The Cheney Syndrome: To a man with a hammer a lot of things look like nails that need pounding. The Importance of Diet and Lifestyle Modification for treatment of Heart disease

Coronary artery disease is the leading cause of death in the United States and has been so for several decades affecting an estimated 12 million Americans. This year approximately 1.1 million Americans are expected to have an acute cardiac event with almost 2/3rds of these (650,000) being recurrent cardiac episodes in people already being treated for heart disease; accounting for 1 out of every 3 deaths [1]. This high rate of recurrence clearly illustrates that the problem doesn’t go away following initial medical treatment, interventional procedures and/ or by simply telling people to change their diet and lifestyle; particularly given all the confusion about what is a health diet and lifestyle.

Coronary artery disease is the leading cause of death in the United States and has been so for several decades affecting an estimated 12 million Americans. This year approximately 1.1 million Americans are expected to have an acute cardiac event with almost 2/3rds of these (650,000) being recurrent cardiac episodes in people already being treated for heart disease; accounting for 1 out of every 3 deaths [1]. This high rate of recurrence clearly illustrates that the problem doesn't go away following initial medical treatment, interventional procedures and/ or by simply telling people to change their diet and lifestyle; particularly given all the confusion about what is a health diet and lifestyle.
Despite the staggering statistics and the knowledge that elevated cholesterol, homocysteine, fi brinogen, lipoprotein (a) and other factors related to dietary and lifestyle practices are responsible for heart disease, little if any signifi cant improvement in preventive behaviors have occurred in either the United States [2], or European [3], communities. While the dietary and lifestyle practices leading to the development and progression of atherosclerosis are formed during our adolescence [4], years, people who are willing to make the necessary dietary and lifestyle practices later in life can reduce their risk of heart disease. Those people who lower their LDLc levels by as little as 5% during 6 weeks of dietary and lifestyle changes, can further lower their risk of heart disease with these dietary and lifestyle changes [5], alone. Further research now shows [6], that following a heart attack, patients started Clearly if the use of interventional procedures alone provided the answer, the battle on heart disease would have already been won. Acute interventional procedures should be viewed as a means to prolong life during the immediate period of crises and provide "short term", rather than "long term" solutions to the problem.
Most patients and many doctors believe that once interventional procedures have been performed, everything will be fi ne and the problem has been solved. this idea by taking patients off their medications following angioplasty, bypass surgery, et cetera, and fail to discuss and reinforce the necessary changes in diet and lifestyle needed to halt the disease and potentially even reverse it.

Despite recommendations by the American Heart
Association, some patients are advised to focus on "getting their strength back" with less attention paid on lower saturated fat intake. This dichotomy in messages about which foods are healthy and which are not is even more confusing to patients and their families, and does nothing to make the needed changes in diet and lifestyle required to reduce the risk of future events. It is after all, these very foods which lead to the buildup of infl ammatory cholesterol plaques. These are the very foods which led to the need for surgery or treatment in the fi rst place. It is important to note, that there has not been a single study, showing an interventional procedure which has reversed or controlled heart disease, yet we have continued to approach heart disease as if interventional procedures and/or surgery are the cure to the problem, instead of the temporary fi x that they provide. The benefi ts of interventional procedures lie in their ability to buy the time necessary to make the changes required to treat the underlying heart disease, assuming the patient lives long enough to make these changes.
For many people, their fi rst real treatment for heart disease isn't diet or lifestyle change, but the use of thrombolytic agents following their presentation to the emergency room with chest pain resulting from a blood clot blocking blood fl ow through a diseased coronary artery. These blood clots can occur in arteries with or without signifi cant narrowings and are frequently associated with an infl ammatory cholesterol laiden plaque rupture. These thrombolytic agents include agents such as tissue plasminogen activator (t-PA), streptokinase, urokinase, and a variety of other agents used to dissolve the blood clot, while other agents are used to reduce the risk of further blood clot formation. These drugs are not without risk and the treatment of an acute myocardial infarction (AMI) and the selection of thrombolytic agents has continued to change [7], over the years along with the consideration of whether thrombolytics should be used, or if angioplasty (PTCA) or stent placement, or a combination of methods, should be used in the acute setting [8].
