Michael Greger's Blog, page 5

Bird Flu: Emergence, Dangers, and Preventive Measures

In the United States in January 2025 alone, approximately 20 million commercially-raised birds, mostly egg-laying hens, were affected by the highly pathogenic avian influenza (H5N1). These numbers are staggering yet barely scratch the surface of a potentially larger threat looming over the country. If action is not taken now, the next pandemic could be far deadlier than the 1918 influenza and COVID-19.

 

What Was the 1918 Influenza?

According to the World Health Organization (WHO), “The 1918 influenza pandemic killed more people in less time than any other disease before or since”; it was the “most deadly disease event in the history of humanity.” Indeed, it killed more people in a single year than the bubonic plague—the “black death”—in the Middle Ages killed in a century. The 1918 virus also killed more people in twenty-five weeks than AIDS killed in twenty-five years. According to one academic reviewer, this “single, brief epidemic generated more fatalities, more suffering, and more demographic change in the United States than all the wars of the Twentieth Century.”

 

What Caused the 1918 Flu Pandemic?

Although the human influenza virus wasn’t even discovered until 1933, an inspector with the U.S. Bureau of Animal Industry had been publishing research as early as 1919 that suggested a role for farm animals in the pandemic. Inspector J.S. Koen of Fort Dodge, Iowa, wrote: “The similarity of the epidemic among people and the epidemic among pigs was so close, the reports so frequent, that an outbreak in the family would be followed immediately by an outbreak among the hogs, and vice versa, as to present a most striking coincidence if not suggesting a close relation between the two conditions. It looked like ‘flu,’ and until proven it was not ‘flu,’ I shall stand by that diagnosis.”

The answer to where the 1918 virus came from was published in October 2005. Humanity’s greatest killer appeared to originally come from avian influenza—bird flu.

 

What Is Bird Flu?

Evidence now suggests that all pandemic influenza viruses—in fact all human and mammalian flu viruses in general—owe their origins to avian influenza. Back in 1918, schoolchildren jumped rope to a morbid little rhyme:

I had a little bird,
Its name was Enza.
I opened the window,
And in-flu-enza.

 

Is Bird Flu Worse Than Regular Flu?

As devastating as the 1918 pandemic was, the mortality rate was less than 5 percent on average. But the H5N1 strain of bird flu virus that first emerged in China in 1997 and spread to more than 60 countries seems to kill about 50 percent of its known human victims, on par with some strains of Ebola, making it potentially ten times as deadly as the worst plague in human history.

Leading public health authorities, from the U.S. Centers for Disease Control and Prevention (CDC) to the World Health Organization, feared that this bird flu virus was but mutations away from spreading efficiently though the human population, triggering the next pandemic. “The lethal capacity of this virus is very, very high; so it’s a deadly virus that humans have not been exposed to before. That’s a very bad combination,” said Irwin Redlener, former director of the National Center for Disaster Preparedness at Columbia University. Scientists speculate worst-case scenarios in which H5N1 could end up killing a billion or more people around the world. “The only thing I can think of that could take a larger human death toll would be thermonuclear war,” said Council on Foreign Relations senior fellow Laurie Garrett. H5N1 has the potential to become a virus as ferocious as Ebola and as contagious as the common cold.

 

H1N1 vs. H5N1

The 1918 pandemic virus was H1N1. The annual flu strain remained H1N1, infecting relatively few people every year for decades until 1957, when an H2N2 virus suddenly appeared as the “Asian flu” pandemic. Because the world’s population had essentially only acquired immunity to H1 spikes, the virus raced around the globe, infecting a significant portion of the world’s population. For example, half of U.S. schoolchildren fell ill. H2N2 held seasonal sway for 11 years. In 1968, the H3N2 “Hong Kong Flu” virus triggered another pandemic and has been with us every year since.

So there were three influenza pandemics in the twentieth century—in 1918, 1957, and 1968—but, as the director of the National Institute for Allergy and Infectious Diseases has said, “There are pandemics and then there are pandemics.” The half-and-half bird/human hybrid viruses of 1957 and 1968 evidently contained enough previously recognizable human structure that the human population’s prior partial exposure dampened the pandemic’s potential to do harm. In contrast, the pandemic strain of 1918 was wholly avian-like. Instead of diluting its alien avian nature, the 1918 bird flu virus “likely jumped straight to humans and began killing them,” noted Taubenberger, the man who helped resurrect it. The same could be happening with the new spate of avian influenza viruses sporadically infecting people in more recent years, like H5N1. The human immune system had never been known to be exposed to an H5 virus before. As the WHO points out, “Population vulnerability to an H5N1-like pandemic virus would be universal.”

 

How Dangerous Is H5N1 Bird Flu?

H5N1 developed a level of human lethality not thought possible for influenza. So far, about half of those known to have come down with this flu have died. H5N1 is good at killing, but not at spreading. To trigger a pandemic, the virus has to learn how to spread efficiently from person to person. Now that the genome of the 1918 virus has been completely sequenced, we understand that it may have taken only a few dozen mutations to turn a bird flu virus into humanity’s greatest killer, and we have seen some of those changes taking form in H5N1. The further H5N1 spreads and the more people it infects, the greater the likelihood that it might lock in mutations that could allow for efficient human-to-human transmission. “And that’s what keeps us up at night,” said the chair of the Infectious Diseases Society of America’s task force on pandemic influenza.

 

How Did Bird Flu Emerge?

More than a century ago, researchers confirmed the first outbreak of a particularly lethal form of avian influenza that they called “fowl plague.” Plague comes from the Greek word meaning “blow” or “strike.” Later, the name “fowl plague” was abandoned and replaced by “highly pathogenic avian influenza” or HPAI.

Domesticated poultry can also become infected with a low-grade influenza, so-called low pathogenic avian influenza, or LPAI, which may cause a few ruffled feathers and a drop in egg production. Influenza viruses with H5 or H7 spikes, however, are able to mutate into the high-grade variety that can cause devastating illness among the birds. Webster’s term for H5 and H7 strains of flu says it all: “the nasty bastards.” And you don’t get nastier than H5.

 

Avian Influenza, Poultry, and Eggs

To avoid contracting bird flu, an influenza expert at the UK Health Protection Agency warned, “[a]void being in touching distance [of birds who could be affected]. Don’t kiss chickens.” Kissing aside, what is the risk of putting our lips on them in other ways?

In 2001, the virus was found and confirmed in frozen duck meat. The investigators concluded, “The isolation of an H5N1 influenza virus from duck meat and the presence of infectious virus in muscle tissue of experimentally infected ducks raises concern that meat produced by this species may serve as a vehicle for the transmission of H5N1 virus to humans.”

The finding of H5N1-contaminated poultry meat triggered a more extensive survey. Top flu researchers at the U.S. Department of Agriculture (USDA) looked into chicken meat. Chickens who inhaled H5N1 became infected even more systemically than did ducks. The virus spread through the internal organs, into the muscle tissue, and even out into the skin. Virus was found in both white and dark meat.

There is a precedent for bird-borne virus-infected meat. Unlike bacteria, viruses can remain infective for prolonged periods even in processed foods. Some methods of preservation, like refrigeration, freezing, or salting, may even extend the persistence of viruses in food. On the other hand, since viruses cannot replicate without living tissue, improper storage of food is less problematic.

