My Plaque Stabilization-Regression Therapy

I started my cardiology practice in 1978 - so, it’s has been over 40 years and have accumulated a large amount of cardiology experience. When it comes to new advances, I am an early adapter. I treated and followed up tens of thousands of cardiac patients and incorporated new scientific advances as they became available into my clinical practice. During the first half of my practice, I saw many CAD cases behaved like terminal cancers - patients died prematurely even after undergoing successful heart bypass, then had multiple stents over a period of years, then survived multiple heart attacks and many hospitalizations, developed heart failure and then just dropped dead before age 65. All those medical advances had only small incremental benefits and they were very expensive. There’s got to be a better way.

The second half of my practice started in 2001 when I decided to find a better approach, a more prevention-centered approach and asked myself - what if I can actually stop cholesterol plaque build up by medical therapy a few years before a heart attack develops and years before a stress test becomes positive. The year 2001 was the year I pivoted to aggressive plaque-centered medical therapy in high risk patients. Coronary calcium scoring by electron beam tomography (EBT) was already available but was expensive - around $400. Now, CAC scoring costs less than $100. 

My professional and personal journey to prevention was a challenging one since there was no formal training in preventive cardiology even now. But in a way it was special about having already practiced cardiology for 20 years and developing your own program. It involved becoming among the first 50 physicians to become board-certified in Clinical Lipidology in 2006, joining the lecture circuit, creating care innovations that closed the prevalent wide treatment gap in my practice, publishing two performance data (2006 and 2017), creating my own websites, then, achieving outstanding patient outcomes and lowering healthcare cost. Yes, I turned off the faucet instead of just mopping the floor before anyone else did.

The heart attack rate per year in my practice has dropped continuously and progressively since 2001 and in the last 10 years, it has been unbelievable low 0 to 1 case per year. 

The cost savings were obvious even without this report - several thousand dollars per year per beneficiary with diagnosis of CAD ($8,790) or diabetes ($6,499).

What is going on with them?

I am disappointed when I watched in YouTube some cardiologists, after embracing the importance of coronary artery calcium scoring in early plaque detection, decided to replace proven medical therapies that saves lives with unproven treatment.

I also saw a cardiologist (an interventionist and department head) who proclaims that using statin is like inducing abetalipoproteinemia. This claim is false and is misleading people with life-threatening disease.

The jury is in (not out).

While the designs of the statin and ezetimibe clinical trials were imperfect and the strength of evidence did not even come close the what over 10 thousand engineers and physicists all over the world (CERN) labored for over 40 years using the largest, most complex and most expensive machine ever built by mankind - the Large Hadron Collider, to discover the Higgs boson and did so with a 5 sigma strength level of evidence. The likelihood of the two high energy photon decay that the physicists used to support the existence of the Higgs boson - the last missing particle that needed to be discovered to complete The Standard Model, was just a statistical anomaly, is 1 in 3,500,000! 

The placebo-controlled statin clinical trials involved over 1 million patient years and for me taken as a whole, the evidence that statin therapy significantly reduces cardiovascular events and that it is safe and that lower the LDL particle/LDL-c level in patients with atherosclerosis is better is the strongest possible in medical science. There is no other drug or intervention that has been more studied than the statins. This subject matter is not quantum physics where the truth is weird, mind-blowing and contrary to common sense: superposition, quantum entanglement, quantum tunneling, wave-particle duality, etc. Even if we do not understand these quantum phenomena fully, we accept them and benefit from its application every minute of every day. 

So what is going on with them? Everyone has their own biases including myself. I want to see the epidemic of premature and preventable heart attacks and strokes and the enormous economic burden go down every year. What are theirs?

Extensive clinical experience and cholesterol treatment guidelines shaped my approach to treating atherosclerosis

Treatment guidelines are not always correct. All the three previous cholesterol treatment guidelines were formulated by NIH under the leadership of Dr. Scott Grundy. But in 2015, the ACC and AHA took over and wiped out the progress made in the NCEP ATP III guidelines. The 2015 ACC and AHA Cholesterol Treatment Guidelines promoted a “prescribe and forget” approach which was a serious error and represented a two step backward approach in preventing more cardiovascular events. 

The landmark COURAGE Trial dramatically reduced the number of unnecessary PCI’s - their conclusion was that in patients with severe but stable multivessel CAD, even with inducible myocardial ischemia, in patients receiving optimal medical therapy, prophylactic PCI had no real benefits - no reduction of heart attack, cardiac death, etc. 

COURAGE Trial - Patient CharacteristicsCOURAGE Trial - The Conclusion









In both PCI and control groups, statin therapy was titrated (not the “prescribe and forget” approach that AHA and ACC advocated in 2015) to get LDL-c levels down to less than 70 mg/dL. 

Inducing Plaque RegressionCOURAGE Trial LDL-c Levels









Clearly, both groups were already on statin at baseline. Appropriate titrations were done and by Year 5, the mean LDL-c levels were 71 mg/dL and 72mg/dL - an exceptional achievement for a large multi-center trial. The COURAGE trial, more than any other, demonstrated the potency of optimal medical therapy in halting the normal progression and rupture course of atherosclerosis.

