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Dean Ornish was the first to show that lifestyle change alone was enough to reverse the development of atherosclerotic plaque and reduce plaque rupture the cause of acute coronary events. No drug or procedure has come close to this effectiveness. While Ornish's diet was mostly vegetarian more liberal diets such as the St. Thomas Atheroma Regression diet or Southern Mediterranean type of diet are probably just as effective. Common to these diets is the reduction of saturated fat and meat and an increase in unrefined plant-derived foods. Ornish's diet did not include addition or refiined omega-3 fatty acids but the other two did.
Clearly, it is unethical to perform further drug or procedure trials for treatment atherosclerosis unless all subjects are using one of these lifestyles and to treat patients in clinical practice with drugs or procedures for atherosclerosis without insisting upon lifestye change first. But investigators are still doing it. See the recent report of the ASTEROID trial in which patients with major lifestyle problems were only given drugs for their atherosclerosis.
Fifteen years after the demonstration of regression of atherosclerotic plaque by lifestyle change alone there was great excitement when expensive high dose statin treatment did the same thing. See the hype attendant to this announcement and the absence of any reference to the diet trials.
In this landmark study a mediterranean diet after a heart attack markedly reduced the rate of recurrent heart attack and significantly prolonged life with no change in blood cholesterol, probably due to a reductiion in modified LDL in the vascular wall.
There was some reduction in LDL levels with this diet but the correlation of blood LDL with plaque reduction is poor. Total cardiovascular events were almost eliminated over 3 years. Addition of cholestyramine, a resin that sequesters cholesterol-containing bile acids in the gut made no significant difference.
It is instructive to compare STARS with the Lipid Research Clinics Coronary Primary Prevention Trial, a trial of cholestyramine superimposed on a "moderate cholesterol-lowering diet". After 7.4 years of 1900 men taking 4 to 5 packets of resin per day coronary events were reduced by 1.5% and total mortality was not reduced.
