Reversing Heart Disease
Reversing heart disease is a holy grail of cardiology. It’s scary when you are told that you have a blockage in your arteries causing symptoms and are at increased risk of a heart attack. It’s even scarier when you are told you may need open-heart surgery or other procedures such as stents to tackle these blockages. That fear of a heart attack remains even after treatment and you ask yourself, what if it progresses and gets worse? Of course we would rather it simply disappear.
What if we could reverse heart disease and make the blockages disappear. Wouldn’t it be great if we could just take a tablet, or follow a drastic diet and the plaques in the arteries would dissolve away, reversing all the years of damage done beforehand? Why even bother on preventing heart disease if we can simply reverse heart disease?
Multiple diets and programs claim to reverse heart disease. Every one claims it works and that it is the best. Below we examine some of these claims and the actual evidence underlying the claims from the Ornish Diet, Esselstyn Diet, Pritkin Diet, Chelation therapy and others.
Heart disease affects everyone, either directly or through someone they know. It’s scary and people are of course interested in whether heart disease can be reversed. Unfortunately, some people, often healthcare related professionals pray on that fear and claim that they have found the cure and that following their special recommendations or program will reverse heart disease. Patients naturally want that claim to be true, and driven by fear will adopt these recommendations in the hope that their heart disease will go away.
Miracle Cures That Can Reverse Heart Disease
The reality is that miracle cures are typically backed with low quality often-laughable research. When asked why the medical community as a whole is dismissive, they blame the medical community for being ignorant, obsessed with big pharma and too arrogant to open their eyes. The reality is that while a minority of healthcare providers lack compassion and the ability to listen to their patients fears and concerns, most healthcare professionals care, and care a lot. They want their patients to benefit from available therapies, and it’s not the case that they are ignorant of alternative methods; rather they are understandably reluctant to recommend therapies that make ludicrous claims on the basis of poor science to back them. I certainly don’t want my patients to be conned and taken advantage of.
Patients looking for miracle cures that reverse heart disease are not stupid, they are simply scared and looking for a glimmer of hope. Of course when they are told that their heart disease can be reversed, they take notice and are attentive. Its particularly distressing therefore that those making the claims do so in an evangelical manner, praying on hope, with the main motive being to be in the limelight, make themselves celebrities, and fuel their profit driven machines. Of course they claim that patients are their priority. Rather than invest in high quality research programs that could give them credibility, they invest massive amounts in direct to patient marketing with wild claims of totally reversing heart disease.
The reality is that there is a lot of hope for patients with heart disease. While heart disease is at an all time high, the deaths from heart disease have not followed that trend. Treatments can act to stabilize the disease even if they can’t necessarily reverse it. It’s actually an amazing era in which to be a heart patient from a treatment perspective.
Reversing Heart Disease – The Obvious
Before even thinking about reversing something we need to understand why it occurs. In the case of heart disease it’s pretty obvious. And a close look at the miracle cure programs show that in general they simply state the obvious. The fact is most of us take very little care of ourselves until an emergency forces us to. Our diets are typically poor and full of refined and processed foods, we don’t make time to exercise, we deal with a lot of stress, smokers keep smoking, we forget to pay attention to blood pressure and cholesterol profile.
Making this worse is the confused advice that the authorities have come out with regarding nutrition. First we should avoid all fats, then we are told that actually fat is ok but carbs are bad. Some say high protein, some say low. Some say calorie count, some say don’t ever count calories. The dietary recommendations are really where the confusion has set in. The reality is however that hardly anyone is capable of following a strict diet plan when most of us struggle to do anything in moderation.
If you look closely at these often highly priced books and programs, in addition to claiming they are the secret to heart disease being reversed, they all have one thing in common. They encourage a holistic integrated approach, which basically means a combination of diet, lifestyle and exercise. It is obvious that we need to be more physically active and make time to exercise regularly several times a week. No one will argue physical activity is bad. Smokers need to stop. Blood pressure and cholesterol goals should ideally be achieved. Stress reduction might be a good idea. Avoid processed foods and sugar. Have moderation in diet, whether it is a plant based diet, a Mediterranean diet, a no carb diet or other. While each one claims to be the best, the reality is that each is likely better than what we do on a normal day to day basis. The reality of a drastic approach such as that outlined by many diets is that it is often destined to failure because hardly anyone can maintain it over the long term. Lifestyle change means true sustainable lifestyle change.
