Plumber's Butt?The right and wrong way to think about heart attacks.

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Why not? Dr. Arthur Agatston, famed for creating the South Beach diet, sensibly points out that partial blockages in coronary arteries don't cause heart attacks. The trigger isn't bad plumbing—but something more akin to a land mine. People at risk of heart attacks have largely invisible cholesterol plaques throughout their arteries, which act, he says, like unpredictable "little bombs that blow up suddenly and cause a sudden and devastating blockage" in previously healthy-appearing areas.

Yet doctors and patients largely ignore the data. Last year, the American Journal of Cardiology reported that 85 percent of all balloon angioplasties and stent implants are done nonurgently for stable blockages. The trial just published in the New England Journal of Medicine confirms this monumental waste. So what does help? Drugs that affect the entire coronary system—and not angioplasty or stenting—prevent heart attacks in high-risk patients. For example, Lipitor helped reduce rates from 21 percent to 13 percent in one study.

But this raises another concern: Relying on widespread use of powerful drugs carries its own risks. Consider that estrogen-replacement therapy became common because of its supposed reduction of coronary "land mines." Not only did that turn out to be completely wrong—the drug actually increased heart attacks—but as the New England Journal just reported, widespread use probably bumped up breast cancer rates by about 10 percent. Thousands of women died needlessly.

And so, in the end, we return to the old standbys, better diet and lifestyle. It's worth remembering that the Nurses' Health Study in 2000 determined that 82 percent of all "coronary events" were avoided by five simple behaviors: not smoking, exercising for 30 minutes daily, eating healthily, maintaining normal body weight, and drinking a small amount of alcohol. Over a lifetime, these healthy behaviors are 10 times more effective than Lipitor in lowering heart-attack risk, and infinitely more sensible than widespread angioplasty.

Almost 70 years after cardiac catheterization was invented, a medical specialty called "behavioral medicine" has been created to help refocus the billions of dollars—and talented physicians—on strategies for improving diet and exercise habits. Patient incentives, such as lower insurance premiums for healthy lifestyles, may also help. And expanding insurance programs for preventive medical services, instead of simply paying for more angioplasty, might motivate doctors to spend more time on the behavioral-change counseling front.

Then there are small but populationwide changes, like New York City's recent drive to eliminate trans fats, which has roughly the same cardiac benefit as treating everyone with Lipitor, without the side effects and cost. With the aid of campaigns to reduce salt intake, Australia has reduced average blood pressure by about 1 percent to 2 percent, potentially preventing 15 percent of strokes and 6 percent of heart attacks. Last year, Arkansas helped stabilize childhood obesity rates with school-based body-mass-index screening.

These kinds of approaches deserve widespread adoption. Someday, maybe we'll figure that out, and the plumbing analogy will finally melt away.

Addendum, May 10, 2007
On Wednesday, the Journal of the American Medical Association released the results of SWISSI II, a European study suggesting that angioplasty can prevent heart attacks. The researchers found that angioplasty may have prevented two-thirds of heart attacks in very high-risk patients.

However, this trial was very small (only 200 subjects total), was not blinded, and enrolled only select people who'd had a heart attack in the prior three months without the benefit of emergency angioplasty. These findings apply to a small subset of people, and do not change my fundamental contention that the great majority of angioplasty for prevention is without benefit.

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