He was a senior leader of a major American corporation, and he looked the part. He was slender, well-groomed, and articulate. I was seeing him for the first time. His reason for the visit was chest pain. He had had two episodes and the most recent was 48 hours before the visit. He said the pains just came “out of the blue,” He was not anxious, upset, or exercising when the pain started. The pain lasted about ten minutes. He said it was about an eight on a scale of one to ten. He had never had anything like it before. It was in the center of his chest and involved his lower jaw. It had an oppressive, pressing quality. It alarmed him, and with good cause. Once the pain went away, he was fine.
I told him that I was really worried about him. “You probably have unstable angina. That means you have cholesterol deposits in your heart arteries that have eroded or broken open, and that caused a clot to form and block a heart artery. You are taking aspirin and that along with your natural clot busting capability dissolved the clot enough that your pain went away. Here are some prescriptions to fill as soon as you can. They will stabilize your cholesterol deposits so you don’t form a clot.You need to see a cardiologist immediately.” If he had had the pain two hours ago, I would have admitted him. But he didn’t. It was two days ago. I called the cardiologist. He saw the patient that day and did a nuclear stress test which was fine. He released the patient.
I got a call the next day. The patient had dropped dead at a meeting in the corporate headquarters. Fortunately, there was a wall-mounted cardiac defibrillator in the office and his co-workers successfully shocked his heart and restarted it. He made it to the ICU, and recovered completely. I saw him within 48 hours after his discharge. He performed very well with his optimal medical therapy and had no more trouble over the five years that I saw him. In restrospect his problem was indeed unstable angina. His clot was forming and breaking up repeatedly. If I faced another patient like this I would add the anticoagulant Plavix to further inhibit clotting for about a month. It takes about two weeks for optimal medical therapy (OMT) to stabilize plaque so that it doe not rupture or erode and cause a clot.
This patient is a great example of how our cardiology system is broken. Just broken. He had a stress test that was entirely normal. One day later he was dead of a heart attack. He had no chronic blockage that would have merited a stent. In fact, only 14% of heart attack victims have a blockage of 70% or greater that would warrant a stent before the heart attack. The article that proved that fact was written by my heroes and published in 1995 in Circulation. It was based on 4 articles, two of which go back to 1988. That is 34 years ago. Medical professional know or should have known that chronic blockages are involved in only 14% of heart attacks since then. That same year, Peter Libby wrote an article in the same journal that said this:
“The above discussion has summarized elements of a new understanding of the pathophysiology of the acute coronary syndromes based on episodes of plaque disruption rather than gradual progression to complete occlusion of fixed coronary stenoses. As noted above, bypass surgery or transluminal angioplasty provide rational and often effective therapies for these fixed, high-grade stenoses. However, these treatments do not address the nonstenotic but vulnerableplaque. It is of interest in this regard that despite the well-accepted benefit of coronary bypass surgery on anginal symptoms, this treatment aimed at severe stenoses does not prevent myocardial infarction. To reduce the risk of acute myocardial infarction, one must stabilize lesions to prevent their disruption, particularly the less stenotic plaques.”
Short version. Almost all blockages that cause heart attack are cause by acute clots in arteries that are not blocked enough to require a stent. Based on this science, stents do not prevent heart attack in stable patients. Period. Optimal medical therapy (OMT) stabilizes plaque so that it does not rupture. That prevents heart attack and sudden death. Beginning in 1995, I copied that quote. I handed it out to every patient. I interpreted it for them, and I told them Dr. Libby at Harvard “wrote the book on hardening of the arteries.”
At this same time, other heroes designed controlled, clinical trials to prove this science mattered. By 2008, the proof was available. The COURAGE trial proved that a stent added to optimal medical therapy alone did nothing to prevent cardiac death or heart attack. Since then there have been 14 other confirmatory trails. The most recent and convincing was the ISCHEMIA trial that proved the same thing. There was no difference even for patients who had severe disease on their stress test. Other heroes showed the same thing in high risk diabetics. Patients who received OMT had one fourth as many heart attacks as patients in usual care. They lived eight years longer. Hospitalizations for heart failure were reduced by 70% during twenty years of follow-up.
This entire site is about this topic. There is a mountain of evidence that proves our cardiology system is utterly broken. For thirty-four years this science has been available. It has been completely ignored. Patients with chest pain get stress tests and stents. They do not get optimal medical treatment. Our approach to other chronic diseases is almost as bad. The National Academy of Medicine laid out a blueprint to address the problem of chronic diseases 21 years ago. They called for extensive reengineering of our system for chronic disease. They described the 17-year gap between new science and adoption in practice. Even after 17 years adoption is highly variable. Nothing has been done. Nothing. We should probably stop talking about “patient-centered care” in cardiology until we do much more to address patients with chronic conditions more effectively.
I am working with 100 people across the country to fix this. Please. Won’t you help? If you “get it.” Please contact me at wbestermann@congruityhealth.com
In my case OMT and stents are the answer. Don't discount the viability and need for stents. I am alive by way of them and OMT. I have familial hypercholesterolemia. The idea of OMT is great , however in my case it requires Repatha (evolocumab) at a cost of about $1500 per month and insurance does not cover this med. I am also on other meds due to atherosclerosis. I am only 60 years old.
Amazing info!