Reversing Heart Disease – What I Tell My Patients
As we discussed above, there are some things that are just obvious and hardly anyone would dispute that they are key in the development of heart disease. We can’t alter our genetics, however there are many risk factors that are modifiable.
Take Responsibility for Doing the Obvious – These things are obvious factors when it comes to stabilizing heart disease and preventing events. If you smoke then obviously stop. Pay attention to your blood pressure and cholesterol levels (it’s not only your doctor’s responsibility but yours), know your treatment targets, keep a diary, and keep up with your medicines. If you don’t exercise then start, make it routine, at least 30 minutes at a good heart rate and at least 3-4 times a week. If you are worried about what you are able to tolerate, then start as part of a cardiac rehabilitation program. If you have a stress filled life that you feel was in part too much then take measures to reduce that. If you have diabetes, obsess about diabetes control. If you need to pay a wellness program or resort to a ton of money to state the obvious then feel free.
There is no miracle cure yet – I am sure to tell patients there is no miracle cure that will reverse heart disease. The key is to stabilize heart disease and if we are fortunate we may see a regression over time although large regressions in blockages are not the goal, as there is no good evidence that can occur. Stabilization of disease is the key and can be achieved through a combination of lifestyle change and currently available treatments.
Don’t be dismissive of medicines – Many of those who make claims regarding miracle cures also like to talk about the evils of the medicines prescribed by doctors. Ironically most of the studies that their claims are based on involve full use of available medical therapies. Unfortunately, despite that, part of the sales pitch of those claiming that heart disease can be reversed with their programs is that patients can completely come off their medicines. Of course medicines should be discussed with the prescribing doctors and side effects discussed and once targets have been met, potential reduction of these can be discussed. This is a responsible approach, unlike the approach suggested by the entirely self-promoting, conspiracy theorist, miracle cure evangelists.
Don’t Look for an Easy Way Out – The bottom line is that it takes hard work and a lot of it to adopt a so-called healthy lifestyle. Anyone looking for a quick fix plan will end up spending a lot of money adopting a drastic change that isn’t backed by any decent level of evidence, and likely will fail in the long term due to the drastic nature of a change that is not sustainable. It takes hard work, dedication and serious long-term goals and plans to succeed. If you want to get serious then get serious, and if you don’t, be realistic about your expectations and outcomes.
When It Comes to Diet, Don’t be Brainwashed or Naïve – Educate Yourself – The reality of all the miracle cures out there is that each one promotes a drastic dietary change in addition to lifestyle changes. Each one thinks it is the best and each one offers a relatively low level of evidence to back it up. Every diet has the following in common – cut out refined and processed foods, eat natural with fruit/vegetables, and cut out sugar. It’s a simple as that. Some are plant based and some are Mediterranean type. Information is widely available on the Internet and my recommendation would be to look at these various diets and learn which ones you feel that you could actually have a chance at doing long term. The bottom line is whether it’s Mediterranean, low carb, plant based or other, it’s clearly better than the high sugar, processed diet that most people eat. No matter what claims they make, none of these miracle diets are going to unblock all of the critical blockages in the heart arteries and totally reverse heart disease. At best we could hope for stabilization and if lucky some mild regression when diet is combined with lifestyle modification and medical treatments.
Be Hopeful – Patients with coronary artery disease have a good outlook in this day and age. Although procedures are not always the answer, they have advanced to where critical blockages can be treated effectively and safely. Modern day medicines have improved outcomes for heart disease patients. Knowledge about diet, particularly avoidance of processed foods and sugar, has allowed more sensible recommendations to be made. Availability of home blood pressure and glucose monitors have allowed patients to have a much higher level of participation in monitoring and controlling important chronic health conditions. Of course any strategy regarding heart disease should focus on prevention since the number of people with heart disease is rising. One good statistic however, is that the deaths from cardiovascular disease is actually falling. Patients with heart disease actually have a hopeful outlook.
