**EP48: Can We Reverse Coronary Artery Disease?**
Welcome to Dr. Warwick's podcast channel. Warwick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warwick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love.
Hi, my name's Dr. Warwick Bishop, and I'd like to welcome you to my consulting room. Today, I'd like to talk about reversing plaque in the arteries—literally, reversing coronary artery disease. In the last month or so, I've had two patients who elegantly and rather impressively demonstrate why we put people on cholesterol-lowering medication and why we go to the trouble of measuring targets and encouraging people to maintain not only a healthy lifestyle but also maintain their cholesterol levels at a low range with the help of pharmaceutical agents, you know, the statins and ezetimibe, etc.
The two cases I want to discuss with you are a little bit different. The first one is Peter. He was a guy in the order of early to mid-50s when I saw him. He had chest pain. During his workup, we found he did have coronary artery disease, and in fact, he had a blockage at the distal part of his left main artery. This is the large single artery that comes out to the front of the heart and then breaks into the left anterior descending and circumflex artery. Needless to say, it is the artery that supplies two-thirds of the heart. If this were to shut down, so would Peter.
At the time we worked him up, we, in fact, ended up doing a CT scan, and we could see and quantify the amount of plaque in that artery. Not only did our invasive angiogram confirm that he had a narrowing at the distal left main, but the CT, to be absolutely sure about that plaque and that it was not a kink within the artery, also demonstrated the same. He ended up with a graft, and that graft bypassed that narrowing, and he's done very well. He's been on all the appropriate therapy ever since. He's been compliant, and his cholesterol levels have been to the sort of targets we've wanted to aim for. He’s come back on a regular basis, and as the targets in the literature have been brought down, we've also brought down our targets for him.
Well, Peter came back recently with some further pains. Really, I didn't think it was necessarily his heart and thought that a good way to be sure about whether his graft was working well was to do a CT coronary angiogram. Well, we did this, and I'm really pleased to say that when we did, we had a very clear image of the left anterior descending of the left main coronary artery, and this clearly showed regression of the plaque within that artery. In fact, it had regressed so much that I now believe his main flow is down his native system.
Well, this means that the anterior wall of Peter's heart is now getting supply from the graft and his native artery. I suspect if that cholesterol plaque in the left main regresses any more, then the bulk of flow will be down his native artery, and that may well end up in his graft becoming smaller and smaller because the flow down there is not as required. I can't tell you how surprised I was to see this significant, visible reduction in the plaque burden. We haven't quantified it, but we don't need to. In the before and after pictures, you can see very clearly the reduction that's occurred.
I had another case, Phil, who I saw in the last couple of weeks. About six to eight years ago, at about 50 odd years of age, we put Phil through CT imaging to try and get an appreciation of his cardiovascular risk. He had pronounced significant soft plaque intruding into his left anterior descending artery, appearing to cause near flow-limiting narrowing. Because of the degree of soft plaque he had, we aggressively managed him. Remember, Phil had never had a problem; we were doing him for risk stratification.
We got his diet sorted, we got his exercise sorted, we got him on a cholesterol tablet, of course, he was on aspirin, and we also got him on a medication to lower his triglycerides. We really nailed everything down as best we could, and Phil came back a couple of years later—or sorry, came back just recently—wanting to know what the impact of this number of years of intervention had had on his arteries. Well, of course, we're on a podcast, so I can't show you the picture, but I can tell you that it's very clear when you look at before and after, there is a reabsorption or a minimization of the amount of non-calcific or soft plaque that was present. This is the stuff that we're worried about because it can rupture, and it's soft, and we believe carries the highest risk with it. That soft plaque has been resolved, but some of it has also been replaced by calcium.
We know that calcium, although it's a marker of risk, is also a marker of stability. For this man, his development of calcification with the resorption of soft plaque is nothing but a great outcome for the intervention we've undertaken for him. I want to share this with you because time and again, people are wondering why we're focusing on cholesterol levels while we're asking you to take medications. I can tell you we do it because we know it works. We know it works from the studies that have been done, from the literature that's available, but I can tell you that I see it on a day-to-day, week-to-week basis in individual cases. And these two men are great examples of the impact we can have by modifying the process that's occurring.
So please, think about taking your tablets, think about understanding what they can do and how they really can work. And think about looking after yourself, because at the end of the day, we do want to stop you from having a heart attack. I'd like to wish you the very best. I hope you got something out of this podcast. By all means, if you have any queries or questions, drop us a note and let us know. If you've got any ideas for other podcasts, please let us know also. For now, I'd like to wish you the very best and goodbye.
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