Angioplasty and stents offer no advantage over medications alone

Our society has been falsely led to believe that only highly technological interventions and drugs are effective at treating disease. In many cases, however, these interventions merely act as band-aids – temporarily relieving symptoms while the disease process continues to progress.

Heart.  Flickr: Vintage Collective
Percutaneous coronary intervention (PCI), a term that refers to angioplasty and stent placement procedures, is already known to have no advantage over optimal medical therapy (OMT); which refers to modest lifestyle changes plus anti-platelet, blood pressure-lowering, and cholesterol-lowering medications) for reducing heart attack incidence or cardiac mortality. This information made headlines in 2007; the COURAGE trial compared PCI plus OMT to OMT alone, and found no advantage associated with PCI procedures. [1] Since that time, literature reviews have confirmed that PCI did not decrease the rate of heart attack or cardiac death compared to OMT. [2]


Considering that PCI only treats a small portion of a blood vessel, but coronary artery disease affects the entire vasculature, this is not a surprising finding. Because of this finding, the indications for PCI evolved. Now, these interventions are indicated only for the purpose of relieving angina (chest pain caused by restricted blood flow to the heart) symptoms in coronary artery disease patients.


However, a recent review of several clinical trials in patients with stable coronary artery disease has revealed that PCI does not lessen angina any more than medical therapy either. [3] The researchers analyzed human trials that compared either angioplasty or stent placement to OMT with respect to angina symptoms. In 5 clinical trials conducted since 2000, 77% of patients were free of angina after PCI, and 75% of patients were free of angina after OMT, suggesting that PCI does not provide enhanced symptom relief compared to OMT. [4]


We must remember that aggressive interventions like angioplasty and stent placement have serious potential adverse outcomes, such as bleeding complications, heart attack, stroke, and death. [5]  Approximately 25% of angioplasties and 21% of stent placements clog up again (called restenosis) within 6 months, and about 60% of arteries treated by angioplasty will undergo restenosis eventually.[6, 7] These data tell us that PCI is not a long-term solution. Diet and lifestyle changes, however, are long-term solutions because they remove the cause of the heart disease. A low-fat, plant-based diet plus exercise and stress management has been shown to reverse atherosclerotic plaque progression. In addition, 74% of the coronary artery disease patients who had angina and made these lifestyle changes were free of angina after only 12 weeks. [8, 9] This is equivalent to the figures cited above for OMT – except of course, without drugs.


Despite the evidence, cardiologists continue to rationalize that angioplasty and stent placements are essential for their patients. The reality is that modern interventional cardiology should be stopped and medical and nutritional cardiology should be the standard of care. Everyone who has heart disease deserves to know that they have safer, noninvasive alternatives to stents and angioplasty.


In spite of the research we already have documenting the dramatic effectiveness of nutritional interventions [8, 10-12] and the futility of angioplasty and stent placement, this obviously still has not been sufficient to change the practices of conventional cardiologists. There are too many economic forces working against it. Nevertheless, for optimal atherosclerosis reversal and angina relief, my clinical experience with hundreds of patients with advanced heart disease, (confirmed by nutritional intervention studies) demonstrates that optimal nutritional therapy (ONT), with a vegetable-based, high-nutrient (nutritarian) diet – focused on vegetables, beans, fresh fruit, seeds and nuts - is dramatically more effective than PCI or OMT. This approach has already been demonstrated to be more effective than other nutritional interventions at lowering cholesterol; if we compare the published effects of dietary interventions on LDL cholesterol levels, a low-fat plant-based diet reduced LDL by 16%, but a nutritarian diet reduced LDL cholesterol by 33%.[13, 14] This data and my results offer more evidence to suggest that a nutritarian diet is ideal and by including more greens, beans, seeds and nuts leads to even more dramatic results and long-term benefits for heart disease patients.


Of course, larger more definitive studies are needed - exactly one of the initial goals of the Nutritional Research Project. Only with better controlled and documented research results can we foster increased awareness and acceptance of the therapeutic effects of a nutritarian diet for heart disease patients.

 

 

References:

