The spasm of resistance vessel concept of ischemic heart disease and other ischemic diseases

The altered homeostatic theory: A hypothesis proposed to be useful in understanding and preventing ischemic heart disease, hypertension, and diabetes – including reducing the risk of age and atherosclerosis

Evidence will be presented to support the usefulness of the altered homeostatic theory in understanding basic pathogenetic mechanisms of ischemic heart disease (IHD), hypertension, and diabetes, and in improving prevention of these disorders. The theory argues that: IHD, hypertension, and diabetes share the same basic pathogenesis; risk factors favor a sympathetic homeostatic shift; preventative factors favor a parasympathetic homeostatic shift; risk and preventative factors oppose each other through a dynamic risk/prevention balance; and prevention should be based on improving the risk/prevention balance. Prevention based on improving the risk/prevention balance should be more effective, as this method is regarded as reflecting more accurately basic pathogenetic mechanisms. As example, the theory argues that the risk of supposedly nonmodifiable risk factors as age and the risk of relatively nonmodifiable atherosclerosis can be reduced significantly. The possible validity of the altered homeostatic theory was tested by a study based on multiple associations. Findings support a common pathogenesis for IHD, hypertension, and diabetes based on a sympathetic homeostatic shift, and the usefulness of prevention based on improving the risk/prevention balance by using standard pharmaceutical and lifestyle preventative measures. The same set of multiple and diverse risk factors favored IHD, hypertension, and diabetes, and the same set of multiple and diverse pharmaceutical and lifestyle preventative measures prevented these disorders. Also, the same set of preventative agents generally improved cognitive function and bone density, and reduced the incidence of Alzheimer's disease, atrial fibrillation, and cancer. Unexpectedly, evidence was developed that four major attributes of sympathetic activation represent four major risk factors; attributes of sympathetic activation are a tendency toward thrombosis and vasoconstriction, lipidemia, inflammation, and hyperglycemia, and corresponding risk factors are endothelial dysfunction (which expresses thrombosis/vasoconstriction and epitomizes this tendency), dyslipidemia, inflammation, and insulin resistance. These findings, plus other information, provide evidence that dyslipidemia acts mainly as a marker of risk of IHD, rather than being the basic mechanism of this disorder. However, prevention generally is based solely on improvement of dyslipidemia; basing prevention on dyslipidemia relatively underemphasizes the importance of other significant risk factors and, by certifying its validity, discourages alternate pathogenetic approaches. Also, development of myocardial infarction is approached differently. It seems generally accepted that dyslipidemia results rather automatically in infarction through the sequence of atherosclerosis, atherosclerotic complications, and thrombosis. In contrast, distinction is made between development of atherosclerosis and acute induction of infarction--where atherosclerosis is only one of multiple risk factors.

Plaque rupture and consequent thromboses probably do not cause acute coronary syndromes

The objective of this communication is to provide evidence that the spasm of resistance vessel (S-RV) concept of ischemic heart disease (IHD) and other ischemic disorders provides a more consistent set of explanations for acute coronary syndromes than the accepted mechanism of plaque rupture and consequent thromboses. The concept avers that S-RV directly induces symptoms in the various syndromes of IHD, including acute coronary syndromes. The S-RV concept is considered to be an alternate paradigm to explain IHD, and interest only develops in such models when there is significant doubt about the validity of the accepted paradigm. This report is an update of a study reported in this Journal in 1999 and has 2 changes; evidence will be evaluated by formal verification/falsification (pass/fail) methods - the method used to evaluate paradigms, and this report focuses on the mechanism of acute coronary syndromes because of the importance of these syndromes. It is well accepted that acute coronary syndromes are due directly to plaque rupture/thromboses, and there is considerable evidence to support this obvious mechanism. In spite of the obviousness of this mechanism, the S-RV concept asserts that S-RV is a more rational mechanism to explain acute coronary syndromes. Consistent with this position, the results of the study favor the S-RV concept. The standard position was given 8 passes, 2 passes with associated possible limited failures, and 2 possible failures. In contrast, the S-RV concept was given 12 passes, and no failures. Hopefully, the results of this study, and other available information about the S-RV concept, will prompt interest in the concept - such as independent testing of its premises.

Can the premises of the altered homeostatic theory permit improvement in the prevention of ischemic heart disease?