Angioplasty itself is associated with the dislodgement of plaques which go downstream and result in infarctions distal to the site of angioplasty. The use of PTCA and stents are not without risk and include re-stenosis [8], heart attacks, strokes and other issues. Many studies now discuss the outcome of initial treatment on the basis of initial reperfusion of occluded arteries (TIMI fl ow) versus longer terms outcomes, such as actual patient survival. Again the point must be made that treatment of the initial occlusion is a "short term" response to a "long term" problem which doesn't get better as the result of a mechanical intervention alone. The underlying problem lies within the artery and "long term" treatment must focus on the causes of the problem and their treatment.
In the absence of an ACS, studies have also shown that there is little or no substantial difference in the survival of people treated either medically or surgically [9][10][11]. The relief of angina does not guarantee longer survival. It is after all simple treating the symptom and not the problem. The exceptions, noted in the Coronary Artery Surgery Studies (CASS), are those patients whose left main or triple vessel [12], disease with left ventricular dysfunction have placed them at an even greater risk of sudden cardiac death. In this instance surgery will keep them alive for now, only to be revisited by the same problem unless they change their diet and lifestyle.
While interventional procedures like angioplasty and atherectomy can be safely performed [13], in many instances, there is an increased incidence of major adverse cardiac events [14], in older individuals, people with prior myocardial infarctions and those with reduced left ventricular function. These recurrent episodes of angina, and/or myocardial infarction, are the result of infl ammatory reactions [15,16], which atherectomy and other interventions cannot change, even if they are used for the treatment of recurrent angina following stent [17], or vessel re-stenosis. Given the restenosis rates of stents and angioplasties [18][19][20], the initial advantage is more one of cost savings [21], with cardiac events occurring in 26.2% of those undergoing stent placement in contrast to 12.2% in those undergoing bypass surgery. Efforts to use laser therapy or rotablator for in-stent re-stenosis have also not been particularly effective [22]. While stents may be less expensive than bypass surgery, they have a greater need for repeat revascularization and repeat risk of heart attacks and stroke. The benefi ts of medical regimen and bypass surgery appear to be equivalent for most individuals, but in the fi nal analysis there is progression of native coronary artery and bypass vessel (both venous and arterial) disease unless risk factor modifi cation is implemented, which includes dietary and lifestyle changes beginning with immediate intervention of such within the hospital setting itself. The use of vitamin supplements, especially in the face of cardiomyopathies have not yet been clearly established.
Given the problems with prior interventional procedures to correct coronary lumen disease (CLD), a term much more descriptive of the disease extending from the coronary artery into the lumen space, newer efforts to change myocardial blood fl ow have included transmyocardial laser revascularization (TMR), gene therapy and even the use of radioactive stents. Despite initial optimism, these procedures have not shown the promise once hoped for. Laser therapy has only demonstrated improvement in coronary blood fl ow for one-third [23], of those studied 3 months after TMR is performed, while other studies have shown deterioration of blood fl ow [24], in the regions of laser treatment, with any benefi cial effects occurring in the nonlasered [25], regions of the heart. While TMR may help some individuals in the "short term" [26], like other interventional procedures it does not solve "long term" problems, and it is not being enthusiastically recommended [26].
The addition of gene therapy (vascular endothelial growth factor, aka. VEGF) which was once thought to enhance angiogenesis through the promotion of collateral blood fl ow, resulting in the reduction of angina by reducing regional blood fl ow differences responsible for angina [27,28], has since been shown to potentially promote further atherosclerotic [29], development, resulting in progression of atherosclerotic lesions. Finally, the use of radioactive stents [30,31] have failed to produce any better results than earlier interventional procedures with the additional development of "candywrapper" lesions at the edges of the stents.
