Is a Stent the Easy Answer?

It is an all too common scenario. The passing years take their toll. Aging bodies change. They slow down. They are not as comfortable as they once were. Artery walls become the hosts for insidious deposits of cholesterol and other fats that create lesions called atherosclerotic plaques. A niggling ache in the chest intensifies; a plea from the heart for more oxygen. A test called an angiogram brings the unwelcome news of arteries no longer able to supply enough blood for a healthy, happy heart. Observing the multitude of our peers in this situation, it could be considered inevitable. But is there a better alternative?

Rates of percutaneous coronary intervention (PCI or angioplasty with a stent) to open narrowed or blocked coronary arteries are steadily increasing. (Coronary arteries are the blood vessels that sit on and within the heart ensuring that the heart receives enough oxygen to keep pumping and distributing blood to all the tissues of the body). Between 1994 and 2005 the number of Canadians undergoing this procedure more than doubled (1). PCI is called a non-surgical procedure and it involves the insertion of a catheter into a blood vessel in the groin or the arm which is then threaded through that blood vessel into the narrowed coronary artery. Once in place a “balloon” is opened to compress the atherosclerotic plaque and expand a small wire mesh tube (the stent). The balloon is then deflated and the catheter withdrawn. The stent stays in the artery to keep it open. Stents can be coated with medication to help keep the artery from clogging up again (drug-eluting stent) or not coated, in which case they are called bare-metal stents. The goal of PCI is to improve blood flow to the heart, relieve heart-related chest pain (angina) and shortness of breath and allow the patient to feel better and be more active. PCI can be planned and completed before a heart attack occurs but it can also be performed during heart attacks to save lives by quickly opening blocked arteries and reducing the amount of damage done to the heart. For more severe coronary artery disease a surgical procedure called CABG (coronary artery bypass graft) can be performed. This involves taking a healthy blood vessel from the leg, arm or chest and connecting it to the blocked arteries in the heart so that blood bypasses the diseased area. (2,3).

PCI has risks. In the past, angioplasty without a stent reclogged in about 30% of cases. New stents were developed and the improved versions are bare-metal stents that reduce the chance of reclogging to about 15%. Drug-eluting stents further reduce clogging risk to less than 10%. Even so, blood clots bad enough to cause a heart attack can form within stents. To decrease this risk, aspirin or another anti-platelet drug is usually prescribed after PCI. Bleeding may occur from the incision on the arm or leg through which the angioplasty catheter was inserted. Usually this bleeding only amounts to a bruise but it can sometimes be severe enough to require a blood transfusion or surgery. Rare risks include heart attack or damaging the coronary artery during the procedure, abnormal heart rhythms that are usually short-lived but sometimes require medication or a temporary pacemaker, kidney problems from the dye used for stent placement or stroke resulting from plaques that break loose during catheter passage through the blood vessel. Blood thinners are used during angioplasty to minimize risk of stroke (2,3).

Does PCI actually work? The 2007 COURAGE trial presented the surprising result that stents in patients with stable coronary artery disease do not reduce the risk of future cardiovascular events or prolong life. This trial compared two groups of patients with one group receiving “optimal medical therapy” consisting of cholesterol- and blood pressure-lowering medications, aspirin, and other medications if needed and the other group receiving the same medications plus PCI. After 4.5 years no significant differences were observed between the two groups in their rates of death, heart attack or other major cardiovascular events (4).

Even more incredibly, in November of 2017, fresh research illustrated that PCI doesn’t even have a benefit in reducing anginal pain. Participants in this study were patients with stable angina diagnosed with one blocked coronary artery. They were all started on medications to reduce heart attack risk and relieve chest pain and then divided into two groups. Both groups underwent a procedure but actual PCI occurred in only half of them. The other half went through a similar “pretend procedure” where enough of the process was done so that it appeared that the patient had undergone PCI but in actuality no angioplasty or stenting occurred. Follow-up after six weeks showed no difference between the two groups. Both had a similar reduction in chest pain and were able to exercise for longer periods. (5)

This recent research concurs with a five-year randomized controlled trial published in 2007 that compared the impact of coronary bypass surgery, PCI or simply medications on patients with stable coronary heart disease. All three treatments yielded comparable, relatively low rates of death. The benefits of taking medication only were similar to those of PCI. Only coronary bypass surgery resulted in a superior heart protective effect compared to medication in that it resulted in 60% fewer repeat procedures. (6)

Fortunately medical experts are gaining new understanding about better therapy options for people with coronary artery disease, especially those with stable disease. Stable angina symptoms are predictable chest pain that usually happens upon exertion. In these cases there is time to make an informed choice. Unstable angina shows up as unexpected and severe chest pain usually while resting. Unstable angina is an emergency situation that requires a prompt remedy and either PCI or CABG will be employed.