In this communication, the altered homeostatic theory will be discussed and updated, and evidence will be presented that the premises of the theory might permit improvement of the prevention of ischemic heart disease (IHD). This hypothesis, first described in 1999, argues that IHD is due basically to an inappropriate shift of homeostasis, and the theory includes the position that S-RV directly induces symptoms. In contrast, the standard approach to IHD is based fundamentally on two principles: that atherosclerosis is due fundamentally to lipid abnormalities, and that symptoms in IHD are due to obstructive complications of atherosclerosis in epicardial coronary arteries. Suggestions for prevention stem from the altered homeostatic theory's different basic conceptualization of this disorder, and it seems reasonable that accepted basic pathogenetic mechanisms help shape measures to prevent IHD. Many of the theory's positions for preventing IHD parallel standard views, but the theory's basic premises have resulted in significant differences between the standard and the theory's overall approach to the prevention of IHD. Positions for the prevention of IHD include: the possibility that any preventative factor can improve any risk factor, the use of substitute preventative factors to counter unmodifiable or difficult to correct risk factors, underestimation of the risk of IHD by the standard position in individuals with normal lipid levels but multiple other risk factors, the probable relative overemphasis of the risk factor of cholesterol, the value of a national program to reduce the incidence of multiple disorders with similar risk factors, an alternate approach to the use of statins, and the value of an evolutionary approach to preventing IHD and other disorders.

Can the premises of the spasm of resistance vessel concept permit improvement in the treatment and prevention of ischemic heart disease?

In this communication, the spasm of resistance vessel (S-RV) concept of ischemic heart disease (IHD) and other ischemic will be reviewed and updated, and evidence will be presented that principles of the hypothesis might improve the treatment and prevention of IHD. The S-RV concept provides a different basic pathogenetic framework for IHD, and suggestions for treatment and prevention stem from its different basic conceptualization of this disorder. The concept asserts that S-RV directly induces symptoms in IHD, and this position challenges the accepted pathogenetic mechanism for this disorder, i.e., that symptoms in IHD are due directly to obstructive occlusions of epicardial arteries secondary to coronary artery disease. The S-RV concept avers that ischemia-induced S-RV is a major factor in IHD, and evidence supporting this position is provided. Another major position of the hypothesis is that no-reflow (reduced flow after infarction and severe myocardial ischemia in the absence of infarction) is due to ischemic injury-induced S-RV, and a variety of evidences to support this position are offered.Proposed improvement in the treatment of IHD is based mainly on treating ischemia-induced S-RV. alpha-Adrenergic sympathetic blockade reverses ischemia-induced S-RV, and alpha-adrenergic blockade is suggested as therapy for acute coronary syndromes and to prevent complications of percutaneous coronary interventions. Also, angiotensin-converting enzyme inhibition, which has actions similar to alpha-adrenergic blockade, is also suggested. Proposals for the prevention of IHD are based the prevention of S-RV, and special emphasis is given to preventing exercise- and stress-related IHD.

Occlusions of epicardial arteries might not directly induce symptoms in ischemic heart disease

It is accepted that primary occlusions of epicardial arteries by thromboses, stenotic coronary artery disease (CAD), and spasm directly induce symptoms in ischemic heart disease (IHD). Because of this acceptance, there has been little interest in alternate mechanisms for IHD--as the spasm of resistance vessel (S-RV) concept of IHD, which asserts that S-RV directly induces symptoms in IHD. To stimulate interest in the S-RV concept, evidence against the primacy of occlusions of epicardial arteries was presented, as well as evidence for this position to provide a balanced discussion; while the evidence was mixed, overall findings appeared to weigh significantly against the primacy of occlusions of epicardial arteries. Also, the S-RV concept was discussed; the discussion included presenting the theory's explanations for events in epicardial arteries, with the aim of demonstrating that the concept provides more consistent explanations than the standard position. It is suggested that there is sufficient information to warrant renewed consideration of the S-RV concept.

The altered homeostatic theory: a holistic approach to multiple diseases, including atherosclerosis, ischemic diseases, and hypertension

The altered homeostatic theory proposes that multiple acquired and genetic factors (risk factors) move the basic homeostatic balance in an 'action' direction which 'inappropriately' activates defense mechanisms and thus favors multiple diseases; factors which improve these disorders move the homeostatic balance in the opposite 'rest' direction. Diseases include hypertension, atherosclerosis, and ischemic disorders as ischemic heart disease (IHD), stroke, migraine, and Raynaud's disease. The theory has its origins in the premises of the spasm-of-resistance-vessel (S-RV) concept of ischemic diseases (which attributes symptoms in ischemic diseases to S-RV), and in a study designed to provide more evidence for this concept. The study showed that multiple risk factors for IHD express the combination of S-RV and a tendency toward thrombosis, and are risk factors for hypertension, migraine, Raynaud's disease, and stroke; factors which ameliorate IHD express vasodilation of resistance vessels and are anti-thrombotic, and ameliorate the other disorders.

