Risk for Repeat Heart Attacks

ByMelissa Schorr

B O S T O N, Sept. 27, 2000 -- The good news: You’ve just survived a heart attack.

The bad news: Your heart troubles could get worse, if your attack was caused by one of several “vulnerable plaques” — tiny, inflamed buildups of fat that burst and plug up blood vessels — any of which could be a ticking time bomb for another attack.

Doctors have come to believe as many as two-thirds of all heart attacks are caused by these vulnerable plaques brewing on blood vessel walls, which become inflamed and suddenly rupture for undetermined reasons. The other third are due to fatty blockages, or clogged arteries, and rarely, vessel spasms.

A new study being published in this week’s New England Journal of Medicine lends further credence to the theory that plaques in several locations throughout the heart’s vessels increase the likelihood of further heart disruptions.

Tip of the Iceberg “When you have a heart attack, the area that emerges is the tip of the iceberg,” explains the study’s lead author, James A. Goldstein, a cardiologist at the William Beaumont Hospital in Royal Oak, Mich. “There is corrosion in the pipes throughout the house.”

In the study, Goldstein and his colleagues examined the angiograms, or the X-ray images of the heart’s blood vessels, from 253 heart attack patients and found that 40 percent of them had several remaining unstable plaques throughout the vessels in their hearts.

Those patients with the multiple plaques, he found, were more likely to be repeat offenders for heart attack within the year. They were also more likely to develop symptoms that require repeated repeat angioplasty or bypass surgery, he says.

Goldstein says these findings may suggest a new treatment style for heart attack patients, including taking megadoses of cholesterol-lowering drugs and anti-inflamatory medications immediately after the attack to stabilize the remaining plaques, as well as interventional surgery on the plaques that look especially “nasty” and rupture-prone.

Treatment Unclear But experts say they have yet to determine the best way to treat these vulnerable plaques to prevent them from doing damage. This month, cardiologists met at a conference held in New York City to discuss the best ways to identify and treat plaques.

“At this point, we’re not certain of the right treatment — aggressive lipid-lowering or addressing these lesions specifically,” says Dr. Sergio Waxman, a cardiologist at the University of Texas Medical Branch in Galveston, Texas, who presented research at the meeting. “There are some data that suggest that being more aggressive is associated with more benefit.”

Waxman adds it may be cheaper to treat the patient with drug interventions than performing costly surgery on each lesion, such as implanting a stent, a wire mesh placed in the blood vessel to hold back any obstruction.

Others doctors are exploring different potential methods of treating the plaques, such as using heat or gene therapy, says Dr. James Willerson, medical director of the Texas Heart Institute in Houston.

The important message from this study is that heart attack victims need to remain on top of their treatment, says Dr. Christopher Cannon, a cardiologist at Brigham & Women’s Hospital in Boston..“The perception is that you have an aggressive treatment for a heart attack, you go home and you’re fixed,” Cannon says. “This is a pretty strong reminder that isn’t always the case — there are other lesions that can cause problems. You really have to follow through with your treatment.”

Plaque Prevention The findings may also have implications for those who have not suffered a heart attack, but are concerned about their future heart health.

In addition to an angiogram, a simple blood test that measures something called C-reactive protein and amyloid protein can be performed to test whether inflammation is present in the body, indicating these vulnerable plaques are present, says study author Goldstein. But the test is not yet widely available.

The plaques also can be aggressively treated with cholesterol-lowering medications, which have been shown to lessen a chance of a rupture by somehow stabilizing the plaques, says Dr. James Januzzi a cardiologist at the Massachusetts General Hospital in Boston and a member of their Vulnerable Plaque Project.

Unfortunately, there is still no way to accurate predict which plaque will go on to rupture and cause a heart attack. “That’s the million-dollar question,” sighs Januzzi. “This doesn’t solve that problem — but it adds all sorts of enthusiasm towards finding a technology that can.”

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