There are frequent questions being asked about the various treatments for coronary blockages. The appropriate treatment is dictated by the location of the blockage, the severity, the symptoms/ if any that the patient presents with and the medical condition of the patient

The options generally include medical treatment with cholesterol reduction, traditional open heart bypass, minimally invasive and robotic assisted coronary bypass. Percutaneous options for treatment include angioplasty often with stenting. A large number of people undergo stenting because of its minimally invasive benefit

Recent questions have arisen regarding the benefit of angioplasty and stenting versus medical therapy in patients who have stable and asymptomatic coronary artery disease.  That is a person without angina, congestive heart failure or other acute heart symptoms.

These studies suggest that for people with asymptomatic, stable disease angioplasty and stenting does not reduce the chance of heart attack or death to any greater degree than aggressive medical therapy. So although the stents increase blood flow immediately and over a short period of time, the benefits diminish over time as the stents begin to develop blockages themselves. This raises the question should more careful consideration be given to treating more people with aggressive medical therapy instead of stents if they have no acute symptoms.

Furthermore, evidence exists that a small percentage of drug eluting stents have a propensity to occlude at a much earlier rate than "bare stents" and these occlusions may occur at periods well after stent placement. this occurs because the medication that prevents scar tissue from developing (which is why the stents theoretically are beneficial) also leaves the stents surface exposed and prevents the develoment of a protective coating that occurs with "bare  stents". This leaves the stent exposed and increases the chance of stent occlusion by the body's natural clotting mechanism

So I think that its very important to have a conversation that includes all of these options including medication as the treatment strategy without stenting.

http://www.nytimes.com/2007/03/27/health/27stent.html?ex=1332734400&en=df83fb632f1ca6ac&ei=5124&partner=permalink&exprod=permalink

I must admit that I believe the jury is still out with regards to heart scan, CT angiography and calcium scoring.
After Tim Russerts death, I must have received 5-10 question a day feom concerned patients and friends. They all wanted to know if they needed a scan. People who were relatively healthy wanted to know if they were going to die suddenly.

The following NY times article does a good job of painting different sides of the story. In my mind, I think that calcium scoring is a very important motivational tool for someone who would change their life style of diet, exercise and nutrition if they had a compelling reason. Some people genuinely need that kick in the butt. But for the person who is doing exactly what they should be in terms of lifestyle and medical risk reduction for cholesterol or hypertension, there is little to be gained.  

Now lets look at a particular exception. You are a 45 year old male. Healty 5'10'' 160 lbs. You eat well. Vegetarian who hates sweets. You exercise 5 times per week. However, your father died at age 55 and lived just as healthy.
This might be a case where someone recommends the scan with calcium scoring to see if there is any apparent reason to begin early statin therapy.

The problem with imaging modalities is that even if they are noninvasive without the risks of cardiac catheterization, there are still risks associated with radiation exposure. A scan is roughly equal to 1,050 chest x ray doses. Not a small amount

I would like to know how many people would get a heart scan if there were no considerations of cost or convenience.
Read the link and provide some feedback

http://www.nytimes.com/2008/06/29/business/29scan.html?ex=1372737600&en=f2b667f06d165ac1&ei=5124&partner=permalink&exprod=permalink

The untimely and unfortunate death of NBC Meet The Press moderator and political analyst revealed an important fact.
Our ability to predict fatal heart attacks is at best an "evolving science". While the US is widely believed to be at the forefront of technology for developed countries, much room for improvement exists.

The problem is that even the current gold standard of cardiac catheterization falls short of identifying everyone who subsequently progresses to have a heart attack. Thats because of plaque rupture. Plaques, caused by cholesterol buildup, may lie dormant and not cause a problem until the previously stable plaque becomes unstable and ruptures.

What causes a plaque to become unstable is not completely understood. Furthermore, our ability to predict and identify the unstable plaques are limited. Take for instance, angiography or cardiac cath which demonstrates the degree of narrowing within the coronary artery. Unfortunately, this degree of narrowing does not necessarily correlate with the chance of plaque rupture. In fact, a mild narrowing can rupture and cause immediate inadequacy of the oxygen to the heart muscle.

Take a look at the NY times article below. It really provides the sobering picture of a man who battled with high blood pressure and cholesterol elevation. Despite having apparently the best physicians and medicine that we can hope to provide, he succumbed to heart disease.

Science still has a way to go to identify the vulnerable plaque. There are ways of predicting unstable plaque in the carotid vessel which causes stroke. Perhaps someday, this technology will be improved and applied to the heart which is more difficult to image deep within the chest an in motion

For right now, I think the most reliable method of individual prevention is on the front end with what you eat, how you exercise, eliminating stress and other behavioral strategies to decrease your risk of getting heart disease

The article also raises the question of the role of the heart scan, CT angiogram or calcium scoring. Ill talk about this topic again in a later blog



To learn more about Russert's pre existing medical condition including autopsy findings, click and paste
http://www.nytimes.com/2008/06/17/health/17russert.html?ex=1371873600&en=976afc1dc9246bb0&ei=5124&partner=permalink&exprod=permalink

As you may have noticed by now, the focus of this forum is cardiovascular disease(CVD) prevention. The statistics speak for themselves. CVD is the leading cause of death in the US and worldwide. Although we have made substantial progress in the development of medications to combat the causes of CVD like high cholesterol, hypertension and diabetes; the rapid proliferation of these diseases virtually negates and medical benefit. In other words, we are treating the consequences, not the cause. It's like mopping up around an over flowing sink basin and forgetting to turn off the faucet

Aside from uncommon genetic disorders, diet is by far the most important factor leading to the development of Diabetes, high cholesterol and hypertension. CVD is virtually unheard of in individuals with total cholesterol < 150 and strict vegetarians have 80% less chance of developing heart attack or stroke.

In my upcoming book, I describe various "regression diets" which have actually been scientifically proven to cause atheroclerotic plaque to diminish in some patients. I can't emphasize enough that without saturated fat and cholesterol in your diet, you will not develop elevated cholesterol and CVD

I think that most people significantly underestimate the amount of fat they eat each day. The key to accurately determining this is keep a food journal for one week. Write down every thin that you ingest and document the total fat, saturated fat, trans fats and calories. Most Americans eat around 100 gms of fat/ day. The most common EXCUSE for not doing this is that it's too much work. If twenty extra minutes per day for one week is too much effort to avoid stroke or heart attack; I would suggest that maybe avoiding those things isn't really that important to you. I have attached a website with a table of total fat, saturated fat and calorie content

http://www.ntwrks.com/~mikev/chart1.html

I would like to get some feedback on what people discover about their fat intake