Reversal therapy consists of:

1. Low Fat diet  [Vigorous cholesterol lowering ]
2. Lipid active drugs - basically STATINS, like Lovastatin / Simvostatin / Atorvastatin
3. Control of Hypertension
4. Smoking abstinence
5. Other life style, modifications-Yoga , Pranayam & Meditation -very important

Effect of reversal therapy:

1.Plaque composition favourly changes so that there is less chance of blockage of coronary artery
2.There is modest improvement of anatomic severity
3.Inner lining of artery, known as endothelium is tuned to produce beneficial bio-chemicals
4.There is increased flow of blood in the artery
5.Deposition of cholesterol plaque may be regressed in some cases
6.Symptoms are decreased

Please follow these instructions which are basis of 
REVERSAL THERAPY

1. Low Fat Diet

'Margaret Thatcher (The Independent, 1987) told - " I want to buy some real farmhouse butter, some real farmhouse eggs and some clotted cream - and I am not going to listen to those dietary faddist who say don't eat it. But here you are advised to take care of your diet if you want to prevent heart attack:
Avoid butter, hard margine, whole milk, cream, ice cream, high fat cheese, fatty meats, and poultry, sausages, pastries, coffee whitener, products containing hydrogenated oils , palm oil and coconut oil. Do not use oils like kardi oil  or sunflower oil etc. These vegetable oils due to high N-6 fat are dangerous - makes Insulin useless and there is increased tendency to clot formation. Fats rich in N-3 like Mustard oil, Fish & Fish oil, Soya bean oil are beneficial for heart. Take plenty of fresh fruits, vegetables ,germinated gram, lentils & unrefined cereal foods. Eat Fish twice a week. Change milk to skimmed /semi-skimmed milk. Maintain sensible alcohol limit.

2. Lipid active drugs

Take advice of your doctor. Statin group of drugs have revolutionized the therapeutic scene. Many studies now advocate for use of these drugs for primary prevention. After you get the problem, statins must be started in usual dosage. Some of the drugs are: Lovastatin - (Lostatin) Simvostatin (Zosta), Atorvastatin (Atorva, Aztor)

3.Other measures

1. Control Of Hypertension - Very Important
2. Changing People habit Elicit motivation, Ascertain health belief, Identify unhealthy influences, Persuation, Planning and 
specific recommendation --- Cassation of smoking --- Improving Exercise---Sensible drinking --- Strict control of Diabetes --- Use of Antioxidants --- Get your Lipid Profile at an early date. If Cholesterol /TG /HDL /LDL etc are not normal--- start taking appropriate measures soon.

Fore more details and your specific problems contact

LET ILLUSION OF CARDIOLOGY   DIE .........URAL DEATH

This article has been published in UPDATE MEDICINE 2006 of Association of Physicians of India

New concepts in cardiovascular medicine is all set to kill the surgical thought process which is so prevalent in treatment of coronary artery disease[CAD]. Arthur Koestler once said , " nothing is more sad than the death of an illusion". The illusion of cardiology that bypass or dilatation of coronary stenoses reduces the risk of myocardial infarction is bound to die with new paradigms.With growing epidemic of CAD and consequent economic implications death of such illusion will be a boon to the society . But dilemma of cardiologists still widely prevails and it is hard to convince .

New knowledge about pathophysiology of coronary atherosclerosis:1

1. 85 % of myocardial infarctions develop at relatively less severely narrowed sites in

coronary arteries where lipid -rich plaque rupture , leading to thrombosis and spasm

2. Coronary atherosclerosis is a diffuse heterogenous process that occurs throughout the

length of coronaries arteries

3.Coronary atherosclerosis alters endothelial and vasomotor function of the microvasculature

4. The diagnostic accuracy of coronary arteriography for diffuse atherosclerosis is poor , as

low as 10% compared to intracoronary ultrasound. Thus arteriography is substandard

for identifying and quantifying the diffuse disease underlying most clinical events.

5. Vigorous cholesterol lowering markedly reduces cardiac events and mortality more than

invasive procedures , which do not alter long term survival or cardiovascular events .