What about eggs? “Be careful with eggs,” the World Health Organization has warned. “Eggs from infected poultry could also be contaminated with the [H5N1] virus…”

 

Mutating and Getting More Virulent

Within a single individual, a virus evolves, adapts, learns. It hits dead ends and tries something new, slowly notching up mutations that may lock into place the ability to effectively survive in, and transmit between, people. Every single person who gets infected presents a risk of spawning the pandemic virus. Describes one virologist, “You’re playing Russian roulette every time you have a human infection.” Experts fear that as more and more people become infected, a virus will finally figure out the combination—the right combination of mutations to spread not just in one elevator or building, but in every building, everywhere, around the globe. Then it won’t just be peasant farmers in Vietnam dying after handling dead birds or raw poultry—it will be New Yorkers, Parisians, Londoners, and people in every city, township, and village in the world dying after shaking someone’s hand, touching a doorknob, or simply inhaling in the wrong place at the wrong time. It’s happened before, and it may soon happen again.

Said a WHO spokesperson about a virus like H5N1, “All the indications are that we are living on borrowed time.” A senior associate at the Center for Biosecurity listed the indications: “The lethality of the virus is unprecedented for influenza, the scope of the bird outbreak is completely unprecedented and the change that needs to happen to create a pandemic is such a small change—it could literally happen any day.”

Never before H5N1 had bird flu spread so far, so fast, and the longer the virus circulates in poultry production systems the higher the likelihood of additional human exposure.

 

Can H5N1 Be Eradicated?

H5N1 may be here to stay. “This virus cannot now be eradicated from the planet,” said Center for Biosecurity director O’Toole. “It is in too many birds in too many places.” The virus seemed to be getting more entrenched. “If you described it as a war, we’ve been losing more battles than we’ve won,” a WHO spokesperson told The Financial Times. “From a public health point of view, and an animal health point of view, this virus is just getting a stronger and stronger grip on the region.”

In a tone uncharacteristic of international policy institutions, the FAO wrote: “Over this bleak landscape sits a black cloud of fear that the virus might become adapted to enable human-to-human transmission and then spread around the globe.” The urgency and alarm among those tracking H5N1’s building momentum was palpable. “It’s like watching a volcano getting ready to erupt,” described a spokesperson of the World Organization for Animal Health (known as OIE, for Office Internationale des Epizooties). “We’re all holding our breath,” said Julie Gerberding, former head of the CDC.

 

Breeding Grounds for Disease

The world’s three leading authorities—the Food and Agriculture Organization of the United Nations, the World Health Organization, and the World Organization for Animal Health—held a joint consultation in 2004 to determine the key underlying causes. Four main risk factors for the emergence and spread of these diseases were identified. Bulleted first: “Increasing demand for animal protein.” This has led to what the CDC refers to as “the intensification of food-animal production,” the factor blamed in part for the increasing threat.

The way we kept animals when we first domesticated them ten thousand years ago is a far cry from how they are reared today. Chickens used to run around the barnyard on small farms. Now, “broiler” chickens—those raised for meat—are typically warehoused in long sheds confining an average of 20,000 to 25,000 birds. A single corporation, Tyson, can churn out more than 20 million pounds of chicken meat a day. Worldwide, an estimated 70 to 80 percent of egg-laying chickens are intensively confined in battery cages, small barren wire enclosures stacked several tiers high and extending down long rows in windowless sheds. The cages are stocked at such densities that each hen is typically allotted less floor space than a standard letter-sized piece of paper. It is not uncommon for egg producers to keep hundreds of thousands—or even a million—hens confined on a single farm. Half the world’s pig population—now approaching one billion—is also crowded into industrial confinement operations. This represents the most profound alteration of the animal-human relationship in ten thousand years.

 

What Can We Do?

To reduce the emergence of viruses like H5N1, humanity must shift toward raising birds in smaller flocks, under less stressful, less crowded, and more hygienic conditions, with outdoor access, no use of human antivirals, and with an end to the practice of breeding for rapid growth or unnatural egg production at the expense of immunity. This would also be expected to reduce rates of increasingly antibiotic-resistant pathogens such as Salmonella, the number one foodborne killer in the United States. We need to move away from the industry’s fire-fighting approach to infectious disease to a more proactive preventive health approach that makes birds less susceptible—even resilient—to disease in the first place.

In the United States, the American Public Health Association (APHA) is among those advocating for “radical” (from the Latin radix, for “root”) change. In 2003, the APHA passed a “Precautionary Moratorium on New Concentrated Animal Feed Operations,” in which it urged all federal, state, and local authorities to impose an immediate moratorium on the building of new factory farms—including industrial turkey, laying hen, broiler chicken, and duck facilities. In November 2019, it reiterated its stance, publishing a new policy statement calling once again for a moratorium on new factory farms, as well as a moratorium on the expansion of existing ones.

 

Eating to Beat Bird Flu

The journal of the APHA published an editorial entitled “The Chickens Come Home to Roost” that went beyond just calling for a deintensification of the pork and poultry industries. The editorial questioned the prudence of raising so many animals for food in the first place, given the pandemic threat they may pose: “It is curious, therefore, that changing the way humans treat animals, most basically ceasing to eat them, or at the very least, radically limiting the quantity of them that are eaten—is largely off the radar as a significant preventive measure. Such a change, if sufficiently adopted or imposed, could still reduce the chances of the much-feared influenza epidemic. It would be even more likely to prevent unknown future diseases that, in the absence of this change, may result from farming animals intensively and killing them for food. Yet humanity doesn’t even consider this option.”

However, thanks to food innovations, this may be changing, with plant-based meats, milks, and eggs growing in popularity with expanded options in supermarkets. And, making healthier choices could also help mediate the next coronavirus epidemic by also decreasing the rates of comorbidities found to increase the risk in SARS, MERS, and COVID-19. For example, consider the underlying risk factors for COVID-19 severity and death—obesity, heart disease, hypertension, and type 2 diabetes—all of which can be controlled or even reversed with a healthy enough plant-based diet and lifestyle.

 

Egg-Free Eggs

There are so many delicious egg-free egg recipes, like this Garden Veggie Tempeh Scramble created by NutritionFacts.org’s own executive director.

 

Conclusion

H5N1 was discovered in chickens decades ago, a flu virus that would forever change our understanding of how bad pandemics could get—a flu virus that appears capable of killing half the people it infects. Imagine if a virus like that started explosively spreading from human to human. Consider a pandemic a hundred times worse than COVID-19, one with a fatality rate not of one in two hundred but rather a coin flip of one in two. Thankfully, H5N1 has so far remained a virus mainly of poultry, not people, but H5N1 and other new and deadly animal viruses like it are still out there, still mutating, with an eye on the eight-billion-strong buffet of human hosts. With pandemics, it’s never a matter of if, but when. A universal outbreak with more than a few percent mortality wouldn’t just threaten financial markets but civilization itself as we know it.

