A stent--just in case

26. March 2007 William Davis (3)
Burt came to me last week. He'd received a stent a few months earlier. He'd been feeling fine except for some fatigue. A nuclear stress test proved equivocal, with the question of an abnormal area of blood flow in the bottom (inferior wall) of the heart.

"The doctor said I had a 50% blockage. Even though it wasn't really severe, he said I'd be better off with a stent, just in case."

Just in case what? What justification could there be for implanting a stent "just in case"? (The artery that was stented did not correspond to the area of questionable poor blood flow on the nuclear stress test.)

Just in case of heart attack? If that's the case, what about the several 20 and 30% blockages Burt showed in other arteries? The cardiologist was apparently trying to prevent the plaque "rupture" that results in heart attack by covering it with a stent. Why stent just one when there were at least 7 other plaques with potential for rupture?

That's the problem. And that's why stents do not prevent heart attack (unless the stent is implanted in the midst of heart attack, when the rupturing plaque declares itself.) Of course, when no plaque is in the midst of rupturing, as with Burt, there's no way to predict which plaque will do so in future. Since only one plaque was stented, there is a 7 out of 8 chance (87.5%) that the wrong plaque was chosen. And that's assuming that there aren't plaques not detected by catheterization angiogram; there commonly are. The odds that the right plaque was chosen would be even lower.

In other words, stenting one blockage that is slightly more "severely blocked" in the hopes of preventing heart attack is folly. If it's not resulting in symptoms and blood flow is not clearly reduced, a stent can not be used to prevent plaque rupture. A stent is not a device to be used prophylactically. It is especially silly when an approach like ours is followed, since plague progession is a stoppable process.

Note: This issue is distinct from the one in which symptoms and/or an abnormal stress test show clearly reduced blood flow and flow is restored by implantation of a stent. While some controversies exist here, as well, a stent implanted under these circumstances may indeed provide some benefit.
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Comments (3) -

  • Anonymous

    3/26/2007 12:45:00 AM |

    Interesting blog.  I have a question: would you be able to offer some comments on Dr. Ornish reversal programme and low fat vegan diets (in reversing CHD), based on your professional experience?

    We are having a little discussion about various pros and cons of various therapies and dietary approaches on the Web MD forum:

    http://boards.webmd.com/webx?14@1016.MAjDbu7Matv.0@.5987f44c

    We would really welcome you and would greatly appreciate some professional comments.  Sincerely,
    Stan Bleszynski (Heretic)

  • Dr. Davis

    3/26/2007 11:36:00 AM |

    Super low-fat diets, while an improvement over a conventional modern American diet of high saturated fat and processed foods, seriously exagerrate the small LDL particle pattern that is among the most powerful causes known of heart disease. It also reduces HDL and raises triglycerides, sometimes substantially. Dr. Ornish would argue that these are inconsequential changes, since his patients regress. Unfortunately, the methods he uses to gauge regression of atherosclerotic plague are flawed: angiography and nuclear imaging. Both can be envisioned as measures of flow, not of atherosclerotic plaque. Only CT heart scans or intracoronary ultrasound actually measure artery plaque. I tell my patients that, if you want heart disease, follow the American Heart Association diet. If you want heart disease and diabetes, follow Dr. Ornish's diet.

  • Cindy

    3/28/2007 12:47:00 AM |

    I know several people who have gone for a "routine" check with a cardiologist, sent for an angio, and ended up with at least 1 stent. (NO symptoms prompted these visits, just "high cholesterol".

    I also know a couple of people that have 9, 10, or more stents!

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My life is easy

My life is easy

17. February 2007 William Davis (3)
In the old days (the 1980s and 1990s), practicing cardiology was very physically and emotionally demanding. Since procedures dominated the practice and preventive strategies were limited, heart attacks were painfully common. It wasn't unusual to have to go to the hospital for a patient having a heart attack at 3 am several times a week.

