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Can heart disease be reversed?

According to conventional medical theory, coronary heart disease is an irreversible, progressive condition. That explains the many thousands of major heart procedures performed every year.

But we’re on the dawn of a new age in which reversal of heart disease is rapidly becoming a reality for more and more people. What exactly happens when coronary heart disease is reversed? What does it look like and how do you know when you’ve achieved it? Is there a scientific rationale behind the Track Your Plaque approach? Here’s our Special Report on everything you wanted to know about heart disease reversal.

Coronary heart disease is the cause of death of half of all males, a third of all women. Beyond the toll in human life, it’s also the costliest disease in financial terms, far outstripping cancer and other human scourges. Reversal of coronary heart disease—essentially a “cure”—should be the holy grail of medicine.

But you’d never think so, listening to physicians, hospital marketing, or media reports. The focus is the next new stent, defibrillator, robotic surgery, heart transplantation, etc. The whole business of conventional heart care is based on a disease that is unstoppable without procedures. Coronary disease is so relentless that a 10” long chest incision is required. Rarely does a single stent or bypass provide the final solution. Multiple procedures over several years are the rule.

"Modern cardiology has given up on curing heart disease."

Caldwell B. Esselstyn, M.D.
Cleveland Clinic

But if you have a CT heart scan score greater than zero and your coronary arteries thereby contain atherosclerotic plaque, it’s natural to ask: Can my plaque be reduced? Can heart disease be reversed?

Studies first hinting that coronary disease regression was possible date as far back as the 1970’s. Back then, however, shrinkage was spotty and inconsistent. With treatment approaches available then, rapid progression was much more common, and a modest slowing of plaque growth was regarded as a success.

There’s also no shortage of misinformation about heart disease reversal. Enter the search phrase “heart disease reversal” into Google and you’ll get over 2 million citations. Countless programs make extravagant claims of “reversing” coronary heart disease with everything from high dose vitamin C, low-fat diets, meditation, to chelation.

How much can you believe? If somebody claims to achieve shrinkage of plaque using treatment X, how can it be proven? How do you really know whether coronary disease is reversed? Does surviving until your next birthday suffice? Does the absence of symptoms mean anything? Does losing 10 lbs tell you whether coronary plaque has shrunk? Should we just follow a treatment program and assume that atherosclerotic plaque has shrunk? How can you know if you have reversed plaque, not just statistical likelihood but actual reversal?

Dr. Ornish had it right—for his time!

The long-time favorite book, Dr. Dean Ornish’s Program for Reversal of Heart Disease, was released in 1995. Ornish details a super low-fat (<10% of calories from fat) approach for “reversal” of heart disease. To achieve this extreme level of fat deprivation, meat, eggs, cheese, cooking oil, butter and other full-fat dairy products, and margarine are completely eliminated. Only vegetables, fruits, and whole grains are included.

In 1985, when Americans were indulging in hamburgers, cheese, sausage, French fries, and discovering the joys of fast-food, the Ornish low-fat diet represented an improvement. Eliminate all sources of fats and total and LDL cholesterol drop 30%.

However, as more and more people followed the Ornish program, it became clear that an extreme low-fat diet is also a high-carbohydrate diet. Carbohydrates expand to fill 60–70% of calories to take up the slack left by slashing fat. Most people experience lower healthy HDL and higher triglycerides, both undesirable effects. Hidden patterns like small LDL and VLDL emerge. Many people develop a constellation of abnormalities called the metabolic syndrome, or pre-diabetes (Krauss RM et al 1995). The net effect in many is not reversal, but worsening—more rapid growth of coronary plaque.

How do you know if you’ve reversed coronary plaque on the Ornish program? Is reducing LDL cholesterol sufficient to know that plaque has shrunk? You won’t know. That is the fundamental problem with the Ornish program and others like it. You will not know if you have or have not reversed heart disease. Lowering cholesterol by itself, in fact, is not sufficient to shrink plaque in most people.

