How to Regress or Reverse Coronary Artery Disease

2. Case Description

Dr. DM, an interventional cardiologist aged 55 years and asymptomatic, underwent a CTCA without any previous cardiac history. His CTCA results were normal two years prior, with a calcium score 0. His most recent treadmill test also showed normal results. Upon presentation at the cardiology clinic, he had a BMI of 23 kg/mm², a systolic blood pressure of 110 mmHg, a diastolic blood pressure of 76 mmHg, and a heart rate (HR) of 64 pulses per minute. His blood glucose level was 95 mg/dL, and his serum creatinine was 0.9 mg/dL. The laboratory results showed HbA1C at 5.7%, LDL at 70 mg/dL, HDL at 38 mg/dL, Lp (a) at 40 mg/dL (desirable threshold of <14 mg/dL), and elevated hs-CRP of 3.0 mg/L which was three times the upper limit. He has been following an omnivorous diet since childhood. Additionally, there is a strong family history of cardiovascular disease, as both his father and mother experienced heart attack and stroke at an early age. He exercised regularly (> 150 minutes of moderate exercise per week) and maintained a low weight through restricted calorie intake. He had been taking statin and ezetimibe for over 15 years and had consistently maintained his LDL levels in accordance with ACC/AHA guidelines.

The assessment and quantification of his atherosclerotic plaque were accomplished using a 128-slice CTCA. During the procedure, a non-ionic contrast was administered, and his resting heart rate was 60 beats per minute, with a breath hold of 15 seconds. The CTCA revealed a calcium score of 58, concentrated in the proximal LAD, with a lesion of approximately 50%. The plaque was characterized as calcified, fibrotic, and containing a lipid core. The plaque measurements were 24.2 mm³ for the calcified plaque, 96.4 mm³ for the fibrotic plaque, and 15 mm³ for the lipid core. He underwent myocardial perfusion scanning, which was unremarkable.

He decided to enter a lifestyle program to regress/reverse his coronary atherosclerotic plaque. He increased his statin dosage and continued on ezetimibe. He started on low-dose clopidogrel to change his platelet hyperaggregation state to hypoaggregation. He took many supplements as he went along with his lifestyle program (adopting a PBD, avoiding unhealthy foods, and continue doing regular exercise) to maximize the effect of a PBD upon reversing atherosclerotic plaque.

Three years after implementing a lifestyle intervention, his BMI decreased to 21 kg/m2. Additionally, his blood pressure and pulse remained unchanged from three years prior. His HbA1C level significantly decreased to 5.2%, while his LDL cholesterol levels decreased to 50 mg/dL. His Lp(a) level decreased by 40%, and HDL cholesterol increased by 30%. His hs-CRP levels became normalized ( one of the indicators of systemic inflammation), and he regularly measured his nitric oxide (NO) levels using an NO strip under his tongue [16]. Additionally, he ensured that his urine readings remained alkaline most of the time (alkaline urine is one of the markers of following a correct PBD).

It is now time to assess the progress of his lifestyle and supplementation intervention, as well as the outcome of his CAC/ CTCA after three years: The CAC/ CTCA findings showed a calcium score of 42, which had regressed by 28% from 58, and his proximal LAD lesion, which was previously 50%, had decreased to 30%, a regression of 40%. The measurements of the plaque were 17.3 mm³, regressed by approximately 30% for the calcified plaque, 57.8 mm³, regressed by 40% for the fibrotic plaque, and 7.3 mm³, regressed by 50% for the lipid core, as can be seen in Figure 1.

3. Discussion

Is it possible to reverse coronary artery disease? When patients ask their doctors if they can help shrink their coronary artery plaque, many doctors may not know the answer. Some cardiologists may suggest lifestyle changes and statins in combination with ezetimibe or a new anti-lipid injection PCSK9 inhibitor [17]. However, in reality, I have rarely seen any of my patients successfully regress their coronary calcium or stenosis simply by using the doctor’s magic word “changing your lifestyle” and taking high-dose statins or ezetimibe. Prior to my diagnosis of coronary atherosclerotic plaque, as outlined in the case report, I had consistently maintained what I believe was a “healthy lifestyle” due to my strong positive family history of CVD, elevated Lp(a) level, and low HDL, all of which contributed to my CVD risk. Therefore, I have been prescribed statins in conjunction with ezetimibe since their inception in the early 1990s and have adhered to the international lipid guidelines recommended by the European Society of Cardiology (ESC) or the ACC/AHA, which have evolved over time. Currently, the recommended LDL level is below 55 mg/dL. Metabolically, I was not overweight, had normal blood pressure, engaged in moderate exercise, effectively managed stress, obtained adequate sleep, abstained from smoking, and consumed almost no alcohol. Even though I adopted an omnivorous diet in the past, I paid close attention to my food choices, limiting my consumption of saturated fats and refined carbohydrates.

