FREQUENTLY ASKED QUESTIONS

What is noninvasive testing?

What is medical treatment of coronary artery disease?

What are the results of such medical treatment?

Is it necessary to do an angiogram in someone with no symptoms but an abnormal stress test, or are there other tests that will provide the same information?

My cardiologist told me that because I had three blocked coronary arteries on an angiogram I need immediate bypass surgery and there is no other way to treat me. I have no symptoms and feel fine. Is this true?

Why, then, would a cardiologist make such a recommendation?

How can my coronary arteries be obstructed and yet I have no symptoms?

Are there any studies that compare angioplasty, bypass surgery and other treatments such as chelation therapy with modern medical treatment with drugs?

Can coronary artery disease be cured or reversed?

Is chelation therapy effective?

I recently had an abnormal stress test. Because I have no symptoms I refused angiograms. Now my cardiologist says medication will not help, and that I can wait until I have symptoms. Is this true?

Question: What is noninvasive testing?

Answer: Noninvasive testing at the Noninvasive Heart Center involves placing electronic sensors, pulse transducers, sonar devices, and microphones on the chest. No catheters, tubes or needles enter or "invade" the body. These tests image and permanently record abnormalities of motion and function of the heart due to obstructive coronary artery disease. Also, information about the heart's valves, the dimensions of its chambers and the flow of blood within the heart is imaged live. These tests are extremely sensitive in the early detection of heart disease, and provide information about both systolic and diastolic heart function,. The information derived allows not only early discovery of disease, or its progression before symptoms appear, but identifies patients with a high risk of future heart attacks. It also makes possible the early detection of complications, provides a more precise determination of cardiac function and disability, and determines effectiveness and optimal dosages of drugs used in treatment. Once heart disease Is found, then predisposing conditions that accelerate its progression can be identified, treated, and eliminated. Drugs which protect the heart and improve its blood supply and function can then be given. The same noninvasive tests used for early diagnosis may be utilized to monitor the patient's progress. These can be compared with previous tests in order to optimize treatment, and to detect and treat adverse changes even before symptoms appear. Noninvasive tests avoid the need for angiograms. Angiograms tell us about the coronary arteries, but not very much about the heart's function. In contrast, noninvasive tests picture the heart's anatomy, its function, and the blood flow through its muscle and its chambers. Since prognosis and survival are related more to the heart's function than to coronary narrowing, such data is vital in deciding if a patient can be treated with drugs or surgery. Bypass surgery and angioplasty are rarely needed. Modern drug therapy combined with serial, noninvasive testing has revolutionized the treatment of coronary artery disease. Such drugs are so effective that an approaching heart attack often may be prevented entirely. Also, other late complications such as heart failure usually can be avoided. Thus, heart disease often becomes a relatively benign illness with few or no symptoms and a normal life span.

Question: What is medical treatment of coronary artery disease?

Answer: When there is a reduction in blood flow to heart muscle due to narrowed coronary arteries, it is like a reduction in income to a business. When that happens the business has two options: one is to find another source of income, and the second is to reduce expenses to free up more money. In the case of the heart, there are drugs that can increase the blood flow to the heart muscle, and there are other drugs to reduce the expenses or work load of the heart. When properly done, the “income” of the heart can be made to balance the “expenses” of the heart. Now such a heart will not have symptoms, the progression of the disease is greatly reduced, if not stopped altogether, and the likelihood of such complications as a heart attack, congestive heart failure, or premature death is vastly reduced. Further information on what drugs are used can be found elsewhere in this Web site.

Question: What are the results of such medical treatment?

Answer: As far as results are concerned, for my own patients with primarily coronary artery disease and/or high blood pressure, 98-99% of patients can be effectively treated with an adequate individualized, medical program. Procedures such as angioplasty or bypass surgery are almost never required. Not only does this result in a saving of thousands of dollars, but it avoids the very common post angioplasty, post bypass surgery complications that occur in up to one-third of the patients who have these procedures. It also avoids the high incidence of post operative heart attacks and premature deaths that are seen in these patients. For example, the combined death and heart attack rate in patients following angioplasty/bypass surgery is about 7-8%/year vs. 1% on a tailored medical program. Thus, in a five year period 35-40% of patients undergoing angioplasty or bypass surgery can be expected to have a major cardiovascular event. In contrast, in the patients I have been following for the past 15 years, the five year cardiovascular event rate has averaged only about 5% (1% / year). During that time, in a practice limited to Cardiology, only 10 of my patients have had to undergo angioplasty or coronary artery bypass surgery. I have never lost a patient because he or she has NOT undergone bypass surgery or angioplasty. Nor have any of them had a heart attack from NOT undergoing one of these procedures. An exception would be patients with severely damaged heart valves. Such patients eventually do require surgery; however, effective medical treatment can often delay the need for such surgery.

