close up of three doctors faces wearing surgical scrubs and masks

This story has almost disappeared without a trace. That’s because it defies conventional wisdom. Doctors do not know what to do when data do not support strongly held beliefs.

The New England Journal of Medicine published an important study on September 5, 2013, titled “Door-to-Balloon Time and Mortality Among Patients Undergoing Primary PCI.” In a nutshell, deaths due to heart attacks have not been reduced despite faster clot busting strategies.


Here’s the story behind the headlines. A heart attack is generally thought to be caused by a blood clot that lodges in a coronary artery, cutting off blood flow to heart tissue. This can lead to cellular damage, irregular heart rhythms and death. The goal of modern-day treatment has been to open blocked arteries as quickly as possible and to restore blood flow and prevent further tissue damage. It seems totally logical.

Interventional cardiologists have been pushing to speed up this process because of the absolute belief that minutes matter. They assess their success by measuring “door-to-balloon” or D2B time, meaning the time from entrance into the hospital to actual insertion of the catheter that contains a small balloon. When the balloon is inflated it is supposed to open the blocked artery through a procedure called PCI (primary coronary intervention, aka angioplasty). Pressure to shorten D2B time has been intense and hospitals congratulate themselves when they make progress shortening the amount of time it takes to get a patient from the ER into the cath lab and open the clogged artery.


Here’s the rub. In the just-published study, researchers analyzed data from 96,738 heart attack patients undergoing angioplasty between 2005 and 2009. These are big numbers and very revealing.

Between July 2005 and June 2006 the door to balloon time across 515 hospitals was 83 minutes. Between July 2008 and June 2009 that time dropped significantly to 67 minutes. That may not seem like much to a layman, but trust us when we tell you that it is a substantial improvement. Hospitals are really humping to accomplish that kind of reduced D2B time.

Perhaps even more impressive is the statistic that 83.1% of hospitals reduced door-to-balloon times to 90 minutes or less (a major goal) by the end of the study compared to only 59.7% of the hospital at the beginning of the study. By all accounts, the grand operation (in the fullest sense of that word) was a success. The trouble is the patients still died at the same rate. There was no improvement in outcome. The same number of patients died at the end of the study as at the beginning, despite faster angioplasty procedures.

What went wrong? No one seems to have a good answer. Here is what the authors conclude with regard to their research. Their “findings raise questions about the role of door-to-balloon time as a principal focus for performance measurement and public reports,” and “suggest that additional strategies are needed to reduce in-hospital mortality in this population.”

You have to understand that the commitment to reduce D2B times was extraordinary. To accomplish a goal of under 90 minutes, or better yet, 67 minutes, took incredible resources and effort by dedicated teams of health professionals. It comes as a tremendous shock to learn that this super-human effort didn’t pay off in reduced mortality.

This isn’t the first time that primary coronary intervention (angioplasty with a stent) has produced unexpected results. A study published in the New England Journal of Medicine (April 12, 2007) rattled the cardiology community to its core. The COURAGE trial (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) pitted stents against drug therapy and lifestyle changes.

The 2,287 patients who participated in this study all had chest pain on physical exertion, what doctors call stable coronary artery disease. They presumably also had some clogging of their coronary arteries. Roughly half were randomized to receive angioplasty and stents plus drugs and lifestyle recommendations. The other half just got medication, diet recommendations and exercise coaching. To the shock of interventional cardiologists (who perform angioplasties), there was no measurable difference between the two groups after five years when it came to heart attacks, strokes or deaths.

Angioplasty costs about $30,000. The medications (which are mostly available generically) are inexpensive and should cost less than $500 a year.

The core of the problem with angioplasty and stenting is that cardiologists have sold this procedure as a plumbing problem. They perform an angiogram in which dye is squirted into the heart so that the arteries can be seen in graphic detail. If there is a blockage it looks dramatic. That is why George Bush had stent surgery this summer. Although he had no chest pain or shortness of breath and was in great shape, an exercise stress test suggested trouble. That led to heart imaging and signs of blockage and that led to angioplasty and a stent.

