Bottom Line Health
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| The Cedars Sinai team will continue to follow the patients to study whether the drug-eluting stents offer long-term benefits. tnfQ The US National Library of Medicine has more information about stents on their MedlinePlus Web site at www.medlineplus.gov. Click on "Medical Encyclopedia."
Volunteer-Operated Defibs Are Lifesavers
Riccardo Cappato, MD, professor of electrophysiol-ogy, University of Milan, Italy.
Mary F. Hazinski, RN, clinical nurse specialist, emergency and clinical care, Vanderbilt University, Nashville.
European Heart Journal. |
| Compared with conventional bare metal stents, the drug-eluting stents—which slowly release medication to prevent the overgrowth of scar tissue inside the stent—significantly reduced the number of heart attacks and repeat procedures, both signs of restenosis (renarrow-ing) within the stent.
THE STUDY
Researchers analyzed data from 223 patients who underwent a stenting procedure to restore blood flow through clogged vein grafts. Of those patients, 139 were treated with a drug-eluting stent, and 84 were treated with a bare metal stent. |
Gerald E. Markle and Frances B. McCrea
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 According to a 1999 editorial in the New England Journal of Medicine, "it is disappointing that no study has shown that stents favorably influence mortality." In fact, several studies report higher death rates among those receiving stents. Remarkably, the editorial concluded that "failure to show a difference in mortality between treatment groups does not necessarily mean that there is no difference."18
"That's literally true, but it's bad science," I said aloud. "The burden of proof is on the innovator. One must prove that a technique works."
"Right," Fran replied. |
Bottom Line Health
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| There was a fourfold reduction in the incidence of restenosis with the medicated stents, at least over the short term. That's very encouraging," says Dr. Raj Makkar, codirector of the Cardiovascular Intervention Center at Cedars Sinai Medical Center.
Overall, the combined rates of heart attack, repeat procedure and death were 10% in the drug-eluting stent group and 37% in the bare metal stent group.
The Cedars Sinai team will continue to follow the patients to study whether the drug-eluting stents offer long-term benefits. |
Dr. Steven R. Gundry
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 In separate procedures, he'd had seven stents placed in various blockages in his heart arteries. Nonetheless, just walking from his bed to the bathroom caused him severe chest pain. No wonder, a scan of his heart suggested that at least half of his heart muscle wasn't getting enough blood flow. Isaiah had been told that additional stents or bypasses were useless. When I reviewed the results of his blood test and dietary habits questionnaire, I immediately found the culprit. Isaiah subsisted on "white" and "beige" foods. |
Bottom Line Health
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| Drug-Eluting stents Four Times Better than Others
Catheterization and Cardiovascular Interventions news release.
Drug-eluting stents improved the outcomes of patients who developed blockages in veins that had been surgically grafted onto the heart, according to a study by researchers at Cedars Sinai Medical Center in Los Angeles. |
Shannon Brownlee
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 In use since the late 1980s, stents have now nearly replaced balloon angioplasty as the preferred technique for opening a blocked section of artery. Altschuler takes a wire with the stent on one end and threads it up the catheter until it rests just inside the narrow spot in Crofton's artery.
Suddenly, the room goes still. All eyes turn to a monitor that shows electrical measurements of the patient's heart. The stent has completely occluded her blood vessel, and her heart's electrical activity is registering the possibility of an actual heart attack. |
Bottom Line Health
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| The US National Library of Medicine has more information about stents on their MedlinePlus Web site at www.medlineplus.gov. Click on "Medical Encyclopedia."
Volunteer-Operated Defibs Are Lifesavers
Riccardo Cappato, MD, professor of electrophysiol-ogy, University of Milan, Italy.
Mary F. Hazinski, RN, clinical nurse specialist, emergency and clinical care, Vanderbilt University, Nashville.
European Heart Journal.
Training volunteers in the emergency use of defibrillators does save lives, even in thinly populated rural areas, a new Italian study has shown. |
Caldwell B. Esselstyn, Jr., M.D.
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 Four percent of patients who get stents have heart attacks during the stenting, and 1 percent die. Let's put flesh on that statistic: since there were more than 1 million stent operations last year in the United States, that means 40,000 patients had heart attacks during the procedure— and 10,000 died. If 10,000 American soldiers died in one year in Iraq, it would be called carnage. As the late Cleveland Clinic uro-logic surgeon William Engel said, "It is acceptable to lose an occasional patient, but best not to hasten them along. |
Shannon Brownlee
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| Yet despite the potential for harm, physicians continue to give patients unnecessary bypass surgery, along with unneeded angioplasties and stents. In 2001, a group of researchers from Harvard and Brown universities published a study that looked at the medical records of nearly four thousand Medicare patients from 1 7 3 hospitals located in five states. Some of the patients had undergone a balloon angioplasty; others had had bypass surgery. |
Caldwell B. Esselstyn, Jr., M.D.