A pandemic triggered by a bird flu virus could leave hundreds of millions dead. “An influenza pandemic of even moderate impact,” Michael Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota, wrote, “will result in the biggest single human disaster ever—far greater than AIDS, 9/11, all wars in the 20th century and the recent tsunami combined. It has the potential to redirect world history as the Black Death redirected European history in the 14th century.”1 Hopefully, for humanity’s sake, the direction world history will take is away from raising birds by the billions under intensive confinement so as to potentially lower the risk of us ever being in this same precarious place in the future. The silver lining of COVID-19 is that the world will be better prepared for the next global health crisis. Tragically, it may take a pandemic with a virus like H5N1 before the world realizes the true cost of cheap chicken.

 

1 Kennedy M. 2005. Bird flu could kill millions: global pandemic warning from WHO. “We’re not crying wolf. There is a wolf. We just don’t know when it’s coming.” Gazette (Montreal), March 9, p. A1.

 

Inhospitable Hospital Food

What do hospitals have to say for themselves about serving meals that appear to be designed to inspire repeat business?

“Hospital food needs a revolution.” I was surprised to learn that most inpatient meals served in hospitals are “not required to meet national nutrition standards for a healthy diet.” An analysis of the nutritional value of food served to patients in teaching hospitals found that many did not meet dietary recommendations. “Warning: Hospital food bad for health,” read the headline.

A registered dietitian wrote to defend hospitals and point out how stringent the guidelines are, saying that “over half the hospitals met or exceeded more than half the guidelines….It would not take more than choosing eggs for breakfast and 2 percent milk with meals to exceed the recommended intake of cholesterol and fat…The provocative conclusions of Singer et al. only lead the media and the public to conclude that we are a bunch of dunces who have no understanding of the relation between nutrition and disease prevention.”

Well, if the white coat fits…

“We spend a fortune on training doctors, but then don’t follow through on the simplest things, like food.” “Good diet is as necessary to recovery of health as good nursing, surgery, or medicine, and it is folly to pretend that it is beyond the power of our profession to change this reproach.” That was written 75 years ago, yet still there is pushback: “Perhaps we should question whether a ‘healthy diet’ given to a helpless patient during a 2- to 10-day hospital stay benefits anyone or anything other than the dietitian’s sense of ‘doing good,’” responded one doctor. He added, “I am always bothered when a healthy 75-year-old…is deprived of a desired morning egg because a ‘healthy’ low-cholesterol diet has been ordered.” I mean, what is a few days of a little heart-unfriendly diet in the scheme of things…

But it’s the message that’s being sent. “The presence of foods on the [hospital] tray sends a message to patients as to what is healthy and acceptable for them to eat,” responded the researchers who did the hospital foods analysis. “We still can think of no better place or opportunity to set an example of good nutrition than when patients are in hospitals.”

After all, public schools in California, for instance, have banned the sale of sodas for more than a decade. Why not children’s hospitals? In a study of California healthcare facilities serving children, 75 percent of beverages and 81 percent of foods sold in vending machines wouldn’t have been allowed to be sold in schools. We’re talking soda and candy. “Having unhealthy items in health care facilities and seeing staff consume these products…contradicts the nutrition and health messages children often receive from health care providers.”

On adult menus, nearly all meals contained excess salt, with 100 percent of daily menus exceeding the American Heart Association’s recommendation for staying under 1,500 mg of sodium a day. This means meals offered to patients may actually “contribute to the exacerbation or slow resolution of the very conditions that may have led to the hospitalization,” as I discuss in my video Just How Bad Is Hospital Food?.

But if hospitals adhered to the recommended limits of salt, the food wouldn’t taste as good, responded an executive from the Salt Institute, to which the researchers replied: Taste as good? “Hospital food is often criticized as having poor palatability, despite the fact that it likely already contains high levels of sodium.” It doesn’t taste good, no matter how much salt it has.

At the very least, we should “prepare all meals with low sodium content and make optional table salt available for those patients who do not have additional restrictions.” Then, if individuals want to add salt, it’s their choice. If they want to get someone to wheel them out into the parking lot and smoke, that’s their business, but we shouldn’t be blowing cigarette smoke into patients’ rooms three times a day, whether they want it or not. Interestingly, studies suggest that when people are allowed to salt food to taste, they rarely add as much sodium as may come in prepackaged foods.

As you can see below and at 3:55 in my video, when researchers switched study participants to a low-sodium diet, they used their saltshakers more, but, overall, their salt intake dipped way down. And they said their food tasted just as salty, because salt added to the surface of foods makes it taste saltier. But when a hospital meal is served pre-salted, “most inpatients may not actually have the option to consume healthy levels of sodium while they are hospitalized.” 

In defense of their unhealthy food, one hospital food service provider explained that they’re just giving people what they want: “People are in the hospital and they are stressed and they need something that they consider comfort food, so I don’t want to deny that to people if that’s what makes them feel better.” That’s a reason one clinical director sends ice cream and candy bars to cancer patients: “We focus on familiar comfort foods, an approach that has enhanced patient satisfaction and improved intake.” You know what else might help? A nice, long drag on a cigarette. Hospitals used to sell cigarettes, “primarily…for ‘patient convenience.’” “‘I don’t think I can deny a paying patient the right to smoke a cigarette,’” said a medical center administrator. “‘As a service to the patient, I will have to insist we have cigarette machines in the hospital.” But others suggested that tobacco products shouldn’t be sold in hospitals at all. This wasn’t from the 1950s, but from the 1980s. Yet, at the time, the “irony of hospitals allowing the sale of cigarettes, which are the major cause of preventable illness and death in this country, has rarely been discussed in the literature…It is especially ironic that smoking is permitted in 89% of doctors’ lounges.”

To their credit, though, U.S. hospitals underwent “the first industry-wide ban on smoking in the workplace” by the mid-1990s. Now, “hospitals again have the opportunity to take the lead and to create food environments that are consistent with their mission to cure the sick and to promote health. Through the simple act of serving food that meets national nutritional standards, our hospitals will act in the best health interests of their patients, and their staff, and will undoubtedly again be leaders in our ongoing dialogue on how to improve our food supply, which in turn will improve the health of us all.”

“Strict antismoking regulations have frequently been criticized as too harsh or difficult to enforce, as if disease and premature death brought on by smoking were any easier to accept and control.” Think my smoking-diet parallel is hyperbole? Well, guess what? Today, the major cause of preventable illness and death in this country is no longer tobacco. The leading cause of death in America is now the American diet, as shown below and at 6:29 in my video. Hospitals in the United States serve “millions of patient meals each day and are optimally positioned to model a healthy diet through patient food.” 

Doctor’s Note:

Have you seen my earlier video on junk food in hospitals? If not, check out Hospitals’ Profit on Junk Food.

For more on how the profit motive is degrading our health, see related posts below.

Gaming the System: Cardiologists, Heart Stents, and Upcoding

Cardiologists can criminally game the system by telling patients they have much more serious, unstable diseases than they really have—fraud that results in unnecessary procedures, unnecessary costs, and unnecessary patient harm.

“The history of medicine abounds with dogmas assumed and later overcome”—sometimes, much later. The Women’s Health Initiative study showed that giving women Premarin, a hormone replacement therapy, increased the risk of the number one killer of women, heart disease, as well as breast cancer risk. Millions of women stopped taking it, and breast cancer rates came down.

