Step 4. Do I Need a Heart Catheterization (angiogram)?
There are differences of practice If your CACS returns at a very high score (e.g. >1000) even if you have no symptoms. Some cardiologists recommend an invasive cardiac catheterization as described in a recent media article. I have performed cardiac catheterization on dozens of people with scores over 1,000 (one as high as 6,000) and often found only mild plaque or one totally blocked artery that was treated with medication and lifestyle. Rarely, the blockages found in an asymptomatic person is so advanced, often coupled with a markedly abnormal stress test, that a discussion about a coronary stent or even coronary artery bypass grafting is appropriate. Overall, this is rare. In my clinic practice, I usually first recommend a stress test rather than a cardiac catheterization in patients without any symptoms or other high-risk features. An individualized approach is recommended when you discuss this with your cardiologist.
Step 5. Do I Need Lifelong Medication?
One of the strongest arguments to have a CACS is that if you have a zero score and have no symptoms, there is growing agreement that there is not need for a daily aspirin or a statin cholesterol lowering medication. Lifestyle discussed below emphasizing a healthy diet is always a recommendation. A statement by a joint group of the American Heart Association and the American College of Cardiology in late 2018 incorporated the concept that a CACS before starting a statin prescription was acceptable and avoiding medication after a Zero CACS was often preferable. The same is true for daily aspiring.
If the CACS is over 100, there are recommendations that incorporate routine low dose aspirin (81 mg) and statin medication daily. An example of the “standard” approach to an abnormal CACS is outlined in a recent medical article. A study recently published looked at a database of 13, 644 patients studied for heart artery disease by a coronary calcium CT scan and followed for over 9 years. The group was also analyzed as to whether they were on a statin medication to lower their cholesterol. When the CACS calculated as abnormal at 100-400, or over 400, treatment with a statin was associated with a lower risk of bad outcomes. In fact, when the calcium score was over 100, only 12 patients needed to receive a statin to prevent one event like a heart attack, stroke, or death.
Step 6. What Can I do to Reverse Atherosclerosis?
In my clinic, a major emphasis after an abnormal CACS is education on the research indicating that CAD can be halted and reversed, even if it requires significant lifestyle changes.
The ability to halt and reverse heart plaque was shown in 1990 with lifestyle changes by Dean Ornish, M.D. He prescribed a plant-based diet without added fats to patients with proven heart blockages. He also recommended walking, social support and stress management including yoga and meditation to help their hearts. He demonstrated that the patients who adhered to his “lifestyle program” felt better and showed reductions in the amount of narrowing in their arteries. Dr. Ornish followed his patients for longer periods of time and with further testing and showed even more improvements, avoidance of hospitalizations, and reduced costs. Since those first reports, the data that heart disease can be reversed by intensive lifestyle changes emphasizing a plant-based diet low in added fats has become so robust that the Ornish Lifestyle program was recognized by Medicare in 2010 for reimbursement as a therapy of CAD. Another similar program, based out of the Pritikin Longevity Center in southern Florida, received the same Medicare designation for intensive therapy and reversal of heart disease with dietary therapy. A similar research program at the Cleveland Clinic Foundation led by Dr. Caldwell Esselstyn monitoring patients with advanced heart disease who converted to totally plant based diets without added oils identified the same types of clinical improvements with documents shrinking and reversal of heart blockages.
Because the only diet pattern that has been demonstrated in peer-reviewed research to reverse atherosclerosis in humans is the whole food plant diet, all patients at the Kahn Center view the documentary Forks Over Knives as homework. They also read books by Drs. Ornish and Esselstyn. There is a support group in Detroit teaching plant-based disease prevention and reversal that they are encouraged to join and attend regularly.
Although all whole plant foods may contribute to heart disease reversal, special mention is earned by a few. The ability of garlic to lower blood pressure, cholesterol, and blood clotting has been recognized for some time. There have actually been a surprising number of studies testing the ability of aged garlic extract to halt heart disease progression. For example, in a study published in early 2016 that that used baseline and follow-up CCTA, aged garlic or placebo was administered. The group receiving aged garlic extract demonstrated reduced areas of plaque in heart arteries at the one-year follow-up. In addition to the sulfur content of garlic, onions also provide a source of sulfur in the diet that may be crucial for maintaining optimal amounts of antioxidants.
