This week a 59-year old woman traveled 2 hours to my office for a 2nd opinion. She was 5’3 and weighed 252 lbs., down from a peak of 320 lbs. a few years earlier. She had been diagnosed and treated for Type 2 diabetes mellitus since the year 2000 and had been treated for hypertension and hyperlipidemia for a decade. She had been treated once with laser for retinopathy and had mild peripheral neuropathy. She never smoked. Due to progressive kidney failure, she began hemodialysis in 2014 and had a kidney transplant in 2017. She had a carotid endarterectomy in 2016. She denied angina or dyspnea but underwent a chemical nuclear perfusion scan this year and had moderate to large reversible defects with an ejection fraction of 61%. She underwent right and left heart catheterization showing normal right heart pressures. Her left main was 10% narrowed, her vessels were large, her LAD after a septal branch was 70% narrowed, a first circumflex marginal was functionally occluded 100%, and her distal RCA to a dominant circulation was 80% narrowed. She was advised to have cardiac bypass surgery.
She could ride her stationary bicycle 20 minutes. She used CPAP to sleep. She had followed a whole food plant diet with no added oil on and off over the years, once reaching 180 lbs, and resumed it fully 6 weeks ago. She was down 12 pounds. She worked full time. She had a supportive family nearby. She was on a statin, aspirin, a beta-blocker, nitrates, and diabetic medications.
The ISCHEMIA Trial
One of the most anticipated and expensive trials in the history of cardiology care ($100 million) was presented at the annual American Heart Association meeting in Philadelphia in November, 2019: The ISCHEMIA study. The study design was previously published.
The study randomized 5,197 patients with stable ischemic heart disease (SIHD) identified at a network of international treatment centers with moderate to large zones of ischemia on stress testing in the setting of suspected CAD (just like the case study). Many had a coronary CT angiogram to evaluate for and exclude severe disease of the left main trunk and those without it were randomized to optimal medical therapy and lifestyle changes alone or those therapies plus catheterization. Of those that underwent coronary catheterization…
