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Avatar universal

How much can I expect from collateral circulation

I had a heart attack on Jan 15,... I am a 42 year old male who doesn't smoke, isn't overweight, has normal blood pressure, low cholesterol, (including quite low hdl which is a problem, apparently) and no previous heart problems or any other health problems.  I have been exercising for years.

My angiogram says that I have

"100% occlusion of the anterior descending artery with collaterals from the left and right.
25% stenosis in mid circumflex
25% stenosis in distal right coronary artery

Single vessel coronary artery disease.
Grade II left ventricular function with anterolateral apical wall hypokinesis.

I have been told to go home for 2 months and that, if I experience angina during routine activities, bypass surgery may be my solution.  

I have adopted a 10% plant based diet (Ornish, Esselstyn), and am hoping that this along with proper exercise, and rest, will make bypass surgery unnecessary.

What I'm hoping is that the collateral circulation will continue to improve enough to restore the previous circulation equal to what my blocked artery could have provided.... Is this naive?.... or should I resign myself to bypass surgery?

I only experience chest pain during exercise stress tests...not during routine activities....one lab technician, says that is not unusual considering how recent my heart attack was, and should improve naturally as my heart heals in the next few months....Is this a fair statement?

I have also heard that one of the side effects of bypass surgery is a minor amount of brain damage.... this apparently being discussed in the New England Journal of Medicine earlier this year... thoughts on this?

thanks in advance for your response.

22 Responses
Avatar universal
This is a fairly complex issue that I would have approached differently. First of all I would have used the results of the stress test to make a decision now. If the stress test was markedly abnormal and showed a large part of your heart was needing more blood, I would likely have recommended a bypass surgery or angioplasty now. Regarding bypass surgery, it can cause subtle cognitive changes that have been increasingly appreciated over the past few years; I do believe this to be true, though the effects are ususally more pronounced in older individuals. I still recommend bypass surgery for circumstances where angioplasty cannot be performed for technical reasons.
Avatar universal
I faced a similar problem to you 18 months ago.  After a minor Heart Attack I had an angiogram which discovered a 100% occlusion of my RCA.  The blockage couldn't be crossed with a wire, so I was only given the option of Bypass surgery.  The blockage was moderately collateralized.  I also had a 70% blockage at the entrance to the circumflex artery.

I decided not to have bypass and see if I could develop the collaterals further and stop the progression of my coronary artery disease.  Because there really is no information on how to rehabilitate in this way, it has been a hit or miss experience for me.

First of all it's important to accept the fact that you have significant Coronary artery disease, which will most likely continue to progress for some time.  As you have stated, your low HDL is probably the most important predictor of your disease.

The next thing to accept is, that without surgical revasularization, you are risking more myocardial damage and potential future heart failure.  The left anterior area serviced by this artery may remodel to a point where it begins bulging out.

That said I have some suggestions.  First of all it is very important that you get daily exercise, but you should give your heart some time to heal.  You should know where you become ischemic and exercise below that point.  If your chest aches after you exercise, you have probably done too much.  

I think that walking is the best exercise.  It's important to warm up very slowly and not exercise after you eat.  After 20 minutes of exercise, your arteries will expand and you will have much more capability.  I have a hilly circuit that I do before work and at lunch time.  I start out easy, but by the end can walk steeply up hill for about .45 miles without stopping.  I don't believe that you can get the same benefit from an indoor machine as you get in the outdoors, walking, hiking, or skiing.  I think that a daily exercise regimen is the most important thing for someone with CAD.

Next, even though you don't have high cholesterol or BP, I believe that you should be on a low dose of Lipitor and an ACE inhibitor like ALTACE.  The statin drugs are proving to benefit the coronary arteries in more ways than just cholestorol reduction.  ACE inhibitors have a renewing effect on the endothelium and also are recommended for heart failure because of beneficial effects on myocardial health.

Supplements are also important.  A multi-vitamin, Vitamin-E, B-Complex, and Folic Acid are probably the most important.  I'm also a big believer in dark berry juices, salmon oil, and Omega-3 oils.

Of course the diet is important, but it sounds like you have a grip on that.  Low fat and plenty of fruit.  Also plenty of water is just as important as vitamins.

