Coronary artery model showing non-occlusive fatty plaques. Blogfinger photo. ©
Bloomberg News (11/5, Cortez) reports that research published in the Journal of the American Medical Association (JAMA) on Nov. 5, 2014, suggests that “early heart disease, when fatty plaque starts to line the arteries without blocking blood flow, can trigger heart attacks and death.”
HealthDay (11/5, Preidt) reports that investigators “looked at data from more than 37,000 U.S. veterans.” The researchers found that one year after diagnosis, those with non-obstructive coronary artery disease were about 2 to 4.5 times more likely to have suffered a heart attack or died than those with no apparent coronary artery disease.
Medscape (11/5, O’Riordan) reports, “Speaking with heartwire, lead investigator Dr Thomas Maddox…said the results are in line with what would be expected based on the biology of CAD and are consistent with prior biologic studies suggesting that a majority of MIs are related to nonobstructive stenoses.” (Note: CAD is coronary heart disease, and MI is myocardial infarction, aka heart attack . —-PG)
Blogfinger Medical Commentary by Paul Goldfinger, MD, FACC
About 20 years ago, some researchers startled the world of cardiology when they found that heart attacks usually occur when a coronary artery which contains non-obstructive fatty deposits (“plaques “) within the lining, suddenly becomes totally obstructed by clot formation due to disruption of an unstable area of athersclerotic plaque. That sudden event causes heart damage (myocardial infarction; “heart attack”) and places the victim in serious jeopardy.
I was in the audience at that presentation delivered at a national meeting of the American College of Cardiology before thousands of heart doctors. I remember practically jumping out of my seat—it was earthshaking. Up to then, we thought that only severe narrowings would precipitate a heart attack. That new revelation abruptly changed the concepts regarding how to treat coronary artery disease.
This current study from the VA, posted in the November 5 edition of JAMA, proves those early findings by assessing the risks in 37,000 veterans who underwent coronary angiography (cardiac “catheterization”) and whose arteries were assessed for narrowing. The study showed that the risk in those with non-obstructive disease increases according to the number of coronary arteries involved and the extent of the fatty buildup. This information was never available before and is extremely important.
Non-obstructing plaques usually exist without revealing their presence via symptoms (chest pains, shortness of breath), ECG abnormalities or abnormal stress tests. Such plaque formation may take years to develop. Over time the buildup often becomes more severe and more diffuse in those coronary arteries, which supply oxygen to the heart muscle, but they have to reach about 80% narrowing before symptoms occur. Meanwhile, those fatty plaques, even minimal ones may become unstable and vulnerable to rupture, inciting a total blockage by clot.
Here is the conclusion of the study: “The results of this study support the concept that non obstructive CAD is not “insignificant” but rather is associated with a significant and quantifiable risk for cardiovascular morbidity and mortality.”
However, the trial did not offer any results that would suggest how to identify such patients in clinical practice, nor did it offer any ideas as to how to alter the negative prognosis.
In my opinion, the approach to identifying and treating non-occlusive plaques is not a procedure such as an angiogram, a nuclear stress test, a stent, or bypass surgery. Instead the answer is to educate potential patients regarding their risk of subsequent heart attacks or sudden death and then to embark on a prevention program. This is called “risk stratification.”
That is the subject of our book (Prevention Does Work: A Guide to a Healthy Heart*) which was last updated in 2011, but all of the prevention information is still relevant. Usually patients at risk are placed on heart healthy diets and weight loss programs. They are counseled about stop smoking techniques, blood pressure control, exercise, and cholesterol management. They usually are given a statin drug and aspirin.
I would say that potential patients need to undergo risk assessment, and if the risk is increased, then a full all-out prevention program is warranted. The higher the risk, the more aggressive the program. Our book spells it all out.
Doctors are not equipped to spend the time educating their patients, for example about heart healthy eating and food preparation. Under the ACA, I’m afraid that doctors will have even less time with patients, and for all the talk about prevention as a way to lower costs, I’m waiting to see if Obamacare provides the programs and personnel that will implement prevention for all the patients who need it. That will be very costly.
* To obtain our book, which is available in soft cover for about $12.00, go to Amazon.com to the books section and type in “Paul Goldfinger, MD” Our goal is to be heard. We will donate any royalties that we receive to the American Heart Association.