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CABG
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CABG

"After six years I have second heart attack.IWMI.Angiography shows all three major vessle blocks to the extent of 90% at near end and 70% block at far end.Physical capacity of body is normal. No pain even during exercise. May be due to colateral circulation. Advised CABG. Fearing problems after surgery not feeling to do that.Please advise."
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976897_tn?1379171202
didn't you already ask this question here?
http://www.medhelp.org/posts/Heart-Disease/coronary-arteries-blockage-Angiography/show/1329279

If test show you are not suffering Ischaemia, then you likely have sufficient flow. It has to be remembered that NOT all people get symptoms and some people don't even realise they have had a heart attack.  Have you had a Stess echocardiogram and/or a Nuclear scan? What problems are you anticipating after surgery?
If tests reveal no Ischaemia, then it should be fine to avoid surgery, but you have to understand that the disease is likely to worsen.
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1346447_tn?1327866172
Yes. I had already askd the question.

As now I understand I have vulnarable plaque. The solution for that lies in stabilising plaque and not by-pass surgery.

Recently my two friends have experienced broken wires of cut chaste bone and they were operated again.Doctor is not giving any guarantee about operation without any problems. Then fearing some thing worst will happen why to go under knife.
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976897_tn?1379171202
There are risks associated with any surgery and I can understand your fears because I had a triple bypass three years ago. I, and millions of others, had no complications from the surgery at all. You are correct to say that bypass will not stabilise the plaque, BUT it WILL get a good blood flow to the areas of the heart which have an insufficient supply. The only way to somewhat stabilise the plaque would be to find a cardiologist who can perform angioplasty on your vessels.
I can understand your way of thinking, I was very much the same and still am. I was not happy with a bypass, leaving the plaque in place, where it could continue to grow and probably cause more problems in the future. I wanted my vessels cleaned.
My bypass failed after just three months, because my Left artery was coated all the way down with quite a thick layer of plaque, and had a huge total blockage at the top. My case was given to a teaching/research hospital which has the best cardiologists, the professors and one cardiologist took on my case. He managed to use angioplasty and remove all the total blockage, then he used rotablation and laser to remove the plaque down three quarters of the left vessel. This leaves the lining quite rough and it took 5 of the longests stents to cover it. Now nearly all the vessel is plaque free. However, I am still getting angina because there are two tiny  blockages right at the bottom so I need to ask his opinion on those. A year later though, the 5 stents are still fully open and working great.
It has to be realised also that not everybody seems to accept stents as well as others. Some people seem to form new disease very quickly around stents and form new blockages, much more quickly than would normally happen. Although research is continuing, it isn't really understood why this happens with some people. Stents also give some people discomfort and the reason for this again is not really conclusive. I had a stent in my circumflex artery nearly 4 years ago, which is still open and disease free. This told my cardiologist I am one of the lucky ones who seems to accept stents with no problems and gave him the boost needed to clean my left artery. If it had diseased again, he said he probably wouldn't have attempted it.
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976897_tn?1379171202
Just to add. Search until you find the option you are happy with. It took me two years but knowing the disease and blockage is now gone from my left artery, I feel much happier. Ask your cardiologist to refer your case to a research hospital.
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367994_tn?1304957193
QUOTE: "As I now I understand I have vulnarable plaque. The solution for that lies in stabilising plaque and not by-pass surgery".

>>>>As you know vulnerable plaque is the soft plaque the resides within the vessel linings. It is this condition that has the highest probability of rupturing and causing a heart attack. I had a test that scored my calcium and soft plaque several months ago.  You are correct, treatment is to prevent any further progression and some people believe the condition can be reversed.  You don't need a bypass.  

Thanks for sharing.  Take care.

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1346447_tn?1327866172
I am sweemer. In case of me I feel there are chances that my vulnerable plaque may get dislodged due to going under water and suddenly coming up. The sudden blood pressure variations may be the cause. I got my chaste pain during sweeming only.

