Collaterization of arteries

[Dr. Erik]

Dear Doctor:

What type of exercise is needed to obtain collaterization of coronary arteres? Does it have to be very intense exercise such as running or can it be accomplished with brisk walking on a treadmill? Thanks for your time.

[Cleveland Clinic]

erik,

I wish it was that easy.  To date noone has specifically been able to correlate the development of coronary collateral vessels with exercise or other specific therapies such as administering various growth factors and angiogenic drugs.  

That said, exercise may contribute in certain populations and should be aggressively encouraged for the multitude of other beneficial effects, such as improvement of endothelial function.

good luck

[HealThySelf]

I think that the best exercise for building collaterals is walking uphill.  It doesn't have to be brisk.  It's just a nice steady load on the heart.  You can do it for 15 minutes or 3 hours.  It all helps.

I have a nicely collateralized 100% occlusion of the RCA.  I do a lot of hiking in the summer, trying to walk up 10,000 feet per week.  This time of year, when I'm working, I normally walk a hilly mile or more before work and at noon.  I try to do something more intense on the weekends like skiing or hiking/climbing.

I don't think that walking on a treadmill gives you the total mind, body, and spirit experience.  Also speed walking just isn't going to give you the relaxation factor which is just as important as the exercise.

Get your cholesterol real low with multiple drugs if necessary.  Somewhere around 125 is where someone with severe heart disease should be.  If your doctor is satisfied with 200 he is killing you.

Get your BP down to normal or below with Ace inhibitors and/or Calcium Channel Blockers. Stay away from diuretics and beta blockers.  

Take some Vitamin E and Omega 3/6 to keep your blood reasonably thin.  Don't take Plavix or coumidin.  

Get your weight down near normal.  Eat more green stuff and cereal.  Switch to soy milk and cut back the meat about 75%.

If your not an alcoholic, drink a glass of dark red wine or a pint of Guiness every night.

And then walk up an down hills every day for a couple of years and you will return to normal health.  A by product of walking outdoors every day is that I haven't had a cold or flu in years.  

Doing what I have outlined above will return you to health. Your arteries can be returned to health even if they have a few artifacts left in them.

Bypass surgery and stenting are only temporary solutions and only lead to more dependence on doctors and more procedures.

Good Luck.

[merf]

Three years after a successful bypass and no medications(I have very bad side effects) I was asked to go on what I considered a very high number of heart/blood pressure drugs. for protection.  I reluctantly did and suffered the inevitable side effects.  Then, a new side effect happened after about 24 months.  My ears and eustacian tube really blocked up and tinnitus began.  Prior to this, I felt I had exceptional hearing. Recently, I needed a phlebotomy because my RBC,HGB HCT were very elevated.  I had mild intermittant elevation of these values dringnthis 24 month period.  I had reviewed this with my cardiologists and ENT doctors in the two places I live with no answers.  I developed a theory after looking at many internet sites and reading the side effect information that it was the meds,especially blood pressure meds, that were causing this new problem.  My primary care doctor now agrees.  The theory goes like this: I know I have a mild chronic sinusitis condition to begin with; then, the ACE/calcium chanel blockers/AII blockers I was taking all can cause rhinitis as a side effect; then, the Androgel I was taking can cause blood to thicken.  The net effect was a constant loop of rhinitis and inflammation coupled with thickening blood.  All causing head pressure,sleepiness, headache, eustacian tube blockages, thick mucus, tinnitus etc.  I have switched to a combination diuretic with noticeable improvment.  However, I just had a Stent put in and started Plavix which has seemed to bring back my congestion/headaches again.  My doctor wants me tostay onPlavix for the short term which I am willing to do but need to get to a clear head sometime in the near future.  I never had this additional head congestion issue until I started with the blood pressure/Androgel meds. Could you please give me your comments on this and any suggestions for relief.  Thank you. Merf.

