"If it's any consolation, the plaque that seems to grow because of a previously inserted stent seems to lack the plaque "rupture" capacity of "naturally-occuring" plaque. It is, indeed, somehow different. It is more benign, less likely to cause heart attack."

Dr. Davis:

You'll pardon my obvious question:  Has anybody actually looked at this phenomenon both in structure and composition at (pardon the word) autopsy?  I would wonder if it's a hyper-reaction to a foreign object, a kind of 'normal' scarring, as you mentioned, or something else.  Obviously there is calcium in this plaque, else it wouldn't be visible on scan. Very curious...

madcook

Madcook--
The phenomenon is known as "edge restenosis". When examined at autopsy, or in years past when plaque was actually extracted by procedures like directional atherectomy, the material is the same as that occuring within the stent, known as "neointimal hyperplasia."

The million dollar question is: Can anything modify neointimal hyperplasia? This is the whole dilemma of stent restenosis, the growth of tissue into stents. Of course, the procedural answer tends to involve drug coated stents. However, I know of no specific preventive strategy that has demonstrated substantial impact on the edge restenosis phemenonon. I've tried several agents, including cilostazol, which holds modest promise.

Thank you for that information... I look forward to hearing more about the use of these agents as time goes by.

"Of course, the procedural answer tends to involve drug coated stents."

I just wonder how many people, who 'flunk' a treadmill test, or having an 'equivocal' result, end up in the cath lab and emerge with stent(s)... Are they _really_ aware beforehand that a lot of stent use is "off label" and they just might end up with a year or two (or a lifetime) on Plavix and aspirin?

I lasted a week on Plavix before I refused anymore... after nearly bleeding to death in the kitchen from a cut (where else would a madcook hang out?).  But then I was very lucky, too as I escaped the cath lab without needing stenting.  A rare event I understand... and aspirin will always be my daily friend (along with most of the other TYP recommendations).

Regards and thank you for the Heart Scan Blog.  It is a tremendous resource and very informative.

madcook

RE: "A year later, there will be a "new" plaque at the mouth of the stent or just beyond the far end."

I'm curious whether or not this is a regular or typical occurrence and if there are symptoms one should be sensitive to that indicate such a development. Also does the size of the stent have a baring on the condition? Does vigorous exercise exasperate the condition?

I appreciate your blog. It's very informative and helpful.

John--
It is, unfortunately, a very common occurrence, though the majority of times it does not result in any specific symptom or clinical consequence. Among the 30% or so of people who do re-develop chest pain, breathlessness, or have a new abnormality on a stress test, most of the time another stent is implanted at the area of tissue growth.

Though this is really outside the realm of the Track Your Plaque program, it is yielding confusing results for people who engage in the program yet have a stent or two. It's my believe that the stent modifies the process of scoring in the stented artery. That's why we can see score reduction in arteries without stents, while the artery with a stent shows substantial increase in score.

The larger the artery, the less likely this occurs. Large means 3.5 mm or greater in diameter.

Great post, and painfully true for me; my father had to undergo his 2nd coronary bypass operation this past April 2007, and despite the strangely 'status-quo' or 'business as usual' attitude of both the surgeons and assisting doctors and nurses involved in my dad's procedure (yes, the whole thing seemed like such a regular day at the beach to them because Holy Cross in Fort Lauderdale performs so many of these operations on a daily basis, with success, of course) did nothing really to quell my family's fears of the severity of this operation; this is still a monstrous operation that not only takes a heavy toll on the patient, but on the family sitting in that waiting room as well.
I still cry at the memory of having to tell my dad, "hey Pop, you need another CABG" after an invasive angiogram revealed disaster after disaster in his arteries.
And this is why your message is so important, and why it needs to get out every day, and loudly.

I'm rooting for you. And I'm thankful you're here.

A few thoughts about this post:
The first is a question. What do you think about ultrasound screenings for carotid artery plaque, abdominal aortic aneurysm, and peripheral arterial disease? A company called Life Line offers these, saying that they show evidence of plaque build-up in the arteries. Are they useful in conjunction with a heart scan, or can they indicate risk similar to a heart scan? It sounds like they are intended to be early detectors of stroke risk. Are they worth the investment?

The second comment is an observation. Those of us not in the medical field tend to assume that anyone who is knows what he or she is talking about on the subject of the human body and illness. However it is apparent that those with M.D.'s can come to very different conclusions about what causes us to get sick and what we should do to prevent illness. Dr. Dean Ornish is an M.D. You are an M.D. Dr. Atkins was an M.D. Yet the dietary advice differs noticeably, so how do we know who is right and who to listen to? I've learned not to believe something just because a doctor says so, because when I followed the low-fat high-carb advice I got fat and felt horrible, but now that I am following a low-carb plan with plenty of protein and fat, I've lost 25 lbs. and feel great. My bloodwork also supports your claims: low triglycerides, high HDL, and low fasting blood sugar. It's kind of sad in a way that I actually get better medical advice from doctors whose blogs I read on the internet (I'm also a Dr. Eades fan) than from my personal physician. And finally, a thank-you: since reading your advice about Vitamin D, my flower garden is in the best shape it's been in in years, since I have a new knowledge about why it's so important spend some time in the sun and a new motivation, therefore, to be outside pulling the weeds.

And concerning your recent post  about breakfast cereals,congratulations are in order: I've broken my husband's cereal for breakfast habit. (I broke my own years ago.)

I have had good results with the Lifeline service, but only when used in conjunction with a heart scan. It cannot replace a heart scan. This is because, while atherosclerosis is a body-wide process, this disease does not perfectly track in parallel in all arteries of the body. You can, for instance, have lots of plaque in the carotid arteries while having only a modest amount of plaque in the coronary arteries, and vice versa.

I agree with your second comment. In fact, I have posted on this Blog about this.

We are all swimming in a sea of information and mis-information, and blind alleys along the way to the truth. We can only educate ourselves as best as possible and then come to our own judgements about the value of this or that argument.

I have a comment too: I think one reason there is so much confusion is because dietery connection with heart disease hasn't been sufficiently studied. We only saw some partial studies by Drs Ornish, Agatston, Atkins, Hayes but not much independent verification, AFAIK. For example there are some studies done by now on the effects of a high fat low carb nutrition in diabetes and epilepsy but virtually nothing that I know of for cardiac patients.  The only one such study I heard of was halted half way through (after showing very promising results) when the funding was cancelled, 27 years ago.
Stan (Heretic)

A somewhat updated comparison of old care versus new care: I was on American Airlines this week, and looked through their magazine. There was a full page ad from the Cooper Clinic in Texas; a 46 year old woman pictured said "I had no idea I had heart disease, but had a family history...an EBT scan and four stents later, with some lifestyle changes, I'm a new woman".

I understand you can't generalize from one case, and while this seems to represent cutting edge treatment, it also gives me the creeps thinking about the obvious drive for revenue here. Couldn't they have tried your approach for awhile before invading? Thanks.

I think that they tell the stories that have a "WOW!" factor. The Cooper Clinic does indeed engage in a low-level grade of preventive care (AKA Lipitor, etc.)

But I really hate those stories, too.

Saw a lady at shul today, she is convinced of Dr. Esselstein's more carbs- is- better method. Ornish, Esselstein.....hard to refute the drumbeat of eat carbs, cut meat and fat.