My normal blood pressure is 140/90. I would like to know how far my blood pressure will increase when I am under 6 feet of water. My doctor was not in a position to tell me. Should I continue sweeming ? I have now all normal activities except sweeming. Or it will again dislodge vulnerable plaque. It may be very interesting to all. Thank you for sharing your information. That will enable me to take my decesions.
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Avatar_f_tn
Swimming causing pressue? How deep are you going? Are you talking about scuba diving here and using gas mixes?
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1346447_tn?1327866172
I am not talking about scuba-diving as is evident "under 6feet of water'. Will blood pressure rise or fall and to what extent? If you know please tell me.
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367994_tn?1304957193
Good question.  There isn't decisive reports regarding arterial blood pressure and values during breath-hold diving is scanty. I found some information with the Journal of Applied Physiology. There has been some reports that have taken blood pressure at the water's surface showing slight or no increase in arterial BP, and from a single study of two simulated deep breath-hold dives in a hyperbaric chamber. Simulated dives showed an increase in ABP to values considered life threatening by standard clinical criteria. For the first time, using a novel noninvasive subaquatic sphygmomanometer, we successfully measured ABP in 10 healthy elite breath-hold divers at a depth of 10 m of freshwater (mfw). ABP was measured in dry conditions, at the surface (head-out immersion), and twice at a depth of 10 mfw. Underwater measurements of ABP were obtained in all subjects. Each measurement lasted 50–60 s and was accomplished without any complications or diver discomfort. In the 10 subjects as a whole, mean ABP values were 124/93 mmHg at the surface and 123/94 mmHg at a depth of 10 mfw. No significant statistical differences were found when blood pressure measurements at the water surface were compared with breath-hold diving conditions at a depth of 10 mfw.

Hope this provides the information you ask.
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1346447_tn?1327866172
Thank you for interest shown. Now I will tell you my exact observation before I got my second heart attack.
I used to submerge in water till the neck and used to walk in water with reduced weight in water. The floor of water tank being slanting the depth of submersion was getting reduced as I walked slowly. It is unique observation that when water came to the level of my heart and when my heart level came out of water I had a strange feeling of sudden change in pressure. This unique observation I was experiencing dailly for about five days. Then on sixth day while doing the same thing I started feeling mild chaste pain and thinking some thing wrong I came out of water immediately. After five minutes I had severe chaste pain which did not stop after Sorbitate and two ecosprine tabs too.This lead me to ask this question of blood pressure changes in water. Thank you once again. But definitely it needs a lot of thinking and research on the subject.
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Avatar_n_tn
I am trying to draw some message from your observation. If I understand you correctly, you had no other symptom prior to your second heart attack except your observation in the swiming pool.

I am had MI in 2007, a stented LAD and 100% blocked LCx. My EF is around 30-35%. I do not feel discomfort during my normal walks and I believe that I am fine. But relating to your experience, the symptoms may emerge only under some specific conditions; like in swiming pool in your case.

How to make sure I do not get second MI. Sorry for interrupting in your question but I am now concerned.
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1346447_tn?1327866172
Thank you for communication. Regular medicine and life style i.e. food and exercise are very important. In my case additional stress was very important .I am personality type 'A'. Perfection being my motto I get a lot of stress every where in dealing with people. And I am sure my both attacks were as a cosequence of my stress . But stress was not immediate cause. After some years we become lax in every thing. That should not happen. I still feel that this time too I will manage with medicine alone. Wishing you will not have second attack. Take care.
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976897_tn?1379171202
A few years of stress and high blood pressure as a result would be enough to start the process of atherosclerosis. Your heart attacks would have been caused by a clot or rupture of existing disease. As disease progresses, most people experience symptoms which enable the blockage to be diagnosed before 100%. Now that Doctors are making a more accurate diagnosis regarding cardiac problems, deaths from heart attacks are reducing in the UK.
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1346447_tn?1327866172
What you said is right. If bypass is the solution for valnerable plaque? I do not think so.Please tell me the proper test to confirm the extent of ischemia to heart. According to me my physical capacity is the best indicator which takes into account colateral blood circulation too. However LVEF is the second best indicator. Please tell me in detail because that is going to enable me to go for bypass or not. I wonder extent of blockage shown by angiography and my LVEF which is 50% do not agree.Why doctor do not think about that. Thank you once again. Please tell me for sure. Or should I think of CPK or CPK-MB?
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367994_tn?1304957193
I believe your questions were answered in another post? May be it was another member's question. Anyway to determine the degree of soft calcium plaque (calcium between layer of the vessel) can be determined with ct scan 64 or greater slices.  Soft plaque accounts for the highest percentage of heart attacks when the plaque ruptures through a crack in the lining.  Hard plaque can dislodge and cause a heart attack as well.

A bypass is appropriate when there vessel stenosis (partial blockage usually hard plaque seen with cath angio).