A BETTER SOLUTION

Dietary changes alone are very successful in reducing the risk of cardiovascular events including death.

A 2008 study recruited people who had recently suffered a heart attack and tested the effect on them of two different treatments. A total of 202 patients were divided into two equal groups.

Group 1 patients received intensive dietary education (individual dietary counseling sessions, 2 within the first month and again at 3, 6, 12, 18, and 24 months, along with 6 group sessions) plus usual medical care (medications). Then they were further divided into two more groups, one of which followed the American Heart Association Step II diet (emphasizing whole grains and fruits and vegetables with moderate intake of lean animal meat) while the other group followed a Mediterranean-style diet (focusing on whole grains, fruits and vegetables along with fish consumption or another source of omega-3 fatty acids in place of animal-based fat). Both of these diet groups were advised to limit cholesterol consumption to less than 200 mg a day and saturated fat to less than 7% of total calories.

Group 2 received usual care which included the customary medications plus a visit with a dietician before being released from the hospital.

Six years later the groups that received intensive dietary education suffered less angina, heart attack and death from all causes. Participants in both dietary intervention groups of Group 1 experienced eight cardiovascular events, none of which were death. Participants in the Group 2 usual care group experienced forty cardiovascular events, seven of which were deaths. To sum this up, participants in the intensive dietary education groups reduced their risk of all events including death by 60% (7).

This is only one of many studies that have shown improvements from dietary changes far greater than those of PCI. Many randomized controlled trials clearly show that comprehensive lifestyle changes can reverse the progression of coronary artery blockages, increase blood flow in the coronary arteries by about four times and cause a 91% reduction in angina in a few short week. The bonus of a healthy diet is that the side effects are all positive. (8,9,10,11,12,13)

So back to the original question. Does it look to you like a stent is the easy answer? Having a tube pushed through an incision in the skin into a blood vessel and snaked all the way up into the important blood vessels feeding the heart doesn’t sound easy…or comfortable. And it’s not like this procedure is a permanent solution to be submitted to once in a lifetime. Chances are another PCI or the more invasive CABG surgery will be required again in a few years unless drastic lifestyle changes are made. Moreover there are the risks to consider. And PCI is not even a real solution to the problems of coronary artery disease. It doesn’t relieve heart pain or prevent early death any better than just taking medication. It doesn’t even treat the underlying cause of this condition.

What steps can a person take to achieve the beneficial results shown in the research? It is quite simple really.
Eat a plant-based diet that emphasizes whole fruits, vegetables, legumes, nuts, seeds and whole grains. Avoid added oils, refined carbohydrates, dairy and red and white meat.
Enjoy 150 minutes of moderate activity or 75 minutes of vigorous activity or a combination of the two every week. Moderate activity can be as simple as walking. Vigorous activity includes jogging, cycling and any number of other intensive sports activities.

The beauty of lifestyle changes is that they benefit every modifiable risk factor for plaque build-up, not just in the coronary arteries, but throughout the whole body. Changing to a plant-based diet reverses coronary atherosclerosis (8,10,13), reduces blood pressure (11,12), reduces cholesterol levels (8,11,14), reverses metabolic syndrome (15,16), controls type-2 diabetes (12), reduces inflammatory markers such as C-reactive protein (15,16), increases ability to exercise (8) and produces weight loss (14). Making healthy dietary and lifestyle choices can considerably lessen or completely stop angina pain in as little as three weeks and their benefits are proving to be long-lasting. Five years after the completion of a study of men who chose an intensive lifestyle program instead of coronary bypass surgery found that 85% of the men were still sticking to the diet most of the time and 77% of them were still exercising. Of the 80% of these men who entered the program with angina, only one-third of them still had some heart pain though it was much less than the discomfort that they started out with. Many were able to discontinue their heart and blood pressure medications altogether (11).