Also mental attitude is very important.  I won't go into it, but I have changed my entire mental attitude since suffering my heart attack.  "Every Day Above Ground Is A Great Day!"

Has it worked?  As far as building collaterals, the answer is yes.  I agreed to undergo an angioplasty, using a new experimental total occlusion device, on January 15th.  The procedure was not done, because the remnants of a ruputured plaque were found in my left main, but the angiography shows an totally occluded RCA with the portion beyond the blockage filling normally.  It's now serviced by a very well developed collateral system.

I have come to peace with that blockage and plan no further attempts to open it.  Also, my cardiolite test shows nearly normal perfusion past that blockage.

Unfortunately I now have the shoulder of a ruptured plaque partially blocking my left main.  The rest of it is gone, and otherwise the artery is now clean as a whistle.  I am pretty sure that I ruptured that plaque when I climbed Mt. Adams this summer.  Fortunately it didn't kill me at that time.

Have I stopped the progression of CAD.  I think so.  I am settled with the RCA and have this artifact in my left main to somehow get rid of, but I doubt that I will have further coronary artery blockages in the future.

So can you develop a good collateral system.  Yes you can, but you have to be extremely careful.  It's risky and not easy.  On the other hand, you could have bypass surgery now and have a whole new set of blockages in a couple of years, if the progression of the disease continues.

Good Luck,

Bill S

Avatar universal
Another thing that you might consider is that chronic infection is the source of your coronary artery disease.  I asked my cardiologist for a strong round of antibiotics on the chance that some of that research might be correct.

I took Zythromax of a month.  I don't think that it will unblock my totally occluded RCA, but it may stop future inflammation in my coronary arteries.

Here is a link:


As far as low HDL goes, about the only medical therapy that significantly raises it is NIASPAN.  Exercise is the next best thing.  A glass of red wine every night will help, if you can stop at one.

Avatar universal
Good answer, Bill.  Sorry to hear about the rupture.  Hope things are going well otherwise.  My cardiologist says there is some evidence that the lipitor changes the nature of plaque to help prevent rupture.  

To the original questioner, I can't add anything to Bill's excellent answer except to say that the Ornish plan you are using is probably one of the best things you could be doing. It seems to be helping me, along with my Dr's other recommendations.

  Good luck.

Avatar universal

I found your answer very informative. You seem to know alot about ischemia caused by blockages. Do you have an opinion on what they refer to as "microvascular" angina, which is supposed to be caused by small vessel disease?

I had a regular stress treadmill test done (negative) followed by a nuclear scan which showed mild ischemia in the area of the left anterior descending artery. A cardiac cath showed normal coronary arteries.  With these findings, I feel the cardiologists have dismissed me. Before the nuclear scan was read they kept telling me what a great test it was. After it turned out positive and then the negative cath, they called it a false positive. They will not agree that I even have angina. Fortunately my pcp takes the situation a little more seriously.

The reason I had it done in the first place was because of neck/throat aching when I walked uphill and stairs, plus left shoulder and underarm pain when I walk briskly in cold weather. They put me on imdur which has helped considerably, but I know its still there.  One thing you said about exercise caught my attention. I found that if I climb the hill and ignore the pain (this was before meds) it will go away as the ground levels, and remain away when I walk downhill, but if I should turn around and start to walk uphill again I did not have much discomfort. Is this because of what you said-that the arterys "expand"? In my case, it would be the small blood vessels that expand?  

Apparently this condition does not increase risk of heart attack, even though I felt like I was choking walking uphill and on occasion even had that "feeling of impending doom" I don't get this on meds.  

I take lipitor for elevated lipids but it was not until I cut way back on carbohydrates did the numbers show much of an improvement. My blood sugar appears to be normal.  I also take toprol xl for hypertension, which seems to be well controlled, and nitrotabs sl which work well.  

Do you know anything about this condition that they call "syndrome x"?

Do you have any opinion on the error rate of cardiac caths? Someone once posted on this forum, or perhaps another, about a negative cath he had, followed by a positive procedure where they found a blockage "around back" that they had missed the first time.