I remember a time when elite interventionalists (them, their hospitals and the device manufacturers made a lot of money) took pride in putting in over 1,000 stents a year. I don’t want see that era return. More Americans will die. Why? Because 68% of all plaques that caused heart attacks only cause mild to moderate narrowing as shown below (left). 

Mild to Moderate Plaques Cause Heart Attacksmri-plaque-regression med hr









Only optimal plaque-centered medical therapy can induce plaque stabilization and regression. The slide shown above (right) is an example of plaque regression (carotid artery).

 It is very unusual for a selected group of very knowledgable physicians to arrive at such a census unless it was a deliberate attempt to push back heart attack and stroke prevention and rejuvenate interventional cardiology. This “prescribe and forget” approach was retracted in the 2018 guidelines under a different leadership - the NCEP ATP veteran Dr. Scott Grundy.

These two AHA presidents that called out the members for holding back CVD prevention for the sake of $$$.

ACC President 2004-2

"There is too much financial investment in the interventional treatment of CVD… the evolution to a more preventive approach is inevitable…it will not come painlessly…"

“It is time to turn off the faucet instead of just mopping the floor.” It was an incredible statement from the president of the American College of Cardiology. It was a rebuke that we are still stuck in the old ways by choice (for financial gains) not because of ignorance.

Me, as my patient

I always tell my patients that I will do for them what I have done for myself.

In 2004, I had my initial coronary calcium scan at age 56. To my surprise, it was not low as I had expected - less than 10. It was 649!. I was at the 93rd percentile. My vascular age was 76!

Dr deGoma CAC Score 2004

My coronary arteries might look like this inside - shown above.

I have a strong family history - my father had heart bypass at 65, maternal grandfather had stroke and heart attack, two paternal male cousins died from a stroke and a heart attack in their 40’s. I have mild hypertension. I had low HDLc - hovering around 28 and high LDLc - around 150. My fasting glucose was around 110 mg/dL. I met the three of the criteria for cardiometabolic syndrome: high BP, low HDLc and impaired fasting glucose. I have insulin resistance, probably for many years already and I was not aware of it. I never smoked. I had a normal treadmill nuclear stream test about 5 years before. I really had no symptoms.

I started myself on triple combination statin therapy - Low dose statin + Ezetimibe 10 + Niaspan 1.5 Gm/day. I was always on low dose statins but switched around from simvastatin 20, atorvastatin 10, pravastatin 40, rosuvastatin 10 and pitavastatin 4 because of mild myalgia. The most well tolerated statins for me were rosuvastatin 10 and pitavastatin 4 mg. I took Niacin ER for almost 10 years and my HDLc went up slowly from 28 to as high as 65. I started talking ezetimibe from the first day it became available and had no side effects from it.

Dr. R.deGoma Lipid Profile 2013

 

My latest comprehensive lipid profile October 2019:

LDLc = 31  LDLp = 596  HDLc = 49  Tg = 90  T.Chol = 97  OxLDLc = 17

28112871-475C-4D4C-86C8-C03118D05E9E
753D2F39-0967-48CC-BB8D-0134736C31EC
ADEE2030-CA45-46A0-B027-0AD469439906 4 5005 c
Even Lower is Even Better

I kept my LDL cholesterol levels in the 30’s and 40’s since after I knew my CACS was 649 (2004) and my vascular age was 20 years older than my chronologic age.

I am 72 now - no symptoms, no procedures, no hospitalizations. My consumption of healthcare resources is very low - only routine blood tests twice a year and generic medications. I exercise at home. I know my plaques have stabilized and regressed. I reversed my CAD. I was at very high risk at age 54. At age 72, I am at low risk. I just started on the metabolic switching eating regimen which I explained in another page in this website.

It is time to turn off the faucet instead of just mopping the floor 

Everything to the right of the prevention wall is just mopping the floor. Most of cardiology is on that side unfortunately. 

I developed my PaKS (Passion, Knowledge, System) approach and ACCEPT clinical management system which helped to close the wide treatment gap (L-TAP study) in my practice, later published two LDL-c treatment goal performance data (2006 and 2017).   

I use the treatment guidelines as my minimum standard of care - for very risk risk patients I will go beyond the standard - lower LDL-cholesterol level and LDL-particle number. I don’t use high dose statin as initial therapy because of high discontinuation rate from side effects. I use low dose statin plus ezetimibe which reduces LDL-c as much and even greater than high dose statin alone. I reserve using PCSK9 inhibitors only when high dose statin and ezetimibe combination is not able to get high risk patient to optimal LDL-c goal. I use CAC scoring more - I don’t like palmistry cardiology. Getting a CAC score is like getting mammography for the heart. Who wants to give chemotherapy to patients with normal mammography and offer no options to patients with hidden breast mass? For less than $100, CAC scoring provides the precise answer that I and my patient need. Are plaques present or not? How much? Which arteries? That is precision medicine.

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