[merf]

Three years after a successful bypass and no medications(I have very bad side effects) I was asked to go on what I considered a very high number of heart/blood pressure drugs. for protection.  I reluctantly did and suffered the inevitable side effects.  Then, a new side effect happened after about 24 months.  My ears and eustacian tube really blocked up and tinnitus began.  Prior to this, I felt I had exceptional hearing. Recently, I needed a phlebotomy because my RBC,HGB HCT were very elevated.  I had mild intermittant elevation of these values dringnthis 24 month period.  I had reviewed this with my cardiologists and ENT doctors in the two places I live with no answers.  I developed a theory after looking at many internet sites and reading the side effect information that it was the meds,especially blood pressure meds, that were causing this new problem.  My primary care doctor now agrees.  The theory goes like this: I know I have a mild chronic sinusitis condition to begin with; then, the ACE/calcium chanel blockers/AII blockers I was taking all can cause rhinitis as a side effect; then, the Androgel I was taking can cause blood to thicken.  The net effect was a constant loop of rhinitis and inflammation coupled with thickening blood.  All causing head pressure,sleepiness, headache, eustacian tube blockages, thick mucus, tinnitus etc.  I have switched to a combination diuretic with noticeable improvment.  However, I just had a Stent put in and started Plavix which has seemed to bring back my congestion/headaches again.  My doctor wants me tostay onPlavix for the short term which I am willing to do but need to get to a clear head sometime in the near future.  I never had this additional head congestion issue until I started with the blood pressure/Androgel meds. Could you please give me your comments on this and any suggestions for relief.  Thank you. Merf.

[merf]

Three years after a successful bypass and no medications(I have very bad side effects) I was asked to go on what I considered a very high number of heart/blood pressure drugs. for protection.  I reluctantly did and suffered the inevitable side effects.  Then, a new side effect happened after about 24 months.  My ears and eustacian tube really blocked up and tinnitus began.  Prior to this, I felt I had exceptional hearing. Recently, I needed a phlebotomy because my RBC,HGB HCT were very elevated.  I had mild intermittant elevation of these values dringnthis 24 month period.  I had reviewed this with my cardiologists and ENT doctors in the two places I live with no answers.  I developed a theory after looking at many internet sites and reading the side effect information that it was the meds,especially blood pressure meds, that were causing this new problem.  My primary care doctor now agrees.  The theory goes like this: I know I have a mild chronic sinusitis condition to begin with; then, the ACE/calcium chanel blockers/AII blockers I was taking all can cause rhinitis as a side effect; then, the Androgel I was taking can cause blood to thicken.  The net effect was a constant loop of rhinitis and inflammation coupled with thickening blood.  All causing head pressure,sleepiness, headache, eustacian tube blockages, thick mucus, tinnitus etc.  I have switched to a combination diuretic with noticeable improvment.  However, I just had a Stent put in and started Plavix which has seemed to bring back my congestion/headaches again.  My doctor wants me tostay onPlavix for the short term which I am willing to do but need to get to a clear head sometime in the near future.  I never had this additional head congestion issue until I started with the blood pressure/Androgel meds. Could you please give me your comments on this and any suggestions for relief.  Thank you. Merf.

[HealThySelf]

That's a great source, I was just reading it.

I've also been following the studies of Dr. Greg Brown at the University of Washington.  He has been showing stabilization and regression of plaques via statins + high dose niacin for several years now.

I do think that endurance exercise is the best for building collaterals and strengthening the heart.

Thanks for the reference.

WJS

[raildown]

I'm assuming you meant the KL Gould 'sorce'....and thanks for your pointer...if you have acces to the Heart journal there is an excellent overview of lipid lowering (drug and non-drug) studies and the effects on all cause and CAD endpoits as well as CAD stabilization and regression which likely involve modalities besides plaque stabilzation/regression....;

see Heart 2003:89: pg 451-458

//

[raildown]

see the journal 'Heart'(from the UK)2003: 89: pg 1352-1357 by Christian Seiler "the Human Coronary Collateral Circulation"...especially towards the end:

after discussions about research eforts at Promoting growth of collaterals via 'growth factors' the results of whch have been disappointing to date he points out that the growth of Large collateral vessels (arteriogenisis) appear to be effectively _promoted_ by activation of monocytes;

arteriogenisis is related to enhanced _shear_ forces at the vessel wall in respose to increased flow in pre-existing collateral connections;

therefore _physical exercise_ would be an ideal therapeutic option because cardiac output and coronary flow is elevated _along_ the arterial brnces of the coronary circulation during exercise;

preliminary data from his lab suggests that, even in the absense of CAD, collateral flow is augmented substantially in reponse to endurance exercise training;

YMMV;

be well;

//

[raildown]

I think you would like reading "heal Your Heart" by K. Lance Gould, M.D.;

also note that a research team led by Dr Eric Topol chairman of cardiology at the Cleveland Clinic has discovered the first gene linked definitively to heart disease...the results are nuanced in their interpretation and application..see the current issue of Science...;

//

[HealThySelf]

Hopefully within 10 years coronary disease will be primarily treated as a chronic condition that can be arrested and regressed through drug therapy, reasonable dietary modifications, and exercise.