6. Positron emission tomography[PET] perfusion images reflect the presence of diffuse

coronary atherosclerosis , endothelial dysfunction , and their changes with vigorous

cholesterol lowering ----- more than is revealed by coronary arteriography

Background:

*Now strong evidence from the CABG literature indicates that revascularization does not prevent myocardial infarction.Muhlabaier et al 3 showed incidence of nonfatal infarction 49% in surgically treated patients and 41% in medically treated patients by an observational 10 year followup of 5428 patients with medical and surgical therapy. Similarly Wiseman et al 4 showed that bypass patients had more reinfarction (40% versus 23%). Worth mentioning , in the CASS [ Coronary artery surgery study 5, the 3-year incidence of myocardial infarction in nonsurgical patients was 8%, whereas in the surgically treated group it was 10%. Although surgery reduces longterm mortality in some subsets, it does not reduce the incidence of myocardial infarction in patients with stable CAD. PTCA is also not successful in reducing infarction rate compared with medical therapy .Meta-analysis of 3371 patients in 8 randomized trials comparing CABG with PTCA suggests that the combined end point of cardiac death and nonfatal ingfarction is slightly higher in PTCA group6

*Further it became clear that most myocardial infarctions occur at sites that did not previously exhibit a significant stenosis. Published angiographic literature suggests that only 13% of the culprit lesions have more than 75% stenoses before myocardial infarction.7,8.

A large body of evidence varifies that plaque rupture typically occurs at milder stenoses ,those of 40%-60%diameter narrowing or less.2 Such lesions do not cause symptoms or ischemia on treadmill testing.The younger ,lipid -rich ,less severe plaques with little luminal narrowing are more prone to rupture than older , more scarred , more severe stenoses 9 . We can not depend on quantitation of focal stenoses on coronary arteriogram. It does not co-relate with risk of plaque rupture.

*Importance of the functional ,endothelially mediated vasomotor abnormalities of epicardial arteries has been now demonstrated .10,11.Risk factors such as smoking ,diabetes ,hypercholesterolema ,hypertension ,hypertriglyceridemia and coronary atherosclerosis impair epicardial coronary arterial and distal arteriolar vasodilatation mediated by endothelium at resting and stress conditions.

* Lastly , the results of cholesterol-lowering trials for stabilizing or reversing coronary atherosclerosis are now available and very important message is knocking the door. It has got great importance and we need to propagate it in the society to curb this growing epidemic.

The first of the major statin trials ,FATS12 [ Familial Atherosclerosis Treatment study] showed a 73% decrease in coronary events over 2-year treatment period and an 85% decrease in coronary events after the first 6 months. 4S13 [ The Scandinavian Simvastatin Survival Study ] demonstrated a 42% decrease in coronary deaths and a 37% decrease in cerebrovascular events. Importantly WOSCOPS14 [ The West of Scotland Coronary Prevention Study] showed significant reduction of coronary events in people with elevated cholesterol without known CAD . Numerous trials like,

NHLBI , CLAS I &II , POSCH , LIFESTYLE, US-SCORE ,SCRIP ,CCAIT ,MAAS ,ACAPS,SINGH,STARS,REGRESS, META-ANALYSIS15 ,CARE ,POOLED,etc, have demonstrated similar findings.

REVERSAL TREATMENT:

It incorporates the beneficial changes in plaque composition and pathology ,modest improvement in anatomic severity , endothelial healing ,increased coronary flow and flow capacity,decreased symptoms and improved survival. Certainly ,regression back to normal in all of these process does not occur. However ,the term regression or reversal appropriately characterizes the cumulative benefits seen clinically.

It includes vigorous cholesterol lowering by low fat diet and lipid active drugs ,control of hypertension ,and smoking abstinence and other life style modifications

Revascularization : when?

It is beneficial

- In selected ,restricted circustances ,primarily for 3-vessel disease and reduced left ventricular function and for hibernating and stunned myocardium.

Benefits of revascularization procedures on survival in patients with good left vertricular

function have not been convincingly documented.

As per De Feyter PJ ,16CABG is preffered when: [1] There is multivessel disease.[2] There is stenosis of the left main coronary artery [3] The nature of the lesion is highly complex [4] Vessel provides the sole remaining blood suuply to the myocardium.

There is growing concensus that although there is argument for performing invasive procedures on high-risk patients ,it may be worthwhile to first attempt to stabilise the patient's condition with medical therapy before reassessing the situation.It must be remembered that even progressive unstable angina frequently responds to the noninvasive approach without ever needing a revascularization procedure with compatible or lower risk of mortality or MI.2 For majority of patients reversal regimen is all that is needed but it requires strong support by a knowledgeable participating physician. But a minority of patients do not respond to vigorous medical management or will not alter risk factors ,despite predictable future morbidity and mortality. Such patients will need revascularization procedure ,with reversal treatment playing a secondary role.

Conclusion

Since the first bypass was performed in 1964 ,there have been amazing advances in the techniques .How to attenuate the progression of atherosclerosis even after bypass or PTCA, is the burning topic in cardiology.Restenosis after ballon angioplasty or stent are to be addressed in future by intracoronary radiation,local gene therapy ,and systemic inhibitors of thrombosis.Therpeutic Angiogenesis is an extremly important area for continued research. Catheter -based Revascularization is also being developed being directed at improveing the safety and effectiveness of PCI [Percutaneous coronary intervention]. MIDCAB ( Minimally Invasive Direct Coronary Artery Bypass ) is also a major advancement. But the question that haunts ,whether these interventions touch upon the root cause of the disease ,i.e. atherosclerosis ?