Pomegranate juice and seeds both have powerful antioxidant properties that may improve the function of HDL cholesterol. This protective cholesterol may boost the reverse cholesterol transport, or “vacuum cleaner” function in arteries, that may reverse CAD. In studies of mice, pomegranates can reduce atherosclerosis although translating animal research to human health can be misleading. In humans with increased stress at risk for CAD, pomegranates can reduce evidence of arterial damage. In another study using pomegranate juice for three years, the degree of narrowing in carotid arteries of five study subjects was reduced.
Beyond diet, there may be other methods supported by scientific studies to reverse atherosclerosis. Over 60 years ago some data surfaced that chelation therapy (Latin for claw) using disodium ethylene diamine tetra acetic acid or EDTA could reverse heart artery disease. It took many decades but the Trial to Assess Chelation Therapy (TACT) was published in 2013 and demonstrated an improvement in outcomes in post-myocardial infarction (MI) patients following IV EDTA versus a placebo. The TACT showed a particularly large reduction in CVD events and all-cause mortality in the subgroup of patients with diabetes. An ongoing TACT2, limited to patients with heart disease and diabetic mellitus type 2, is further examining this unique therapy in the hope that it may enter the armamentarium to reduce the atherosclerotic risk of their diabetic patients. There is an oral agent called Nanobac TX that has reported reversal of calcification in human research subjects and it is used in the Kahn Center.
Other promising therapies for the reversal of atherosclerosis using nutraceutical therapies have appeared. In a recently published randomized study from China, 76 patients with carotid atherosclerosis were treated with either nattokinase (NK) 6,000 FU or simvastatin 20 mg (). In both groups, cholesterol fell, and in the NK group HDL-cholesterol rose. Reversal of atherosclerosis over 26 weeks was profound with NK and plaque volume fell by 37%.
Another natural plant agent, citrus bergamot, was studied in patients with atherosclerosis over 6 months without randomization. Lipid fractions improved as anticipated during therapy with bergamot and there was a stunning decrease in the carotid plaque (CIMT) falling from 1.2 cm to 0.9 cm.
A promising combination therapy has been reported to promote the reversal of carotid atherosclerosis. The study combined pycnogenol with centella asiatica and followed 391 patients with ultrasound measurements of plaque for over 4 years in a randomized trial. The progression of plaque over time was least in the patients treated with the combination nutraceutical and there was reduction in the number of angina episodes and myocardial infarctions in the treated cohort.
Finally, vitamin K2 can be difficult to obtain from a heart disease reversal diet unless soy derived natto is consumed. A study of over 4,800 residents of Rotterdam demonstrated that higher intake of vitamin K2 was associated with less arterial calcification and fewer CAD events. Higher intake of vitamin K2 favors calcium deposition in bones and teeth rather than arteries. At the Kahn Center, a supplement of vitamin K2 is a routine measure in persons with an elevated CACS.
Step 7. What Follow-Up do I Need?
As above, it is a consideration to repeat a CACS 5-10 years later if the initial scan was a ZERO. I have mine done every 10 years as my risk is ultra-low. If the CACS is abnormal, particularly if it is high, new symptoms that might be cardiac should be reported to a health care provider or ER ASAP. If there are no new symptoms. a treadmill stress test can be done every 2-3 years if insurances will approve. Labs can be repeated. A long-term commitment to lifestyle change, absence from smoking, fitness, good sleep, and stress management is key. Continuing on medications and natural therapies without interruption is to be encouraged.
Hopefully you will arrange a CACS and get the call or message that you joined the ZERO club, one I am in and that has an excellent prognosis for health. However, if you score is not zero, whether it is 6 or 600, there is a plan that I have used over and over at the Kahn Center successful that is outline in part here. Altering you diet in the manner that research studies show can halt, and reverse CAD may be the most important therapy of all. Wishing you a long and healthy life from the Kahn Center for Cardiac Longevity.