Non-surgical treatment for blocked coronary arteries

Hard truths about heart disease

Coronary heart disease is one of the top killers in Singapore accounting for 1 in 5 deaths in 2023. On average, 34 heart attacks occur every single day, and even more disturbing is that more of these heart attacks are occurring in younger people aged 45 years or less. Heart disease is a silent killer, often the heart arteries supplying blood to the heart block up quietly and slowly. Many sufferers don’t experience any significant symptoms until it has become severe or after they have had a heart attack

Early detection and risk stratification for prevention

Exactly because of this insidious nature; early detection and identification of high-risk individuals are key strategies in its prevention and treatment. Non-invasive imaging techniques with Computed Tomographic (CT) scans allow accurate assessment of the health of the coronary arteries and detect blockages in the blood vessels even before there are symptoms. Identification of risk factors forms the other cornerstone of heart disease management. Risk factors include hypertension, diabetes, high cholesterol, smoking, lack of exercise, obesity, poor sleep, stress, air pollution, excess alcohol, chronic inflammation and genetic predisposition.

What should I do next if I have blocked arteries?

Early detection and quantifying an individual’s cardiovascular risk is just the beginning. What should we do once blockages are found? Not every blockage needs a stent or surgery. Some cases of severe blockages may indeed benefit from ballooning and stents inserted into the arteries to dilate the blood vessels (a catheter procedure known as percutaneous coronary intervention, or coronary angioplasty, Fig. 1), other more severe or extensive disease may need coronary artery bypass grafting surgery. However, thankfully many blockages do not, and this applies even to seemingly tight blockages causing more than 70% narrowing, these can often be managed with lifestyle changes and medicines alone, provided symptoms are controlled and tests show no high-risk features. Heart blockages that are asymptomatic and/or have undergone special evaluations known as functional tests and passed, may be treated safely with a combination of medication and aggressive risk factor modification through lifestyle interventions. These key therapies reduce inflammation, decrease the likelihood of blood clots and improve vascular health and function. This strategy has been shown to stabilise blockages, and in some people shrink them slightly, thereby reducing the risk of developing heart attack and its complications in the future. This process of shrinking the cholesterol deposits (called atherosclerotic plaques) in the blood vessels that cause blockages is called “plaque regression”, as opposed to the procedures mentioned above (angioplasty or bypass surgery) (Fig. 2).

Is a stent “surgery”? Angioplasty vs bypass

Of the two main procedures, only one is an operation.

• Angioplasty and stenting (PCI): a catheter procedure. A thin tube (catheter) is passed through a blood vessel, usually in the arm or leg, to the narrowed artery, a balloon widens it and a small mesh tube (stent) holds it open. The chest is not opened, and recovery is usually much quicker than after surgery. Read more about angioplasty and stenting.
• Coronary artery bypass grafting (CABG): open-heart surgery. A healthy blood vessel from another part of the body is used to route blood around the blockage. It may be advised when several arteries or the main left artery are narrowed. Recovery usually takes about 6 to 12 weeks. Read more about bypass surgery.

Your cardiologist may first check how much a narrowing limits blood flow, with a stress test or a pressure-wire study during an angiogram. Neither procedure removes the underlying disease, so medicines and lifestyle changes are still needed afterwards.

Non-surgical treatment and lifestyle medicine for coronary heart disease

Several modifiable risk factors contribute to the development and progression of heart blockages. These include high cholesterol, high blood pressure, diabetes, smoking, obesity, diets low in fruits and vegetables, lack of exercise, excessive alcohol, psychosocial stress, and poor or inadequate sleep.

Once it is determined that invasive treatment is not required, a detailed assessment of the individual’s modifiable risk factors and heart attack risk estimate is made in order to prescribe a personalized treatment plan combining holistic lifestyle optimization and medication. Using lifestyle interventions to improve the above lifestyle risk factors is known as lifestyle medicine. The American College of Lifestyle Medicine defines it as the use of evidence-based lifestyle therapeutic intervention - including a whole-food, plant-predominant eating pattern, regular physical activity, restorative sleep, stress management, avoidance of risky substances, and positive social connection - as a primary modality, delivered by clinicians trained and certified in this specialty, to prevent, treat, and often reverse chronic disease. Targeting these 6 pillars, the doctor can educate, activate, and initiate a lifestyle-first approach with patients at risk for or with established heart disease. Small studies of very low-fat, plant-based programmes (Ornish, Esselstyn) reported less plaque progression and some regression, but these results have not been confirmed in large trials. Cardiac rehabilitation programs consisting of guided exercise and aggressive risk factor modifications have also shown similar positive effects on blockages. Intensive cholesterol lowering through a combination of dietary adjustments and lipid lowering medications is another key driver of plaque regression.

Can blocked arteries be cleared or reversed?

Not cleaned out. Plaque builds up inside the artery wall over years, and no medicine, diet or supplement removes it. Treatment can:

• Stabilise plaque: make it less likely to rupture and trigger a clot, the usual cause of a heart attack.
• Slow or stop its growth: by lowering LDL (“bad”) cholesterol, controlling blood pressure and diabetes, and not smoking.
• Shrink it slightly in some people: imaging studies show a modest reduction with intensive LDL lowering. Calcified plaque usually stays.

The benefit is fewer heart attacks and less chest pain, not a “clear” artery.

Medicines used to treat heart blockages

Most people take a combination, chosen individually:

• Statins, sometimes with ezetimibe or a PCSK9 inhibitor, to lower LDL cholesterol and stabilise plaque.
• Antiplatelet medicines, such as low-dose aspirin, to reduce the risk of a clot forming on plaque.
• Beta-blockers, nitrates or calcium channel blockers to ease angina by reducing the heart’s workload or widening blood vessels.
• Blood pressure and diabetes medicines, where needed.

They work only while taken. Don’t stop any, especially after a stent, without asking your cardiologist. Cardiac rehabilitation helps combine medicines with exercise and lifestyle change.

Conclusion

Despite advances in detection and treatment, coronary heart disease remains a major cause of death and disability in Singapore and the world. Fortunately, many coronary artery blockages can be prevented or stabilised, and some may shrink slightly, with non-surgical methods consisting of appropriate use of plaque modifying medication, and optimization of one’s lifestyle habits performed adequately in a measurable and consistent manner.

This write-up has been medically reviewed by Dr. Peter Ting, a senior consultant cardiologist at The Harley Street Heart & Vascular Centre in Singapore, to ensure the accuracy and reliability of the information provided.

Frequently asked questions

When is a stent or bypass needed rather than medicines alone?

Usually after a heart attack, when angina continues despite medicines, or when tests show high-risk blockages. For stable blockages without these features, starting with medicines and lifestyle changes is often reasonable. Your cardiologist will advise on your situation.

Does a stent cure the blockage?

No. It opens one narrowed segment, but plaque can form elsewhere, so medicines and lifestyle changes continue.

What symptoms need urgent attention?

Chest pain or pressure lasting more than a few minutes, pain spreading to the arm, jaw or back, breathlessness, sweating or fainting. Call 995.