With heart
disease you face the biggest of all the medical businesses. In 2001, in
the United States, more than one million coronary angioplasty procedures
were performed at a cost of more than $30 billion, and more than 500,000
coronary bypass operations were performed at a cost of another $30
billion.1 Assume that your local general hospital derives 80%
of its income from heart disease. The average total
healthcare cost after three years is $63,896 for angioplasty (compared
to $84,364 for bypass surgery).2 You had best be prepared for some high pressure sales when you become
involved with heart surgery—and take all the necessary time to be sure
you are making a wise purchase. My experience has been most patients
are misinformed by their doctors about the real benefits and harms of
the treatments offered—and all that money plays a big part in the
dishonesty.
The Angioplasty Procedure
Angioplasty is a surgical procedure used to
open blockages caused by atherosclerosis in the arteries, most commonly
in the heart arteries. The most descriptive name used for this
treatment is: Percutaneous (through the skin) transluminal (inside the blood vessel) coronary (relating to the heart) angioplasty (blood vessel repair). When a stent is also used the
procedure is called a Percutaneous Coronary Intervention (PCI).
The stent is a tiny wire mesh tube used to help keep the treated artery
open after the initial angioplasty. About 90 percent of angioplasty
procedures these days include the use of a stent.
Terms Used for
Angioplasty:
Balloon angioplasty
Coronary angioplasty
Coronary artery angioplasty
Cardiac angioplasty
Percutaneous transluminal coronary angioplasty
PTCA
Heart artery dilatation
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During the procedure a catheter with a guidewire is placed in the
femoral artery of the leg, near the groin, or a main artery in the arm.
Using x-rays, the catheter is fed up into the heart (coronary)
arteries. Dye is then injected in order to visualize shadows of the
inner artery lumen. When a narrowed segment is identified a
balloon-tipped catheter is passed into this area and inflated. The
balloon compresses the plaque that is causing the narrowed area,
squashing it outwardly against the arterial walls.
A stent is next placed
over a catheter and inserted into the area that has been compressed
during the angioplasty procedure. When the balloon is inflated again,
the stent expands and stays permanently in place.
Angioplasty Does Not
Save Lives
Although angioplasty
has been performed for nearly 3 decades and over one million procedures
are done annually, you should be astonished to learn this fact:
Angioplasty has never been shown to save the lives of patients who are
treated for chronic heart blockages.3,4 I know this
statement defies logic. After all, the skilled surgeon has just dilated
a stricture in your heart artery.
To understand why this
procedure does not save lives, you need to learn how a heart attack
occurs. All doctors know, and all patients need to realize, that a heart
attack occurs when a small volatile plaque, better pictured as a tiny
festering sore, located on the inside of an artery ruptures and causes
the blood to suddenly form a clot (thrombus).5,6 The
clotting occurs as a result of the release of “products of injury” when
the sore ruptures—similar to the clot that forms when you cut your
hand—except this clot often fills the blood vessel. The event of blood
clot formation in the heart artery is known as a coronary artery
thrombosis, or heart attack. The reason lives are not saved by
angioplasty is this treatment completely ignores the dangerous part of
the artery disease, the volatile plaques (sores). Instead the doctor’s
efforts are directed toward dilating a narrowing caused by a large,
stable, fibrous, plaque—this latent stage of artery disease almost never
ruptures and therefore does not lead to a heart attack when left alone.
However, when the plaque is ruptured by angioplasty surgery, heart
attacks occur in 3 to 5% of patients.7
Half the Arteries
Operated on Close down within Five Months7
A potentially
devastating result from the injury caused to the artery wall by
angioplasty is blood clot formation and closure of the treated artery.
This should not be surprising. When the plaque is ruptured by the
expanding balloon, “products of injury” are released—as expected, these
substances cause the blood to clot within the artery. Within five months
of the surgery up to 50% of arteries treated by angioplasty are
completely closed down.7 This is common knowledge among
doctors, therefore many efforts have been made to reduce this
complication, including the use of blood thinning agents, such as
aspirin, Plavix, fish oil and heparin before and after surgery. The
benefits from these medications have been limited. The next effort to
stop postsurgery artery closure has been the use of mechanical devices,
called stents, which prop the artery open.
Stents, a Temporary
Solution
Since the mid 1990s
wire mesh stents have become a standard part of the angioplasty
procedure. Unfortunately, these wire cylinders (stents) irritate the
smooth muscle cells of the artery walls causing these cells to grow
aggressively (to proliferate). This growth is an effort by the body to
cover up the foreign metal that has just been introduced into the artery
by the surgeon. This should not be surprising. Whenever an irritating
alien material is placed in the body, cells grow around it in order to
isolate the unfamiliar substance, which the body perceives as
potentially harmful. The growth of the muscle cells (and blood clots)
eventually closes 20% to 41% of the arteries containing these metal mesh
stents.8 Furthermore, the use of stents results in no better
survival than angioplasty alone7,9—and remember angioplasty
does not improve the chances of living longer.3,4 If only
treatments could be developed to stop these cells from growing.
Scientists had to look no further than cancer therapy to find tools to
stop cells from proliferating.
Brachytherapy, Stop
Proliferation with Radiation
Radiation kills cells and stops them from
proliferating—a treatment used for decades to stop cancer cells from
growing. Brachytherapy is the use of radioactive seeds placed after
angioplasty through the catheter to the site of balloon treatment. The
seeds stay in place for about 20 to 45 minutes, and then the catheter is
removed. Brachytherapy is effective in preventing in-stent closure (restenosis)
by stopping the proliferation of blood vessel smooth muscle cells, and
associated scar tissue. Unfortunately, the early benefits of this
therapy were not sustained, and the injury to the arteries caused by the
radiation encourages the formation of blood clots that occlude the
arteries and cause death.