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| Most demoralizing for those who had been the beneficiaries of the clinic's surgical interventions was the recognition that so much that had been done to save them—repeated open heart surgery, angioplasties aplenty, stents, and a host of medications—seemed no longer to have any useful effect. Almost all the men had lost their sexual potency. Most had chest pains, the terrifying condition known as angina. For some, it was so agonizing that they couldn't lie down and had to sleep sitting up. Only a few could take long walks, and some couldn't even cross a room without excruciating pain. |
Shannon Brownlee
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| The jury is still out on whether these stents will turn out to be superior. But even if they do prevent scar tissue from reblocking the artery, they still won't prevent heart attacks. That's because a heart attack occurs when a bit of plaque ruptures, triggering a blood clot that flows toward smaller and smaller arteries until it blocks the flow of blood. |
| Drug-coated stents alone cost U.S. taxpayers and insurers $3.4 billion. More than a billion dollars a year are being wasted by cardiothoracic surgeons who perform bypasses on patients whose symptoms could be controlled with medical management, using drugs, diet, and exercise, which are not only cheaper but also safer and far less invasive. |
| Yet most of the narrowings that cardiologists feel compelled to treat with stents, saysTopol, are perfectly innocent. "They aren't tied to symptoms in the patient," he says, and they don't pose a risk of causing a heart attack. Opening them up with a stent almost certainly won't make the slightest difference in either the patient's chances of suffering a heart attack in the future or his longevity and quality of life. |
| In fact, it turns out that in places where cath labs are widely available and patients are getting more angioplasties and stents, cardiologists aren't necessarily performing the procedures on the right patients. Doctors in areas where there are lots of cath labs underuse their procedures on many patients who would likely benefit and overuse them on many others who are least likely to benefit and would have done just as well with medical management. |
Caldwell B. Esselstyn, Jr., M.D.
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| And they underscore a point I have repeatedly stressed: patients with stable coronary artery disease should be cautious about the "quick fix" approach of bypass surgery and stents, which pose significant risks of complications and mortality. They should be offered intensive lifestyle change for twelve weeks in a reasonable trial. If they devote themselves to the progam with unwavering commitment, many will avoid entirely the need for surgical intervention.
I still cherish the naive dream I had when I started this research. |
Stephen T. Sinatra, M.D.
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 So if any of you are anticipating cardiac procedures, including angioplasty, stents, cardiac bypass, and valvular surgery—as well as those of you recovering from heart attacks and heart procedures—to take heed and protect yourselves right away. And because the aging heart responds so strongly to physical and emotional stressors, it is crucial that if you are 70 or older, you protect your heart by taking coenzyme Qi0, no matter how healthy you feel at the moment. I believe that is absolutely essential to protect your heart from the nutraceutical point of view. |
Caldwell B. Esselstyn, Jr., M.D.
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| The newer drug-eluting stents (coated with drugs to lessen the body's natural healing response to the injury caused by the stent's insertion) may also suddenly block after a few years because a clot forms where the endothelium was injured; the drug in the stent that prevents inflammation also inhibits the endothelium's capacity to heal.
We can do better. We can go right to the source of the disease. We can cut off the supply of fatty substances that accumulate in the arteries to such catastrophic effect.
We can go directly to the bottom line. |
| His coronary artery anatomy excluded him as a candidate for surgical bypass, angioplasty, or stents, and at such a young age, with a wife and three small children, Dr. Crowe was understandably disconsolate and depressed. Since he already exercised, did not use tobacco, and had a relatively low cholesterol count of 156 milligrams per deciliter (mg/dL), there seemed to be nothing he could modify, no obvious reforms in lifestyle that might halt the disease.
Joe was aware of my interest in coronary disease. |
Bottom Line Health
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| Recent study: People who had coronary angioplasty and stents had a 50% lower rate of death, new heart attacks or other coronary events within one year than people who underwent more conservative treatments.
Key: Coronary intervention should occur as early as possible.
Michael Mogadam, MD, clinical associate professor of medicine, George Washington University School of Medicine, Washington, DC.
