raised the risk of a heart attack or death.

Stents were designed to keep the flattened plaque in place. But studies of stable patients found no greater protection against heart attacks from stents than from treatments like making lifestyle changes and taking drugs to lower cholesterol and blood pressure.

A Small CulpritA new understanding of how most heart attacks occur suggests why these procedures have not lived up to their promise. According to current evidence, most heart attacks do not occur because an artery is closed by a large plaque. Rather, a relatively small, unstable plaque ruptures and attracts inflammatory cells and coagulating agents, leading to an artery-blocking clot.

In most Americans middle age and older, small plaques are ubiquitous in coronary arteries and there is no surgical way to treat them all.

“Interventional cardiology is doing cosmetic surgery on the coronary arteries, making them look pretty, but it’s not treating the underlying biology of these arteries,” said Dr. Ozner, who received the 2008 American Heart Association Humanitarian Award. “If some of the billions spent on intervention were put into prevention, we’d have a much healthier America at a lower cost.”

Dr. Ozner advises patients who are told they need surgery to get an independent second opinion from a specialist.

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NYT

New Thinking on How to Protect the Heart

By JANE E. BRODY

Published: January 12, 2009

Many measures are probably familiar: not smoking, controlling cholesterol and blood pressure, exercising regularly and staying at a healthy weight. But some newer suggestions may surprise you.

It is not that the old advice, like eating a low-fat diet or exercising vigorously, was bad advice; it was based on the best available evidence of the time and can still be very helpful. But as researchers unravel the biochemical reasons for most heart attacks, the advice for avoiding them is changing.

And, you’ll be happy to know, the new suggestions for both diet and exercise are less rigid. The food is tasty, easy to prepare and relatively inexpensive, and you don’t have to sweat for an hour a day to reap the benefits of exercise.

The well-established risk factors for heart disease remain intact: high cholesterol, high blood pressure, smoking, diabetes, abdominal obesity and sedentary living. But behind them a relatively new factor has emerged that may be even more important as a cause of heart attacks than, say, high blood levels of artery-damaging cholesterol.

That factor is C-reactive protein, or CRP, a blood-borne marker of inflammation that, along with coagulation factors, is now increasingly recognized as the driving force behind clots that block blood flow to the heart. Yet patients are rarely tested for CRP, even if they already have heart problems.

Even in people with normal cholesterol, if CRP is elevated, the risk of heart attack is too, said Dr. Michael Ozner, medical director of the Cardiovascular Prevention Institute of South Florida. He thinks that when people have their cholesterol checked, they should also be tested for high-sensitivity CRP.

Diet Revisited
The new dietary advice is actually based on a rather old finding that predates the mantra to eat a low-fat diet. In the Seven Countries Study started in 1958 and first published in 1970, Dr. Ancel Keys of the University of Minnesota and co-authors found that heart disease was rare in the Mediterranean and Asian regions where vegetables, grains, fruits, beans and fish were the dietary mainstays. But in countries like Finland and the United States where plates were typically filled with red meat, cheese and other foods rich in saturated fats, heart disease and cardiac deaths were epidemic.

The finding resulted in the well-known advice to reduce dietary fat and especially saturated fats (those that are firm at room temperature), and to replace these harmful fats with unsaturated ones like vegetable oils. What was missed at the time and has now become increasingly apparent is that the heart-healthy Mediterranean diet is not really low in fat, but its main sources of fat — olive oil and oily fish as well as nuts, seeds and certain vegetables — help to prevent heart disease by improving cholesterol ratios and reducing inflammation.

Virtues Confirmed
It was not until 1999 that the value of a traditional Mediterranean diet was confirmed, when the Lyon Diet Heart Study compared the effects of a Mediterranean-style diet with one that the American Heart Association recommended for patients who had survived a first heart attack.
The study found that within four years, the Mediterranean approach reduced the rates of heart disease recurrence and cardiac death by 50 to 70 percent when compared with the heart association diet.

Several subsequent studies have confirmed the virtues of the Mediterranean approach. For example, a study among more than 3,000 men and women in Greece, published in 2004 by Dr. Christina Chrysohoou of the University of Athens, found that adhering to a Mediterranean diet improved six markers of inflammation and coagulation, including CRP, white blood cell count and fibrinogen.

The same year Kim T. B. Knoops, a nutritionist at Wageningen University in the Netherlands, and co-authors published a study showing that among men and women ages 70 to 90, those who followed a Mediterranean diet and other healthful practices, like not smoking, had a 50 percent lower rate of deaths from heart disease and all causes.

“The Mediterranean diet is one people can stick to,” said Dr. Ozner, author of “The Miami Mediterranean Diet” and “The Great American Heart Hoax” (BenBella, 2008). “The food is delicious, and the ingredients can be found in any grocery store.

“You should make most of the food yourself,” Dr. Ozner added. “When the diet is stripped of lots of processed foods, you ratchet down inflammation. Among my patients, the compliance rate — those who adopt the diet and stick with it — is greater than 90 percent.”
Among foods that help to reduce the inflammatory marker CRP are cold-water fish like salmon, tuna and mackerel; flax seed; walnuts; and canola oil and margarine based on canola oil. Fish oil capsules are also effective. Dr. Ozner recommends cooking with canola oil and using more expensive and aromatic olive oil for salads.

Other aspects of the Mediterranean diet — vegetables, fruits and red wine (or purple grape juice) — are helpful as well. Their antioxidant properties help prevent the formation of artery-damaging LDL cholesterol.

Other Steps
Several recent studies have linked periodontal disease to an increased risk of heart disease, most likely because gum disease causes low-grade chronic inflammation. So good dental hygiene, with regular periodontal cleanings, can help protect your heart as well as your teeth.
Reducing chronic stress is another important factor. The Interheart study, which examined the effects of stress in more than 27,000 people, found that stress more than doubled the risk of heart attacks.

Dr. Joel Okner, a cardiologist in Chicago, and Jeremy Clorfene, a cardiac psychologist, the authors of “The No Bull Book on Heart Disease” (Sterling, 2009), note that getting enough sleep improves the ability to manage stress.

Practicing the relaxation response once or twice a day by breathing deeply and rhythmically in a quiet place with eyes closed and muscles relaxed can help cool the hottest blood. Other techniques Dr. Ozner recommends include meditation, prayer, yoga, self-hypnosis, laughter, taking a midday nap, getting a dog or cat, taking up a hobby and exercising regularly.
He noted that in a 1996 study, just 15 minutes of exercise five days a week decreased the risk of cardiac death by 46 percent.

Even very brief bouts of exercise can be helpful. A British study published in the current American Journal of Clinical Nutrition found that accumulating short bouts — just three minutes each — of brisk walking for a total of 30 minutes a day improved several measures of cardiac risk as effectively as one continuous 30-minute session.

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