Although science has a large body of evidence to back up the use of statin medications in the use of cardiovascular disease, some controversy remains. The current overwhelming recommendation from most medical authorities is that they are a front line treatment for coronary artery disease and to prevent cardiovascular events. In this article some of the evidence for the role of statins in the stabilization and potential reversal of coronary heart disease is reviewed. Of course much of this is industry and profit driven although most drugs are now available generically.
Atherosclerotic Heart Disease
Atherosclerosis causes plaques responsible for blockages in arteries causing coronary heart disease. These plaques can increase in size over time to where they cause angina chest pains, or they can burst and lead to total blockage of the artery as happens in a heart attack. Often these plaques can be stabilized to reduce their progression over time by the use of medicines and lifestyle changes. Severe blockages can be treated with the use of stent procedures or bypass operations. But can coronary heart disease be reversed to prevent the need for emergency treatment or heart attacks?
When Does It Start?
Atherosclerosis begins at an early age with the earliest lesions appearing in late adolescence with advanced lesions typically developing at ages 30-40. With advancing age, the lesions become even more advanced, hard and calcified. Risk factors such as high cholesterol, smoking, diabetes and high blood pressure are associated with the development of lesions and control of these risk factors are associated with a lower likelihood of developing significant disease.
Studies In Animals
In the 1950’s a study was done in rabbits. The rabbits were fed extremely high levels of cholesterol and as a result developed very widespread atherosclerotic lesions. The rabbits were then injected with a substance that was known to break down fat in a process called lipolysis. As a result the lesions were much smaller and less widespread. The idea of shrinking plaques and reversing heart disease gained more traction with studies in monkeys in the 70’s. The animals were fed a high cholesterol diet for about 1½ years then a low fat diet for just over 3 years. After the high fat diet there were high levels of disease seen in the coronary arteries with blockages up to 60% narrowing, however after the subsequent low fat diet, the coronary blockages were noted to shrink significantly to about only 20% narrowing. Further similar studies in pigs and also in rabbits demonstrated that despite plaques containing complex features previously thought to be irreversible, they were still able to regress and show signs of stability. Further work over the years involving genetically modified animal models has helped to identify the mechanisms that underlie the regression of the plaques in these animal models and the potential to reverse heart disease to some degree.
Studies In Humans
Many large trials done in humans have demonstrated that the use of cholesterol medications such as statins has lowered the rate of clinical events such as heart attacks. The degree of plaque regression has been relatively mild however, and a potential explanation for this is that the medications are working to stabilize the plaques and therefore make them less vulnerable to burst and therefore less likely to cause heart attacks or progress to severe blockages. This plaque stabilization is important even if the lesion regression is minimal as shown in one study where there was only a 0.4% reduction in plaque size, but an almost 90% lower chance of having a heart event. Some studies have actually used ultrasound to look inside the arteries of the heart and assess the response to cholesterol lowering therapy with statins. In one study 24 months of high dose statin therapy was associated with a 7% reduction in plaque volume. Importantly, the lesions did not worsen over time, in of itself a major goal.
What To Make Of It
If modern day evidence based medicine is to be believed, then the cholesterol lowering medications (statins) are clearly associated with a decrease in cardiovascular events. Underlying this is likely a role in stabilization of plaques that cause coronary artery blockages that likely prevents rupture of the plaques that would cause heart attacks. There is some evidence that statins cause some mild reversal of the plaques also. Studies suggest that if started earlier in those at high-risk then statins can prevent the development of complex plaques. There is currently no magic bullet to go and clear out arteries and totally reverse plaques, however statins appear to be the most well researched medication available to stabilize plaques and prevent progression.
Is it worth trying?
I personally recommend and would be on these medications if I had significant heart disease. The body of evidence is remarkable. It would be better if patients would all adopt strict lifestyle changes and dietary measures, but most won’t and these medications have been credited with reduction in cardiac events despite the evolution of a terrible current day lifestyle. Its easy and often appropriate to be skeptical of industry and its motives, but in this case I think the sheer volume of trials and participants show a benefit in patients with clear coronary artery disease at risk of events.
Plant Based Diets – Esselstyn Type Plan
What is a plant-based diet?
