Here's Who's Most at Risk for the 'New' Type of Heart Disease Researchers Have Just Identified
Can You Reverse Coronary Artery Disease?
If you have coronary artery disease (CAD), it means the arteries that supply blood to your heart muscle have plaque in their walls that may cause blockages. Getting those arteries to widen and become flexible again might seem daunting, but you're far from powerless.
You can absolutely prevent CAD from worsening, and with some hard work, you might even be able to reverse some of the damage, says Gregg Fonarow, MD. He's the co-director of the UCLA Preventative Cardiology Program at the David Geffen School of Medicine and a spokesperson for the American Heart Association.
CAD is the most common type of heart disease and the leading killer in the U.S. Of both men and women. By taking action, you can reduce the chances of having a heart attack, which may happen if the plaque that's lining your arteries blocks blood flow to the heart.
To protect yourself, you'll need to stay on top of your diet and exercise and take your medications every day, says Fonarow. If your goal is to actually reverse CAD, those medications will likely include high-dose statins.
Most people with CAD benefit from taking statins, drugs that lower levels of LDL "bad" cholesterol in your blood. Your doctor will likely recommend a specific statin and dosage based on your current LDL level and how much improvement is needed.
A "low-intensity" statin is designed to lower LDL by 30%. A "high-intensity" one should lower it by 50% or more.
There is very good evidence that high-intensity statins, also called high-dose statins, can reverse CAD, says Steven Nissen, MD, chair of cardiovascular medicine at the Cleveland Clinic. Nissen's 2006 study, called the ASTEROID trial, found that patients who took a very strong statin daily for 2 years were able to reverse plaque buildup and thickening of their arteries.
"They had to get their LDL down to very low levels for us to see these results, around 60 mg/dL," or 60 milligrams per deciliter of blood, Nissen says. (Normal LDL cholesterol is usually defined as anything lower than 100 mg/dL.)
Since then, other studies have shown similar results. "We know now that if your LDL cholesterol is lowered below 70 mg/dL, you can see a regression in the plaque by up to 24%," he says.
High-intensity statins aren't for everyone. About 3% of the time, people report side effects like headache and muscle soreness. Statins, especially when taken at high doses, have also been linked to a higher risk of type 2 diabetes.
Some people who want to stick with high-intensity statins but have muscle soreness find that this symptom relents if they switch to a different high-intensity statin or if they add a coenzyme Q10 supplement, Nissen says.
If you still can't tolerate high-dose statins, you might be able to reverse CAD by taking a lower-intensity statin along with a different type of cholesterol medication called a PCSK9 inhibitor. You get these medications as a shot every 2-4 weeks. Nissen and colleagues found that this combination caused plaque to decline in almost two-thirds of all patients. Those findings appeared in The Journal of the American Medical Association in 2016.
Even more drug options may be coming up. A medication called inclisiran, now in clinical trials, lowers cholesterol by preventing production of PCSK9 in the liver.
"It's been shown to significantly lower LDL levels, and with it, some of the plaque associated with coronary artery disease," Fonarow says. "It also may be easier for patients to stick to, because it's just a twice-a-year shot, unlike statins, which you have to take every day."
Lifestyle changes alone likely aren't enough when you have coronary artery disease, but there's no doubt that they're a powerful addition to medication, Foranow says.
The American Heart Association recommends a diet that's rich in:
You should also limit saturated fat, sodium, red meat, and sweets.
A nutrition plan created by Dean Ornish, MD, has been shown in small studies to lower cholesterol and reverse CAD. Ornish's diet requires you to follow a mainly plant-based eating plan that focuses on whole grains, fruits, vegetables, legumes, and soy products, with the option of nonfat dairy and egg whites. The plan is very low in fat, limiting fat to about 10% of your total calories. That can be very hard to stick to, Fonarow says. "We want to encourage people to make dietary changes that they'll be able to stick with long-term," he says.
Other parts of a healthy lifestyle won't necessarily reverse coronary artery disease but may prevent it from getting worse. These include:
"Taken together, all these steps can help lower your risk of having a heart attack or stroke," Nissen says. "Our goal is to keep you alive and healthy," even if your coronary artery disease doesn't fully reverse.
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Dr. Roach: High Blood Calcium Might Not Correlate With Coronary Disease
Dr. Roach: I am a 62-year-old white male who is 5 feet, 11 inches tall and weighs 205 pounds. I have diabetes, high blood pressure and high cholesterol. I was recently diagnosed with "moderate to significant coronary disease" by a CT coronary calcium scan. This was based on a finding of "severe calcification in the coronaries," as per the radiologist's cardiac scoring report.
Separately, for the past 20 years at least, my blood tests have shown a high level of calcium in my blood. I understand that the normal range for blood calcium is 8.5-10.3 mg/dL. However, my calcium level has been at 12-13 mg/dL in every test for the past 20 years.
My question is: How much, if any, do my high blood calcium levels contribute to my coronary disease? — J.L.J.
Answer: You very likely have a condition called primary hyperparathyroidism (PHPT), as it is, by far, the most common cause of high blood calcium in healthy people. I am quite surprised, though, that the diagnosis wasn't made and you weren't recommended for surgery, since a blood calcium level of more than 1 mg/dL above the upper range of normal is an indication for surgery. Your calcium level is more than 2 mg/dL above this amount.
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A parathyroid hormone (PTH) level and an ionized calcium level are likely to confirm the diagnosis, and you should have these done if you haven't already. PHPT is sometimes treated surgically or with medication.
Coronary artery disease are blockages in the blood vessels that supply blood to the heart. Although a high calcium score makes obstructive coronary artery disease more likely, it is possible to have calcium in the blood vessels without blockages in the coronary arteries.
Being a man of 62 with diabetes, high blood pressure and high cholesterol already puts you at a significant risk, even without the additional risk from having a high calcium level. It's impossible to say which one of these risk factors was most important in your case.
It is true that high calcium in the blood leads to higher coronary calcium scores, but recent studies have shown that surgical treatment of the parathyroid gland tumors that cause PHPT do not reduce the risk of heart disease. So, it shouldn't be part of your decision to treat PHPT with surgery.
Dr. Roach: Over 40 years ago, I was diagnosed with sciatica. Along the way, I had a chiropractor who advised me to hug my knees as tight as I can each time before getting out of bed. She said that most doctors won't tell you this because they want you to come back. I have had various problems, but I feel that this has helped me. — J.B.
Answer: Hugging knees is a good way to stretch the hamstring muscles. Tight hamstrings can absolutely contribute to back pain, abnormal posture, and even compression of the sciatic nerve, so this is good advice. Warming up the muscles first with walking might make the stretching safer and more effective.
I don't agree with the gratuitous fling about physicians. Chiropractors and physicians have different approaches, but we are all trying to help our patients. Deliberately withholding effective treatments would be unethical.
Readers may email questions to ToYourGoodHealth@med.Cornell.Edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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