1. Boden, W.E., et al., Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med, 2007. 356(15): p. 1503-16.
2. Trikalinos, T.A., et al., Percutaneous coronary interventions for non-acute coronary artery disease: a quantitative 20-year synopsis and a network meta-analysis. Lancet, 2009. 373(9667): p. 911-8.
3. Wijeysundera, H.C., et al., Meta-analysis: effects of percutaneous coronary intervention versus medical therapy on angina relief. Ann Intern Med, 2010. 152(6): p. 370-9.
4. Relief from Angina Symptoms: Percutaneous Coronary Intervention Not a Clear Winner. Journal Watch General Medicine, 2010.
5. Angioplasty and stent placement - heart. MedlinePlus.
6. Agostoni, P., et al., Clinical effectiveness of bare-metal stenting compared with balloon angioplasty in total coronary occlusions: insights from a systematic overview of randomized trials in light of the drug-eluting stent era. Am Heart J, 2006. 151(3): p. 682-9.
7. Hanekamp, C., et al., Randomized comparison of balloon angioplasty versus silicon carbon-coated stent implantation for de novo lesions in small coronary arteries. Am J Cardiol, 2004. 93(10): p. 1233-7.
8. Ornish, D., et al., Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet, 1990. 336(8708): p. 129-33.
9. Frattaroli, J., et al., Angina pectoris and atherosclerotic risk factors in the multisite cardiac lifestyle intervention program. Am J Cardiol, 2008. 101(7): p. 911-8.
10. Esselstyn, C.B., Jr., et al., A strategy to arrest and reverse coronary artery disease: a 5-year longitudinal study of a single physician's practice. J Fam Pract, 1995. 41(6): p. 560-8.
11. Esselstyn, C.B., Jr., Updating a 12-year experience with arrest and reversal therapy for coronary heart disease (an overdue requiem for palliative cardiology). Am J Cardiol, 1999. 84(3): p. 339-41, A8.
12. Ornish, D., Avoiding revascularization with lifestyle changes: The Multicenter Lifestyle Demonstration Project. Am J Cardiol, 1998. 82(10B): p. 72T-76T.
13. Barnard, N.D., et al., Effectiveness of a low-fat vegetarian diet in altering serum lipids in healthy premenopausal women. Am J Cardiol, 2000. 85(8): p. 969-72.
14. Jenkins, D.J., et al., Effect of a very-high-fiber vegetable, fruit, and nut diet on serum lipids and colonic function. Metabolism, 2001. 50(4): p. 494-503.

 

Vitamin D update: Diabetes, cognitive decline, asthma, and heart attack

Vitamin D is continuing to make news.  Although previously well-known for its effects on calcium absorption and therefore bone health, vitamin D has now emerged as a contributor to many nonskeletal physiological processes, and functions have been attributed to vitamin D in the prevention of cancer, cardiovascular disease, infections, autoimmune diseases, and more. There are vitamin D receptors in almost every cell in the human body, and vitamin D regulates the expression of over 200 different genes. It is not surprising that sufficient vitamin D is crucial to the proper function of so many of our body’s tissues.1

Scientists estimate that 50% of the population of North America and Western Europe has insufficient blood vitamin D levels (as measured by 25(OH)D; sufficient is defined as greater than 30 ng/ml). Although recommended vitamin D intakes remain at only 200-400 IU per day, there is consensus among the scientific community that 2000 IU or more may be necessary for most  people to maintain sufficient blood levels.2

The newest research has found that vitamin D sufficiency is important for preventing type 2 diabetes, cognitive decline, asthma, and cardiovascular disease.

 

 

 

Type 2 diabetes

There is some evidence that vitamin D is involved in insulin secretion by pancreatic beta cells, since insulin secretion is a calcium-dependent process. Vitamin D may also prevent the development of insulin resistance by stimulating expression of the insulin receptor on the surface of cells that use glucose as fuel.3 A recent study performed at Johns Hopkins University School of Medicine on type 2 diabetics found that 91% of the patients were either deficient (less than 15 ng/ml) or insufficient (between 15 and 30 ng/ml) in vitamin D. Furthermore, there was inverse association between vitamin D levels and HbA1c, an indicator of blood glucose levels over the preceding 2-3 months, implying that vitamin D sufficiency contributes to glycemic control in diabetics.4 Vitamin D’s effects are not specific to type 2 diabetes; there is also convincing evidence that vitamin D supplementation during pregnancy and early childhood can reduce the risk of type 1 diabetes, and prospective studies on this topic are ongoing.1,5

Cognitive decline

Vitamin D receptors are present throughout the entire human brain, and genes that are regulated by vitamin D are involved in processes such as memory formation and neurotransmission.6,7 Although previous studies have been inconclusive8, this new data supports a role for vitamin D in maintaining brain health in older adults. 

Asthma

Two recent studies on asthma, one in adults and one in children, has linked vitamin D insufficiency with increased asthma severity.9 Those with 25(OH)D levels above 30 ng/ml had greater lung function, and used less medication.10 A similar study in children also found that lower vitamin D levels were associated with increased asthma severity, and that higher vitamin D levels were associated with reduced odds of hospitalization for asthma.11 Vitamin D’s anti-inflammatory actions or regulation of smooth muscle cell contraction via calcium handling may be the responsible factors. The researchers are currently conducting a trial investigating vitamin D supplementation as a therapeutic option for asthma. Vitamin D is also important for lung development in utero, so maternal supplementation with vitamin D during pregnancy is recommended.12