I had a heart attack about 6 years ago, and my EF was below 29% and an enlarged heart.  With medication a stent, my heart is currently a normal size and the EF is 59%.  

Ejection fraction is the amount in a percentage of the blood pumped with each heartbeat.  Normal is 50 to 70%.  When there is a decrease in the EF it is usually due to heart muscle damage that impairs contractility due to having had a heart attack.

I haven't been following all of your posts, and ed is certainly capable of giving you helpful information.  Take care.
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976897_tn?1379171202
Why do you feel there's a link between your LVEF and your blockages?
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1346447_tn?1327866172
Thank you both of you. Blockages result in reduced blood supply to heart muscles. This may result in ischemia of heart muscles. Due to this heart can not pump as efficiently as before. LVEF get reduced. This is the link.
My question about test to find out extent of ischemia remains unanswered.Thank you once again.
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976897_tn?1379171202
Interesting, but LVEF doesn't necessarily reflect Ischaemia occurring. It would really depend on the amount of heart tissue being affected. In my case, just the bottom of the LV is low on blood and my EF is 70% which it always has been.
The best test to show blood supply to the heart tissue is a nuclear perfusion test. This comprises of 2 scans, one with the heart stressed and one with it at rest. It gives a good idea to the cardiologist if collaterals have formed and which vessels are likely to be giving problems. In some cases a stress echocardiogram can reveal a weaker function in certain areas of the heart due to Ischaemia, but most are inconclusive and the patient ends up having a nuclear scan.
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1346447_tn?1327866172
Thank MedHelp and all who answered the questions. My own decesion is not to go for bypass and manage with medicine.On 21st I will be seeking second openion with cardiologist. I have faith in him that he is not interested only in money. In my first heart attack also I had consulted him. I will let you know about that.
Answers both by ed34 and kenkeith were in agreement with my openion. When we three agree there is little left to be decided. Till then thank all of you.
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367994_tn?1304957193
QUOTE: "Why do you feel there's a link between your LVEF and your blockages?"

In my situation, the blockage and lack of oxygen caused hypokinesis (heart wall movement disorder) that weakened heart wall contractions and lowered the EF to below 29% (heart failure range). The good news is/was the heart cells were hibernating (google for more info) and the heart cells were revitalized with an increase of blood flow with a stent and medication.  After several months an echo indicated hypokinesis was minimal and my heart size and EF were now normal. Take care.
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1346447_tn?1327866172
First and formost requirement is my body should get adequate quantity of blood. This means heart should pump out that much blood to body. If heart muscles are damaged herat's capacity to pump blood will be reduced. Heart muscles will be damaged if coronary arteries supplying blood to heart are narrowed or blocked. In this process LV plays important part. And if blood supply through coronary artery to LV is affected quantity of blood pumped will be affected. Therefore coronary blockages and LVEF are linked. Provided other factors are normal.
Thank you for giving me opportunity to explain.
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976897_tn?1379171202
"If heart muscles are damaged herat's capacity to pump blood will be reduced"

It depends on how much heart tissue is affected. Like I said, just the bottom of my LV is restricted and I have 70% LVEF.
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367994_tn?1304957193
I agree with ed that the location of the damaged heart cells will have an effect on the cardiac output (stroke times heart rate)..

QUOTE: "And if blood supply through coronary artery to LV is affected quantity of blood pumped will be affected. Therefore coronary blockages and LVEF are linked. Provided other factors are normal".

>>>>>Cardiac output involves compensating system components that include heart rate, ejection fraction (not static....will normally dilate to increase contractility), vascular constriction and dilation, etc.to maintain a balance of blood flow between right and left side of the heart.  If the normal condition is compromised and not properly treated, the LV will continue to dilate (over compensate) to the degree that is abnormal and that will cause a drop in LVEF (Frank-Starling mechanism).  

