Beating Back a Ruthless Killer

By LEON JAROFF

They begin to form when he is still an adolescent, smooth fatty streaks on the interior wall of a major coronary artery -- the ominous consequence of a typically American high-cholesterol, high-fat diet. By his 20s, the streaks have formed plaques, growths with a fatty center covered by a fibrous cap of smooth muscle cells. By his 40s, the plaque, its buildup accelerated by smoking and high blood pressure, has protruded well into the bloodstream, closing 65% of the arterial passage. The blood swirls and eddies dangerously as it forces its way past the swelling obstructions.

He now has a well-developed case of heart disease. Eventually the narrowing arterial passage could be blocked by a blood clot or by a spasm that constricts and closes the artery. That could cut off the blood supply to his heart, causing possibly fatal damage to its muscle. In short, he is a prime candidate for heart attack, which annually strikes 1.5 million Americans, killing half a million of them. (Women as well as men are vulnerable to heart disease, though usually later in life.)

But in this case some of the plaques start to shrink, almost imperceptibly at first, as the fatty material in its core migrates back into the bloodstream. Blood begins flowing more smoothly through the rejuvenated artery, and two years later, only 50% of the passage is blocked. The seemingly inexorable advance of cardiovascular disease has been reversed, and as the plaque continues to shrink, the risk of a heart attack has largely passed.

Only a few years ago, this happy ending would have been considered unlikely, if not impossible. While the progression of heart disease could be slowed and perhaps even halted by diet and drugs, surgery was apparently the only way to reverse -- albeit temporarily -- the damage from heart disease and restore a healthy blood flow. Now, for many cardiac patients, there may be a safer and much less expensive way.

In separate controlled studies, Dr. David Blankenhorn of the University of Southern California and Dr. Greg Brown at the University of Washington have shown that the buildup of arterial plaque can be reversed by a combination of drugs and a low-fat diet. A third study, by Dr. Dean Ornish of the University of California at San Francisco, has generated even more remarkable results. In his book, Dr. Dean Ornish's Program for Reversing Heart Disease, published by < Random House this month, Ornish describes how changes in life-style alone, like reducing stress as well as fat, can effectively reverse heart disease.

Results of the experiments far exceeded expectations. Brown, for example, designed his study only to determine if the progress of heart disease could be halted. "The biggest surprise," he says, "was that the arteries actually got better. I thought that they probably wouldn't get worse, but I was a disbeliever about possible regression of the disease." Now Brown and an increasing number of cardiologists have been converted. And for many cardiac patients, that could drastically change the way atherosclerosis is treated.

In the U.S. alone, surgeons annually perform 330,000 coronary bypass operations. An additional 190,000 cardiac patients every year undergo angioplasty, which usually involves the use of a balloon-tipped catheter to widen their arterial passages. Both operations provide immediate, dramatic relief for the cardiac patient. But there are some risks: in rare cases, either technique can trigger a heart attack. Then, too, relief is only temporary. Five years or so after bypass surgery, on average, plaque has built up in the grafted veins. And arteries opened by angioplasty sometimes become partly blocked again within three to six months. Finally, the price tags are staggering: about $7,500 for angioplasty, between $30,000 and $40,000 for bypass surgery. All told, some $11 billion is spent in the U.S. each year on surgery for coronary heart disease.

In many cases, bypass surgery or angioplasty will remain the strategy of choice. There are those with advanced heart disease, says Blankenhorn, "who clearly can't wait. If they try therapy alone when they really need surgery, they can have a disastrous outcome -- a catastrophic heart attack." But others, with less serious cases, may be able to avoid surgery -- if they are willing to make radical changes in their diet and life-style.

While trials beginning in the 1950s had shown that drugs and diet could reverse atherosclerosis in laboratory animals, Blankenhorn's groundbreaking work, begun in 1980, was the first controlled study demonstrating that the same results could be produced in humans. His subjects were 188 nonsmoking males who had undergone bypass surgery. (Most heart-disease research has been done on men rather than women.) Blankenhorn placed half of them on a diet containing 22% fat and gave them colestipol and large doses of niacin, both standard cholesterol-reducing drugs. The other recruits, the control group, merely limited the fat content of their diet.