Another such reversal of an established medical practice is percutaneous coronary intervention (PCI)—angioplasty and stents for stable coronary artery disease. Billions of dollars are spent on procedures shown “unequivocally” to offer no benefits.

So, why are cardiologists still doing them? Researchers did some focus groups and concluded: “Although cardiologists may believe they are benefiting their stable patients with CAD [coronary artery disease] by performing PCI, this belief appears to be based on emotional and psychological factors rather than on evidence of clinical benefits.”

“The sense of irrationality surrounding this practice is so strong that the phenomenon has been coined the oculostenotic reflex (I see a stenosis; I stent it).” They see a narrowing and stent it as though they can’t even help themselves.

Since the procedure carries some risks, including death, there’s an argument that stents should only be used for individuals who are actively having heart attacks and are in an emergency or unstable situation. Thankfully, there are now published, appropriate-use criteria in place to help guide cardiologists, and the good news is that 82 percent of stents are “reported to be performed in emergency or unstable situations.” So, we can disregard that ORBITA study that showed there was no benefit in stable patients since it’s now almost always performed only in unstable patients, right? Well, that’s how it’s almost always reported. “There are 2 ways a physician can become compliant. One is to do fewer unnecessary procedures”—which is the whole point (but where’s the money in that?)—“and the other is to make unnecessary procedures seem necessary.”

Is the implication that a doctor would try to game the system by telling a patient that they had a much more serious, unstable disease than they actually had, so the procedure could be carried out anyway? This is referred to as “upcoding.” Another word for it would be “fraud.” Researchers found that “some of that decline [in inappropriate use] may be driven by upcoding, falsely and intentionally misclassifying patients with stable angina as UA,” having unstable angina. As soon as those appropriate-use criteria went into effect, suspiciously, there was a four- to tenfold greater increase in rates of stents for acute coronary syndromes like heart attacks. “In New York, the proportion of PCIs labeled as acute, but performed as outpatient procedures, increased 14-fold…” There’s no biologically plausible reason why that would happen, so they were unnecessary procedures with unnecessary cost and unnecessary patient harm. And harm not only from the risk of getting an unnecessary stent but also from lying to the patient by exaggerating how bad their heart disease is. “This practice, at best, damages the credibility of the profession, increases health care spending, violates patient autonomy, puts the patient at risk of procedural complications and, at worse, may cross the threshold into criminal activity…”

What’s the solution? There could be an independent review panel to protect patients. “Simpler might be to remove the financial incentive to perform more procedures.”

“How many established standards of medical care are wrong? It is not known.” Bloodletting was the standard of care for thousands of years, for example. “Rigorous questioning of long-established practices is difficult. There are thousands of clinical trials, but most deal with trivialities or efforts to buttress the sales of specific products. Given this conundrum, it is possible that some entire medical subspecialties are based on little evidence.”

In the landmark COURAGE trial that showed stents were useless for extending life, what did seem to determine longevity? Ironically, in the case of heart stents, it was how many risk factors the patients were able to control. Those who achieved all six by lowering their blood pressure, cholesterol, weight, and smoking, while improving their diets and activity, had five times the survival over the subsequent 14 years than those who didn’t, as shown below and at 4:36 in my video Heart Stents and Upcoding: How Cardiologists Game the System.

Should we be surprised that angioplasty and stents fail to improve prognosis? After all, they do nothing to modify the underlying disease process itself. In other words, it doesn’t treat the cause. Even if stents helped with symptoms beyond the placebo effect, they would still just be treating the symptoms and not the disease. So, it’s no wonder the disease continues to progress until the patient is disabled to death. Dr. Esselstyn wrote, “Thus, the leading killer of men and women in Western civilization is being left untreated. What is being practiced is ‘palliative cardiology’: nontreatment of heart disease leading to disease extension and frequently an eventual fatal outcome.”

Deaths by the planeload every week, are “regarded as unfortunate,” rather than a national, preventable tragedy. “It is as though in ignoring this dairy, oil, and animal-based illness, we are wedded to providing futile attempts at temporary symptomatic relief”—rather than the cure.

Thankfully, “we are on the cusp of a seismic revolution in health…not another pill, procedure, or operation,” but instead treating the underlying cause of heart disease with whole food, plant-based nutrition, “the mightiest tool medicine has ever had in its toolbox.”

To get there, we need to fight a key nutrition deficiency in education. A study found that 90 percent of cardiologists reported receiving no or minimal nutrition education during their cardiology training, leaving fewer than one in ten feeling confident in their nutrition knowledge. So, maybe it’s a good thing that most spend just three minutes or less discussing nutrition with their patients. Only one in five cardiologists themselves even ate five servings of fruits and vegetables a day.

Thankfully, this lifesaving information is slowly but surely getting out there. “Medical education has focused on being the ambulance at the bottom of the cliff rather than a fence at the top. Money talks, and there’s very little money in promoting eating broccoli and going for a walk, despite them being much more effective.” I was so eager to see the citation they used for that and was so honored when I did, as shown below and at 7:14 in my video. 

Why Use Stents When They Don’t Work?

Again and again, studies have shown that doctors tend to make clinical decisions for patients based on how much they themselves will get paid.

In 2007, we learned from the COURAGE trial that angioplasty and stents—percutaneous coronary intervention (PCI)—don’t reduce the risk of death or heart attack, but patients didn’t seem to get the memo. Only 1 percent realize there was no mortality or heart attack benefit, perhaps because most cardiologists fail to mention that fact. One can imagine that if patients actually understood that symptomatic relief was all they were going to get, with “no additional mortality benefits,” they’d be less likely to go under the knife. Then, ten years later, the ORBITA trial was published, showing even the promise of symptom relief was an illusion.

“The implications of ORBITA are profound and far-reaching. First and foremost, the results of ORBITA show unequivocally that there are no benefits for PCI compared with medical therapy for stable angina,” that is, heart disease. Basically, patients would be risking “harm for no benefit. It is hard to imagine a scenario where a fully informed patient would choose an additional invasive treatment for no added benefit.” Remember the stent consent form I discussed previously, shown below and at 1:17 in my video Why Are Stents Still Used If They Don’t Work?: 

Now, it looks like this, seen below and at 1:21.

So, is the ORBITA trial the “last nail in the coffin for PCI in stable angina?” That is, for stents in non-emergency situations? An editorial in the journal Cardiovascular Revascularization Medicine disagreed, pointing to “the broad angina relief that occurred in both arms.” In other words, stents helped—even if the sham operation without stents helped just as much. So, “if the patient is treated with PCI and is benefiting from the ‘placebo effect,’ who am I to interfere with that benefit of this ‘therapy’?” In that case, why not perform fake surgeries? Stent placement can cost around $40,000. It’d be cheaper to just fake it all. The reason we shouldn’t keep electively stenting people is because there’s a body count. During stent placement, 2 percent of patients develop bleeding or blood vessel damage, while another 1 percent die or have a heart attack or a stroke. And because something is stuck in your chest, 3 percent of patients have a bleeding event from the blood thinners that must be taken. Or the blood thinners don’t work and the stent clots off and causes a heart attack.