I am confident that my coronary experience is not unique, as I have observed many of my colleagues who were disheartened upon being diagnosed with coronary obstruction. In the past, the guidelines recommended intervening in cases of significant coronary obstruction, such as stenosis above 50% or 70%, and many of my colleagues underwent PCI as a result. Unfortunately, they were not aware that regression or reversal of coronary stenosis was possible. Does this sad reality change now? Apparently not. Not only in my country but also in the United States, until now, the program of reversing/regressing coronary plaques has been confined by professionals who have truly learned how the program may work. In my experience, learning the real healthy lifestyle to regress or reverse coronary plaque is quite challenging, time-consuming, and full of sacrifices.

Numerous studies have underscored the critical significance of PBDs in managing chronic inflammatory diseases, including atherosclerosis, hyperlipidemia, obesity, non-insulin-dependent diabetes mellitus (NIDDM), and hypertension. It has been widely acknowledged that PBD may not only contribute to the prevention of atherosclerosis but may also cause regression of coronary plaques that have occurred [18,19,20,21,22,23,24]. The role of PBDs as an anti-inflammatory, immunomodulatory, and assisting vascular healing (important following intervention) has been recognized and published as beneficial in chronic inflammatory diseases, especially atherosclerosis. Consuming PBD in conjunction with anti-platelet drugs may aid in mitigating thrombosis processes, potentially reducing the risk of developing acute coronary syndrome (ACS) [25,26,27,28,29,30,31]. This is particularly relevant for managing vulnerable plaque, as it may lessen the future potential for the plaque to cause an ACS.

Atherosclerosis is a systemic disease resulting from metabolic dysfunction and persistent inflammation rather than a localized process. Consequently, it is classified as a metabolic chronic inflammatory condition. Patients who have experienced coronary obstruction due to the atherosclerosis process have typically exhibited a state of metabolic disorder and systemic inflammation for a prolonged period. Cardiologists who exclusively employ interventions such as using stent implantation or DCB technology to manage systemic diseases are likely to be disappointed if they do not address these systemic issues. Following coronary interventions, the balloon causes localized arterial distortion, and the implantation of a foreign body, such as a stent, or using a drug-coated balloon (DCB) results in a healing process for the local injury. However, the systemic environment plays a significant role in the local healing process. At a minimum, the systemic process of atherosclerosis continues to develop. Even if a patient does not experience ISR or ST, there may still be an ongoing atherosclerosis process that could form new coronary stenosis in the vessels distinct from those treated with coronary interventions. As such, it is not advisable to manage patients with coronary atherosclerotic plaque solely by addressing the local vessel issue. This explains why clinical trials that compared PCI with OMT have produced disappointing results for PCI. Interventional cardiologists often neglect the metabolic and systemic issues of their patients, leading to increased MACE after coronary intervention. They may be unable to perform complete revascularization due to complex, challenging coronary anatomies or high-risk interventions. These interventions can only be performed at top centers with minimal complications. These factors may create significant negative outcomes during the comparison study, PCI vs OMT. Studies have shown complete revascularization (CR) is only achieved in approximately 50% of PCI cases [6,32,33,34,35,36,37,38]. Additionally, as previously discussed, they tend to overlook the presence of vulnerable plaques.

In 1998, a small randomized controlled trial known as the Lifestyle Heart Trial was conducted by Ornish et al. The study demonstrated that intensive lifestyle changes with PBD could reverse coronary atherosclerosis. The most important mechanism of this process is the repair of endothelial dysfunction [39]. In 2014, Esselstyn et al. presented a famous image, as depicted in Figure 2, which illustrated strict PBD (without oil) can regress coronary stenosis [40].

It has been a decade since the remarkable research studies on atherosclerosis have garnered significant praise and acceptance within the PBD community and among practitioners who recommend PBD. Despite this, the widespread adoption of recommending PBD to patients has not been extensively embraced within the interventional cardiology community. As an interventional cardiologist myself, I initially had reservations about these findings. However, after being diagnosed with coronary stenosis on my CAC/ CTCA, I decided to follow the advice of these PBD experts. Experience in my case also has been applied to many of my patients and almost all showed regression and reversal of their coronary obstructions. Moreover, I found that this method effectively reduced the incidence of my patient’s ISR and ST [41].