Happy Thanksgiving

WJS

[HealThySelf]

I ended up with severe CAD because of family history, a sendentary lifestyle, overeating, workaholism, a bad lipid profile with low HDL (approx 30), and other factors.

I've got a 100% occluded RCA, a "cratered" plaque in my left main, and an approximate 70-90% ostial occlusion of the circumflex.  After my second failed attempt at angioplasty (fortunately they didn't leave any steel in me) the attending gave me a 40% chance of sudden death within 5 years, if I didn't have bypass surgery.  It was one of the cruder sales pitches that I have heard, but I imagine that it's effective with most people.

After my heart attack 4 1/2 years ago my cardiologist put me on Pravachol, which is one of the lesser effective statins, atenolol because it's indicated after a heart attack, and Plavix also indicated after a cardiac event.  My total cholesterol only came down to 190, I had difficulty exercising and developed very distressing episodes of near syncope.  All standard therapy, but I was still walking deeper into the woods of coronary artery disease, plus had serious side effects from the drugs.

After some study, I decided that I needed much more agressive lipid therapy, had to get off the beta blocker and the blood thinner.  I got on a combo of Lipitor + Niaspan + Welchol which brought my TC down to between 110 and 130.  The Niaspan and exercise brought my HDL up 50% from 30 to 45 which I think is the most important factor to arresting the progression of the disease.

Fortunately I live in a part of the country that has mountains and wilderness and I have really returned to an outdoor life with lots of hiking and skiing in the winter.  I also have developed strong walking habits and walk religously morning and noon during the work week.

After a few years I have really started feeling like a healthy person.  Every morning I walk right up a hill that I had to stop halfway up 2 years ago because of angina.  I take the summers off and hike some treacherous mountainsides up to 4,000' per day without any residual inflammation.  I still have to pace myself, but I have more capability than I did when I was 35.  I don't do high demand aerobic activities like running however.

To me it makes little sense to give an active person without rythym problems a beta blocker.  It also makes no sense to give a diuretic that sucks the water out of their cells.  I'm always trying to put a couple of quarts in.  Also the key to recovery is endothelial health.  I believe that taking something like Plavix will eventually be found to be very detrimental to endothelial health.

Yes an ACE inhibitor should be a first choice.  I take Altace and believe in it, but it doesn't do enough by itself to lower BP.  I had to experiment with a few drugs to hit the right combo, but Altace combined with Norvasc does a great job of keeping my BP low normal which I believe is very important for people with CAD.

You might not see people that are as motivated as I am to live and change the coarse of there disease everyday.  Perhaps older inactive people that sit in a chair or walk around the mall a little should be on a blood thinner, beta blocker, and/or diuretic to try to prevent further cardiac events as their disease progressess.

I also think that Cardiologists and Surgeons believe in their system of doing things.  If they see a blockage, they believe the best course of action is to stick a stent in it.  If that doesn't work, the best course is bypass.  I believe that your profession is in serious denial about the true benefits of what they are doing.  I'm not cynical enough to think that it's only because a good hand with a catheter can make $30,000 for their organization before lunch.  I do think that it's a cultural indoctrination.

I believe that the goal should be to be able to live an active life without pain, stop the progression of your disease, and reduce the risk of future cardiac events to minimal.  I believe that these goals can be better attained with extreme lipid reduction, exercise, and bp control, and other life changes.

Of course not everyone is willing or able to do that.  If you've had hepatitis or another liver problem, you might not be able to take drugs.  Others might have a physical disability that keeps them from walking or live in a city with few convenient places to walk or swim.  Others may just not be able to make the habitual changes required to walk opposite the path that caused their disease.

And the bottom line is that I can be dead wrong, but part of life and health is believing in what you are doing.  The plus of having had a serious heart attack and bad prognosis, is that you become selfish about enjoying what remaining life you may have, whether that be today or 40 years.

I'm still with that cardiolgist, even though he said that the doctors in his group tell people like me to find another doctor.  He says that he humors me, because whatever I'm doing is working.  I believe that I am humoring him and that I will eventually turn him around.

Thanks for your reply.