Chris S.
Avatar universal
My mother has had 2 by-pass surgeries: the first lasted 20 years, the 2nd was a total failure. No one wanted to "open her up" again unless absolutely necessary (i.e. she was on her "death bed").
I discovered something called EECP - Enhanced External Counter Pulsation (now also called "Natural Bypass"). It is noninvasive and has been a lifesaver in her case. She is going strong after almost 5 years. EECP is now available in many locations. When she had it, it was still experimental. You owe it to yourself to try it before anything more invasive. Its whole principle is based on improving collateral circulation. Best of luck.
Avatar universal
Hi Chris,

I imagine that, if they can't do angioplasty or bypass surgery, the cardiologists don't really have a remedy for your situation.  I think the cardiolite test is generally pretty accurate.  I do know that they missed the problem in my left main with the angiogram 18 months ago and only discovered it after the interior of the arterial wall ruptured.  The use of tools to discover lipid pools in your arterial walls is mostly experimental yet.

I've heard about small vessel disease but know nothing about it.  I would say that the solution is to figure out how to stop the process and how to stimulate vasular growth.

I would say that beta blocker's wouldn't be my first choice in a BP drug, especially if you are physically active.  I would go for an ACE inhibitor, such as Altace.  You might read some research on them.  They seem to have a beneficial effect on the endothelial cells.

Also, although I carry nitro, I have never taken it.  As far as Imdur goes, if you are constantly stimulating your arteries with nitro it seems to me that they are unlikely to produce their own, as they should when you exercise.  You may completely lose their natural response over time.  

Research has shown that production of vascular growth factor is a response to ischemia, which makes sense.  So exercising just below the point where you feel ischemia, may promote vascular growth and expansion.  For people with our condition, low intensity exercise such as walking is best.  I walk a nice hilly 1.75 mile course before work and at noon each weekday and hike or ski both days on the weekend.  I take the summers off and pretty much hike in the mountains every day.

I would say that you should try walking at lease twice a day.  Don't eat before you walk, it lowers the blood flow to the heart and aggravates angina.  If it hurts to walk up hill, walk on the level or with moderate ups and downs for a mile or so first and then walk up very slowly, staying below the level that produces angina.  You have to have a good walking program and lots of patience, because you will improve very slowly.

Although it can be risky, another thing that I do every year is spend time at high altitude.  I keep thinking of those people in Peru and Katmandu and how their vascular system has developed to compensate for the altitude.  Last summer I spent a couple of weeks at 9,000' - 10,000' feet in Wyoming.  At first, it was tough just walking 5-6 miles every day.  I had to take it real easy.  But after a few days, I felt pretty normal up there and it really helped condition me for later high altitude climbing.

I don't know if you drink or not, but more than a drink a day is probably too much.  Drinking beer really aggravated my angina and I have recently quit drinking completely.  I think that a single glass of red wine would be beneficial, if you can stop there.

I don't know which supplements would be good.  I would go way up on the folic acid, Vitamin E, and an OMEGA 3&6 formula.  If you don't have a problem with antibiotics, I would try a month of something strong.  I did Zythromax for a month.

I don't know about syndrome "x".  I thought it was familial HDL deficiency, which I have, but I think that it's something else.

In the end we do have to save ourselves, if we can.  

Best of luck,


Avatar universal
Thanks Bill for your response.

It was during my walking routines that I discovered the angina problem!  There is a moderate hill at the beginning of my walking routine as I leave my house and I discovered I had problems with it, as well as with problems with other hills early in my walking routine. This had been going on for about 3-4 years before I said anything. I figured I was young, female, and since the discomfort was not at all in my chest then it had to be something else. Then I developed a stubborn hypertension problem and decided to admit having the exertional problem. It got so bad that I really feared going up these hills-that feeling of impending doom is awful. As you pointed out, it is worse after lunch.  The imdur helps tremendously, as did the sl tabs, but they are so short acting and inconvenient. If the situation did not improve after 3-4 years (got worse in fact) is it likely it will? Perhaps if I increased my frequency of walking.

I tried an ACE Inhibitor (Lotensin) but I got that cough they sometimes give, along with a funny sensation in my throat. It worked for the hypertension, but that was kind of scary.  The toprol xl works great on the hypertension (atenolol did not) and doesn't seem to affect my ability to exercise by walking (not sure about anything more strenuous)

It as interesting to read that they missed your problem 18 months ago. I sure hope they don't change their mind on me, after I have a "cardiac event" which they told me would be unlikely to happen.