While interventional procedures do and must play an important role in the initial treatment of acute coronary syndromes, prevention remains the key [32] to reducing coronary heart disease (CHD) morbidity and mortality. Poor dietary and lifestyle practices have resulted in greater numbers of Americans and people throughout the world becoming overweight [33], with an increasing incidence of heart disease. Our current unsuccessful prevention of, and intervention driven treatment of heart disease is responsible for greater numbers of individuals either dying from heart attacks or living with congestive heart failure [34,35] following AMIs. In 2001, 700,000 Americans will died in heart failure [36], a result of failure to correct the underlying cause of heart disease and culminating myocardial infarctions. However, people need not die from or even necessarily experience a heart attack, if they make the appropriate changes in their diet, lifestyle and medical management.
As already discussed, risk factor modifi cation if done right, can signifi cantly reduce mortality in people who have experienced, and survived, a heart attack. Changes in dietary consumption of saturated fat has been shown to be associated with a reduction in serum lipid levels [37]. For some, even a moderate fat diet [38] may be detrimental if they are used to diets with lower fat content. There are now several studies [39][40][41][42][43][44] which have shown either improvement in cardiac risk factors or regression of heart disease when dietary and lifestyle changes are instituted. Still other studies have shown actual recovery of viable myocardium [45][46][47][48] when aggressive medical and dietary programs are undertaken to reverse atherosclerosis by reducing cholesterol, triglycerides, homocysteine, fi brinogen, lipoprotein (a) levels and the other risk factors responsible for heart attacks and strokes. These dietary and lifestyle practices not only reduce the risk of heart attacks; but, strokes and heart failure as well. Additionally, other types of dietary patterns [49][50][51] have been shown to be associated with the progression of heart disease and to impair coronary blood fl ow, including diets which are high in saturated fat and excess calories. These diets can result in the rapid progression [52] of heart disease.
The use of today's interventional procedures can truly be lifesaving for many individuals, at lease in the acute setting; but, they provide only a temporary measure which can allow us the necessary time needed to correct the underlying problem, which must be corrected through the treatment of the cause(s) and not the symptom(s) of coronary artery disease. Sometimes, the use of these procedures prevents the correction of the underlying problem by leading physicians and patients both down the path of complacency. It is easy to forget the underlying problem once the symptoms have been temporarily controlled even though the cause of those symptoms continues to worsen and even easier to resume the old dietary and lifestyle practices which led to the problem in the fi rst place.
The following is a case example of how the use of interventional procedures help for a while, but the long term treatment of the problem requires a different approach. An approach which can successfully reduce the risk of heart disease and the risk of death.

Case Presentation
Dr. SK is a 63 year old gentleman referred for evaluation from Washington, D.C. where he lives, after recurrent angina resulted in chest pain with any activity immediately after eating or with walking less than a quarter of a block. The presentation of his angina described as a "squeezing" (Levine sign) retrosternally discomfort began in October of 1979 when as a student he sought medical attention at student health. He was initially told he was too young and in too good a shape to be having a heart problem and presented with his fi rst myocardial infarction four-hours later in the local hospital emergency room. with 100% occlusion of the LAD at its origin, 100% occlusion of OM2 (LCx) which was now receiving collateral blood fl ow from a dominant RCA which had "several" lesions with greater than 70%DS narrowing of the coronary lumen. The SV grafts to both the RCA and LCx were 100% occluded. Only the LIMA graft remained open; but, to a "diffusely" diseased LAD.