You are correct, if coronary vessel blockage is severe, the normal compensating components will be ineffective and the result will be an enlarged left ventricle and a drop in the LVEF. If  there is blockage that is not significant the LVEF will likely be in the low normal range or possibly lower!  Referring of course to an ischemic heart condition.  
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1346447_tn?1327866172
My LV dimentions are normal after 2D-echo. No hyper trophy. IWMA-inferior wall motion abnormality is observed. Inspite LVEF is 50% then why go for bypass? MY heart beets 60 bm. My blood pressure 175/105.According to me you have fully understood me.Thank you for your contribution. Your answer is the best answer. I will verify with second openion to to find out the best solution.
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1346447_tn?1327866172
Second openion in my favour.Not going for bypass. i will manage with medicine.Thank you.Your replies helped me to understand nad communicate in effective way with medical practisioner.Thank you MedHelp.
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367994_tn?1304957193
Very good news.  I wish you well in the long term also.
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976897_tn?1379171202
"My blood pressure 175/105"

WHAT? you are on the verge of severe hypertension stage 3. Your BP needs to be seriously looked into and medicated if needed. With BP THAT high, you are asking for another heart attack :(
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1346447_tn?1327866172
Thank you for your concern. During second openion that is taken care of. As soon as it normalises I will let you know. I am called after two months again.
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367994_tn?1304957193
Yes, there should be a concern to get your pressure under control.  I missed reading your other post. Yes, I understood the significance of your comments.  What did your doctor say about the high blood pressure?  Is this an isolated reading and not sustained?

I will add an insight to what is termed left ventricle diastolic dysfunction. LVDD can be occur from high blood pressure, and the result can be the thickening of the heart  walls. The thickening (dimensions) of the heart walls can be a condition and a normal EF can be misleading.. An echo can determine if the walls are normal size, and I believe that has been ruled out by your medical provider otherwise you would have posed different questions..

With LVDD the heart chamber does not relax very well due to the inflexibility of the thickened heart walls.  With reduced capacity (filling disorder) the heart can still pump the same percentage of blood into circulation...but the amount of blood pumped into circulation is reduced.  If not effectively treated the reduced amount of blood/oxygen will eventually go to the LV and will cause heart failure (low cardiac output).  Your low normal heart rate does not support a cardiac output problem.  With low CO It woud rise to put more blood into circulation...likely over 100 bpm at rest.

From reading all the posts, your doctor has never told you there were abnormal heart wall dimensions and apparently not an issue!  Isolated blood pressure you have cited is not very high but nevertheless can be problematic if sustained for a period of time and should be treated...we all can agree on that.
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1346447_tn?1327866172
From 2D-echo my LV dimensions are ok. All rest dimensions of heart are also ok. Cardiac out must affect the patient some way or the other. I am physically and mentally very normal person.I can give you a coy of Echo report if you want.Thank you.Before my second heart attack my usual blood pressure was 140/90. Copy of my notes I discussed with doctor is below for your information.

Copy of note----
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1346447_tn?1327866172
Copy of note----

1 -  Inspite of expert cardiologist you are selected because intelligence matters more than mere certified expertise.

2 – Advice to me is to go for Revascularisation i.e. by pass-surgery as an out come of angiography.
There being possibility of third heart attack any time and I may be paralised or may die. It is clarified that my heart attacks were due to vulnerable plaque in coronary arteries. Inspite of severe blockages my physical capacity is intact due to co-lateral blood circulation. According to what I know till to day bypass-surgery is not the solution for vulnerable plaque as that will cause heart attack inspite of CABG. When physically and mentally I am ok on medicine I fail to understand why should I take risk of by-pass-surgery.

3 – Twice I had heart attack without warning signs. I did not have paralysis or even damage to heart muscles due to them. I did not have even arithmia. My LVEF is 50%
I have good control over my my food and exercise. My personality being type 'A' I am perfectionist. That is a bit problematic while dealing with surrounding peoples. That is the main cause of stress many times. I believe that my both heart attacks were out come of stress but stress was not the immediate cause.
My wife had brain stroke and is bed ridden and I am taking her care. I am 71 years old person. I will not like to live with reduced physical capacity for longer time. No-body guarantees that after bypass my physical capacity will not be reduced.
I will like to live on medicine may be few years but with same physical capacity.

4 – While climbing stairs my legs get exhausted first than the heart. If for bypass they remove vein from leg that will creat problem of walking.

5 – Difference between first and second heart attack:-

First one- Every half an hour heating sensation in the heart. Continued from 0700 Hrs to !400 Hrs. Then heating sensation spread to both hands and head. Sweating in head too from 1400 Hrs to 1700 Hrs. Afterwards it spread to legs too. Then at 1900Hrs my both hands and legs started trembling. All this did not stop even after taking four sorbitol tablets. After 12 hours I was given blood clot bursting treatment and was admitted to hospital. Pain was not severe. Treatment started very late.