I had low HDL (26 at one point) but have managed to get it up to 43.    

Thanks again,

CHris S.
Avatar universal
Hi Chris,

Of course I have no medical training, so anything that I say is just opinion from my personal experience.

It's too bad that you had the ACE inhibitor cough.  I don't know whether it would pay to try another, or if you would have the same problem.  I'm still not a fan of beta blockers for active people.  They work on your head and I beleive that they desensitize your autonomic system.  How about Norvasc, which is a calcium channel blocker?

Moving your HDL from 26 to 43 is an accomplishment.  I think mine was 29 at one time.  I haven't checked it recently, but I have gotten it up to the low 40's on previous tests.  My brother has the same problem and my mother died from coronary artery disease, so I believe that it's familial.

If you can design your walking so that you don't do anything strenous for the first 20 minutes or so, perhaps you can avoid the angina.  Also, food has a big effect on Angina.  You shouldn't eat anything, except perhaps a piece of fruit, at least 2 hours before you exercise.  That's why I do it in the morning before work.  I then have a bowl of cereal when I get to work.  Also I eat lunch after I walk.

I don't think that you have any choice but to keep exercising.  Just find a way to stay below the point where you experience angina.  I suggest getting a pulse watch.  I can roughly tell that if my heart rate goes above 110 for very long early in the exercise that I will experience angina.  At the end, I run my heart up to 140 climbing the last hill without angina.

Also, you probably have a great deal of stress around this.  If you can find a way to relax, I think that it would help.  I have my little dog which really soothes me.  I pick her up from time to time and she focuses her little lime green aura on my left main blockage.  She is going to knock those remnants out of there sooner or later.

The funny thing is that I never experienced real angina with my totally occluded RCA.  It was only after I ruptured the interior wall of my left main that I felt classic angina.  I would go out walking first thing in the morning, after having breakfast, and I could only walk 150 yards before experiencing extreme pain in the center of my chest.  After that I could only walk a short distance before having to stop.  After 20-30 minutes of this I would eventually get through it.

Now I don't eat breakfast and try to stay below that threshold in the first 20-30 minutes.

I've nearly got my femoral artery back to normal since my last catheterization in January.  Now I am going to seek out someone to vaporize the shoulder of this ruptured plaque that is sticking up in the left main with an eximer laser.  Other than that, the artery looks good and the rest of my system looks good and I have a great natural bypass for my RCA.  I guess that I will be going to Canada for that.

Good luck to you.


Avatar universal

Thanks for all your advice. Even though you are not a medical person, I can tell you know what you are talking about by the description of your experiences. Sometimes, first hand experience is more helpful than textbook knowledge.

I do plan to ask my doctor about a calcium channel blocker because I have been told that they work with "syndrome x" and for me it would mean taking 1 pill instead of both toprol and imdur, since I also have hypertension.  Yes, that ACE Inhibitor cough was annoying. I only got it after I increased the lotensin. Also, lotensin did nothing for the exertional angina.

If I waited to eat until after I walked, I would come home ravenous. I do try to wait 1-2 hours after eating though or else I have more discomfort, although on imdur it is bearable.

What is wrong with your femoral artery?

Avatar universal
Hi Chris,

Oh the femoral artery still is a little messed up from the last cath in January.  It's almost back to normal, but had a few lumps in it.  I probably went out back-country skiing before I should have.

I know that it's hard not to eat before you go out, but it makes a big difference.

I was real good this morning and I was trying to figure out why.  No angina at all.  All I can think is that I ate one of those 71% organic chocolate bars last night - either that or I finally got rid of that artifact in my left main.  They're almost too bitter to eat.  Seriously, really good chocolate will open up your arteries.  Also green tea will do the job.

You can write me at bill.***@**** if you get tired of posting on this board.  We don't have the same condition, but I hope that I have been of some help.  I might be kidding myself, but in the long term we have to believe in what we are doing to stay well and live.

Best wishes,


Avatar universal
Hi Chris,

Oh the femoral artery still is a little messed up from the last cath in January.  It's almost back to normal, but had a few lumps in it.  I probably went out back-country skiing before I should have.