Those were the old days. Nowadays, my life is easy. Heart attacks, for the most part, are a thing of the past in the group of people who follow the Track Your Plaque principles. I can't remember the last time I had a coronary emergency for someone following the program.

But I am reminded of what life used to be like for me when I occasionally have to live up to my hospital responsibilities and/or cover the practices of my colleagues. (Though I voice my views on prevention to my colleagues, the most I get is a odd look. When a colleague recently covered my practice for a weekend while I visited family out of town, he commented to me how quiet my practice was. I responded, "That's because my patients are essentially cured." "Oh, sure they are." He laughed. No registration that he had witnessed something that was genuine and different from his experience of day-to-day catastrophe among his own patients. None.)

I recently had to provide coverage for a colleague for a week while he took his family to Florida. During the 7 days, his patients experienced 4 heart attacks. That is, 4 heart attacks among patients under the care of a cardiologist.

If you want some proof of the power of prevention, watch your results and compare them to the "control" group of people around you: neighbors, colleagues, etc. Unfortunately, the word on prevention, particularly one as powerful as Track Your Plaque, is simply not as widespread as it should be. Instead, it's drowned out in the relentless flood of hospital marketing for glitzy hospital heart programs, the "ask your doctor about" ads for drugs like Plavix, which is little better than spit in preventing heart attacks (except in stented patients), and the media's fascinating with high-tech laser, transplant, robotic surgery, etc.

Prevention? That's not news. But it sure can make the slow but sure difference between life and death, having a heart attack or never having a heart attack.
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Comments (3) -

  • Jeff

    2/19/2007 11:23:00 PM |

    Dr. Davis, I'd like to invite you to visit ad comment on my blog: http://wordworks2001.blogspot.com

    Thanks,

    Jeff Brailey

  • Dr. Davis

    2/19/2007 11:30:00 PM |

    Hi, Jeff-
    I took a look at your Blog and congratulate you on takin the time and effort to talk about the bizarre state of affairs in heart disease. We know that the principle that explains much of what happens is "follow the money". I see it as my role to facilitate this conversation.

  • katkarma

    2/21/2007 12:54:00 AM |

    Dr. Davis - I have been trying to follow your recomasmendations on diet and supplements and am really confused today as the new studies on Women and Heart Disease have contridicted the use of folic acid.  I take 2mg a day and it has brought my homocysteine down below 7 for the first time.   Do you think Women should be treated entirely differently than men as far as heart disease and plague is concerned.   Do you find a difference in the genders in your studies?   If so, how and what?   Thanks so much,
    Noreen Boles

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Good time for a heart attack?

Good time for a heart attack?

22. January 2007 William Davis (0)
Man Has Heart Attack At Right Place, Right Time

If Robert Ricard had picked the wrong restaurant for lunch, he might have died.

The 71-year-old Michigan man suffered a heart attack shortly after ordering a glass of wine with friends at Bentley's Roadhouse on Saturday.

Luckily, a disaster medical team was sitting nearby.


A TV station in Michigan reported the above story. You've heard these "if it wasn't for ___, so and so would have died" stories. They're reported in all cities at one time or another.

What amazes me about these common local stories is that they're accepted at all. The question that comes to my mind is "Why couldn't the heart attack have been averted in the first place?" Early identification then, as close as humanly possible, elimination of risk would have been a preferable path.

Of course, it may not be the role of the media to cast judgement on why and how the entire episode could have been completely prevented from occurring. But you shouldn't fall into the same trap of complacency. We cannot expect others to save us when the "big one" hits. Your best assurance is to never have one in the first place.
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Tribute to Tim Russert

Tribute to Tim Russert

14. June 2008 William Davis (11)
The sudden passing of news giant, Tim Russert, yesterday of sudden cardiac death struck a blow to American consciousness.

Perhaps his hard-hitting interviewing style, while making guests squirm, made him seem invincible. But, of course, none of us is invincible. We are all vulnerable to this disease.

We should not allow Mr. Russert's tragic death to occur without taking some lessons. The media have already resorted to interviewing prominent doctors for their opinion.