Question: I recently underwent a stress test. Even though I have no symptoms, it was abnormal, and my primary care physician referred me to a cardiologist. He spent only a few minutes with me and said I needed an immediate angiogram. He said the angiogram was the only test that would provide him with the information he needed to know, that it was a routine x-ray of the heart and it was perfectly safe. Are there other tests that can be performed? Is he telling me the truth and is it as safe as he says?

Answer: He is not telling the truth. The angiogram, which is anything but a routine x-ray of the heart, is usually safe when done by a skilled cardiologist, but even in expert hands something can go wrong. Each year over 13,000 patients in this country have a heart attack, stroke or die during an angiogram. There are other, safer, noninvasive tests that will provide a cardiologist with all the information he needs to know. An angiogram is needed only when bypass surgery or angioplasty is to be used to treat the patient. In other words, your cardiologist has already made up his mind on how he wishes to treat you, even though you have no symptoms. This is contrary to accepted guidelines so presumably he is doing this for self serving reasons.

Question: I'm 58 and have already had an angiogram because of an abnormal electrocardiogram on a routine examination. I have been told I have blockages in all three of my coronary arteries. One of those blockages is 100%, the other two are 50% and 70%. Yet, I have no symptoms, even though I'm very active, play singles tennis three times a week, hike in the mountains, and have never had a heart attack. The cardiologist says unless I undergo bypass surgery, those arteries will close off and I could die. He say there is no other treatment besides surgery. My father had bypass surgery and died a few months later. I don't know what to do.

Answer: This is a common ploy of cardiologists and surgeons to lure the patient into the operating room by using tactics I call medical terrorism. No doctor can predict from an angiogram which artery will close off, or indeed, whether any artery will close off. In addition, he has no prior angiogram to compare with. Had an angiogram been done on you 5 or even 10 years ago, it might have looked exactly the same. The inference of the cardiologist that by undergoing bypass surgery a future heart attack or death can be prevented is merely wishful thinking. There are no modern studies that compare surgical treatment or angioplasty with medical treatment of the Nineties. Indeed, quite a number of recent studies have showed just the opposite. Not only is aggressive medical treatment with surgery or angioplasty no better than modern medical treatment, but patients undergoing such treatment had much higher mortality rates.

Question: Why, then, would a cardiologist make such a recommendation?

Answer: There are many reasons. The kindest view is that the training your cardiologist had was so narrow and focused that surgery or angioplasty are the only ways he knows how to treat coronary artery disease. Cardiologists also have quotas. They must perform at least 75 angiograms and angioplasties a year to maintain their hospital privileges. If the cardiologist is employed by a hospital, the hospital must perform several hundred heart procedures a year to maintain their accreditation. Thus, his job may depend upon keeping the operating room full.

Still another reason is that doing high tech procedures is very profitable. Many hospitals would go out of business if it were not for the surgeries that they do. Thus, if you have coronary artery disease, and there is a choice on how you should be treated, guess which choice is going to be made. There are still other reasons but this gives you an idea why surgery is the preferred treatment for coronary artery disease. It is not because it is the best treatment.

Question: How can my coronary arteries be obstructed and yet I have no symptoms?

Answer: An angiogram is a relatively primitive technology being over 40 years old. The resolution (smallest size that can be seen) is only 0.5 mm. That's only about the thickness of a piece of lead in a mechanical lead pencil. Vessels smaller than 0.5 mm are invisible on an angiogram. We call these vessels collateral vessels. Even if an artery is completely obstructed, there may be a vast network of tiny, collateral vessels through which blood can flow. In addition, an adaptive response that occurs with blocked vessels is that upstream from the blockage, new vessels will grow out from the artery and reconnect to the obstructed artery downstream. This process is called angiogenesis (angio= blood vessels and genesis= birth off). In a sense, the heart puts in its own bypasses. Not unlike a freeway that has been blocked off, traffic has to be rerouted but it still gets to its destination---it merely takes a little longer, but the flow of traffic is continuous. In the same way, if one or more coronary arteries are blocked, blood is rerouted through the small collateral vessels. These vessels cannot carry the quantity of blood that a large artery can, so if the heart rate is too fast, or the blood pressure too high, there may be a temporary reduction in blood flow to the heart muscle. This may cause a stress test or radioactive imaging test to be temporarily abnormal. That does not mean, however, that the patient is at risk of a heart attack or of dying.

