I have heart disease. Now what?

Just what are the various camps saying about reversing heart disease?

Cardiovascular disease continues to be the leading cause of death in the Western world, accounting for half of all deaths. Sadly, the majority of cardiovascular-related deaths are largely preventable, as pointed out in this special issue.

But say you have been diagnosed with coronary heart disease. Your physician says something like "you have a 70 percent occlusion in the circumflex artery, and 80 percent occlusion in the left anterior descending artery." In other words you're in pretty bad shape. What are your options?

The wonders of medical science. If a permenent blockage is detected in one or more coronary arteries, the typical treatments include medical management, coronary artery bypass grafting (CABG), percutaneous transluminal coronary angioplasty (PTCA), or other new forms of plaque removal, such as coronary laser (burning the plaque) and high-speed rotational atherectomy (cutting and removing the plaque), and to a lesser degree, prescription of lifestyle modifications.

Coronary artery bypass grafting (a procedure in which veins are harvested from a patient's leg and sewn from the aorta to the coronary artery past the blockage) does appear to prolong life in patients with severe three-vessel disease, but in comparison to medical therapy it does not seem to prolong life in those patients with less-severe disease. However, total relief of angina typically occurs in 60 to 75 percent of patients during the first five years following a CABG.

The use of percutaneous transluminal coronary angioplasty (a procedure that uses a small balloon at the tip of a heart catheter to push open plaques) are on the rise. Unfortunately, approximately 30 percent of patients receiving a successful PTCA will have blocking again within the first three to six months. Less-severe cases of coronary artery disease are typically treated with lifestyle modification and medical therapy.

Now, what if someone told you your coronary artery disease could be reversed through lifestyle modification alone--would you be willing to take a chance on it? Can lifestyle changes reverse coronary heart disease? Some experts now believe so.

How far we've come. For decades physicians denied that coronary heart disease could be "cured" or reversed. In fact, as late as 1987 the clinical evidence of regression in humans was quite uncertain. However, since the mid-1980s clinical evidence has accumulated demonstrating that human atherosclerosis is not only preventable but to some extent reversible, or at least the progression delayed.

Probably the first published report of reversal of atherosclerosis came from postmortem examinations of World War I casualties, those killed in battle and those who died after spending time in war camps. The soldiers who spent time in war camps had significantly less coronary heart disease, thought to be because of the semi-starvation conditions.

Less-severe coronary artery disease has been seen in persons who lost significant weight before they died than in persons without such weight loss; animals who were fed a high-fat diet, but exercised, compared to the group that didn't exercise; persons who followed a structured lifestyle and/or drug treatment programs versus those that didn't.

Today few medical experts would argue that with the right intervention the progression of coronary artery disease can be reversed or at least delayed to some degree.

Even in cases in which plaque does not reverse, lifestyle intervention can have a protective effect. As John LaRose from George Washington University says, "even though the opening may not change much, the plaque is stabilized, which reduces the susceptibility to clotting, and thus future heart attack."

Different schools of thought. So why isn't lifestyle modification a more commonly prescribed intervention? Aggressive lifestyle changes as the primary treatment of coronary artery disease is not popular among most physicians, probably because of liability as well as the poor probability of patient compliance to such interventions. Many physicians you talk to regarding reversing heart disease through lifestyle modification generally feel that more research is needed. But the question remains, How much research is enough?

Perhaps the two most recognized names in the "reversing heart disease game" are Herman Hellerstein, M.D., and Dean Ornish, M.D. In his new book Healing Your Heart: A Proven Program for Reversing Heart Disease Dr. Hellerstein shares the findings of his 58-year career. He believes that coronary heart disease can be reversed through lifestyle modification.

Dr. Hellerstein's Seven Goals for Reversing Coronary Heart Disease

Recommendations include:

1. Reduce total cholesterol to below 200 mg./dl. and LDL below 130 mg./dl., with a total cholesterol/HDL ratio of 3:5. Diet recommendations--1,500 to 2,500 calories per day, with saturated fat content under 10 percent and total fat less than 30 percent of total calories, 50 to 100 milligrams cholesterol per day.

2. Achieve a normal blood pressure of 140/90 or better.

3. Burn at least 150 to 300 calories per day through aerobic exercise.

4. Maintain a normal body weight.

5. Reduce the amount of stress in your life.

6. Do not use any tobacco.

7. Maintain normal blood-sugar levels.

In Dr. Ornish's new book, Dr. Dean Ornish's Program for Reversing Heart Disease, he claims that "he is the first to scientifically prove heart disease is reversible."

In his Lifestyle Heart trial, Dr. Ornish set out to determine the effects of lifestyle modification on coronary heart disease. He placed 28 patients on a comprehensive lifestyle modification program, while another group of 20 received usual medical care. At the start of the study the amount of blockage was assessed in both groups and again assessed one year later.

After one year the group that followed the lifestyle modification program showed a significant overall regression of coronary atherosclerosis as measured by coronary angiography (a procedure in which dye is released from a catheter and X-rays taken of the coronary arteries). The other group following a less-stringent lifestyle modification program showed significant overall "progression" of coronary artery blockage.

Dr. Ornish's Program for Reversing Coronary Heart Disease

Recommendations include: 1. Maintain a very low-fat diet (10 percent of daily calories).

2. Restrict intake of cholesterol (5 milligrams per day).

3. Consume no animal products, except egg whites and one cup of nonfat milk or yogurt.

4. Eat largely of complex carbohydrates (70 to 75 percent of daily calories).

5. No caffeine.

6. No smoking.

7. Exercise three hours a week for a minimum of 30 minutes per session at an intensity of 50 to 80 percent of your training heart rate.

8. Engage in stress management techniques one hour a day and include stretching, meditation, progressive relaxation exercise, and deep-breathing exercises.

Dr. Ornish states that "a comprehensive lifestyle change may be able to bring about regression of even severe coronary atherosclerosis after only one year, without the use of lipid-lowering drugs."

Unlike Dr. Hellerstein, Dr. Ornish believes that "if you have coronary heart disease, then your intake of fat and cholesterol needs to be very low." The findings of Dr. Ornish's program leads you to believe that conventional dietary recommendations for heart patients (no more than 30 percent of daily calories from fat) are not sufficient enough to cause regression of coronary heart disease in many patients.

Even with such impressive results, most of us are not willing to follow Dr. Ornish's strict guidelines. And many researchers and medical experts believe that it doesn't take such a radical diet to start to unclog your arteries.

So I have options. What do I do?

Sufficient evidence exists demonstrating reversal and delayed progression of heart disease with several different types of interventions. The most appropriate treatment is the one that is decided upon between you and your physician.

Regardless of the intervention chosen, lifestyle changes should be part of every heart patient's prescription. Never attempt to self-diagnose the extent of heart disease, or follow a treatment program without direct physician supervision.

If you've been diagnosed with coronary heart disease and want to try lifestyle modification, you have to find a physician who will support your decision, and clearly explain the risks and benefits. Don't be afraid to ask questions. Physicians often recommend the treatments they feel most comfortable with, or specialize in.

If you don't feel your physician is willing or able to counsel you in the risks and benefits of lifestyle modification as a primary intervention for coronary heart disease, get a second opinion.