TIME: Almanac 1993/TIME Almanac 1993.iso/time/102990/1029350.000

Text File | 1992-08-28 | 10.8 KB | 232 lines

                                                                                MEDICINE, Page 87

Beating Back a Ruthless Killer


Blocked arteries can be unclogged without surgery, according to
studies by leading researchers, and that could transform the
way doctors treat heart disease

By LEON JAROFF -- Reported by Christine Gorman/Boston and Jeanne
McDowell/San Francisco


    They begin to form when he is still an adolescent, smooth
fatty streaks on the interior wall of a major coronary artery
-- the ominous consequence of a typically American
high-cholesterol, high-fat diet. By his 20s, the streaks have
formed plaques, growths with a fatty center covered by a
fibrous cap of smooth muscle cells. By his 40s, the plaque, its
buildup accelerated by smoking and high blood pressure, has
protruded well into the bloodstream, closing 65% of the arterial
passage. The blood swirls and eddies dangerously as it forces
its way past the swelling obstructions.

    He now has a well-developed case of heart disease.
Eventually the narrowing arterial passage could be blocked by
a blood clot or by a spasm that constricts and closes the
artery. That could cut off the blood supply to his heart,
causing possibly fatal damage to its muscle. In short, he is
a prime candidate for heart attack, which annually strikes 1.5
million Americans, killing half a million of them. (Women as
well as men are vulnerable to heart disease, though usually
later in life.)

    But in this case some of the plaques start to shrink, almost
imperceptibly at first, as the fatty material in its core
migrates back into the bloodstream. Blood begins flowing more
smoothly through the rejuvenated artery, and two years later,
only 50% of the passage is blocked. The seemingly inexorable
advance of cardiovascular disease has been reversed, and as the
plaque continues to shrink, the risk of a heart attack has
largely passed.


    Only a few years ago, this happy ending would have been
considered unlikely, if not impossible. While the progression
of heart disease could be slowed and perhaps even halted by
diet and drugs, surgery was apparently the only way to reverse
-- albeit temporarily -- the damage from heart disease and
restore a healthy blood flow. Now, for many cardiac patients,
there may be a safer and much less expensive way.

    In separate controlled studies, Dr. David Blankenhorn of the
University of Southern California and Dr. Greg Brown at the
University of Washington have shown that the buildup of
arterial plaque can be reversed by a combination of drugs and
a low-fat diet. A third study, by Dr. Dean Ornish of the
University of California at San Francisco, has generated even
more remarkable results. In his book, Dr. Dean Ornish's Program
for Reversing Heart Disease, published by Random House this
month, Ornish describes how changes in life-style alone, like
reducing stress as well as fat, can effectively reverse heart
disease.

    Results of the experiments far exceeded expectations. Brown,
for example, designed his study only to determine if the
progress of heart disease could be halted. "The biggest
surprise," he says, "was that the arteries actually got better.
I thought that they probably wouldn't get worse, but I was a
disbeliever about possible regression of the disease." Now
Brown and an increasing number of cardiologists have been
converted. And for many cardiac patients, that could drastically
change the way atherosclerosis is treated.

    In the U.S. alone, surgeons annually perform 330,000
coronary bypass operations. An additional 190,000 cardiac
patients every year undergo angioplasty, which usually involves
the use of a balloon-tipped catheter to widen their arterial
passages. Both operations provide immediate, dramatic relief
for the cardiac patient. But there are some risks: in rare
cases, either technique can trigger a heart attack. Then, too,
relief is only temporary. Five years or so after bypass surgery,
on average, plaque has built up in the grafted veins. And
arteries opened by angioplasty sometimes become partly blocked
again within three to six months. Finally, the price tags are
staggering: about $7,500 for angioplasty, between $30,000 and
$40,000 for bypass surgery.  All told, some $11 billion is spent
in the U.S. each year on surgery for coronary heart disease.

    In many cases, bypass surgery or angioplasty will remain the
strategy of choice. There are those with advanced heart
disease, says Blankenhorn, "who clearly can't wait. If they try
therapy alone when they really need surgery, they can have a
disastrous outcome -- a catastrophic heart attack." But others,
with less serious cases, may be able to avoid surgery -- if
they are willing to make radical changes in their diet and
life-style.

    While trials beginning in the 1950s had shown that drugs and
diet could reverse atherosclerosis in laboratory animals,
Blankenhorn's groundbreaking work, begun in 1980, was the first
controlled study demonstrating that the same results could be
produced in humans. His subjects were 188 nonsmoking males who
had undergone bypass surgery. (Most heart-disease research has
been done on men rather than women.) Blankenhorn placed half
of them on a diet containing 22% fat and gave them colestipol
and large doses of niacin, both standard cholesterol-reducing
drugs. The other recruits, the control group, merely limited
the fat content of their diet.