Cardiovascular disease

There is continually building evidence in the literature that sufficient vitamin D levels protect against cardiovascular disease. Vitamin D deficiency is extremely prevalent among heart attack sufferers – 96% of heart attack sufferers in a recent study were either insufficient (21%) or deficient (75%) in vitamin D. Those with sufficient vitamin D levels are less likely to die from heart attack or stroke.  Vitamin D insufficiency may allow for increased cholesterol uptake by inflammatory cells, which contributes to atherosclerosis.13 A newly published study recorded vitamin D levels at baseline and throughout 6 years of follow-up. At the start of the study, the average 25(OH)D level was 19.3 ng/ml (insufficient). During the trial, about half of the subjects increased their levels to the sufficient range (above 30 ng/ml), and these subjects had significantly reduced incidence of heart attack, heart failure, and coronary artery disease. Some subjects raised their 25(OH)D levels above 44 ng/ml, and they received even stronger protection against cardiovascular disease. Compared to those who reached levels above 44 ng/ml, those whose levels stayed between 10 and 19 ng/ml had a 27% increase in coronary artery disease, a 32% increase in heart failure, and a 59% increase in heart attack incidence.14

Maintaining sufficient vitamin D levels is essential to our health. 

Very few foods naturally contain vitamin D and we cannot rely on sun exposure alone because of indoor jobs, cool climates, and the risk of skin cancer that may arise from adequate amounts of sun exposure to maintain vitamin D levels.   Plus, requirements vary with genetics and skin type greatly effecting Vitamin D production in the skin.  Taking a multivitamin is not the answer because almost all  multivitamins still provide an inadequate amount of vitamin D (400 IU). Favorable levels can be confirmed with a blood test, and supplementation can be adjusted accordingly.   I recommend supplementing with an adequate amount of vitamin D in order to maintain 25(OH)D levels of 35-55 ng/ml. For some people 2000 IU will be sufficient, but others may require more.

References:

1. Hyppönen E. Vitamin D and increasing incidence of type 1 diabetes-evidence for an association? Diabetes Obes Metab. 2010 Sep;12(9):737-43.

2. University of California - Riverside (2010, July 19). More than half the world's population gets insufficient vitamin D, says biochemist. ScienceDaily. Retrieved July 28, 2010, from http://www.sciencedaily.com /releases/2010/07/100715172042.htm

3. Pittas AG, Lau J, Hu FB, Dawson-Hughes B. The role of vitamin D and calcium in type 2 diabetes. A systematic review and meta-analysis. J Clin Endocrinol Metab. 2007 Jun;92(6):2017-29.

4. The Endocrine Society (2010, June 21). Poor control of diabetes may be linked to low vitamin D. ScienceDaily. Retrieved July 28, 2010, from http://www.sciencedaily.com /releases/2010/06/100621091209.htm

5. Zipitis CS, Akobeng AK. Vitamin D supplementation in early childhood and risk of type 1 diabetes: a systematic review and meta-analysis. Arch Dis Child. 2008 Jun;93(6):512-7.

6. McCann JC, Ames BN. Is there convincing biological or behavioral evidence linking vitamin D deficiency to brain dysfunction? FASEB J. 2008 Apr;22(4):982-1001.

7. Llewellyn DJ, Lang IA, Langa KM, et al. Vitamin D and Risk of Cognitive Decline in Elderly Persons Arch Intern Med. 2010;170(13):1135-1141.

8. Annweiler C, Allali G, Allain P, et al. Vitamin D and cognitive performance in adults: a systematic review. Eur J Neurol. 2009 Oct;16(10):1083-9.

9. EurekAlert! Low vitamin D levels associated with more asthma symptoms and medication use. http://www.eurekalert.org/pub_releases/2010-04/njma-lvd041510.php#

Jancin B. Vitamin D Tied to Airway Hyperresponsiveness. Family Practice News. May 1, 2010.

10. Sutherland ER, Goleva E, Jackson LP, et al. Vitamin D levels, lung function, and steroid response in adult asthma. Am J Respir Crit Care Med. 2010 Apr 1;181(7):699-704.

11. Brehm JM, Celedón JC, Soto-Quiros ME, et al. Serum vitamin D levels and markers of severity of childhood asthma in Costa Rica. Am J Respir Crit Care Med. 2009 May 1;179(9):765-71.

12. Litonjua AA. Childhood asthma may be a consequence of vitamin D deficiency. Curr Opin Allergy Clin Immunol. 2009 Jun;9(3):202-7.

13. Washington University School of Medicine (2009, August 25). Why Low Vitamin D Raises Heart Disease Risks In Diabetics. ScienceDaily. Retrieved July 28, 2010, from http://www.sciencedaily.com /releases/2009/08/090821211007.htm

14. Jancin B. CAD Events Less Likely With Normal Vitamin D. Family Practice News, May 15, 2010.