Harvard Heart Letter

Ask the doctor: Are advanced blood tests needed for coronary artery narrowing?

Q. I had a stent put in several years ago, at age 59. Thanks to a better diet, more exercise, a statin, and niacin, my LDL, HDL, and triglycerides are excellent. My latest nuclear stress test showed some ischemia, even though I am not having any symptoms, and the follow-up angiogram showed several new blockages requiring two additional stents. I think my cardiologist should order tests like apolipoprotein A, LDL particle size and number, etc., to dig more deeply into why my coronary arteries keep getting clogged despite my best efforts. Is that a good idea or a waste of time and money?

A. It is not surprising that someone with enough atherosclerosis in his coronary arteries to need a stent at age 59 would have continuing progression of this artery-clogging disease, in spite of taking a statin and niacin and living a healthy lifestyle. These preventive measures can certainly slow atherosclerosis, but they cannot always stop or reverse it. I don't think that the tests you mentioned would change the overall situation or give you and your doctor better ideas for treatment.

So, what to do? I would check to be sure that your cholesterol-lowering strategies are getting your LDL well below 100 milligrams per deciliter, and ideally below 70. Also consider pushing the envelope on your diet, maybe even trying a very low-fat approach like the Ornish diet. More exercise or one alcoholic drink per day might help raise your HDL and thus provide more protection against atherosclerosis. There are some promising HDL-raising drugs in testing, and you might consider getting involved in one of those trials.

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