A plant-based diet includes fruit, legumes, vegetables and whole grains. This diet is worth mentioning as it has some evidence underlying it regarding its effectiveness. We will discuss the limitations of this evidence later. In the studies the plant-based diet is defined as avoidance of dairy, meat, fish and added oil. Also its important to note that in these studies the plant based diet was advocated in combination with cholesterol medications. It is a profit driven program that centers around books and wellness institutes. It claims to reverse heart disease and avoid the need for heart procedures.
What did the studies show?
In the landmark study by Esselstyn and co-workers, 18 patients with severe coronary artery disease were followed. Most of the 18 patients had experienced failure of previous bypass surgeries or interventional procedures and were experiencing symptoms. The study is remarkable in that pictures of the heart arteries were repeated in most cases after 5 years. These patients were placed on a plant-based diet and attention was paid to cholesterol goals also. Reportedly, over the next 12 years, no patient experienced a further coronary event. In the 8 years before the study the same group of patients had almost 50 coronary events between them. In the repeat angiogram pictures, 70% of the patients had some regression of the degree of blockage and the remaining 30% had stable disease without progression. 90% of the patients were reported to adhere to the diet.
In the next study of a plant-based diet, the same author followed almost 200 people that were counseled on a plant-based diet in addition to usual cardiovascular care. They reported that the majority of patients were adherent to the plant based diet. Of the patients that followed (177/198) the diet strictly there was only 1 event, a stroke. That’s an event rate of only 0.6%. In the patients that were not adherent 13/21, (62%) had an event.
What to make of the studies?
Basically, this study claims to blow all other studies out the water. The findings are so incredible that one has to wonder if they are real. I’m an interventional cardiologist who sees such patients day in and day out and so one may wonder why if the results are so convincing, we aren’t all forced to put everyone on a plant based diet. It would be safer, more cost effective and beat almost any procedure for treating advanced severe coronary disease. This makes the findings hard to believe, although I think it would be arrogant to be entirely dismissive.
Of course there are many issues. Firstly there are only 18 patients. On the spectrum of trial evidence, this is weak, there is no randomization, no control, no multicenter, small sample etc.… For these reasons, the article itself is published in a journal that would typically never be read by cardiologists and is certainly not a high-ranking journal. The final issue is that the primary author of the study is author of several related books and therefore potential conflict issues arise on further discussions of the work by that team.
So does a plant based diet reverse heart disease? According to the findings of the initial study there can be some regression of blockages in patients on a plant-based diet and if there isn’t regression there will be stability. Importantly there is possibly a remarkable reduction in heart events. The findings would be much more believable if there was a larger study conducted, with randomized groups, and across different centers. I really cannot understand why this has not been done as if there is major belief in this approach this should have been done or at least attempted by the authors and their institutions.
Is it worth trying?
There is too much evangelical marketing that far overstates the true potential benefits of such a program and in reality somewhat discredits it in the eyes of the scientific community. It’s important that people understand that this is profit driven. I don’t think it’s harmful however. There is a potential benefit to this approach particularly in combination with standard therapy. The problem is the real life ability to stick to this diet would likely be dismal given the dietary habits of today! It would be much more compelling if the evidence was stronger. If I had significant blockages, I’d certainly want to hope it worked it although it would be hard. I think standard therapy should be continued alongside the diet. It’s certainly no miracle cure in isolation. Such diets also fail to take in to account potential beneficial effects of good fats such as olive and coconut oils championed by Mediterranean type diets that have shown to be associated with potentially favorable outcomes also.
Lifestyle Changes and Low Fat Vegetarian Diet – Ornish Type Plan
What is the Ornish Plan?
The definition often used in research studies of this plan is low-fat vegetarian diet, stopping smoking, stress management training, and moderate exercise. Its often neglected that this plan is not simply a diet, it is a comprehensive lifestyle change with all of the above that would be required to see the claimed results. It is a profit driven enterprise that centers on books and programs.
What did the studies show?
In 1990 a study was published named “Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial.” In this study 28 patients were assigned to the lifestyle intervention and 20 were assigned to standard care at the time. Study duration was a year. It was found that the intervention group had a decrease in blockage by a few percent and the standard care group had an increase in blockage by a few percent. It was concluded that comprehensive lifestyle changes might be able to bring about regression of even severe coronary atherosclerosis after only 1 year, without use of lipid-lowering drugs.