Second one – Heavyness in chest at 0730 Hrs. Did not stop after taking sorbitol tablet. Chestpain  started. Taken two ecosprin tablets. Pain did not stop. Severe pain shifted to hospital. There twice severe chest pain occurred. I got clot bursting treatment at 0930 Hrs. I was shifted from local hospital to Fortig hospital at Mulund.

In my case cardiac out put is not affected inspite of severity of coronary blockages over the years. LVEF is 50% even now as judged from my physical ability.
If due to second attack damage to heart has increased? According to me – no. If heart muscles damage is there? If nercosis to heart muscles is developed?

6 – If periodical reperfusion can prevent blood clot  to be formed. Or dissolve formed blood clots.

7 – Last time we had reduced medicine gradually. This time how my medicines will be different than last time.

8 – Why not improve quality of blood  by medicine i.e. by increasing Haemoglobin and RBC's. And by reducing debris in the blood like uric acid, chlostrol etc.

9 – In case of third heart attack what should I take Immediate medicine as handy with me in my pocket. Sorbitol, Ecosprin and any other.

10 – How about bypass with minimum invasion or robotic bypass through holes. Where it is available?

11 – Chelation Therapy---How about Impedence Cardiography?  If heart eschemia can be found out with the test. If this test can find out small blockage even 15% Instead going for ECG and 2D-Echo can we go for this test. Relability of test?

12 – Why plaque in coronary arteries only inspite they are vibrating and not in other arteries in body.

13 – Sweeming pool incidence- If blood pressure changes can occure suddenly when diving. I have experienced changes in prssure on heart when water level goes down from heart level to down below. I jhad second attack in such fashion. Has it got anything to do with vulnerable plaque? If plaque can be dislodged with such things?

Thank you once again.
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976897_tn?1379171202
"bypass-surgery is not the solution for vulnerable plaque as that will cause heart attack inspite of CABG"

It was my understanding that the pressure build up over vulnerable plaque made it more likely to break. Your blood pressure is high. A bypass should ease that pressure on the plaque.

"In case of third heart attack what should I take Immediate medicine"

If you are not on aspirin, I would take around 75mg and carry a nitro spray around with you. When you have an attack, spray some under the tongue, or get someone else to.

"Why plaque in coronary arteries only inspite they are vibrating and not in other arteries in body"

Good questiona and one which I asked specialists for 2 years with no response. However, it is the position of the coronary arteries which cause the problem, so I was told. They are very small vessels fed directly off the largest artery in the body, and fed basically direcly from the hearts output. They take a huge pounding, and are the most likely to suffer damage, causing atherosclerosis.

"While climbing stairs my legs get exhausted first then the heart. If for bypass they remove vein from leg that will create problem of walking"

No it will not. I've had 2 veins removed from one leg and I can assure you it feels as healthy as the other leg.

"Why not improve quality of blood  by medicine i.e. by increasing Haemoglobin and RBC's. And by reducing debris in the blood like uric acid, chlostrol etc."

Raising haemoglobin would have little effect if the blood isn't reaching an area of tissue.
Also raising haemoglobin could upset the control mechanisms of the body which regulate breathing etc. The blood would end up too acidic or too alkaline.

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367994_tn?1304957193
Info from Cleveland Clinic...number 1 medical heart center.
Normal Blood Pressure: For an adult, relaxed at rest Less than 120/80 mmHg.  Treatment  practice healthy lifestyle

Pre-Hypertension Systolic pressure of 120-139 mmHg or Diastolic pressure of 80-89 mmHg Treatment: Modify lifestyle and close monitoring.

High Blood Pressure (appears to be your case if the bp is sustained at that level).
Stage 1 Systolic pressure of 140-159 mmHg or Diastolic pressure of 90-99 mmHg:  Treatment Modify lifestyle, take medication

High Blood Pressure - Stage 2 Systolic pressure of 160 mmHg or higher or Diastolic pressure of 100 mmHg or higher.  Treatment modify lifestyle and take medication. Bypass of vessels is not a remedy nor have I ever heard of surgery for high blood pressure.

What is the link between high blood pressure and heart attack?
High blood pressure increases the risk of coronary artery disease (also called atherosclerosis). People with high blood pressure are more likely to develop coronary artery disease because high blood pressure puts added force against the artery walls. Over time, this extra pressure can damage the arteries. These injured arteries are more likely to become narrowed and hardened by fatty deposits....