All the men in the drug-taking group realized what Blankenhorn terms a "spectacular reduction" in their total cholesterol, and 16% of them showed decreases in their arterial plaque. "As long as you don't batter arteries with cigarettes and high cholesterol," he concluded, "they have a remarkable healing ability."

Brown's study, begun in 1984 and reported at an American Heart Association meeting last year, involved 146 men with high cholesterol levels and a family history of heart disease. Brown divided his subjects into three groups, one taking niacin and colestipol, the second receiving colestipol and another cholesterol reducer, lovastatin. The third or control group got only a pair of placebos. All the men were placed on a diet that limited fats to 30% of total calories, the level recommended by the A.H.A. Here, too, after 2 1/2 years, those taking the drugs experienced large drops in their total cholesterol level, and 35% showed a decrease in arterial plaque.

While these results convinced both Blankenhorn and Brown that reduced cholesterol was the major contributor to the reversal, Ornish has his doubts. "If lowering cholesterol were the primary factor in causing reversal of heart disease," he notes in his book, "most of the patients in the studies by Dr. Blankenhorn and Dr. Brown who were taking cholesterol-lowering drugs should have shown reversal, since almost all of these patients had substantial decreases in blood-cholesterol levels. Yet only a minority showed reversal."

Why? Ornish believes these studies, unlike his, did not deal with other factors that he believes contribute greatly to cardiovascular disease: stress and an individual's "sense of isolation." His trial was small, involving only 41 San Francisco Bay area men with heart disease. The 19 participants in his control group were to follow their doctors' recommendations; for the 22 others in the experimental group, however, he ordered a strict, exacting regimen.

They kept to a vegetarian diet that contained less than 10% fat and banned all oils. At twice-weekly meetings, a psychologist held group support sessions. Everyone was taught stress-management techniques, including yoga, and was told to spend an hour a day meditating, visualizing arteries unclogging, and doing relaxation and breathing drills. Smoking was prohibited and moderate exercise recommended.

After just one year of the study, blockages in the arteries of two-thirds of the control group had worsened. But 18 of the 22 in Ornish's experimental group had an increase in blood flow to the heart and a regression of blockages, on average, from 61.1% to 55.8%.

Could the "togetherness" and reduction of stress account for at least part of that remarkable reversal? Some experts think so. They point to studies that associate a sense of isolation with increased risk of many illnesses, including heart disease. And at the New England Deaconess Hospital in Boston, Harvard cardiologist Herbert Benson is studying the biochemical effects of stress on the body.

Stress, Benson explains, brings on a rise in blood pressure and spurs the release of catecholamines, substances that increase the tendency of blood to clot and make arteries more vulnerable to spasm. Over time, these changes play an important role, many doctors believe, in the progression of heart disease. However, Benson has shown, the changes can be largely counteracted by the "relaxation response" that follows 15 minutes of meditation a day.

Still, most researchers continue to believe that lowering cholesterol levels is the master key to reversing heart disease. Dr. William Castelli, director of the famed Framingham Study, which since 1948 has monitored the coronary health of 5,000 people in the Massachusetts town, offers this prescription for regression: reduce the level of total cholesterol below 150 mg per deciliter of blood and the level of LDL, the bad form of cholesterol that clogs arteries, below 90. In addition, says Castelli, the ratio of total cholesterol to HDL, the good cholesterol that helps clear arteries, should be less than 3.5.

Clearly, preventing heart disease is better than trying to reverse it once the process starts. Experts differ on the best mix of prevention strategies, but they agree on one thing: Americans should cut down on the fat in their diet. Otherwise, they could be eating themselves into an early grave.

With reporting by Christine Gorman/Boston and Jeanne McDowell/San Francisco