WJS

[kd re: longstanding MR]

This is only my opinion and comes from observing and talking to others and my own experiences with collateralization.  Some people collaterlize easily and some do not.  My parents' friend was having some problems and when they did a catheterization.  Several of his major heart vessels had developed collaterals and they were amazed that he was doing so well considering the number of occlusions that he did have.  He is in is 70s and has worked outdoors as a carpenter and is fairly active and likes fishing but does not have a regular exercise routine.  I have known others who were active and did not develop the collaterals.
In my own case, I seem to develop vascular collaterals well - and I hope it stays that way.  My collateralization has to do with peripheral arteries and cerebral arteries. My carotid artery system and cerebral arteries seem to be shutting down but other vessels seem to be taking up the work. Each time something shuts down, I am left with less ability but gradually move back toward something approaching normalcy - it has consistently surprised my docs.  I exercise as I can but mostly try to stay active.
So, I guess, from my viewpoint, is to shoot for the amount of exercise that you can do, whether organized or unorganized, and hope that you were given a good collateralization system.
Not much help...but it is a personal view from someone who has benefited from the ability to collateralize.

[Dr. Erik]

This is the best stuff I've ever read on his forum! Let's keep it up and share this wealth of knowledge. Hope everyone had a nice thanksgiving!

[Cleveland Clinic]

Im not going to really debate your opinions of the medical profession.

I would like to point out that I too believe that the best therapies for cardiovascular disease  lie in extreme lipid reduction, exercise, and bp control, and other life changes.
Most do not take this course, and one of the singlemost goals of a cardiologist should be to attempt to gain their patients respect enough that they are willing to attempt aggressive lifestyle changes.

If you look in the media, the major trials coming out in the last few weeks involve stopping the progression of coronary disease with high dose statins, reversing some of the lipid plaque with new HDL agents, and cloning a gene involved in myocardial infarction.  None of these involve stenting, and really represent the future of cardiology.

You should also realize that many medications go beyond what they are on the surface.  Beta blockers have mutiple effects beyond heart rate including antiinflammatory effects, they also effect the myocardial demands of the heart beyond heart rate, thus in large studies of people with heart attacks, they save lives. Plavix, goes well beyond its anti platelet effects and actually has effects on the endothelial function (through monocyte recruitment, p-selectin etc..) and the control of inflammation.  Thus to dismiss its actions, would on your part negate the beneficial effects seen in large clinical trials in people post stenting.  On the other hand, despite the touted effects of the antioxidant effects of vitamin e, it has never been shown to be beneficialin heart disease, and in collective may actually be harmful in patients with coronary disease.

I never force anything on patients, I try to present the facts about their disease and the medications they can use to reduce their risk.

Hope this explains a few thing and tells you not all of us are just stenters and bypassers.

good luck

[raildown]

based on my research, it seems that the majority of collateral development excists secondary to serious coronary artery disease;

there is some evidence of collateralization in people w/o CAD (maybe 20 % of that population) but the basis for it is not well understood;

see the journal Circulation Nov. 25 pg 108 for a discussion of genetics and coronary collateral foration response; also the journal Heart Nov 2003 pg 352-7 "the human coronary collateral circulation";

there is some evidence of improved collaterilzation in CAD patients taking statins, also those taking ACE inhibitors;

? why do you ask about the effects of exercise on collateralisation ?

[Cleveland Clinic]

Again,

Its difficult to argue with what empirically works for an individual, but there are no specific proven therapies for collateral development.

However, a few points that medically should be followed.

LDL cholesterol should actually be lower then 125 in someone with coronary disease. As low as possible on a high dose statin is probably the best number.

ACE inhibitors have been shown to be effective in preventing cardiovascular events in people predisposed to CAD. Beta blockers are effective in preventing events in patients with prior MI. Calcium channel blockers have never been shown to have benefit in mortality compared to other agents, and should really be a last line agent, after ace inhibitors, beta blockers and diuretics. Diuretics, were recently shown to be as effective as ACE inhibitors in a large study of primary control of hypertension looking at outcomes. They are effective and inexpensive, and in the setting of no other indication (CAD, impared ejection fraction) should be considered a first line agent.

Vitamin E and omega fatty acids have no effect on blood thinning.

Plavix and coumadin have both been shown to be effective in reducing cardiovascular events in people with known disease. In someone with recuurent events, recent angioplasty, or elevated CRP or out of conrol lipdis, plavix should be considered as a therapy for secondary prevention. Of course aspirin therapy is a must for secondary prevention.

Your comments on exercise are probably the most important of all.

[Dr. Erik]

I read somewhere that exercise caused collaterization of the coronary ateries. I thought it was a known phenomenon. I guess I was wrong. I will continue to exercise, however.