Why are they still done when we not only don’t have evidence of benefit but, in many cases, we have explicit “evidence of no benefit”? One of the sources of resistance may be all the financial gain. These procedures make a lot of money for hospitals. Don’t expect them to begin promoting “lifestyle changes to combat heart disease. Nor will physicians quickly abandon a practice that both supports their income and seems to make sense.” Is it that simple? Is it that famous Upton Sinclair quote: “It is difficult to get a man to understand something when his salary depends upon his not understanding it.” Think that’s just cynicism? Let’s ask doctors themselves.

Thousands of physicians were surveyed, and 70 percent “believed that physicians provide unnecessary procedures when they profit from them.” That’s what doctors themselves believe. And the data bear this out. Doctors have been shown to make clinical decisions for patients based on how much they get paid. For example, when choosing which chemotherapy to treat breast cancer, increasing a physician’s margin by 10 percent can yield up to a 177 percent increase in the likelihood of choosing one drug over another.

That may be why Caesarean sections “are more likely to be performed by for-profit hospitals as compared with non-profit hospitals.” “Operating on commission.” Pay surgeons per procedure, and you can increase surgery rates by 78 percent. Could that explain why we do 101 percent more angioplasties than any other affluent country? A study on “physicians’ financial incentives and treatment choices in heart attack management” found that they do indeed “respond positively to the payments they receive and that the response is quite large…Unconditionally, plans that pay physicians more for more invasive treatments are associated with a larger fraction of such treatments,” seeming to result in more invasive treatments. So, it may actually be quite common for patients to receive different treatments based on whether the doctor is getting paid per procedure.

One of my heroes, Dr. Caldwell Esselstyn—who always tries to see the best in people—had to admit that compensation may be playing a role. Evidence surfaced that “doctors have run up millions of dollars in medical bills by doing unnecessary stent implants,” doctors like Mark Midei who inserted 30 stents in a single day. That could be about a million dollars worth of billing. As a token of gratitude, a sales representative from the stent company spent more than $2,000 to buy “a whole slow-smoked pig, peach cobbler, and other fixings for a barbecue dinner at Dr. Midei’s home.”

“The US is just about the only developed country where health care is delivered on a fee-per-service basis and we very liberally incentivize physicians for doing invasive procedures,” explained the chief of cardiovascular medicine at the Cleveland Clinic. “The economic incentives are just too strong.” 

Do Heart Stents Benefit Angina Chest Pain?

Sham surgery trials prove that procedures like non-emergency stents offer no benefit for angina pain—only risk to millions of patients.

Angioplasty and stents—percutaneous coronary intervention (PCI)—for stable, non-emergency coronary artery disease are among “the most common invasive procedures performed in the United States.” Though they appeared to offer immediate relief of angina chest pain in stable patients with coronary artery disease, that didn’t actually translate into a lower risk of heart attack or death. This is because the atherosclerotic plaques that narrow blood flow tend not to be the ones that burst and kill us. Symptom control is important, though, and is much of what we do in medicine, but cardiology has a bad track record when it comes to performing procedures that don’t actually end up helping at all.

Case in point: internal mammary artery ligation. Though it didn’t make much anatomical sense—why would tying off arteries to the chest wall and breast somehow improve coronary artery circulation?—it worked like a charm with immediate improvement in 95 percent of hundreds of patients. Could it have just been an elaborate placebo effect, and surgeons were cutting into people for nothing? There’s only one way to find out: Cut into people for nothing.

As I discuss in my video Do Heart Stent Procedures Work for Angina Chest Pain?, people were randomized to get the actual surgery or a sham (or fake) surgery where patients were cut open and the surgeon got to the last step but didn’t actually tie off those arteries. The result? “Patients who underwent a sham operation experienced the same relief.” Check out the testimonials: “Practically immediately, I felt better.” “I’m about 95 percent better.” “No chest trouble even with exercise.” “Believe I’m cured.” And these are all people who got the fake surgery. So, it was just an extravagant placebo effect. Think about it. “The frightened, poorly informed man with angina [chest pain], winding himself tighter and tighter, sensitizing himself to every twinge of chest discomfort, who then comes into the environment of a great medical center and a powerful positive personality and sees and hears the results to be anticipated from the suggested therapy is not the same total patient who leaves the institution with the trademark scar.” He hears how great he’s going to feel, goes through the whole operation, and leaves a new man with that trademark scar.

One sham patient was actually cured, though. “The patient is optimistic and says he feels much better.” The next day’s office note reads: “Patient dropped dead following moderate exertion.” This has happened over and over.

What if we burn holes into the heart muscle with lasers to create channels for blood flow? It seemed to work great until it was proven that it doesn’t work at all. Cutting the nerves to our kidneys was heralded as a cure for hard-to-treat high blood pressure until sham surgery proved that procedure was a sham, too. “The necessity for placebo-controlled trials has been rediscovered several times in cardiology, typically to considerable surprise.” Before they are debunked, “often a therapy is thought to be so beneficial that a placebo-controlled trial is deemed unnecessary and perhaps unethical.” That was the case with stents.

Hundreds of thousands of angioplasties and stents are done every year, yet placebo-controlled trials have never been done. Why? Because cardiologists were so unquestioningly sure it worked “that it might be unethical to expose patients to an invasive placebo procedure.” Why perform a fake surgery to prove something we already know is true? “When patients are aware they have had PCI, they have a clear reduction in angina and improved quality of life.” But what if they weren’t aware they had a stent placed inside them? Would it still work?  

Enter the ORBITA trial. After all, “anti-anginal medication is only taken seriously if there is blinded evidence of symptom relief” against a placebo pill, so why not pit stents against a placebo procedure? “In both groups, doctors threaded a catheter through the groin or wrist of the patient and, with X-ray guidance, up to the blocked artery. Once the catheter reached the blockage, the doctor inserted a stent or, if the patient was getting the sham procedure, simply pulled the catheter out.”

The researchers had problems getting the study funded. They were told: “We know the answer to this question—of course, PCI works.” And that’s even what the researchers themselves thought. They were interventional cardiologists themselves. They just wanted to prove it. Boy, were they surprised. Even in patients with severe coronary artery narrowing, angioplasty and stents did not increase exercise time more than the fake procedure.

“Unbelievable,” read the New York Times headline, remarking that the results “stunned leading cardiologists by countering decades of clinical experience.” In response to the blowback, the researchers wrote that they “sympathize with our community’s shock and its instinct to invalidate the trial. Applying a positive spin could have smoothed the reception of the trial, but as authors we have a duty to preserve scientific integrity.”

While some “commended them for challenging the existing dogma around a procedure that has become routine, ingrained, and profitable,” others questioned their ethics. After all, four patients in the placebo group had complications from the insertion of the guide wire and required emergency measures to seal the tear made in the artery. There were also three major bleeding events in the placebo group, so they suffered risks without even a chance of benefit. But “far from demonstrating the risks of sham-controlled PCI trials, this demonstrates exactly what patients are being subjected to on a routine basis, without evidence of benefit.”

