Michael D. Ozner, MD
Cardiovascular Prevention Institute of South Florida

Americans get more than 1.5 million cardiac bypass surgeries and angioplasty procedures a year, which makes heart surgery among the most commonly performed surgical procedures in the US.

Fact: These procedures have not been proved to extend lives or to prevent future heart attacks except in a minority of patients.

Between 70% and 90% of angioplasties and bypass surgeries are unnecessary in stable patients with coronary artery disease.

While American patients are seven times more likely to undergo coronary angioplasty procedures and bypass surgery than patients in Canada and Sweden, the number of Canadians and Swedes who die from cardiovascular disease is nearly identical (per capita) to the number of people who die from heart disease in this country.

These are not harmless procedures. About 30% of angioplasties fail, requiring patients to repeat the procedure — and eventually, many of these angioplasty patients will undergo bypass surgery.

People who have bypass surgery are nearly four times more likely to suffer a stroke at the time of surgery and are vulnerable to postsurgical infections.

Between 3% and 5% of patients die from bypass surgery — that’s 15,000 to 25,000 lives lost a year.

So why do we keep doing these procedures?

A FLAWED MODEL

Cardiologists used to compare the coronary arteries to simple pipes under a sink.

The thinking went that these arteries sometimes accumulated sludge, called plaque (cholesterol deposits within an artery wall), that impeded the flow of blood to the heart.

Treating this sludge with angioplasty or shunting blood around it with bypass surgery seemed obvious.

That approach, however, is flawed. We now know that the arteries are highly dynamic structures. What happens within the artery wall is more significant than blockages that obstruct the lumen (arterial openings).

The majority of heart attacks can be linked to small, yet highly inflamed, plaques. These small plaques have no effect on circulation because they take up little space within the lumen.

Yet they may rupture and cause a sudden heart attack due to a clot that forms at the site of the rupture.

What happens: Cholesterol-carrying particles that enter an artery wall undergo oxidation and modification that trigger an immune response.

White blood cells flood the area and engulf the oxidized cholesterol particles and cause plaque to form.

Then the white blood cells secrete substances, such as proteinases, that break down the fibrous cap that covers the plaque.

When the fibrous cap ruptures, blood enters the plaque and a blood clot forms that can block the artery.

Sudden clots that form following plaque rupture are the cause of most heart attacks. Angioplasties and bypass surgery do nothing to prevent plaque rupture or clot formation.

HEART-SAVING STEPS

The following steps may save lives. Of course, always ask your doctor about the best heart-health strategies for you.

Test for high sensitivity (hs)-C-reactive protein (CRP). It’s a “marker” that indicates simmering inflammation in blood vessel walls and can be measured with a simple blood test.

Inflammation within arterial plaques contributes to plaque rupture, clot formation and subsequent heart attacks.

The landmark JUPITER study looked at more than 17,000 participants with elevated hs-CRP (above 2 mg/dL) and normal cholesterol.

Those who were treated with medication to lower hs-CRP were significantly less likely to have a heart attack or stroke or to die than those in the control group.

CRP can be lowered with lifestyle changes (diet, exercise, weight loss, smoking cessation) and medical therapy (including statin drugs).

Test for apolipoprotein B (apoB). This is a better indicator of heart disease than standard cholesterol levels (including HDL, LDL and triglycerides).

Even if your LDL “bad” cholesterol level is normal, you still could have elevated particle numbers, which means that your LDL cholesterol is distributed across a lot of very small, dense particles.

These small, dense particles are the most dangerous kind — they are more likely to squeeze through the lining of the artery and more likely to become oxidized once they’re there, leading to atherosclerosis (hardening of the arteries).

You can check your “bad” particle number by testing for apoB. Blood tests for apoB are performed routinely in Europe and Canada but not in the US. Ask for this test when you have your usual cholesterol screening.

The optimal level of apoB is less than 90 mg/dL (or even lower for high-risk patients). To lower apoB, follow the recommendations for lowering CRP.

Choose an anti-inflammatory diet. People who follow a Mediterranean-style diet — high in plant foods and cold-water fish (such as salmon) and low in red meat and processed foods — can reduce inflammation.

The Lyon Diet Heart Study compared a Mediterranean diet to a diet resembling the American Heart Association’s cholesterol-lowering Step 1 Diet.

Participants on the Mediterranean plan were 70% less likely to die from all causes and 73% less likely to have a recurrent cardiac event than those on the standard “healthy” diet.

The Mediterranean diet is effective partly because it limits saturated fat and does not contain trans fat. The fat present in the Mediterranean diet, mainly from olive oil and fish, has anti-inflammatory effects.

Also, the antioxidants in fruits and vegetables reduce the oxidation of cholesterol-containing particles within artery walls.

Avoid high-fructose corn syrup, which goes straight to the liver, where it causes an increase in triglycerides, a major risk factor for heart disease.

Laugh, pray, get a pet. Anything that reduces stress can significantly reduce your risk for heart disease. Research at the University of Maryland Medical Center, for example, found that laughing is almost as effective as exercise at improving arterial health.

Laughter relaxes blood vessels and improves circulation to the heart. And like other stress-control strategies, including prayer, loving relationships (with pets as well as people) and yoga, it lowers cortisol, a stress-related hormone.

Get moving. There is a dose-response relationship between exercise and the heart — more exercise gives a greater benefit. Aim for 30 to 45 minutes of exercise most days of the week.

Good news: Walking for as little as 30 minutes five to seven days a week can significantly decrease the risk of dying from heart disease.

Personal interviewed Michael D. Ozner, MD, cardiologist and medical director of Cardiovascular Prevention Institute of South Florida in Miami.

He is the symposium director for “Cardiovascular Disease Prevention,” an annual international meeting highlighting advances in cardiology.

He is author of The Great American Heart Hoax: Lifesaving Advice Your Doctor Should Tell You About Heart Disease Prevention (But Probably Never Will) (BenBella). http://www.DrOzner.com

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