Douglas Zipes, M.D., former President of the American College of Cardiology,was quoted in the media:

"An automated external defibrillator (AED) could have been a life-saver. AEDs should be as common as fire extinguishers."

This is typical sleight-of-hand, medicine-is-too-complex-for-the-public-to-understand sort of rhetoric that is surely to issue from the conventionally-thinking medical people and the press. Instead, let's cut the BS and learn the real lessons from Mr. Russert's needless death.

It is virtually certain that:

--Mr. Russert ruptured an existing coronary atherosclerotic plaque, prompting rhythm instability, or ventricular fibrillation.

--Making automatic external defibrillators (AED) available might have Band-Aided the ventricular fibrillation, but it would not have stopped the heart attack that triggered it.

--Though full details of Mr. Russert's health program have not been made available, it is quite likely that he was prescribed the usual half-witted and barely effective panoply of "prevention": aspirin, statin drug, anti-hypertensive medication. Readers of The Heart Scan Blog and members of Track Your Plaque know that this conventional approach is as effective as aspirin for a fractured hip.

--It is highly unlikely that all causes of Mr. Russert's heart disease had been identified--did he have small LDL (it's certain he did, given his body habitus of generous tummy), Lp(a), low HDL, pre-diabetic patterns, inflammatory abnormalities, vitamin D deficiency, etc.? You can be sure little or none of this had been addressed. Was he even taking simple fish oil that reduces the likelihood of sudden cardiac death by 45%?

--Far more could have been done to have prevented Mr. Russert's needless death. And I don't mean the idiocy of making AED's available in office buildings. I'm talking about preventing the rupture of atherosclerotic plaque in the first place.

Far more can be done to prevent future similar deaths among all of us.

Our jobs are to use the tragic death of Mr. Russert to help those around us learn that heart disease is identifiable and preventable. Though Mr. Russert did not stand for BS in his political commentary, he sadly probably received it in his health advice. Don't let this happen to you or those around you.
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Comments (11) -

  • Anonymous

    6/14/2008 2:09:00 PM |

    Amen to everything you said Dr. and one other point I heard a nimber of times yesterday, everybody was in shock because Mr. Russert had just had a stress test done in April and passed with no problems ! As all your readers know what a stupid thing to say.

  • lenjoe

    6/14/2008 8:59:00 PM |

    Dr Davis,
    I appreciate your posting on Tim Russerts passing.  I was a big fan of his. I believe if he had worked half as hard on his heart health as he did on his career we would be enjoying him on TV for many years to come.  Of all the commentators discussions since his passing, the most important things aren't being discussed.  His diet (low fat I'd guess), his meds (statins I'm sure)...He did have a good stress test April 29.  Lot of good that did.

  • Anonymous

    6/15/2008 12:00:00 AM |

    Russert had both CAD & diabetes.

    Newsweek health article about Russert and sudden cardiac arrest:

    http://www.newsweek.com/id/141450?from=rss

    Usual blather about not being able to prevent/predict sudden cardiac death, risk factors, and usefulness of defibrillators, etc.

  • The Daley Planet

    6/15/2008 12:33:00 AM |

    Thank you for this commentary.
    His passing is very sad.
    My uncle had the same thing happen at a relatively young age as well.

    By the way, can you suggest a fish oil for those of us whom are allergic to shellfish?
    I've heard we can use any type of fish oil; just not krill oil.
    Does Sam's Club Maker's Mark fall under that category?

    Thank you!

  • Mike Donovan

    6/15/2008 3:33:00 AM |

    Regarding the death Of Tim Russert:

    In the new issue of Newsweek, Dr. Steven Nissen, chair of cardiovascular medicine at the Cleveland Clinic told the magazine when asked about the role of STRESS and heart attacks:

    "Most of us do not think it is terribly relevant," and explained this with a shocking lack of logical thinking: Newsweek writes, "After all, he notes, "many people in this world have stressful jobs," and they don't all die of of heart attacks.