We won’t enter the controversy over whether this was a life-saving procedure or an overreaction. What we can say is that most patients believe getting a stent will prevent a future heart attack. There are no data to support that belief. Angioplasty and stents can often ease chest pain (if it exists). The COURAGE trial demonstrated that this procedure doesn’t necessarily save lives or prevent heart attacks or strokes.

That’s in part because the blockage that can be seen on an angiogram may not be the demon we once thought. Some cardiologists now believe that it is invisible plaque inside the wall of the artery that may be most vulnerable. When this ruptures, it spills inflammatory proteins into the artery that creates a blood clot and a heart attack.


We are not therapeutic nihilists. Anyone who suspects he is having a heart attack should immediately call 911 and get to an emergency department for evaluation and treatment. But the new study is a wakeup call that a speedy angioplasty and stenting procedure is not necessarily the magic bullet we all were led to believe. There may be other factors, as yet unidentified, that will make surviving a heart attack more successful.

Of course we prefer prevention, but that too remains controversial. There are many physicians who believe that statin-type drugs are the best way to prevent a heart attack or a stroke despite a meta-analysis of clinical trials suggesting that such drugs are not very good for accomplishing this in otherwise healthy people. Here is a link to this research.

We think diet can often be as effective as medications. To read about this controversy in more detail so you can decide for yourself, here is a link.

Share you own experience below.

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  1. Susan

    I had a heart attack last November, taken by ambulance to the ER, rushed to cath lab and received a stent. They had to resuscitate 5 times. I was prescribed and am taking Effient, Metoprolol, Lisnopril, low dose aspirin, I also started taking CoQ10, Vitamin D3 with coconut oil, B Complex with probiotics.

    Can I take proteolytic enzymes while on the meds I take? I really want to stop all meds and take all natural. Any and all suggestions would be appreciated.

  2. First Response

    Please site the reference to back your claim so others may benefit from your findings.
    If you can’t site a scientific study with conclusive results, the reader must do the footwork you failed to do or disregard your post.

  3. MR

    I, too, would love to learn what supplements and essential oils were used by PMA to improve her heart health.
    I would also urge people to research the use of proteolytic enzymes between meals. People have gotten exceptional results from taking pancreatic enzymes, nattokinase, and/or serrapeptase between meals, and there are other enzymes that are also helpful. I have read from numerous sources that they can dissolve plaque and fibrin, and serrapeptase is also reported to be anti-inflamatory and reduce pain. I heard a remarkable story from a retired doctor who got rid of a sizable blockage of his carotid artery by using nattokinase.
    Please check out these proteolytic enzymes yourself, because they can do so much for people.

  4. JMS

    I am very interested in how you reduced the plaque in your arteries. I had a stent 4 yrs. ago and would love to get off the statin because of muscle decline and pain. Looking forward to an email back.

  5. maggie

    I too would welcome your sharing of the regimen you use of supplements and essential oils. Please share with us.

  6. Pat

    Your story was so interesting. My doctor has been wanting me to take a statin for the last
    couple of years due to what he considers high cholesterol. I’ve been more afraid of a statin
    than the cholesterol. When reading that your plaque had actually decrease, I would love to
    know what natural supplements you are taking.
    Presently, I’m taking 3 Krill oil for women (has some primrose oil in it), multi-vitamins,
    Vit. K2 and additional B vitamins with some magnesium. Also, just started to take some L-Argine.
    I hope that you receive my email and am looking forward to learning what natural supplements, etc… that you use.
    Thank you for posting your comment.

  7. DS

    I am glad to hear you are doing well. I hope your doctor learned from you. How did you go about finding a holistically inclined cardiologist?