Those few complications in the trial “are dwarfed in magnitude” by the thousands who have been maimed or even killed by the procedure over the years. Do you want unethical? How about the fact that an invasive procedure has been performed on millions of people before it was ever actually put to the test? Maybe “we should consider the absence, not the presence, of sham control trials to be the greater injustice.”

When a former commissioner of the U.S. Food and Drug Administration was asked at the American Heart Association meeting “whether sham controls should be required for device approval, he thought that it was more of a decision for the clinical community: ‘Do you want to get the truth or not?’”

The Risks vs. Benefits of Angioplasty and Heart Stents

What do physicians and stent companies have to say for themselves, given that they promote expensive, risky procedures with no benefit?

“Percutaneous coronary intervention (PCI)”—angioplasty and stent placement—“continues to be frequently performed for patients with stable [non-emergency] coronary artery disease, despite clear evidence that it provides minimal benefit…” The procedure does not prevent heart attacks or death for patients with stable angina pectoris, for example, yet nearly nine out of ten patients mistakenly believed that it would reduce their chances of having a heart attack. “At the same time, the cardiologists who referred them for PCI and those who performed the procedure generally did not believe that PCI reduces the risk for MI [myocardial infarction or heart attack] in stable angina.” Then why on earth were they doing it?

“Focus groups of cardiologists have documented a chasm between knowledge and behavior; while aware of the results of clinical trials”—that is, evidence to the contrary—“they recommend and perform PCI because they believe that it helps in some ill-defined way.” “Physicians tended to justify a non-evidence-based approach (‘I know the data shows there is no benefit, but’) by focusing on the ease of PCI and belief that an open artery was better”—even if it doesn’t actually affect outcomes—“while minimizing the risks of PCI.” The procedure only kills 1 in 150, so some are blaming the patients for not listening, but maybe the physicians are the ones who are ignoring the evidence.

Or “physicians may have too poor a grasp of relevant statistics to adequately inform their patients.” Regardless, what we have is “a failure to communicate.” So, tools have been developed. For example, a sample informed consent document lays out the potential benefits and risks, even laying out how many procedures doctors have performed and any out-of-pocket costs. As you can see below and at 1:58 in my video Angioplasty Heart Stent Risks vs. Benefits, there are a lot of blanks to be filled in. What are some concrete numbers? 

As you can see below and at 2:20 in my video, the Mayo Clinic came up with some prototype decision-making tools. In terms of benefits, “Will having a stent placed in my heart prevent heart attacks or death? No. Stents will not lower the risk of heart attack or death,” but a week later those getting stents report they feel better—though, a year later, even the symptomatic-relief benefit appears to disappear. Nevertheless, there appeared to be a benefit of temporary relief of chest pain. What about the risks? 

As shown below and at 2:53 in my video, during the stent procedure, out of a hundred people, two will have bleeding or damage to a blood vessel and one will have a more serious complication, such as heart attack, stroke, or death. Then, during the first year after the stent placement, three will have a bleeding event because of the blood thinners that must be taken because of the foreign material in the heart, but that doesn’t always work, so two people will have their stent clog off, leading to a heart attack. 

What does the world’s number one stent manufacturer have to say for itself? It acknowledges that the evidence shows that stents don’t make people live longer, but the manufacturer thinks living longer is overrated. If we only cared about living longer, in medicine, “entire disciplines would dwindle or even disappear, such as dermatology, ophthalmology, orthopedic surgery, and dentistry.” So why go to the dentist? Of course, the difference is that 80 percent of people don’t believe that getting a cavity filled is going to save their life, like they mistakenly do for stents, as shown here and at 3:18 in my video, and there isn’t a one in a hundred chance you won’t make it out of the dentist chair. 

The stent companies actively misinform with ads making heart-warming copy. “Open your heart and your life.” “When you open up your heart, you open up your life. LIFE WIDE OPEN.” “Freedom begins here.” Their TV ads mention a few side effects, but it turns out they missed a few. More importantly, they’re giving the false impression that stents are more than just expensive, risky band-aids for temporary symptom relief. But what’s wrong with symptom relief? Even if the benefits are only symptomatic and won’t last long, what’s the problem if people think that outweighs the risk?

What if I told you that even the symptom relief might just be an elaborate placebo effect, and you could get the same relief from a fake surgery, so there really aren’t any benefits at all? We’ll see what the science says—next. 

Heart Stents and Their Risks

Why are doctors killing or stroking out thousands of people a year for nothing? How do doctors even convince patients to sign up for procedures that are all risk without benefit?

Millions of people have gotten stents for stable coronary artery disease (CAD), yet we now know that angioplasty and stent placement don’t actually prevent heart attacks, offer long-term angina pain relief, or improve survival for such patients. Why? Because the most dangerous plaques—the ones “most vulnerable to rupture or erosion—leading to a subsequent cardiac event,” that is, a heart attack, are not the ones doctors put stents into. They aren’t even the ones that are often seen on angiograms to be obstructing blood flow. So, “we need to avoid the ‘therapeutic illusion’ that we are accomplishing more than is shown by the evidence.” Percutaneous coronary intervention (PCI) looks great. Angioplasty and stents open up blood flow again, but if PCI doesn’t actually help, why do it?

We aren’t just talking about billions of dollars wasted either. Stent placement and the blood-thinner drugs that need to be taken can cause complications, including heart failure, stroke, and death, but the risks are relatively low. There is less than a 1 percent chance PCI will kill you or stroke you out, and the 15 percent risk of heart attack is only if your stent clogs off at a later date, which only happens in about 1 percent in the near term. There is a 13 percent chance of kidney injury, though, due to the dyes that have to be injected, but that typically heals on its own. The most serious complications, like death, happen in only about 1 in 150 cases, but that must be multiplied by the hundreds of thousands of procedures being done every year.

In an emergency setting, like while you’re actively having a heart attack, angioplasty can be lifesaving, but these hundreds of thousands of procedures are done for stable coronary artery disease, for which there appear to be no benefits. So, doctors are killing or stroking out thousands of people a year for nothing. And that’s not even counting the tens of thousands of silent mini-strokes that may contribute to cognitive decline caused by these procedures. Between 11 and 17 percent of people who go through angioplasty or stenting come away with new brain lesions, as you can see below and at 2:16 in my video The Risks of Heart Stents. That’s up to about one in six individuals.

How do doctors convince patients to sign up for PCI when it doesn’t lower the risks of death or heart attack, nor does it offer long-term symptom relief? Apparently, by conveniently failing to “inform the patient that PCI would not lower their risk of death or MI [myocardial infarction or heart attack], or that the symptom benefit is gone after 5 years,” thereby not offering long-term symptom relief.

Cardiologists are aware of how little they help, but studies have “consistently demonstrated” that patients think stents will reduce their risk of heart attack or death. More than 70 percent of patients erroneously believed that stents would extend their life expectancy or prevent future heart attacks. That’s why this study was done—to figure out “why patients overestimate these benefits.” Where are they getting these wild ideas? The answer is that many patients are being kept in the dark. Doctors, who overstate the benefits and understate the risks, may pressure patients into procedures that won’t benefit them the way they think. Why? Well, one reason may be because doctors may be paid per procedure. “Current reimbursement favors procedures over medication and lifestyle change, and it is possible that reimbursement may influence physicians’ recommendations.” Doctors are paid more for offering stents than recommending common sense diet and lifestyle changes.