Eating poor-quality food that is high in sugar (refined carbohydrate), devoid of fiber-phytonutrients, highly processed, and contains saturated and trans fats, cholesterol, and chemicals that promote chronic inflammation is a major contributor to the development of atherosclerosis. The consumption of these unhealthy foods has been demonstrated to increase levels of LDL cholesterol, triglycerides, apolipoprotein (a), apolipoprotein (b), C-reactive protein (CRP), pro-inflammatory mediators, pro-inflammatory chemokines/ cytokines, Trimethylamine N-oxide (TMAO), persistent organic pollutants (POPs), oxidative stress, tumor promotion, and cell proliferation, among other factors. All of these factors play a significant role in the development of atherosclerosis and make plaque more vulnerable [42,43]. On the contrary, eating healthy PBD with adequate supplementation will enhance our body's ability to fight against inflammation. Healthy foods such as vegetables, fruits, and legumes contain carotenoids, isoflavones, phytoestrogens, and phytosterols, which have been shown to prevent atherosclerosis. These polyphenols and phytochemicals' role in molecular signaling are anti-inflammatory, antiplatelet aggregation, inhibitor to VSMCs proliferation and migration, and safeguard for lipid oxidation [44,45]. Oxidized LDL (ox-LDL), in addition to its infamous role in causing atherosclerosis, also plays a significant part in developing vulnerable plaque [46]. Healthy PBD will also help to restore endothelial function.

The key mechanism by which a healthy PBD can reverse atherosclerotic plaque and stabilize vulnerable plaque is by changing one’s diet to PBD, thereby eliminating the consumption of foods that contribute to the development of atherosclerotic plaque in the first place. These unhealthy eating behaviors have also been linked to dyslipidemia, insulin resistance, hypertension, glucose intolerance, endothelial dysfunction, chronic systemic inflammation, increased oxidative stress, elevated trimethylamine N-oxide (TMAO), low nitric oxide (NO), gut dysbiosis, mitochondrial damage, and shortened telomeres (accelerating the aging process) [41,47,48,49,50,51]. All of these are widely accepted as risk factors for the development of atherosclerosis.

The processes through which PBD aids in the regression of atherosclerotic plaque include enhancing NO availability, modifying the microbiota, repairing endothelial dysfunction, reducing inflammation, protecting against oxidative stress, fortifying mitochondria, and extending telomeres [41]. It is crucial for individuals who utilize PBD for regressing coronary plaque purpose, to pay close attention to their food choices and consume items that possess properties that suppress inflammation, combat oxidative stress, increase NO availability, support healthy microbiota, strengthen mitochondria, heal telomeres, and exhibit anti-thrombotic properties [41] as can be seen in Figure 3. The precise quantity of these foods must also be determined to prevent nutrient deficiencies (protein, Omega 3, B12, D, K2, Fe, Zn, Cu, and Se), and the food processing method should be carefully considered to ensure maximum benefit. For instance, to obtain the highest NO source from vegetables, consuming them raw rather than cooked is recommended.

Many nutrition experts have specifically emphasized the deficiency of essential nutrients in PBDs, such as vitamins B12 and D, and minerals, like iodine, iron, zinc, selenium, and calcium, which can have detrimental effects, particularly for pregnant individuals. In this context, I have included dietary supplements in my dietary program, including vitamin C, vitamin D, vitamin K2, vitamin B3/NAD⁺, zinc, copper, selenium, and natural anti-inflammatory products such as astaxanthin, curcumin, quercetin, as well as CoQ10, taurine, and multivitamins (containing various small doses of minerals and vitamins as recommended for daily RDA). These supplements ensure no nutrient deficiency occurs when following PBDs and enhance the anti-inflammatory, antioxidant, immunomodulator, repair mitochondria, and strengthen telomere, which will be useful in the anti-aging process, including regressing coronary plaques.

4. Conclusion

Being diagnosed with coronary stenosis of 50% does not necessarily indicate it is benign since it does not need immediate intervention, as studies have shown that 68% of acute myocardial infarctions (AMIs) are caused by coronary obstruction less than 50%, likely due to a vulnerable plaque [8]. Recent developments have suggested that identifying the presence of a vulnerable plaque and intervening before it causes an acute coronary syndrome may be beneficial [13,14]. However, sophisticated tools are required to diagnose a vulnerable plaque but are currently unavailable in Indonesian hospitals. Therefore, individuals diagnosed with 40-70% stenosis in their coronary arteries have three options: 1. Finding hospitals that have sophisticated tools to determine and intervene the vulnerable plaque 2. Waiting until the lesion becomes symptomatic or causes an acute coronary syndrome, at which point coronary intervention is recommended. 3. Implementing the correct lifestyle changes and pursuing OMT. Simply advising patients to modify their lifestyle may not be effective, but medical practitioners must be knowledgeable about the lifestyle program, including selecting appropriate foods with the correct quantities and knowing the processing methods. They must also understand how to avoid nutrient deficiencies while following the program. Additionally, understanding the role of vitamins, minerals, and nutraceuticals, particularly those that may aid in plaque regression, is necessary.

In the past, doctors even recommended smoking to their patients, but through research and advancing knowledge, smoking is now banned in almost all countries worldwide. We believe that unhealthy foods will eventually be viewed in a similar manner, and individuals who consume them will be warned, similar to smoking.