The Ornish program was a good solution for its time, just like the 1957 Chevy was a great car for its era. But the time for this program is now long past.

How do we prove that plaque is growing or shrinking?

We know that just feeling good cannot signify whether plaque is growing or shrinking. We also know that indirect measures of risk like cholesterol do not reflect plaque growth. Plaque can grow like wildfire with low cholesterol. Eating healthy and exercise without symptoms? It tells us nothing about plaque growth.

There are several basic requirements for a program for reversing heart disease, i.e., reducing coronary atherosclerotic plaque. They are:

1. We need a method to measure atherosclerotic plaque.

The method should be precise, easy to obtain, and safe. We don’t want a measurement tool that is inaccurate, expensive, or dangerous. Intracoronary ultrasound, or ICUS, is an accurate tool for measuring coronary plaque. But it involves invasive methods inserting catheters, a 2–3% risk of heart attack and stroke (because catheters are threaded deeply into arteries), and is costly ($10,000–$15,000). Repeating it every year is an even tougher prospect.

Stress testing won’t do because stress tests (stress thallium or other nuclear material, stress echo, etc.) are too crude as measures of plaque. Stress tests are really tests of coronary blood flow. They show abnormalities in the most advanced phases of disease, such that the majority of people at risk for heart attack have normal stress tests. Former President Bill Clinton provides a good example: five stress tests (thallium nuclear tests which were thought to be the "gold standard" for detecting heart disease)) over five years, all normal—until he needed urgent bypass surgery because of severe blockage in all three coronary arteries. In fact, the majority of people destined for future heart attacks have normal stress tests. Stress tests are therefore useless for tracking heart disease reversal.

2. The measurement we choose should reflect the amount of plaque present.

This seems obvious, but in years past, many studies were performed using measuring tools that were poor reflectors of the disease. For instance, researchers used stress tests to gauge whether coronary disease had progressed or not. They reasoned that, if blood flow measured by a stress test improved, then plaque must be shrinking. At first blush, this seems to make sense. Unfortunately, it’s not true: blood flow can improve simply because the artery dilates, or enlarges. It tells you nothing about the amount of plaque in the artery wall. Blood pressure medications were initially thought to reverse plaque because they dilated arteries and thereby improved flow, even while plaque grew. Plaque can grow substantially yet not result in any drop in blood flow.

Likewise, images obtained through heart catheterization can appear to show shrinkage of plaque if the artery enlarges. Dozens of studies suggesting 1,2, or 3% plaque shrinkage really proved very little because of artery dilatation.

Another reason both stress tests and catheterization can yield misleading information is because of the “Glagov phenomenon”: as plaque grows within an artery, the total diameter of the artery enlarges with it. This means that any test that relies on measuring the internal diameter of the artery, like stress tests and catheterization, can be fooled. Plaque can grow yet not reveal itself by reducing the diameter of the path for blood flow.

The Glagov Phenomenon

There are tests that fit our criteria of safety and accuracy, but don’t reflect coronary plaque very well. Ultrasound of the carotid arteries, and ultrasound and ankle-brachial index (blood pressure measurement) in the legs, i.e., tests of arteries outside the heart, do indeed identify risk for heart attack, but are poor measures of actual coronary plaque—they’re simply too indirect. One level of plaque in a leg artery, for instance, does not necessarily correlate well with plaque in the coronaries.

There’s only one way to accurately and safely measure coronary plaque that meets all our requirements: CT heart scans for coronary calcium scoring. Year to year, they accurately reflect plaque growth or reversal, don’t rely on artery diameter measures and are not fooled by the Glagov phenomenon. CT heart scans are also performed with only modest radiation exposure, meet our criterion for safety, and are available at a cost within reach for most people.

What happens when plaque “reverses”

If plaque reverses, it obviously should shrink in size. But what actual changes occur in the plaque?

Most of this information has been obtained from observations in animals, since we are unable to extract plaque from living humans just to assess composition. Among the changes that have been documented include:

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Copyright 2006, Track Your Plaque.