With this knowledge you can choose to take steps toward healthier living long before you are ever confronted with coronary artery disease. Even better, embracing a healthful lifestyle will drastically reduce your chance of ever facing this debilitating disease.

SOURCES:

1 Hassan, A., Newman, A., Ko, D.T., Rinfret, S., Hirsch, G., Ghali, W.A., Tu, J.V. Increasing rates of angioplasty versus bypass surgery in Canada, 1994-2005. American Heart Journal November 2010; 160(4): 958-965.

2 http://www.heartandstroke.ca/heart/treatments/surgery-and-other-procedures/percutaneous-coronary-intervention

3 https://www.mayoclinic.org/tests-procedures/coronary-angioplasty/about/pac-20384761

4 The COURAGE Trial Research group: Boden, W.E., O’Rourke, R.A., Teo, K.K., Hartigan, P.M., Maron, D.J. et al. Optimal Medical Therapy with or without PCI for Stable Coronary Disease. N Engl J Med 2007; 356:1503-1516.

5 Al-Lamee, R., Thompson, D., Dehbi, H.-M., Sen, S., Tang, K., Davies, J., Keeble, T. et al. Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial. The Lancet, November 2, 2017.

6 Hueb, W., Lopes, N.H., Gersh, B.J., Soares, P., Machado, L.A., Jatene, F.B., Oliveira, S.A., Ramires, J.A. Five-year follow-up of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multi-vessel coronary artery disease. Circulation. 2007 Mar 6; 115(9): 1082-1089.

7 Tuttle, K.R., Shuler, L.A., Packard, D.P., Milton, J.E., Daratha, K.B., Bibus, D.M., Short, R.A.
Comparison of Low-Fat Versus Mediterranean-Style Dietary Intervention After First Myocardial Infarction (from The Heart Institute of Spokane Diet Intervention and Evaluation Trial). American Journal of Cardiology June 1, 2008; 101(11): 1523–1530.

8 Ornish, D., Scherwitz, L.W., Billings, J.H., et al. Intensive Lifestyle Changes for Reversal of Coronary Heart Disease. JAMA. 1998; 280(23):2001-2007.

9 Ornish, D., Scherwitz, L.W., Doody, R.S. et al. Effects of Stress Management Training and Dietary Changes in Treating Ischemic Heart Disease. JAMA. 1983; 249(1):54-59.

10 Ornish, D., Brown, S.E., Billings, J.H., Scherwitz, L.W., Armstrong, W.T., Ports, T.A. et al. Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial . The Lancet July 1990; 336(8708): 129–133.

11 Barnard, R.J., Guzy, P.M., Rosenberg, J.M., and Trexler O’Brien, L. Effects of an intensive exercise and nutrition program on patients with coronary artery disease: five-year follow up. J Cardiopulm Rehabil 1983; 3:183-190.

12 Roberts, C.K., Barnard, R.J. Effects of exercise and diet on chronic disease. 2005. J Appl Physiol; 98: 3–30

13 Gould, K.L., Ornish, D., Scherwitz, L., Brown, S., Edens, R.P., Hess, M.J., Mullani, N., Bolomey, L., Dobbs, F., Armstrong, W.T., et al. Changes in myocardial perfusion abnormalities by positron emission tomography after long-term, intense risk factor modification. JAMA. 1995 Sep 20; 274(11): 894-901.

14 Barnard, R.J. Effects of Lifestyle Modification on Serum Lipids. Arch Intern Med. 1991; 151(7): 1389-1394.

15 Roberts, C.K.,, Won, D., Pruthi, S., Kurtovic, S., Sindhu, R.K., Vaziri, N.D., Barnard, R.J. Effect of a short-term diet and exercise intervention on oxidative stress, inflammation, MMP-9, and monocyte chemotactic activity in men with metabolic syndrome factors. J Appl Physiol (1985);100(5): 1657-1665.

16 Wegge, J.K., Roberts, C.K., Ngo, T.H., Barnard, R.J. Effect of diet and exercise intervention on inflammatory and adhesion molecules in postmenopausal women on hormone replacement therapy and at risk for coronary artery disease. Metabolism. 2004 Mar; 53(3):377-381.