    Time Magazine named Dr. Nissen one of the 100 Most Influential People In The World in their "Scientists and Thinkers" section.

    Think about that.

    Now, consider the completely illogical statement from Dr. Nissen bolded above. One thing should be made perfectly clear in light of this statement: He believes cholesterol as very relevant to heart attack risk. Yet, to turn his Newsweek comments around, "many people in this world have **high cholesterol**" and they don't all die of heart attacks.

    In fact, study after study shows countries with the highest rates of fat intake and the highest average cholesterol rates have the lowest incidence of heart disease. Imagine that!

    Dr. Nissen's irresponsible and illogical comments in Newsweek shows - again - the complete bamboozlement the cholesterol hypothesis has on western medicine just because, "everyone knows," high cholesterol causes Coronary Heart Disease. How do they know this? "Because everyone knows." Ad nauseum. With a little research, the facts show this is simply not true.

    What Dr. Nissen said about stress can be said about high cholesterol. Plenty of people live with both without having heart attacks.

    Maybe Mr. Russert's death can help in bringing us back to real science as opposed to what Big Pharma dictates as what is science - and what is not. Follow the money.

    How ironic that it was Dr. Nissen who made such a horrible misstep in logic with his comments to millions of readers in Newsweek.

  • Henry Fielding

    6/15/2008 11:00:00 AM |

    I have a couple of questions that were put to me about Heart Scans that I can't answer. Perhaps you will indulge me.

    First, from a Doctor friend of mine:  Most of the widely used diagnostic tests have been studied with respect to their Specificity, Sensitivity, positive and negative predictive value, etc. We know how to use them, and we know how to interpret the information they provide. Last I read, there is not enough correlation between the amount of calcium present in the walls of the coronary arteries, and the degree of coronary sclerosis. Maybe in time there will be enough convincing data - but for now, it is wrong to blame the slowness of the acceptance of the test by the medical community solely on financial interest.

    Second, from another friend:

    I had the EBT test and showed a calcium score of 950. An angiogram showed no blockage. Go figure. The Doc thinks the calcium is in between the artery walls with the lumen free.

  • Dr. B G

    6/15/2008 5:02:00 PM |

    Russert traditionally appeared on Charlie Rose right before Father's Day.  They were good friends -- Rose sold his house in Washington DC to him and aired a moving tribute the night after his sudden MI.

    Russert loved his father and wrote a famous book about him 'Big Russ'. It is ironic his own death was right before Father's Day today. And so much much more awful for his surviving son whom he loved so much and was very vocal about.

    I hope a new movement for cardiovascular and diabetes prevention may be sparked over this needless, rescue-able, tragic event.

    He touched so many lives... fathers, Buffalo fans, media, political enthusiasts...

    (I'm glad my Dad is aware of Track Your Plaque -- Thank you Dr. Davis... and Happy Father's Day!)

    -G

  • Dr. William Davis

    6/15/2008 9:36:00 PM |

    Mike--

    Thank you for your thoughtful and insightful comments. I coudn't agree more.

  • Dr. William Davis

    6/15/2008 9:38:00 PM |

    Henry--

    I'm sorry, but if friend told you that, you need new friends.

    The literature exists and there's quite a bit of it. Just because your friend is completely ignorant of a body of scientific literature several thousand studies long does not mean that it doesn't exist.

    All of your questions can be answered on the www.trackyourplaque.com website.

  • Henry Fielding

    6/15/2008 9:40:00 PM |

    I buy my Fish Oil from Costco. It happens to be Nature Made 1200mg softgels. Don't let anybody worry you about mercury content on this kind of product. None of these brands have any in them.

    If it causes any problems, take it with food.

  • buy jeans

    11/3/2010 2:23:19 PM |

    --Far more could have been done to have prevented Mr. Russert's needless death. And I don't mean the idiocy of making AED's available in office buildings. I'm talking about preventing the rupture of atherosclerotic plaque in the first place.

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