I know that it's hard not to eat before you go out, but it makes a big difference.

I was real good this morning and I was trying to figure out why.  No angina at all.  All I can think is that I ate one of those 71% organic chocolate bars last night - either that or I finally got rid of that artifact in my left main.  They're almost too bitter to eat.  Seriously, really good chocolate will open up your arteries.  Also green tea will do the job.

You can write me at bill.***@**** if you get tired of posting on this board.  We don't have the same condition, but I hope that I have been of some help.  I might be kidding myself, but in the long term we have to believe in what we are doing to stay well and live.

Best wishes,


Avatar universal
I can not add to this conversation, but I have certainly enjoyed following it. It is one of the best conversations on this board in some time and involves questions where individual experiences are valuable. I have conditions similar to yours. I have long felt that the concerns of how to improve collateral circulation and prolong the life of bypasses does not get enough attention by researchers and information providers. I hope you do not move the discussion off of this board.

Good luck to both.

Avatar universal
Hi Roger,

I think that it's quite simple.  The heart tries to compensate for poor circulation by producing VEGF as a response to ischemia.

I think that it's very important to keep exercising to keep this process going.  The disease is going to eventually come and get those that sit in a chair and take it easy.  After years of punishing their body, many people think that a cardiologist or heart surgeon, or some medications are going to fix them.  It doesn't work that way.

I tend to be aggressive and have pushed too hard physically at times.  I do think that you have to take care not to damage your heart further.  This means being sensitive to indications of angina and learning to be very conscious of when your heart muscle is experiencing ischemia.

Low intensity exercise with slow warmups is best.  Walking is great, if you have good legs.  Swimming might even be better.  I prefer to walk, x-country ski, and hike.  I don't believe that exercise on a machine is nearly as good as outdoors.  Outdoor exercise gives you variability and also benefits you on many more levels than just the physical.

If you want to see a great set of RCA collaterals built by this method, send me an e-mail and I will send you a shot from my last cath.  My heart has built a much better bypass than I could have had done surgically.

Take care,


Avatar universal
Re syndrome x... there was a question about this not too long ago, and the doctor gave a very thorough response that included the text of several articles on the subject.

Re angina... I also "exercise through" the (mild)angina - it usually goes away after several minutes of walking and stays away.

I recovered really well from a heart attack by exercising moderately - trying to stay below the "angina threshold" but to keep moving. I got stronger and stronger over three years. After the heart attack I couldn't walk more than .1 mile without pain on a bike path I go to. Then I took up rollerblading - and you should see me now - same path. I still have occasional chest pain, but I'm in much better shape than I was in. I was told that people develop collaterals at different rates - some faster than others - and that some don't develop them at all. I was also told by same cardiologist that Imdur seemed to hasten the development of collaterals, but another cardiologist expressed doubt in that regard, and I decided to go off Imdur - stick to Toprol xl and verapamil sr.

So now I get mitral valve prolapse (not related to ischemia)... oh well! Take care - Emj

Avatar universal
I have enjoyed this thread and agree that not enough attention is given to how to prolong the life of by-pass graphs. I had a triple by-pass last year. I am 36, was very fit, never smoked, and had a pretty good diet. I got back to exercising, but my heart rate shoots up quickly, and its tough to keep it below 150 at moderate exercise levels. When I play soccer it is usually around 175-185 and will sometimes go over 200. My cardiologist has said to forget about the rates and carry on as long as I feel OK. Any views?
Avatar universal
Hi Ken,

That must be tough - having bypass surgery at 36.  Do you think that the traditional risk factors caused this or could it be bacterial?

Of course everyone is different, but I don't think that I would run a HR of 175 with coronary artery disease.  Of course I'm 51 and you are in your 30's.

I think that your HR will come down over time as you exercise.  I would do more of the low intensity exercise than the high intensity until you are more conditioned.

Walking uphill gives you a good cardiovascular workout and you can control your HR by stopping as much as necessary.  Fortunately, here in Washington State, almost every trail goes uphill for a few thousand feet, but you really only need a hundred feet of variation to work your heart.  Just walking fast on the level my HR tops around 100.  As soon as I go up it's easy to get up to 120, but I normally try to keep it under 110 for any sustained period.  That's after a long slow warmup.