In 1998 the five-year follow up study was published. In similar findings to the 1-year study it was found that the intervention group had a decrease in blockage by a few percent and the standard care group had an increase in blockage by a few percent. The effect of the diet appeared to be even more pronounced over time. Importantly there were more than twice as many cardiac events in the control group.
What to make of these studies?
Again there is too much evangelical marketing that far overstates the true potential benefits of such a program and in reality somewhat discredits it in the eyes of the scientific community. It’s important that people understand that this is profit driven. I don’t think it’s harmful however. There may be a potential benefit to this approach particularly in combination with standard therapy. The studies demonstrate the potential for such a diet to have an effect on heart disease however the level of evidence is certainly not definitive and should not be marketed as a miracle cure. At least an attempt has been made to underpin the findings with research and evidence. A large multicenter controlled trial, with thousands of patients would provide a more compelling case. Regardless, the diet is an improvement on the diet that most people currently have and so it’s hard not to at least consider this as an improvement over current care. If there is a benefit then it would be due an approach is that it is holistic in nature and is not simply a diet, but a comprehensive lifestyle change. Such diets also fail to take in to accounts potential beneficial effects of good fats such as olive and coconut oils championed by Mediterranean type diets that have shown to be associated with potentially favorable outcomes also.
The Pritkin Program
What is the Pritkin Program?
It is a program for diet and exercise. The program champions unprocessed or minimally processed foods in addition to regular exercise and physical activity. It is more of a brand than a scientific method however. It centers on books and a resort that aim to improve cardiovascular health through the associated lifestyle.
What did the studies show?
When researching this I was a little disturbed by the overreaching scientific claims made. This program aims to distinguish itself from the others by saying it is the most scientifically studied and backed however the claims are overreaching. They claim that over 100 studies in prestigious journals have documented the efficiency of the program in helping thousands of patients worldwide. Lets look a little closer at these claims. The New England Journal of Medicine is considered amongst the most prestigious medical journals. The only article regarding the Pritkin Program in this journal is in fact a letter to the editor that is written by an author who is now central to the program. Furthermore the findings were that serum cholesterol could be reduced through lifestyle modification. The same article concludes “the long-term effects of the lower serum lipid levels on health and longevity are not addressed by these data. Whether severe restriction of dietary fat is a realistic public health approach to lowering serum cholesterol levels is uncertain.” Another article, which was really a “rapid communication”, was published in a good journal called “Circulation.” This study only looked at 11 people and demonstrated that low fat high fiber diet in combination with lifestyle modification and exercise can reduce blood pressure and some markers of inflammation. Importantly the findings of these studies whilst interesting and thought provoking do not meet a high level of evidence such a multicenter, randomized trial with high levels of participants. These studies do not show rigorously tested hard endpoints.
What to make of these studies?
Basically the Pritkin program states the obvious, but charges a high price to state it. If we exercise, stop smoking; stop eating processed foods and make healthy lifestyle modifications then we can potentially improve some health parameters. Whether this translates in to long term hard outcomes is not really known and it’s sad that these programs are driven by the need for instant gratification and profit as opposed to really showing they believe in their work by getting together and conducting high level scientific studies that would lessen the skepticism. Such diets also fail to take in to accounts potential beneficial effects of good fats such as olive and coconut oils championed by Mediterranean type diets that have shown to be associated with potentially favorable outcomes also.
Is it worth trying?
Would I try the obvious, lose weight, stop smoking, eat less processed food, exercise regularly and change my lifestyle to be healthy? Obviously less. Would I make drastic dietary changes that aren’t proven to change outcome and almost impossible to follow? No. Would I pay a lot of money to do the obvious? No.
Fruit, Vegetables and Risk of Heart Disease
The EPIC study is a study that is ongoing and had basically followed a large number of patients over many years in order to learn about factors associated with diseases from cancer to heart disease. One of the related studies looked at fruit and vegetable intake and its association to dying from heart disease.
What did the study show?
