Experience has shown that progression of coronary artery disease can be arrested and reversed by changes in diet and lifestyle. Because of the high cost of treatment of coronary artery disease in the United States (an estimated $56.3 billion in 1994), there is considerable incentive to finding alternative interventions that are less expensive, yet effective. Ornish describes the Multicenter Lifestyle Demonstration Project, a one-year program that was designed to determine if comprehensive lifestyle changes could be a cost-effective alternative to revascularization in select patients with severe but stable coronary artery disease.

The program proposed lifestyle changes that included a very low-fat, low-cholesterol diet (whole-foods vegetarian diet, approximately 10 percent fat, less than 10 mg per day dietary cholesterol, high in complex carbohydrates and low in simple sugars), stress management techniques, moderate exercise and psychosocial support.

This program was offered as a less-costly alternative treatment to revascularization in selected patients eligible for bypass graft or angioplasty. A bypass graft is effective in decreasing angina and improving cardiac function. When compared with medical therapy, however, survival is improved in only a specific group of patients: those with decreased left ventricular function and stenotic lesions of the left main coronary artery of greater than 59 percent. The mortality and morbidity benefits of angioplasty are unknown because it has never been compared with medical therapy in stable patients with coronary artery disease.

Patients eligible for the program had angiographically documented coronary artery disease severe enough to warrant revascularization. Exclusion criteria included (1) greater than 50 percent stenosis in the left main coronary artery, (2) bypass graft within six weeks or angioplasty within six months, (3) chronic unresponsive congestive heart failure, (4) malignant uncontrolled arrhythmias, (5) myocardial infarction within one month, (6) homozygous hypercholesterolemia, (7) psychosis, (8) hypotensive response to exercise, (9) alcohol or drug abuse and (10) life-threatening co-morbidity.

The author notes that the lifestyle-change program required patients to have commitment, discipline and willingness to accept personal responsibility for their health. Those who decided to undergo revascularization more often wanted a “quick fix,” making randomization for a controlled trial impossible. Of the 194 patients in the experimental group, 150 were able to avoid revascularization for at least three years, and the frequency of adverse cardiac events was not increased. Reductions of angina were also achieved in the experimental group that were comparable with those achieved with revascularization. The average cost saving per patient was almost $30,000.

The author concludes that patients with coronary artery disease should be offered several therapeutic options, including comprehensive lifestyle changes, medications (including lipid-lowering drugs), angioplasty and bypass surgery. Unfortunately, most third-party payers will cover the drug therapy and revascularization but not the cost of instructing patients in a lifestyle-change program. This lack of widespread insurance coverage is more of a limiting factor for lifestyle changes than is a shortage of motivated patients.

editor's note: Lifestyle modification requires a highly motivated patient and a clear treatment plan. Using techniques similar to those used in all treatments, Winslow and associates outlined three steps to accomplishing lifestyle changes in patients: (1) help the patient understand the value of the treatment, (2) discuss ways in which the treatment will evolve and set appropriate goals, and (3) monitor and encourage progress while identifying barriers or adverse effects (Am J Med 121:4A25S–31S, October 8, 1996). Programs need to be individualized, with the patient receiving frequent feedback and encouragement. Written material is a helpful adjunct to patient education and enthusiasm. Lifestyle modification may require significant investments in time but may help a patient avoid a treatment or condition with higher morbidity.—r.s.