Patients with stable coronary disease who undergo angioplasty and stent placement are frequently misinformed of the benefits. Of 59 recorded conversations between cardiologists and their patients, only two discussions included all seven elements of informed decision-making—telling people they have a choice, explaining the problem, discussing alternatives and the pros and cons, informing patients the procedure may not work, asking if they understand, asking if they have any questions, and asking them what they want to do. Only 3 percent of doctor-patient discussions about stents hit even just these basic elements! And this was the case when “the physicians and patients knew that they were being recorded, which could have affected their behavior. If so, it is likely that this represents a best-case scenario for these physicians.” Only 3 percent! Quoting from the Cleveland Clinic Journal of Medicine, when it comes to angioplasty and stents, “true informed consent rarely occurs.”

It’s no wonder that among the nearly 1,000 patients surveyed across ten U.S. academic and community hospitals, just 1 percent knew the truth. Remarkably, some blame the patients for their ignorance, saying patients are the ones who “commonly overestimate or misunderstand the benefits of treatment, such as patients with cancer who believe that palliative chemotherapy offers the potential for cure—the ‘therapeutic misconception.’”

“Why are so many patients having procedures with benefits that they poorly understand? Don’t look at the patients to find out why. Instead, examine the doctor’s motivation…Patients think they are having life-saving procedures because medical professionals want them to believe that this is so.” Now, it’s not like those 95 percent of cardiologists are lying to their patients and saying it will reduce their risk; they just happen to conveniently omit those details. But “[i]n the absence of information to the contrary, most patients and some doctors assume that PCI is life-saving and are biased towards choosing it. As a result, patients are rarely able to give true informed consent to undergo PCI.”

Why would they assume that? Because many have a wild concept of “‘personal care’—that a physician’s first obligation is solely to the patient’s well-being,” but isn’t that naïve? “In the absence of information, or even when presented with evidence to the contrary, patients tend to believe that treatments offered will be beneficial.”

It’s true, even if you explicitly tell patients that stents do not reduce the risk of heart attacks. You can cut that misperception in half “with relatively little effort—as little as 2 lines of text,” dispelling the myth in many people. But many participants continued to believe that angioplasty and stents prevent heart attacks, even when explicitly told they do not and given a detailed explanation of why they do not. After all, why would doctors be pushing them if they didn’t help? That’s a good question, which we’ll address next. 

2024 Year in Review

Celebrating 2024. Celebrating Your Support.

What a year NutritionFacts.org had! Our successes, output, and outreach in 2024 are thanks to your support. We simply cannot do what we do without your generosity. Thank you.

You’re invited to read our 2024 Year in Review in full. Please share in the work we were able to accomplish. The lives we were able to touch.

Some of our highlights:

Dr. Greger’s book tour for his New York Times Best-Selling How Not to Age took him to more than 70 events, presenting to thousands of individuals in the United States, Canada, and Europe, and the companion four-part webinar series was our most popular ever, drawing more than 9,000 participants who wanted to learn how to live longer, more vibrantly.NutritionFacts.org hired Kristine Dennis, PhD MPH, as our first Senior Research Scientist.We released our first self-published book— Ozempic: Risks, Benefits, and Natural Alternatives to GLP-1 Weight-Loss Drugs .On the Chinese platform WeChat, we hit nearly 400,000 blog views in just one month.We prepared the manuscript for the forthcoming How Not to Age Cookbook , once again working with famed recipe creator Robin Robertson.

See our 2024 Year in Review for the full scope of our work last year and a preview to what we’re focusing on in 2025.

Thank you, again, for your commitment to sharing evidence-based nutrition and health information and your dedication to NutritionFacts.org.

Why Aren’t Angioplasty Heart Stents More Effective?

Most heart attacks are caused by nonobstructive plaques that infiltrate the entire coronary artery tree. There is no such thing as “1-vessel disease,” “2-vessel disease,” or “left main disease.” Atherosclerotic plaque is continuous throughout the coronary arteries of heart attack victims. 

In angioplasty, a tiny balloon is inserted into a narrowed coronary artery that feeds the heart to force it to open wider to improve blood flow. It wasn’t put to the test in a randomized controlled trial until 1992. It not only failed to prevent heart attacks, but it also failed to show any survival benefit. However, the researchers only followed patients for six months and included people with relatively minor diseases who might not have been sick enough to benefit from the procedure. Enter the MASS trial. Researchers enrolled those with severe blockage high up in their left anterior descending coronary artery—the widow-maker or widower-maker (since coronary artery disease is also the number one killer of women)—and followed them for years. The findings? There was no difference in subsequent mortality or heart attack rates. There were only about 200 patients in that trial, though. Maybe the benefit was so subtle that a greater number of patients were needed to tease out the effect. Enter the RITA-2 study, which randomized more than a thousand patients. Researchers did indeed find a clear difference in the risk of future death and heart attack, but it was in the wrong direction. The angioplasty group suffered twice the risk compared to those randomized to forgo surgery, as shown below and at 1:18 in my video Why Angioplasty Heart Stents Don’t Work Better. 

This was all before stents came into vogue, though. Instead of just ballooning up the artery, how about permanently inserting a stent, a metal mesh tube, to prop open the artery, as you can see here and at 1:33 in my video? Surely, that’s got to help. 

Enter the MASS-II trial, which, again, saw no benefit after one year—but no benefit was seen after five years or even ten years. Then came the Courage Trial, which randomized thousands of patients, and it, too, fell flat on its face. 

Those mostly used bare metal stents, though, not the newer “drug-eluting” ones that release drugs slowly. And what about high-risk groups, such as those diagnosed with diabetes and other more serious diseases, or those who have 100 percent blocked arteries days after having a heart attack? In meta-analysis after meta-analysis, looking at five trials with 5,000 patients, there was no reduction in death, heart attack, or even angina pain. In ten trials with more than 6,000 patients, there was no benefit for survival, heart attacks, or pain relief. Now, we’re up to more than a dozen major trials and nothing: no benefit from angioplasty and stents. “Furthermore, multiple analyses have failed to identify a single high-risk subset that benefits…” How is that possible? You’re physically opening up blood flow.

The reason it doesn’t work is that the majority of heart attacks in real life are caused by narrowings less than 70 percent—“i.e., most likely non-flow-limiting lesions”—so the plaques in our arteries that kill us tend not to be the ones that are restricting blood flow. Shown below and at 3:21 in my video are two atherosclerotic plaques. The one circled in green and labeled “Flow-limiting lesion” is squeezing off the blood flow so much that it can be seen on an angiogram and doctors can go after it with a stent. 

Problem solved and life saved, right? No, because it was the invisible one (circled in yellow below) that wasn’t even impeding blood flow that was going to kill us all along, as you can see here and at 3:27.

Indeed, most heart attacks are caused by nonobstructive plaques that don’t even cut blood flow by 50 percent, as seen below and at 3:40 in my video. 