Depression May Hamper Recovery After Heart Attack
Depression after a heart attack can be particularly dangerous. |
Stephen T. Sinatra, M.D.
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| In anyone with a history of coronary calcification, coronary artery disease or in those with stents or bypass, I would also strongly recommend vitamin K2.
Vitamin K2-Coenzyme Q10's Cousin
I stumbled upon vitamin K2 inadvertently when I wrote my last book Reverse Heart Disease Now (Wiley, 2007). Vitamin K2, specifically MK7 (short for mena-quinone-7) is actually a relative of coenzyme Qiq. To refresh your memory, when Dr. Fred Crane discovered coenzyme Qio he thought it was originally a carot-enoid but it turned out to be a quinone. |
Dr. Steven R. Gundry
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| We inserted two more stents, but scans revealed poor blood flow to one-third of his heart muscle.
After being released from the hospital, Jed came back to my office. "Let's start again," he said. He began Diet Evolution that day. I also prescribed supplements to augment his diet—there was no time to lose. Six weeks later, Jed's triglycerides were one-third their previous level. His LDL ("bad") cholesterol followed suit. More important, his HDL ("good") cholesterol, and specifically a subgroup of HDL that actually scours arteries had doubled. |
Gerald E. Markle and Frances B. McCrea
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| A review of stents in JAMA, which sorts benefits into two categories, "proven" and "unproven,"19 is similarly bad science.
"The logic here is really disappointing," I exclaimed. "There is no such thing as an 'unproven benefit.'"
"Right again," said Fran. "It's more like political spinning than science."
"What's really troubling," I countered, "is that this so-called evidence is being used to justify life or death decisions."
A 1998 editorial in the New England Journal of Medicine asked an important question: Why is stenting often performed "without obvious indication? |
Dawson Church
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 How did we get to a point in medicine where interventions such as radioactive stents, coronary angioplasty, and bypass surgery are considered conventional, whereas eating vegetables, walking, meditating, and participating in support groups are considered radical?"22
Yet I predict that our definition of what is—and is not—conventional in medicine will shift, and shift quickly. Scholar Jean Houston, in her book Jump Time, points out that social evolution does not happen in a gradual upward curve.23 It is marked by long plateaus, followed by rapid jumps. |
Caldwell B. Esselstyn, Jr., M.D.
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| In recent years, the use of stents has become more common. A stent is a wire mesh tube that is inserted during angioplasty. When the balloon is inflated, the stent expands and locks into place inside the artery, holding it open after the balloon and catheter are withdrawn.
Bypass surgery is exactly what its name implies. The physician uses a short length of blood vessel from another part of the body to provide a way for blood to go around blockages in coronary arteries, much as a detour functions to route traffic around the congestion caused by an accident or by highway construction. |
Dr. Steven R. Gundry
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| If you take medications for high blood pressure, diabetes, arthritis, cholesterol, depression, stomach acid, or pain—or get stents or bypass surgery or have colon polyps removed-you're doing just that: covering up the signals that killer genes have been activated.
Shockingly, the number of people on Medicare being treated simultaneously for four or more medical conditions has doubled from 1987 to 2002.30 During this same period, the rate of obesity in the United States also doubled-a one to one correlation. |
Gerald E. Markle and Frances B. McCrea
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| As an editorial in the prestigious British medical journal, Lancet, concludes—with typically English humor: "Stents clearly have a great future—they give excellent predictive results in angiography, are clinically safe, and most of all, calm the interventional cardiologist."21
"Finally, something I can agree with," proclaimed Fran. "Were I the patient, I would most assuredly want a calm cardiologist!"
Alas, where in these procedures is the fierce warrior? A small incision in the groin is hardly heroic surgery! |
| Thus, stents and cabbages cannot prevent the formation of these deadly clots.
"I think it is ingrained in the American psyche," said one cardiologist, "that the worth of medical care is directly related to how aggressive it is. Americans want a full-court press," he concluded, blaming the patient for the physician's unscientific judgment. Instead of stenting and cabbages, we would be better off with "boring old advice"; give up smoking, and get blood pressure and cholesterol levels down. |
| In chapter 3, we examined the efforts of surgeons, and found that the seemingly obvious benefits of cardiac bypass surgery and stents are maddeningly difficult to demonstrate with clinical evidence, a statement that is strangely and counterintuitively true for many common surgeries.
Surely emergency medicine saves lives. Such a statement, which would seem to have what logicians call "face validity," is difficult to substantiate. |
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