Question: Are there any studies that compare angioplasty, bypass surgery and other treatments such as chelation therapy with modern medical treatment with drugs?

Answer: There are no valid studies on angioplasty that document that it is any more effective than placebo in the relief of symptoms. Nor are there studies comparing angioplasty, or for that matter, bypass surgery with modern medical treatment. These procedures are popular for two reasons. The first and most important is that it make a great deal of money for the cardiologist and surgeon who do them. Second, bypass surgery does relieve symptoms, but only temporarily in 80% of patients with chest pain. Neither procedure prevent heart attacks, premature death, progression of the coronary artery disease, or late complications such as congestive heart failure. The popularity of these procedures have nothing to do with their therapeutic efficacy.

Question: Can coronary artery disease be cured or reversed?

Answer: You cannot cure coronary artery disease. Without adequate medical treatment it will progress, develop long range complications such as heart failure and ultimately result in death. Angioplasty, bypass surgery and chelation therapy will not change that because none of these treatments address the underlying results of the disease, the factors that accelerate its progression, and the complications of ischemia (reduction in blood flow to heart muscle. On the other hand, modern medication, when given in sufficient numbers, and in adequate amounts, will accomplish this goal. Sadly, most patients with coronary artery disease never receive anywhere near the proper number of drugs and/or in adequate dosage. Dozens of studies have documented this. Programs such as the Ornish program that claim to reverse heart disease are misleading. They do no such thing. An adaptive response on the part of an obstructed artery is to become larger in the vicinity of an obstruction. Thus, the arteriosclerotic plaque appears smaller. But there is hope. While coronary artery disease cannot be cured, it can be turned into a benign illness compatible with a normal life span and with few if any symptoms in most patients.

Question: Is chelation therapy effective?

Answer: The best that can be said for chelation therapy is that any effectiveness in relieving chest pain is in the eyes of the beholder. Testimony abounds about the relief of chest pain that occurs after a series of treatments. The problem is that similar relief can be obtained with prayer, meditation., acupuncture, angioplasty, coronary artery bypass surgery and placebos. Given the heart's own ability to revascularize itself, if it has enough time, the majority of patients with angina will eventually get better---if they don't die first. If you had chest pain, and undergo a series of treatments over a period of months, and paid $4,000-$5,000.00, and your pain disappeared, you would be convinced the chelation therapy did the trick. I wish it were true. Unfortunately, there is no scientific evidence that this treatment does what it claims. In itself, it may do no harm. Its danger lies in the fact that effective treatment is delayed or does not occur at all. If the patient is already on a medical program, the doctor who pushed chelation therapy may recommend to the patient that he or she can now discontinue their medications and this may have disastrous results. The doctors who recommend this form of treatment may be sincere, and may themselves have been duped by the false claims and testimonies. While testimonies may be acceptable if you're buying a car or a washing machine, it has no place in medicine for treatment of a lethal disease.

Question: My cardiologist recently had me undergo a stress test and it was abnormal: He now wants me to undergo angiograms and thinks I may need angioplasty or bypass surgery. I have refused because I have no symptoms. He now tells me I can wait until I have symptoms. This doesn't sound right to me and he has not offered to put me on any medication. Is this approach correct?

Answer: No, it is not. This is like locking the barn door after the horse is stolen. Too many cardiologists only know how to treat coronary artery disease with angioplasty or coronary artery bypass surgery. The kinder view is that their training has been so narrow and focused that they never learned how to treat coronary artery disease with modern medication. An example of the consequences of not treating silent coronary artery disease is congestive heart failure. Instead of a major decline in the incidence of heart failure with modern medications, congestive heart failure has now become the number one discharge diagnosis from hospitals with an annual incidence of 400,000 to 800,000/year depending upon who you read. Proper medical treatment of coronary artery disease can prevent that from happening as well as preventing future heart attacks and premature death.