Most Heart Attacks Are Caused By Vulnerable Plaque and Inflammation

An excerpt from the Kurzweil and Grossman book, "Live Long Enough to Live Forever"

The large, calcified plaque growing on the inside surface of coronary arteries is not the cause of most heart attacks. Rather, the primary culprit is the soft, relatively small "vulnerable" plaque that forms within the vessel walls.

Large, calcified plaque is actually relatively stable and, because of its hard calcified covering, less commonly cracks. The more dynamic, less stable soft plaque is much more likely to suddenly rupture. As the body forms a clot to try to heal such a rupture, the result may be a total blockage of blood flow; in other words, a heart attack. The soft plaque is hidden inside the walls of the artery and often causes no obvious blockage or loss of blood flow until, of course, the often-fatal rupture.

Yet there is good news hidden in this new understanding because the buildup of soft, vulnerable plaque is much easier to reverse than that of hard, calcified plaque. Levels of the two types of plaque are related, since the same process appears to result in both forms. One prevalent theory on the origin of the hard plaque is that it's the body's attempt to protect the artery from vulnerable plaque by covering it with a hard, calcified layer. However, bypass surgery and balloon angioplasty do not slow down the process of soft or hard plaque formation; they often accelerate them.

An early research study in 1986 by Dr. Greg Brown of the University of Washington at Seattle demonstrated that sudden blockages causing heart attacks were occurring in locations of coronary arteries that had very little plaque, not nearly enough to qualify for bypass or angioplasty surgery. In the late 1980s, Dr. Steven Nissen of the Cleveland Clinic began to examine the coronary arteries of heart patients with an innovative ultrasound camera that he guided into the blood vessels. He found many soft bulges of plaque, often numbering into the hundreds in a single patient, but relatively few areas of calcified plaque. He proposed the idea that it was these widely distributed soft bulges of plaque, not the deposits of hard plaque, that were the primary culprit behind heart attacks. Brown's and Nissen's research, as well as similar studies, were slow to be accepted. Recently, Dr. Nissen has emerged as a leading innovator in fostering new therapies for heart disease, playing a leading role in several new drugs. Dr. Nissen also conducted an important study that indicates that lowering LDL cholesterol to levels significantly below the standard recommendations reduces risk.

The pivotal study that began to rapidly change minds on the importance of vulnerable plaque was conducted in 1999 by Dr. David D. Waters of the University of California. In the study, which was called AVERT (atorvastatin versus revascularization treatments), Dr. Waters randomly assigned patients who had been referred for angioplasty surgery to two groups. One received the surgery and standard follow-up care. The other received cholesterol- lowering statin drugs but no surgery. The non-surgery group actually had fewer heart attacks and fewer visits to the hospital for chest pain than the surgery group. Dr. Waters commented that the research "caused an uproar. We were saying that atherosclerosis is a systemic disease. It occurs throughout all the coronary arteries. If you fix one segment, a year later it will be another segment that pops and gives you a heart attack, so systemic therapy, with statins or antiplatelet drugs, has the potential to do a lot more. There is a tradition in cardiology that doesn't want to hear that. There is a culture that the narrowings are the problem and that if you fix them, the patient does better."

Dr. Eric Topol, a cardiologist at the Cleveland Clinic in Ohio, adds, "There is just this embedded belief that fixing an artery is a good thing." Dr. Topol describes the typical situation in which a patient has symptoms such as vague discomfort in the chest, goes to a cardiologist, gets a heart scan that shows signs of calcified plaque, has an angiogram - itself an invasive procedure - and then quickly receives a recommendation for surgery. "It's this train where you can't get off at any station along the way," Dr. Topol says. "Once you get on the train, you're getting the stents. Once you get in the catherization lab, it's pretty likely that something will get done."

Dr. David Hillis, a cardiologist at the University of Texas Southwestern Medical Center in Dallas, explains some of the motivation. "If you're an invasive cardiologist and Joe Smith, the local internist, is sending you patients, and if you tell them they don't need the procedure, pretty soon Joe Smith doesn't send patients anymore. Sometimes you can talk yourself into doing it, even though in your heart of hearts you don't think it's right." Explaining the patients' perspective, Dr. Hillis adds, "I think they have talked to someone along the line who convinced them that this procedure will save their life. They are told, 'If you don't have it done, you are a walking time bomb.'"

The makers of stents acknowledge that the research fails to show a benefit in terms of avoiding heart attacks and death. Paul LaBiolette, senior vice president of Boston Scientific, a leading stent maker, says, "It's really not about preventing heart attacks per se; the obvious purpose of the procedure is palliation and symptom relief."

However, angina pain can be managed without surgery in most cases, often very quickly. "The results are now snowballing," says Dr. Peter Libby of Harvard Medical School. "The disease is more stable than we had thought."

This new perspective explains why bypass and angioplasty surgeries don't work, and it helps explain why heart attacks typically strike with no warning and often to people who appear to be "perfectly healthy," according to conventional diagnostic methods. Armed with this more accurate model, we can apply noninvasive methods to address each stage of this progressive and degenerative process. By combining targeted therapeutic approaches, we can rapidly and dramatically reduce the risk of a heart attack to very low levels. With few exceptions, no one need suffer a heart attack.

With the recent recognition that inflammation plays a crucial role in every step of plaque formation, as well as in the final eruption of vulnerable plaque that initiates a heart attack, another major front in the war against heart disease has emerged. Following are some important tips for combating inflammation.

Inflammation — The Latest "Smoking Gun"

Testing

• Get a fasting hs-CRP

• If at high risk of heart disease, Alzheimer's, or cancer (because of family history or lifestyle), consider genomic testing for inflammatory markers and essential fatty acid testing

Treatment

• Decrease insulin sensitivity and excess silent inflammation by eating a lower-glycemic-load diet

• Avoid excessive amounts of foods rich in inflammatory arachadonic acid (egg yolks, shellfish, red meat)

• Increase dietary anti-inflammatory foods and spices, such as cold water fish, green tea, onion, garlic, turmeric, ginger, rosemary

• Decrease exposure to sources of inflammation (dietary, infectious)

• Practice good dental hygiene

• Employ EFA supplementation with EPA/DHA and GLA

• Patients at high risk for cardiovascular or Alzheimer's disease should consider low dose aspirin therapy (81 mg/ day).

 

About the Author

Ray Kurzweil is one of the world's leading inventors, thinkers, and futurists. Called "the restless genius" by the Wall Street Journal and "the ultimate thinking machine" by Forbes magazine. Kurzweil's ideas on the future have been touted by his many fans, who range from Bill Gates to Bill Clinton. Time magazine writes, "Kurzweil's eclectic career and propensity of combining science with practical - often humanitarian - applications have inspired comparisons with Thomas Edison." A recipient of the National Medal of Technology and an inductee in the National Inventors Hall of Fame, among many other honors, he is the author of three previous books: The Age of Spiritual Machines, The 10% Solution for a Healthy Life, and The Age of Intelligent Machines.

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Terry Grossman, M.D., is the founder and medical director of Frontier Medical Institute in Denver, Colorado, a leading longevity clinic. certified in anti-aging medicine, he lectures internationally on longevity and anti-aging strategies. In the words of Arline Brecher, coauthor of Forty Something Forever, "I've met good writers and good doctors, but seldom are they one and the same. Dr. Terry Grossman breaks the mold and sets a new standard for physicians." He is the author of The Baby Boomer's Guide to Living Forever.