    All the men in the drug-taking group realized what
Blankenhorn terms a "spectacular reduction" in their total
cholesterol, and 16% of them showed decreases in their arterial
plaque. "As long as you don't batter arteries with cigarettes
and high cholesterol," he concluded, "they have a remarkable
healing ability."

    Brown's study, begun in 1984 and reported at an American
Heart Association meeting last year, involved 146 men with high
cholesterol levels and a family history of heart disease. Brown
divided his subjects into three groups, one taking niacin and
colestipol, the second receiving colestipol and another
cholesterol reducer, lovastatin. The third or control group got
only a pair of placebos. All the men were placed on a diet that
limited fats to 30% of total calories, the level recommended by
the A.H.A. Here, too, after 2 1/2 years, those taking the drugs
experienced large drops in their total cholesterol level, and
35% showed a decrease in arterial plaque.

    While these results convinced both Blankenhorn and Brown
that reduced cholesterol was the major contributor to the
reversal, Ornish has his doubts. "If lowering cholesterol were
the primary factor in causing reversal of heart disease," he
notes in his book, "most of the patients in the studies by Dr.
Blankenhorn and Dr. Brown who were taking cholesterol-lowering
drugs should have shown reversal, since almost all of these
patients had substantial decreases in blood-cholesterol levels.
Yet only a minority showed reversal."

    Why? Ornish believes these studies, unlike his, did not deal
with other factors that he believes contribute greatly to
cardiovascular disease: stress and an individual's "sense of
isolation." His trial was small, involving only 41 San
Francisco Bay area men with heart disease. The 19 participants
in his control group were to follow their doctors'
recommendations; for the 22 others in the experimental group,
however, he ordered a strict, exacting regimen.

    They kept to a vegetarian diet that contained less than 10%
fat and banned all oils. At twice-weekly meetings, a
psychologist held group support sessions. Everyone was taught
stress-management techniques, including yoga, and was told to
spend an hour a day meditating, visualizing arteries
unclogging, and doing relaxation and breathing drills. Smoking
was prohibited and moderate exercise recommended.

    After just one year of the study, blockages in the arteries
of two-thirds of the control group had worsened. But 18 of the
22 in Ornish's experimental group had an increase in blood flow
to the heart and a regression of blockages, on average, from
61.1% to 55.8%.

    Could the "togetherness" and reduction of stress account for
at least part of that remarkable reversal? Some experts think
so. They point to studies that associate a sense of isolation
with increased risk of many illnesses, including heart disease.
And at the New England Deaconess Hospital in Boston, Harvard
cardiologist Herbert Benson is studying the biochemical effects
of stress on the body.

    Stress, Benson explains, brings on a rise in blood pressure
and spurs the release of catecholamines, substances that
increase the tendency of blood to clot and make arteries more
vulnerable to spasm. Over time, these changes play an important
role, many doctors believe, in the progression of heart
disease. However, Benson has shown, the changes can be largely
counteracted by the "relaxation response" that follows 15
minutes of meditation a day.

    Still, most researchers continue to believe that lowering
cholesterol levels is the master key to reversing heart
disease. Dr. William Castelli, director of the famed Framingham
Study, which since 1948 has monitored the coronary health of
5,000 people in the Massachusetts town, offers this
prescription for regression: reduce the level of total
cholesterol below 150 mg per deciliter of blood and the level
of LDL, the bad form of cholesterol that clogs arteries, below
90. In addition, says Castelli, the ratio of total cholesterol
to HDL, the good cholesterol that helps clear arteries, should
be less than 3.5.

    Clearly, preventing heart disease is better than trying to
reverse it once the process starts. Experts differ on the best
mix of prevention strategies, but they agree on one thing:
Americans should cut down on the fat in their diet. Otherwise,
they could be eating themselves into an early grave.


____________________________________________________________
BEATING BACK A RUTHLESS KILLER


    DIET

    While Dr. Ornish's experimental group feasts on
chef-prepared, low-fat, low-cholesterol meals, most people will
benefit merely by eating less meat and dairy products and more
seafood, fruits and vegetables.

    DRUGS

    For those who cannot effectively lower cholesterol by diet
alone, these drugs could help; however, they can cause side
effects and may cost as much as $2,000 a year.

    EXERCISE

    By working out at a Manhattan corporate fitness center,
employees can lose weight and increase HDL, their good
cholesterol. But for cardiac patients, gentler exercise is
prescribed.

    STRESS REDUCTION

    To alleviate stress, a cardiac patient at Boston's New
England Deaconess Hospital practices meditation. Stress can
lead to high blood pressure and other changes damaging to the
arteries.