Of additional concern was a history of diabetes mellitus, hyperlipidemia, hypertension, prior myocardial infarctions and left carotid disease. Given these fi ndings the patient reports that he was advised by his physicians including 2 cardiologists and 1 internist, to do one of three things: (1) fi nd a program that could help him reverse his heart disease, (2) try for a heart transplant, and/or (3) update the status of his "will". The He underwent myocardial perfusion imaging (MPI) to determine the extent of prior myocardial injury, LVEF, regional wall motion abnormalities and coronary regional blood fl ow [27,28,53]. Prior to our understanding of sestamibi redistribution and quantifi cation of true ASCAD, we had conducted MPI with semi-quantifi cation. His initial resting image demonstrated prior myocardial injury in the inferoposterior, posterolateral, distal anterior and apical regions as shown and described in panel 3 of Figure one. The LVEF was 84.5% and there were no regional wall motion abnormalities at rest. He was then pharmacologically "stressed" with dipyridamole. Four minutes into "stress" he reported "chest and throat" discomfort which radiated into his left mandibular region. The patient reported these symptoms as identical to his "typical" angina. This was associated with QRS widening on the electrocardiogram.
The study demonstrated decreased coronary blood fl ow in all three vascular territories as described in table 1. Following pharmacologic stress, regional wall motion abnormalities were noted in the posterolateral wall with a reduction in LVEF (71.0%) of 13.5% compared with the resting study.
Dr. SK was placed on a dietary program [33], eliminating essentially all fats from the diet. The fi sh oils were discontinued as well, to eliminate any reduction in blood fl ow [50] and endothelial function. He was additionally started on L-arginine which was used both as a free radical scavenger mechanism and to enhance endothelial function. The L-arginine was started at 500 mg TID and was slowly increased over the next several weeks to 3 grams TID. His ACEI was changed to quinapril beginning at 10 mg daily and increased over the next several  following multiple interventional procedures. These state of the art interventional procedures performed in the hands of skilled clinicians provide "short term" answers to a "long term" problem. The reclosure rate of arteries opened mechanically is 1in 3 during the fi rst 6 months, which may sound good to the 2/3rds who do well initially, until one realizes that even these vessels will continue to have progression of coronary artery disease unless something is done to prevent it.
The answer has always been to look at what causes the problem and to correct it. Treating the symptom and not the cause has never worked "long term" in medicine and never will. To many physicians we have been taught to address the "short term" problem with an immediate fi x, but we have forgotten to deal with correcting the "long term" problem which is admittedly more diffi cult to address. The short term solution is much as Mark Twain suggested, "To a man with a hammer a lot of things look like nails that need pounding." As cardiolgists and cardiovascular surgeons we all have our own hammers which we are inclined to use. The limitations of these hammers in the treatment of heart disease is that they treat the symptom and not the underlying cause of heart disease.
This approach at best simply delays the problem for another day. A day which may come tomorrow or six months from now, but a day that will come. The disease is after all, an infl ammatory reaction occurring all too often in response to poor dietary and lifestyle practices, and only changes in these dietary and lifestyle practices can change the course of the disease. Dr. SK is a classic example of just such a lesson.
The physicians taking care of him had provided the best interventional procedures possible and while they provided temporary solutions, they did not provide long term answers.
This case is not unlikely many other Americans, some of whom we have heard of, and others we have not. Their course like his requires a change in lifestyle, diet and medications designed to address the infl ammatory character of the underlying coronary artery disease and promoted its regression.
As Dr. SK's case points out, this approach may not only improve the coronary blood fl ow, but also allow the recovery of viable myocardium reducing the ever imposing threat of heart failure or even death. The obvious ramifi cations to Dr. SK was improvement in exercise tolerance, reduction in angina, an improvement in his diabetes and the opportunity to grow older with his wife. The ramifi cations to other patients are the same.

Conclusion
The process of succesful intervention in individuals with coronary artery disease (CAD) is determined by when intervention begins; primary or secondary. Clearly, once an Major Adverse Cardiac Event (MACE) has occurred, physicians have little choice but to mechanically intervene. That does not however mean the problem of CAD has been resolved; time has merely been bought to make the necessary changes needed to reduce or potentially reverse the underlying "Infl ammatory Process" of CAD. [57,58].
Independent of the next steps taken, there remains considerable debate over the role of dietary and lifestyle changes and the effect of vitamin supplementation, which appears to be dependent upon the type of dietary and lifestyle changes recommended [59]. What is needed now is a clinical study to