The study looked at over 300,000 participants followed over an 8-year period. The participants were from many European countries. The study placed emphasis in to into refining dietary methodology across centers, which is a great strength. Each portion of fruit/vegetable was defined as 80 g. The lowest fruit and vegetable group was seen as 3 portions or less and the highest 8 portions a day. It was found that when compared to the lowest group, those having 8 portions a day had a 22 percent reduction in death from heart disease. Further analysis showed that every unit increase in portion of fruit or vegetables resulted in a lowered risk. These findings held true regardless of intake of other food groups.
What to make of it?
Hardly anyone would argue against encouraging fruit and vegetable intake to prevent chronic diseases and improve their outcomes. This was one of the first studies to back that up with good evidence. Any study that uses complex statistics needs to be taken with caution however and will always be limited.
Is it worth trying?
Its like physical activity and lifestyle changes, it seems a no brainer to incorporate fruit and vegetables in to the diet. The interesting thing about this study is that it suggests that even those who had less than ideal dietary habits otherwise, fruit and vegetable can still reduce risk. Also don’t forget a reduction in cancers, blood pressure and stroke.
Traditional Risk Factors and Risk of Heart Attacks
What are Traditional Risk Factors?
Traditional risk factors are those such as smoking, exercise and blood pressure. These are the risk factors that doctors have targeted over years when giving advice to patients about reducing their cardiovascular risk. In the INTERHEART study, the investigators looked at the effect of 9 risk factors on the development of heart disease. These 9 risk factors were felt to be potentially changeable or “modifiable” risk factors. The risk factors were abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits, vegetables, and alcohol, and regular physical activity.
What did the study show?
The study looked at 30,000 participants across every continent. It was found that abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits, vegetables, and alcohol, and regular physical activity account for most of the risk of heart attack worldwide in both sexes and at all ages in all regions. Most of the risk was attributed to smoking, lipids, hypertension, diabetes, and obesity.
What to make of it?
This study tells us what we already knew, but backed that up with evidence. Moderating alcohol and weight, increasing fruit and vegetables, stopping smoking, increasing physical activity, reducing stress and waistline, controlling blood pressure and diabetes are all felt to be important. Importantly these risk factors are felt to be modifiable, which means we can do something about them.
Is it worth trying?
I don’t think anyone would argue against modifying the risk factors mentioned above. Its important to realize that not diet alone, but an integrated approach that incorporated lifestyle is likely to be the most effective in reversing and preventing heart disease.
Chelation Therapy for Heart Disease
What is Chelation Therapy?
Chelation therapy consists of intravenous infusion or sometimes-oral administration of a treatment containing disodium EDTA and various other substances. With regard to heart disease, it is thought these substances go through the bloodstream and can remove the calcium from plaques in the arteries therefore shrinking blockages. In the 80’s and early 90’s some proponents of chelation therapy were touting this as a miracle cure. The scientific community has remained very skeptical, as the evidence was poor and the therapy potentially harmful. A landmark trial called the TACT trial was performed and commissioned by the NIH to investigate the effects of chelation therapy on heart disease.
What did the study show?
The study looked at around 1700 patients who had a heart attack in the 6 weeks prior to the study. The study concluded that among stable patients with a history of MI, use of an intravenous chelation regimen with disodium EDTA, compared with placebo, modestly reduced the risk of adverse cardiovascular outcomes. Most of that was driven however by the need for repeat interventional procedures. They then said these results provide evidence to guide further research but are not sufficient to support the routine use of chelation therapy for treatment of patients who have had an MI. There is certainly no evidence that heart disease can be reversed by chelation therapy.
What to make of it?
To know what to make of this trial we don’t really need to look beyond the editorial articles that accompanied the article. In one editorial it reported “these findings do not support the routine use of chelation therapy as secondary prevention for patients with previous myocardial infarction and established coronary disease”. In another more scathing editorial it reported that “given the numerous concerns with this expensive, federally funded clinical trial, including missing data, potential investigator or patient unmasking, use of subjective end points, and intentional unblinding of the sponsor, the results cannot be accepted as reliable and do not demonstrate a benefit of chelation therapy. The findings of TACT should not be used as a justification for increased use of this controversial therapy.
Is it worth trying?
I personally wouldn’t try or recommend it based on the evidence provided. There is no good evidence it reverses heart disease.