New evidence for the spasm-of-resistance-vessel concept of ischemic diseases

The spasm of resistance vessel (S-RV) concept of ischemic diseases avers that S-RV representing vascular autoregulatory dysfunction directly induces symptoms in ischemic diseases. The most important ischemic diseases, ischemic heart disease (IHD) and stroke, generally are not attributed to S-RV, and new evidence will be provided in this communication that S-RV induces IHD and stroke. Hypertension and the ischemic disorders of migraine and Raynaud's disease have been attributed to S-RV and to vascular dysregulation, and this information was used to help structure the study. It was found that these disorders are closely associated with IHD and stroke, and this is consistent with S-RV and vascular dysregulation as the mechanism for IHD and stroke. Also, it was found that multiple risk factors for IHD foster S-RV and are risk factors for hypertension, migraine, Raynaud's disease, and stroke, and this supports S-RV as the mechanism for IHD and stroke.

Bartonella bacilliformis or a similar organism and cardiovascular disease

Bartonella bacilliformis invades the endothelial lining of the cardiovascular system. Damage to the red blood cells and white blood cells, the effects of the toxins, invasion of the brain and electrical charges induced by the organism so interfering with normal electrical stimulation of the heart may explain many of the features of cardiovascular disease (1-5).

Evidence in support of the spasm of resistance vessel concept of ischemic heart disease: an update in 1993

The goal of this communication is to provide more evidence for the ischemic heart disease (IHD) component of the spasm of resistance vessel (S-RV) concept of IHD and other ischemic diseases. The S-RV concept of IHD is considered to be an alternate paradigm which challenges the accepted understanding of this disorder. The theory asserts that primary S-RV directly induces symptoms in IHD, and this position is in opposition to the accepted view that symptoms are induced directly by primary occlusions of epicardial arteries by coronary artery disease, spasm, and thromboses. The theory, if valid, should be useful in reducing the impact of IHD, as it generally is accepted that the correct appreciation of basic pathophysiological mechanisms helps ensure the most appropriate prevention and treatment of disease.

A case that biomedicine is unduly negative to radical hypotheses and to theorizing--evidence based on cardiology's reaction to the spasm of resistance vessel concept and on the nature of scientific research

This communication will attempt to make a case that biomedicine is unduly negative to radical hypotheses and to theorizing. Evidence will be based on a proposed undue negativity by cardiology to a radical hypothesis I first described two and a half decades ago--the spasm of resistance vessel (S-RV) concept of ischemic heart disease (IHD). The theory is regarded as an alternate paradigm and deals with basic pathogenetic mechanisms of IHD, the most significant disorder of Western civilization. The concept, if valid, might help in reducing the impact of this disorder, and I believe that the evidence for the theory and the importance of IHD support a more open minded attitude toward the idea. Cardiology's negativity is attributed to the nature of research; the most important factor is considered to be the Kuhnian negativity of scientific communities to hypotheses which are destructive of conventional wisdom, and a second factor is the special nature of biomedical research. Biomedicine is regarded as special because a low level of specific information about complex biomedical processes has fostered an essentially total study-based approach. Such an approach is assumed to have resulted in biomedicine's use of induction as 'the' method of scientific inquiry, and prompted negativity towards the hypothetico-deductive method used to develop and test the theory. Also, the study-based nature of biomedicine appears to have fostered an intuitive reliance on only newly performed studies to test hypotheses, which led to ignoring evidence for the concept derived from known information about IHD. Biomedicine is also regarded as special because its infrequent use of paradigm-change has resulted in unfamiliarity with this method, and because the practical method of training in biomedical research has worsened the general unfamiliarity of scientists with theoretical aspects of science. Because of these factors, the S-RV concept has not yet been properly evaluated--a quarter of a century after it was first created.

Variability of coronary blood flow reserve assessed by Doppler catheter after successful thrombolysis in patients with acute myocardial infarction

To establish whether abnormal function of small coronary vessels might limit the advantages of thrombolytic treatment, coronary flow reserve in the infarct-related artery was measured in nine patients with acute myocardial infarction early after successful coronary thrombolysis by using a Doppler catheter and intracoronary adenosine infusion. In each patient coronary flow reserve was calculated as the ratio between coronary blood flow velocity during the highest tolerated intracoronary dose of adenosine (0.5 mg/min in five patients and 1 mg/min in four patients) and baseline velocity. Coronary flow reserve ranged from 1 to 3 (mean 2 +/- 0.7). No correlation (r = 0.20; p = 0.58) was found between coronary flow reserve and the severity of residual coronary stenosis, which ranged between 23% and 76% (mean 47% +/- 17%). No correlation (r = 0.33; p = 0.39) was found between either coronary flow reserve and the interval between pain onset and administration of the thrombolytic treatment, which ranged between 2.2 and 6 hours (mean 4.2 +/- 1.4 hours). Thus, in patients with acute myocardial infarction, coronary flow reserve early after successful thrombolysis is strikingly variable and may be extremely low despite widely patent epicardial coronary arteries. This restriction of coronary blood flow, probably caused by abnormal function of small coronary vessels, might limit the potential benefit from successful coronary thrombolysis.