The long term follow up of patients treated
with this procedure has shown an unacceptable high rate of major adverse cardiac events despite prolonged
administration of combined therapy with blood thinning (antiplatelet)
drugs.10 The adverse events are mainly due to blood clot
formation and artery closure. This closure usually occurs during the
first year after brachytherapy. In one recently reported study 38% of
people suffered life-threatening episodes and 53% had to be reoperated
on within 5 years.11 As a result, the two companies that
made brachytherapy devices removed their machines from the market.
Drug Eluting Stents,
Stop Proliferation with Chemotherapy
Placing a coating of
cancer drugs onto the stents is now the most popular method used to
inhibit the proliferation of smooth muscles cells after angioplasty.
Two kinds of stents are available: the sirolimus-eluting (Cypher) and
the paclitaxel-eluting (Taxus). Around 6 million people so far have drug
eluting stents in their heart arteries. The restenosis rate was zero at
six months after placement of the drug eluting stent compared to 26%
after the bare metal stent.12 But at one year there was no
difference in deaths or heart attacks between the drug-eluting stents
and the bare metal ones.13,14 However, four years later the
results are disturbing. Two recent studies showed the risk of death and
heart attacks are higher with the drug-eluting stents compared to the
bare metal, uncoated stents.15
Mandatory Blood
Thinners Post-Op for Life
Because of the high
risk of artery closure (restenosis) from blood clotting after an
angioplasty with or without a stent, blood thinners have been routinely
prescribed. A baby aspirin daily has been the time honored treatment to
prevent the formation of clots in the arteries—this drug is relatively
safe and effective. To aspirin has been added another class of blood
thinner drugs called thienopyridine—these include Plavix (clopidogrel)
and Ticlid (ticlopidine). When combined with aspirin, there is a high
risk of bleeding from this class of drugs.16
The risk of blood clot
formation after a bare metal stent decreases after 2 to 4 weeks as the
smooth muscles cells cover the bare metal.17 Because the
drug-eluting stents delay coverage of the stent by proliferating cells,
the risk of blood clotting is prolonged. Until recently,
recommendations were to use a drug like Plavix for a minimum of 3 to 6
months after surgery in addition to lifelong aspirin therapy.17 Recent reports of sudden death months and years after the placement of
drug-eluting stents has caused doctors to rethink the time someone
should be taking these medications.17 The truth is they
really don’t know what to do—so, doctors, running scared from fear of
law suits, are now recommending that patients who have these kinds of
stents should be on aspirin and a Plavix-like drug for life.
What Would I Do?
I have studied heart
disease for the past 35 years, and everything I know about angioplasties
and bypass surgery makes me want to stay clear of these businesses
unless there is absolutely no other alternative. The real alternative
that too few people take advantage of is prevention: A low-fat,
plant-food based diet, exercise, and clean habits will prevent this
disease. Once the disease has started it can be stopped and in most
cases reversed with this lifestyle medicine.18
The only indication for
angioplasty is to relieve incapacitating chest pain—since this surgery
has not been shown to save lives.3,4,7,9,13,14 To use the
promise of prolonging lives as the sales pitch is dishonest.
If I had incapacitating
chest pain I would have an angioplasty. The key word here is incapacitating. If I got chest pains while climbing to the top of a
mountain, I would not have surgery—I would just give up climbing because
I do not care for this kind of activity. However, if I had chest pains
so severe that they kept me from riding my windsurfer across the bay, I
would have surgery—because, for me, this limitation would be
incapacitating. Of course, before agreeing to surgery I would change my
diet; this change alone has been shown to reduce chest pain episodes by
90% in 3 weeks19 and I would consider medications known to
relieve chest pains—medications like nitrates (nitroglycerin) and beta
blockers. I would also use enough cholesterol-lowering medication to
lower my levels to below 150 mg/dl. (See the June 2003 McDougall
Newsletter article: Cleaning Out Your Arteries.)
My first surgical
attempt to reduce the blockage that is causing my heart to hurt would be
with a standard angioplasty, no stent. If that procedure failed then my
next effort would be the use of a bare metal (uncoated) stent. After
surgery, I would take aspirin and Plavix for one month, and then stop
the Plavix, but continue one baby aspirin a day for life.
I am sure situations
exist that would cause me to elect bypass surgery if the angioplasty
failed, fortunately, I cannot think of any right now. The indications
for bypass surgery are:
1) Incapacitating chest
pain
2) Damage to the left
ventricle (heart chamber) causing 50% or less of the blood to be ejected
from the heart with each beat (ejection fraction). For these patients
there is an 18% survival advantage with surgery over 10 years.20
For me, this small benefit would not cause me to rush into the operating
room.
Hopefully, you will
never become involved in the heart disease businesses—you can’t win
here. If you do, then you must make every effort to become a
well-informed consumer and a very “squeaky wheel” by asking questions
and getting complete scientifically backed answers, until you are fully
satisfied that this is your best choice. My educated guess is that over
95% of angioplasty and bypass surgeries could be avoided if proper
medical indications were adhered to, patients were fully informed of the
limitations and hazards, and every patient took full advantage of the
powerful healing which can be effected by a change to a low-fat,
plant-food based diet and by commitment to exercise.
References:
1) One million
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Lyttle C, Hynes DM, Henderson WG; Investigators of Veterans Affairs Cooperative Studies Program #385
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