There’s a misconception, a “clogged pipe analogy of stable coronary heart disease [that] has been particularly difficult to dislodge,” in which cholesterol plaques slowly and inexorably encroach on blood flow, eventually cutting it off completely and triggering a heart attack. In reality, “coronary artery disease…is an inflammatory disease in which cholesterol from the blood is deposited in artery walls, causing an inflammatory reaction, like a pimple. When those pimples pop, they cause the blood in the arteries to clot at the site…Before rupture, these plaques often do not limit flow and may be invisible to angiography and stress tests. They are, therefore, not amenable to percutaneous coronary intervention (PCI),” that is, to angioplasty and stents. Old plaques are like “scarred old pimples.”

The tightest blockages are made up of mostly calcified and dense fibrous scar tissue. They can still rupture and kill us, but there are so many more of the smaller lesions brewing, which are hidden from view. The way we visualize coronary arteries is with an angiogram. X-rays are taken after a black-looking dye is injected into the arteries, so we can only see plaques that encroach on the blood flow. That’s why we get these kinds of tip-of-the-iceberg illustrations, the point of which “is to emphasize that most of the atherosclerotic plaque in the coronary arteries is not seen well by angiography,” as you can see below and at 4:49 in my video. To really understand what’s going on in people’s arteries, we must turn to autopsy. William Clifford Roberts is probably the most pre-eminent cardiovascular pathologist in the world. What did he learn after studying coronary arteries for 50 years? After examining nearly 2,000 bodies, he learned that atherosclerosis is a systemic disease. 

“In patients with fatal coronary artery disease…the quantity of plaque is enormous. There is not just 1 plaque here, another plaque there, with normal lumen [clean arteries] between plaques. Plaques are continuous! Not a single 5-mm segment is devoid of plaque” in the entire coronary artery tree. So, says Dr. Roberts: “Isolated coronary disease is a myth. There are no such things as ‘1-vessel disease,’ and ‘2-vessel disease.’ Plaque is in all of the epicardial coronary arteries if it is in 1 of them.”

Four main coronary arteries feed the heart—the right coronary artery, the left main coronary artery, the circumflex coronary artery, and the left anterior descending coronary artery, as seen here and at 6:00 in my video. 

If we add up their lengths, that’s about 11 inches (28 cm) of coronary arteries, which, for examination, can be cut into about 50 quarter-inch (5-mm) slices. Shown below and at 6:17 in my video is what is seen: Plaque isn’t gunking up one or two slivers but throughout all the coronary arteries. If we look at more than a thousand of these slices from dozens of patients who died of heart attacks, “not a single segment was devoid of plaque.” So, it’s no wonder that stenting open in just one area has no impact on heart attacks or death.

The Effectiveness of Angioplasty and Heart Stent Procedures

There are demonstrably no benefits to the hundreds of thousands of angioplasty and stent procedures performed outside of an emergency setting. They don’t prevent heart attacks, enable you to live longer, or even help with symptoms any more than placebo (sham) surgery. 

Large national cardiology conferences may attract the majority of cardiologists across an entire country, convening them in one place. “While at the large cardiology conventions…[it’s been] joked that the convention center would be the safest place in the world to have a heart attack.” And, indeed, that’s when the American Heart Association president had his, within hours of his presidential address. With so many of the nation’s top cardiologists at a conference, that may be a bad time to go into cardiac arrest anywhere else, though. You don’t know until you put it to the test.

To much surprise, researchers found substantially lower mortality among those going into cardiac failure or cardiac arrest during the dates of national cardiology meetings. Why is the death rate lower when most of the cardiologists are away? “‘One explanation for these findings is that the intensity of care provided during meeting dates is lower and that…the harms of this care may unexpectedly outweigh the benefits,’ the researchers wrote.” Their results “echo paradoxical findings documented during a labor strike by Israeli physicians in 2000, in which hundreds of thousands of outpatient visits and elective surgical procedures were canceled, but by many accounts mortality rates dramatically fell during the year.” And it wasn’t just one strike. “Doctors’ strikes and mortality” have been looked at multiple times. In all reported cases, “mortality either stayed the same or decreased during, and in some cases, after the strike.” In four of the seven cases, “mortality dropped as a result of the strike, and three observed no significant change in mortality during the strike or in the period following the strike.”

The fact is that many current medical practices have been found to offer no benefit and present potential harm. Even physicians themselves estimate that about one-fifth of medical care is unnecessary. A national summit was convened by The Joint Commission, which accredits hospitals, and the American Medical Association to identify areas of overuse, “described as the provision of treatments that provide zero or negligible benefit to patients, potentially exposing them to the risk of harm.” Five practices were called out, including prescribing antibiotics for viral upper respiratory tract infections and spending a billion dollars prescribing drugs that don’t work (and, if anything, make things worse). Another overused practice identified was elective percutaneous coronary intervention (PCI)—in other words, angioplasty and stents, as I discuss in my video Do Angioplasty Heart Stent Procedures Work?.

To get everyone on the same page before we dive in: Coronary artery disease, the number one killer of men and women, involves blockages in the blood vessels that supply the heart muscle itself. Low blood flow can lead to angina, a type of chest pain, or, if it’s severe enough, to a heart attack. Plant-based diets and lifestyle programs have been shown to reverse these blockages by treating the cause of why our arteries are clogging up in the first place, but for those unable or unwilling to change their diets, there are drugs that can help, as well as more invasive treatments, such as open-heart surgery to try to bypass the blockage or percutaneous coronary intervention, when “doctors insert small balloons or tunnels (stents) attached to flexible tubes (catheters) into the large blood vessels in the patient’s groin and thread them up into the heart. The stent and catheter are passed through the blocked vessels, a process that opens up the vessels.” In this way, they can get inside the blocked vessels and try to open them up and keep them propped open. During a heart attack, this can be lifesaving, but hundreds of thousands of these procedures are performed every year for stable angina, meaning on a non-emergency basis. It can relieve angina symptoms “but it does not reduce a person’s chances of having or dying of a heart attack.”

However, not everyone knows that. “Some patients and doctors mistakenly believe that PCI does more than just reduce symptoms.” That’s one of the reasons I’ve created a video series on the topic. As Harvard put it: “Stents are for pain, not protection.” Then, unbelievably, it was discovered that stents may not even help with pain, as revealed in a double-blind, randomized controlled trial. People can be blinded to the active treatment in a drug trial by receiving a placebo sugar pill, but wouldn’t they notice if they had surgery? If a doctor cut into their groin? Not if they had sham surgery—placebo surgery. “In both groups, doctors threaded a catheter through the groin or wrist of the patient…up to the blocked artery. Once the catheter reached the blockage, the doctor inserted a stent or, if the patient was getting the sham procedure, simply pulled the catheter out.” The results? Those who underwent the fake surgery did just as well as those who had the regular PCI surgery.

There are no benefits to angioplasty and stents outside of an emergency setting. They don’t prevent heart attacks, they don’t enable us to live longer, and they don’t even help with symptoms. “Since the procedure carries some risks, including death, stents should be used only for people who are having heart attacks…” How are hundreds of thousands of people getting these operations for nothing? How do the doctors justify it? Is it just greed? How do they get patients to consent to it? Do they just not tell them the truth? And why doesn’t it work? After all, a blocked artery is being opened up. There are just so many questions, which we’ll start addressing next.