When I mountain climb, I have to let it go higher in order to get anywhere in a reasonable amount of time.  I normally let my HR go up to 135 and then stop until it goes back to 120.  Sometimes when you are on a 30 degree slope above 10,000 feet for a couple of hours, this only means taking 5 or 6 steps up and stopping for 30 seconds. It's slow, but I eventually get to the top.

Although I do a lot of backcountry skiing, I just went downhill skiing for the first time this winter.  On a steep long run my HR got up to 145 a few times and I felt angina.  This was a combination of exersion and adrenalin from fear - I'm just a lot more fearful on the steep stuff than I used to be.  I sometimes had to stop for a couple of minutes.  It's good to get this type of variable exercise, but it's more risky and you have to pace yourself.

If you don't have a good HR monitor, I would suggest buying one and using it.  

Good luck to you,


Avatar universal
I too have learned a great deal from this thread! I am a 52 "young" female who had triple bypass in 3/00  stents in 6/00  stents closed as well as the graft in 9/00 ... It seems everytime I get ok, then the angina starts again.  I had a heart cath this monday.. and it looks like everything is holding..no big gains but no losses.  I need to start a exercise program, but not sure what my heart rate should be..and how far to push myself.. it seems from what I've read  you need to push in order to gain...and I'm willing to do that! just give me some direction.. I'm going shopping for a heart monitor, any advice on which one works best for walking? Thanks for any and all advice.. Here to COLLATERAL VIENS!
Avatar universal
Hi ro,

I'm sorry to hear about all of the procedures that you have had to go through.  I have been pushed for bypass surgery for 18 months, but haven't been buying it so far.  Also, I consider myself lucky that the two attempted angioplasties were failures and that they didn't leave any hardware in me.

I would caution that it's important that you do daily low intensity exercise, but you do want to be careful not to push too hard into angina.

Everyone is different, but my arteries dilate with exercise to a point where I have a lot of capability.  Early in the session, I have to take it very easy, however.  I stop a lot and look at the trees and listen to the birds sing.  It seems that around 20 minutes I really start clicking.  

This is why I don't think that a treadmill gives you nearly the good effects that walking does.  Walking is much more variable.  You can stop and take in the world for a moment whenever you want.  It relaxes you much more, which is just as important as the exercise.

Also there is such a thing as silent ischemia, which they say that many people have.  I feel that I am very sensitive to the subtle signs the precede the onset of angina, but I have trained myself to be more aware of them.  If I rest before or when I encounter that first subtle feeling, I will have a long enjoyable walk, hike, or ski without pain.  But you do have to have patience on that warmup.

The important thing is to condition yourself, and hopefully expand collaterals, without doing myocardial damage.

But daily exercise is important.   I walk 1.75 hilly miles in he morning and at noon.  Now that it is getting more light in the evening, I also stop a the local dog park after work and walk another 1.75 miles.  That evening walk is important, because I am full of stress by that time.  The first half I am tight and can only walk so fast.  By the second half, I could run back to my car if I wanted to - but I don't.

It's much better than going home and drinking or eating too much to relax after work.

So now I walk over 5 miles per day and am very habituated to it.  If I didn't do it I would be unhappy.  On the weekends, I used to be lazy, but now I have a real need to be on skiis, or be out on a hike.  I think that it's important to develop these types of habits.

Also, if you are on cholesterol meds, think about putting some good oils back into your body.  I take salmon oil tabs and/or an Omega 3/6 formula.  I also think that a high dose of Vitamin E is important.  Also a B-complex.

Good Luck,


Avatar universal
Thanks so very much for your insight!  I truly think its the most Practical advice I have been given...because of you..I am now going on a "sightful walk"!
Avatar universal
In order to solve the above type of occlusions and restenosis:
1---Has anyone had " double injection " do open calcification during angioplasty?
2---Are you aware of any new guide wires designed to get through total occlusions?
3---I was told that Dr Patrick Whitlow posted an article about a new device whigh separates plaque in occlusions: do you know what device was this and who made it?  Alos does anyone have DR Whitlow's email address?
Direct: ***@****
Avatar universal
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