No doubt ,new boilogy ,as defined by Dr Libby 17 includes two new approaches to vascular medicine : [1] Unstable angina is not due to  tight stenotic lesion but rather to a vulnerable ,lipid-rich plaque.[2] Stabilization of coronary atherosclerotic lesions with medical therapy is perhaps as important as direct intervention on established plaque.

Then as per Dr Hegde ,why so much hue and cry for bypass or dilatation ? Is it a simple business proposition? '' One ,and possibly the only one ,area where the doctors ,hospitals and the sellers of medical equipment,get billions of doller in cash in addition to prestige and status , is the prosedure which claims to "bypass" the blocked coronary vessels on the surface of the

heart, the latter supply blood to the heart muscle.'' Numerous recent literature all over world now pleads to break this ILLUSION of CARDIOLOGY that any block in the x-ray picture of coronary arteries need bypass . Reversal therapy is a solid state of affairs ,but physicians are not bold enough to advocate it . As per Dr Hegde, medical leaders must wake up and act conscientiously ; as otherwise we will all be hypocrites swearing by the Hippocratic Oath. Long live mankind on this planet. We have been here for well over 9,00,000 years in 50,000 gererations. If mankind were to depend only on revascularization procedures for survival ,we have been extinct like the dianosaurs.

W e must remember that the history of cardiovascular medicine has innumerable examles of of ideas that were compellingly logical but wrong.

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REFERENCES :

1. Gould KL. Reversal of coronary atherosclerosis :clinical promise as the basis for the non-invasive management of coronary artery disease . Circulation.1994;90:1558-1571.

2. Gould KL. New concepts and paradigms in cardiovascular medicine:The non-invasive management of coronary artery disease. American Journal of Medicine.1998 ; 104: 2s -17s.

3.Mahlbaier L et al . Observational comparison of event -free survival with medical and surgical therapy in patients with coronary artery disease ;20 years of followup. Circulation.1992;86(suppl II ):II-198-II-204.

4. Wiseman A ,Waters D , Walling A ,TherouxP. Long term prognosis after myocardial infarction in patients with previous coronary artery bypass surgery. J Am coll Cardiol .1998; 12:873-880.

5. Mock ME .Survival of medically treated patients in the coronary artery surgery (CASS) Registery . Circulation. 1982;66:562-568.

6. Pocock S, Henderson R et al . Meta-analysis of randomized trials comparing coronary angioplasty with bypass surgery. Lancet 1995;346:1184-1189.

7. Ellis S . Alderman et al. Prediction of risk of anterior myocardial infarction by lesion severity and measurement method of stenoses in the left anterior decending coronary distribution. J Am Coll Cardiol. 1998 ;11:908-916.

8. Webster M et al . Myocardial infarction and coronary artery occlusion : a prospective 5-year angiographic study . J Am Coll Cardiol .1990 ; 15 : 218A.

9. Smith SC . Risk -reduction therapy :challenge to change .Circulation.1996;93:2205-2211.

10. Penny WF ,Long J , et al . Heterogeneity of vasomotor response to acetylcholine along the human coronary artery . J Am Coll Cardiol.1995;25 :1046-1055.

11. Reddy KG , Nair RV ,et al .Evidence that selective endothelial dysfunction may occur in the absence of angiographic or ultrasound atherosclerosis in patients with risk factors for atherosclerosis . L Am Coll Cardiol.1994;23 :833-843.

12. Brown BG , Zhao XQ ,et al. Lipid lowering and plaque regression . New insights into prevention of plaque disruption and clinical events in coronary artery disease. Circulation .1993;87:1781-1791.

13. Scandinavian Simvastatin Survival Study Group. Randomized trial of cholesterol lowering in 4444 patients with coronary heart disease :the Scandinavian Simvastatin Survival Study (4S) .Lancet.1994;344:1383-1389.

14. Shepherd J, Cobbe SM ,et al . For the west of Scotland Coronary Prevention Study Group.Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia . N Engl J Med .1995 ; 333:1301-1307.

15. Yusuf S ,Anand S. Cost of prevention . The case of lipid lowering . Circulation.1996;93:1774-2172.

16. De Feyter PJ . The benefits and risk of coronary intervention - balancing the equation. Clin Cardiol 1997;20 (sppl.I):114-121.

17. Libby P, Fuster V, chairs . A tribute to Dr Russell Ross-- The vulnerable Plaque :1999 Update . Presented at the American Heart Association 72nd Scientific Session , Atlanta ,Ga , November 7-10 ,1999 .Special Session I ,Nov-8.