What a worrisome conundrum: experiencing a cardiovascular event and compelled to make that crucial decision. Are you to consent to a doctor cutting into you toward an immediate albeit slightly risky solution or will you embark on the long route–sticking to a strict diet that will take months to provide that delayed and elusive yet almost certain remedy?

            The invasive option may not be as gruesome as it sounds. It oft involves making an incision into a blood vessel in an extremity, typically one of your limbs. Perhaps the term “cardiac event” evokes terrors of undergoing open heart surgery. The vascular stenting procedure is not nearly that grave or intricate and is considered routine. But still…

            Coronary artery disease, that dire and concerning condition, denotes an event where a clot, or thrombus, forms in a blood vessel that supplies the heart, known as the coronary artery. Much like a highly restrictive dam that cuts off most of a river’s flow downstream, this clot blocks the lumen or interior space of the vessel, impeding blood flow to the heart and depriving it of oxygen and nutrients. This cascade of events results in what is commonly called a heart attack which manifests as a metabolic strain that may eventually result in loss of consciousness and ultimately death. A major cause of coronary thrombosis—blood clot formation in the artery—is atherosclerosis, where low density lipoproteins (LDLs) consumed in the diet are deposited in the vascular wall much akin to sediments deposited on a riverbed, “thickening” with time. These deposits constrict the luminal space and increase the chance of blood clot formation.

            What tools then are employed in cardiovascular practice to remedy a clots that blocks such an essential artery? Enter the cardiac stent, the go-to device used to treat coronary thrombosis. Stents are surgical devices or implants utilized in different medical interventions. “Endovascular devices” implanted into the hollow interior of blood vessels, they are constructed into a hollow, mesh-like structure, typically metallic, with spaces interspersed in the meshwork. “A stent is basically a tubular medical device that may be inserted in the body’s vascular system to “open up a vessel”,” Dr. Debbie Castillo-Lowell explains. Currently based in the private sector, she previously worked in the Office of Device Evaluation at the Food and Drug Administration (FDA) where she served as a device engineer and branch manager. “It mainly opens up a closed artery for various treatments,” she elaborates, pointing to its therapeutic use when the luminal space of an artery, or other blood vessel, becomes occluded.

            Current invasive interventions for coronary thrombosis or advanced atherosclerosis mostly include coronary stents. Back in 1987, early research with animals employed balloon angioplasty to resize inserted stents into their full cylindrical form in the coronary artery. The balloon served two purposes: inflating the occluded vessel and expanding the then collapsed stent to prop the vessel open. Current medical practice involves introducing an inflatable balloon-tipped catheter through peripheral blood vessels in the extremities and inflating the balloon once it traverses the stenosed arterial site. In coronary stent angioplasty, the coronary stent is inserted around the deflated balloon. Once the assembly reaches the site of occlusion, the balloon is inflated, dislodging the clot and installing the stent.

            A patient may be inclined to think the worst is over after stenting corrects her blocked coronary artery; that she is in essence “cured.” Actually, a good number of patients may not be completely out of the woods, depending on their body physiology. There is always a chance of the phenomenon’s recurrence, even with the stent still snugly in place in the treated artery. As it turns out, after stenting to correct thrombosis, there is a propensity for subsequent clotting at or proximal to the same site that was previously stenosed, a phenomenon termed restenosis. Restenosis is a repeat occurrence after stenting where the coronary artery’s luminal walls thicken around and at the edges of the stent, constricting it and increasing the likelihood of formation of another blood clot. Does that mean that coronary stents offer lower merit as interventions? Should we eschew this option and give dieting the chance it deserves as the less risky alternative? I must urge calm; contain the worry and dread. Technology with its infinite potential and adaptability has witnessed the advent of more efficacious stents.

There are different types of stents available in the market. “Stents may be grouped or classified based on their mechanical properties, biocompatibility, material properties such as rates of degradation, coated versus non-coated, size, and placement and location intended to treat,” Dr. Castillo-Lowell points out in response to a query on how stents are classified. As categorized by structure or composition, they are either bare-metal stents or drug-eluting stents. The latter type is coated with a polymer material serving as a vehicle for a drug that is emitted into the bloodstream by “controlled release”—a feature in which the drug contained in the polymer passes into the bloodstream at a steady, predetermined rate.