Vulnerable plaque is soft plaque that resides between the layers of a vessel.  There is no treatment other than diet and lifestyle.  I had a ct scan 128 slice and that test showed soft plaque in all 4 major arteries.  The score was high (over 100 total) and indicated I have a risk of heart event within a year....that was almost 2 hears ago.  When the soft plaque has increased to a particular level for an individual the plaque can burst through inner lining into the vessel chamber (lumen) or between the two of 3 linings. A rupture into the lumen can clot and cause a heart attack.  There can be stenosis (narrowing) of the vessel that a stent or medication may help

Hard plaque resides within the lumen and blocks blood flow so a by-pass or stent will widen the lumen.  Medication can also dilate the vessels.

Yes, if you post your results of an echo that would help.  Frankly, I am surprised your heart walls are not thickened or the chamber dilated (left ventricle)...that is very good news.

QUOTE: "Why plaque in coronary arteries only inspite they are vibrating and not in other arteries in body".  There usually is plaque buildup in the peripheral vessel of the legs, etc.  Can cause pain (PAD is the medical term).

  







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159619_tn?1318997813
I don't have the personal experiences of Ken and Ed, but let me throw in my 2 cents concerning Chelation therapy. From the AHA;

"Chelation therapy is administering a man-made amino acid called EDTA into the veins. (EDTA is an abbreviation for ethylenediamine tetraacetic acid. It’s marketed under several names, including Edetate, Disodium, Endrate, and Sodium Versenate.) EDTA is most often used in cases of heavy metal poisoning (lead or mercury). That’s because it can latch onto or bind these metals, creating a compound that can be excreted in the urine.
Besides binding heavy metals, EDTA also "chelates" (naturally seeks out and binds) calcium, one of the components of atherosclerotic plaque. In the early 1960s, this led to speculation that EDTA could remove calcium deposits from buildups in arteries. The idea was that once the calcium was removed by regular treatments of EDTA, the remaining elements in the plaque would break up and the plaque would clear away. The narrowed arteries would be restored to their former state.

Based upon this thinking, chelation therapy has been proposed to treat existing atherosclerosis and to prevent it from forming.

After carefully reviewing all the available scientific literature on this subject, the American Heart Association has concluded that the benefits claimed for this form of therapy aren’t scientifically proven. That’s why we don’t recommend this type of treatment."

Organized medicine opposes chelation therapy because it’s an unproven procedure and it involves extreme risks to patients who receive it. There is also a concern that some people who rely on this therapy may delay undergoing proven therapies like drugs or surgery until it’s too late. This is the added danger of relying on an unproven "miracle cure.

Hope this helps and good luck,

Jon
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976897_tn?1379171202
I still worry that if chelation removes calcium, then this could weaken a calcified plaque cap holding vulnerable plaque underneath it. This would allow pressurised soft plaque to errupt. It's a bit like saying there are benefits to removing a radiator cap on a hot engine.
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367994_tn?1304957193
QUOTE: "It was my understanding that the pressure build up over vulnerable plaque made it more likely to break. Your blood pressure is high. A bypass should ease that pressure on the plaque".

I see it somewhat differently.  Soft plaque buildup causes a bulge (into lumen) of the innermost lining.  It is not unlike an aneurysm of large vessel for instance the aorta, and in that situation blood pressure needs to be controlled from its harmful effects as the pressure is directly into the aneursym and can cause growth and rupture.  

But with a bulge into the lumen of the vessel,  although it is not unlke the AA in appearence, system blood pressure is from inside out and if anything mitigates against the soft plaque from rupture.  The issue is the inside layer (endothelium cells), and a rupture may have more to do with the vessel cells integrity and resistivity and that varies with individuals.  My calcium score (soft plaque) totals over 1000 (error in other post of 100), but the vessel's anatomy appears to be structually sound.  It is not unthinkable that a stent of the stenosis can cause a rupture, clot and damage the endothelium cells before there can be a new growth of cells over the stent.

I don't believe there is much pressure from outer layer to another lower layer or into the lumen as the rupture would cause the plaque to ooze out, but shear stress of the blood flow can certainly break away substance and/or clot for a heart attack.  Maybe there is something in beween different views and/or exceptions.  



Hard plaque develops from shear stress, blood velocity (blood flow is slower the closer to vessel wall...friction) blood cell turbulance, gradient pressure, etc.  Where the break from the main artery into circumflex and LAD there is blood turbulance, etc that often causes hard plaque buildup and often difficult to stent.  
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