  8. PMA

    My only symptom was fatigue on walking a distance. Evidence of a silent heart attack was found on an EKG incidental to a MD visit for other issue. Subsequent stress test found “possible” blockage of artery on back of heart. In the weeks to follow I had occasional “niggles” (like very slight pinch) in my left chest wall which increased significantly one night. Given the “possible” blockage, I went to a local cardiac hospital where blockage was deemed questionable. A cardiac cath was recommended and a 99% blockage was found on the front left artery of my heart. I oped for a stent.
    Following the procedure Lipitor, Plavix and Omaprozole were prescribed and I was told that if I didn’t take them I would die.
    Within month I had difficulty walking and almost collapsed. On recommendation of a pharmacist (when I described symptoms) I stopped the Lipitor. When I started the renewed prescription for Plavix I started feeling very bad. We know now about Omaprazole’s negative side effects. (I do have a history of allergies to some meds and sensitivities to others).
    After doing a lot of research I began a regimen of supplements and essential oils (I will be happy to share upon request). I began seeing a cardiologist who was more holistically inclined, but very skeptical at first, and willing to support my alternative regimen. Now, after four and a half years, he is VERY supportive – as is my primary physician – because my overall heart health has improved significantly. Last year my cardiologist was ecstatic because my test showed very little plaque in my arteries and my heart function improved even more. Last week he told me that there was less plaque in my carotids than last year.
    I am an 81 yo holistic nurse but it still took a leap of faith to stop the prescriptions and risk death and making the choice for alternative regimen that I now use. I’m glad I did.

  9. RLO

    I am one of those people who entered emergency with a heart attack in progress. That occurred just over one year ago. I was quickly rushed to the cath lab for a stent. Throughout that incident I was continuously asked how long I had been pain. It appeared to me that swift action at the hospital was important but also that the duration of the attack was even more important.
    They tried to get me into surgery within 30 minutes of the onset of the attack. I would suggest that while the time from entry to emergency to surgery is important, even more crucial is the time from onset of symptoms to insertion of the stent.
    I survived with minimal, perhaps even no injury, to my heart. Today I am a healthy 76 year old with no heart problems. Yesterday I passed a stress test with no difficulty. I am grateful for the rapid care I received from EMS and the emergency lab personnel that made it possible for me to live life as a healthy person today.

  10. EMD

    Great reporting and so very important given the medical hype we have to sift through each day just to make the right decisions for ourselves. Thank you.

  11. MR

    The enzyme nattokinase is known to dissolve blood clots, and this is backed up by scientific research. Nattokinase taken between meals, away from food, enters the blood stream and cleans up both blood and artery walls.

  12. JND

    Very interesting information.

  13. DS

    Keep me posted.

  14. Ken L

    In actual practice there is more than one event going on here. Eleven and one-half years ago I had severe shortness of breath and other symptoms suggesting something was seriously wrong. Although the symptoms came on over a period of weeks, perhaps months, the shortness of breath accelerated rapidly one afternoon and I took myself to the hospital emergency room–barely able to walk in. During the examination, while hooked up to a EKG I experienced a heart attack which I both felt and which was registered on the equipment. Because of my situation I was immediately administered anti-clotting drugs which stopped the attack without any damage to the heart. Since I was stabilized and there was not a cardiology department in the hospital I was not moved to another hospital until the next day where I was evaluated and underwent a “routine” dye test showing the classic blockage and immediately received single stent placement.
    In my case, I believe the important element was the rapid thinning of the blood to permit it to flow though a narrowing of the artery preventing any damage to the heart. I also believe that the stent or some similar procedure was necessary to open that particular area of the artery to more normal blood flow; medicine and diet alone would not have re-opened the narrow artery. However, when the flow of blood through the artery is sufficient to keep the heart active, then the speed with which a stent is or is not implanted (D2B) is not particularly significant. Since then I have used a statin and aspirin to help keep the blood consistency appropriate to flow normally. I am now able to undergo as much exercise as I desire without any symptoms.

  15. GCB

    I need all the information available to make such important decisions.

  16. FDH

    Very interesting.

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