"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.

Amen to everything you said Dr. and one other point I heard a nimber of times yesterday, everybody was in shock because Mr. Russert had just had a stress test done in April and passed with no problems ! As all your readers know what a stupid thing to say.

Dr Davis,
I appreciate your posting on Tim Russerts passing.  I was a big fan of his. I believe if he had worked half as hard on his heart health as he did on his career we would be enjoying him on TV for many years to come.  Of all the commentators discussions since his passing, the most important things aren't being discussed.  His diet (low fat I'd guess), his meds (statins I'm sure)...He did have a good stress test April 29.  Lot of good that did.

Russert had both CAD & diabetes.

Newsweek health article about Russert and sudden cardiac arrest:

http://www.newsweek.com/id/141450?from=rss

Usual blather about not being able to prevent/predict sudden cardiac death, risk factors, and usefulness of defibrillators, etc.

Thank you for this commentary.
His passing is very sad.
My uncle had the same thing happen at a relatively young age as well.

By the way, can you suggest a fish oil for those of us whom are allergic to shellfish?
I've heard we can use any type of fish oil; just not krill oil.
Does Sam's Club Maker's Mark fall under that category?

Thank you!

Regarding the death Of Tim Russert:

In the new issue of Newsweek, Dr. Steven Nissen, chair of cardiovascular medicine at the Cleveland Clinic told the magazine when asked about the role of STRESS and heart attacks:

"Most of us do not think it is terribly relevant," and explained this with a shocking lack of logical thinking: Newsweek writes, "After all, he notes, "many people in this world have stressful jobs," and they don't all die of of heart attacks.

Time Magazine named Dr. Nissen one of the 100 Most Influential People In The World in their "Scientists and Thinkers" section.

Think about that.

Now, consider the completely illogical statement from Dr. Nissen bolded above. One thing should be made perfectly clear in light of this statement: He believes cholesterol as very relevant to heart attack risk. Yet, to turn his Newsweek comments around, "many people in this world have **high cholesterol**" and they don't all die of heart attacks.

In fact, study after study shows countries with the highest rates of fat intake and the highest average cholesterol rates have the lowest incidence of heart disease. Imagine that!

Dr. Nissen's irresponsible and illogical comments in Newsweek shows - again - the complete bamboozlement the cholesterol hypothesis has on western medicine just because, "everyone knows," high cholesterol causes Coronary Heart Disease. How do they know this? "Because everyone knows." Ad nauseum. With a little research, the facts show this is simply not true.

What Dr. Nissen said about stress can be said about high cholesterol. Plenty of people live with both without having heart attacks.

Maybe Mr. Russert's death can help in bringing us back to real science as opposed to what Big Pharma dictates as what is science - and what is not. Follow the money.

How ironic that it was Dr. Nissen who made such a horrible misstep in logic with his comments to millions of readers in Newsweek.

I have a couple of questions that were put to me about Heart Scans that I can't answer. Perhaps you will indulge me.

First, from a Doctor friend of mine:  Most of the widely used diagnostic tests have been studied with respect to their Specificity, Sensitivity, positive and negative predictive value, etc. We know how to use them, and we know how to interpret the information they provide. Last I read, there is not enough correlation between the amount of calcium present in the walls of the coronary arteries, and the degree of coronary sclerosis. Maybe in time there will be enough convincing data - but for now, it is wrong to blame the slowness of the acceptance of the test by the medical community solely on financial interest.

Second, from another friend:

I had the EBT test and showed a calcium score of 950. An angiogram showed no blockage. Go figure. The Doc thinks the calcium is in between the artery walls with the lumen free.

Russert traditionally appeared on Charlie Rose right before Father's Day.  They were good friends -- Rose sold his house in Washington DC to him and aired a moving tribute the night after his sudden MI.

Russert loved his father and wrote a famous book about him 'Big Russ'. It is ironic his own death was right before Father's Day today. And so much much more awful for his surviving son whom he loved so much and was very vocal about.

I hope a new movement for cardiovascular and diabetes prevention may be sparked over this needless, rescue-able, tragic event.

He touched so many lives... fathers, Buffalo fans, media, political enthusiasts...

(I'm glad my Dad is aware of Track Your Plaque -- Thank you Dr. Davis... and Happy Father's Day!)

-G

Mike--

Thank you for your thoughtful and insightful comments. I coudn't agree more.

Henry--

I'm sorry, but if friend told you that, you need new friends.

The literature exists and there's quite a bit of it. Just because your friend is completely ignorant of a body of scientific literature several thousand studies long does not mean that it doesn't exist.

All of your questions can be answered on the www.trackyourplaque.com website.

I buy my Fish Oil from Costco. It happens to be Nature Made 1200mg softgels. Don't let anybody worry you about mercury content on this kind of product. None of these brands have any in them.

If it causes any problems, take it with food.

--Far more could have been done to have prevented Mr. Russert's needless death. And I don't mean the idiocy of making AED's available in office buildings. I'm talking about preventing the rupture of atherosclerotic plaque in the first place.