To this end, medical professionals have resorted to using “controlled release” stents that elute select drug compounds into the surrounding milieu. These inhibit formation of further clots or constricting by the impinging vascular walls. These are known as polymer-coated eluting coronary stents. They release the drug at optimal concentrations to regions about the site of interest, discouraging any processes that would lead to further occlusion such as blood clotting or restenosis. “Coated stents are preferable at current,” Dr. Castillo-Lowell weighs in. “They prevent the re-closure or regrowth of the surrounding vascular tissue into the stent to form another occlusion. The drugs eluted hinder closure and may have an anti-inflammatory effect hinders a clotting cascade.”

            An example is the Sirolimus-eluting stent. Sirolimus, a branded drug synthesized by Wyeth Pharmaceuticals chemically known as rapamycin is utilized therapeutically as an immunosuppressant. It quells immune reactions occurring after stent implantation. This coated stent has witnessed considerable success in mitigating restenosis. A 2011 study compared several outcome measures between two experimental groups implanted either with bare-metal or Sirolimus-eluting stents. The latter group saw significantly lower target-vessel failure at nine months and significantly higher target-vessel failure-free survival. Thus, drug-eluting stents, in this instance the Sirolimus type, are the preferable invasionary intervention in the event of coronary artery disease, particularly owing to atherosclerosis.

Perhaps an invasive option seems radical, if not unnecessary. You would like to weigh your options: an alternative that is less imposing or glaring and promises little to no need for anesthesia-laced recuperation in a hospital bed for several days. Not to mention the plethora of blood draws and incessant imaging requests to follow up on the procedure. As it turns out, you may be in luck. There are documented dietary alternatives that have realized some success in several studies to decrease the very risk of atherosclerosis and concomitant coronary artery disease.

One such intervention is the Mediterranean diet, named for cuisine endemic to Mediterranean areas. Its hallmarks, as assessed in a 2015 study, include food items such as olive oil, yogurt, fresh fruits, whole and refined grains, and fresh herbs such as onion and garlic to be taken daily; nuts, fish or seafood, eggs, poultry and legumes such as beans and peas to be taken weekly; and finally a very rare consumption of red and processed meat, commercial and refined sweets, soda and sugary drinks, and refined carbohydrates. As concerns one outcome measure of the diet, a 2009 study found an associated 22% decline in mortality in men and a 19% decrease in mortality in women in a longitudinal study conducted over twenty years.

A second dietary intervention that has been efficacious against cardiovascular disease is the Alternate Healthy Eating Index (AHEI). The AHEI emphasizes incorporating fruits and vegetables, considered vegetarian alternatives in context, as major components of daily dietary intake. The index also discourages inclusion of saturated fatty acids which play a role in propagating atherosclerosis. As assessed with the AHEI, the study found that men who scored in the top twentieth percentile had a 39% decreased propensity toward experiencing cardiovascular disease than those in the bottom twentieth percentile; the risk was 28% lower in women.

Both the Mediterranean diet and the AHEI share a discouragement of “unhealthy food items” containing saturated fatty acids and LDLs, two sets of molecules that directly contribute to atherosclerosis. Furthermore, both dietary interventions promote dietary fiber.

But there’s a catch: dietary alternatives are most effective if the issue is nabbed early such as in instances of family histories of being overweight, high cholesterol or LDL profiles that may predispose an individual to atherosclerosis. Also, what proportion of individuals will have the will and discipline to follow restrictive diets? Healthy eating is a constant clarion call made by health professionals, yet compliance is less than stellar at best. Conversely, if a blood clot is formed in a coronary blood vessel, an immediate invasive intervention will be called for and likely sought out.

I can suggest a third, integrated and more pragmatic option. In the absence of warning signs and on experiencing a cardiovascular event in the coronary artery, the gravity of the situation necessitates employing a stent, preferably a coated stent. Upon recovery, diet management or overhaul to decrease LDL and fatty acid intake and excess body levels would be in order. The Mediterranean diet and the AHEI are a good place to start. Finally, a suggestion that has become trite in the face of repeated advice from healthcare professionals yet pivotal and vital: engaging in physical exercise to boost body metabolism, in effect “burning off” those lipogenic stores. Here’s wishing you a healthy heart that will beat for decades.