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Am Fam Physician. 1998;57(5):945

to the editor: Drs. Gutstein and Fuster1 review the management of stable coronary artery disease by detailing the considerations behind the revascularization options of coronary artery bypass grafting and angioplasty. Modest attention is given to medical therapy, suggesting that these procedures have become standard and often preferred therapy for stable coronary artery disease.

In his accompanying editorial,2 Dr. Grauer discusses the family physician's role in stable coronary artery disease; he emphasizes proper diagnosis and referral and assisting the patient in deciding about revascularization options. Dr. Grauer also mentions medical therapy and encourages family physicians to promote smoking cessation, estrogen replacement therapy and regular physical activity. Vitamin E and folic acid are mentioned as “controversial measures.” A “healthy diet” is mentioned in the patient information handout that accompanies the article.

Something is seriously missing here. Ornish and colleagues3 demonstrated in the 1980s that coronary artery disease can be reversed with a low-fat diet and stress reduction. Dramatic results, such as the elimination of symptoms, can be achieved in 30 days. While Ornish's approach has been considered impractical by many, his books have become bestsellers, and the belief that individuals with coronary artery disease should follow a very-low–fat diet has become more widely accepted.4,5

Family physicians should routinely offer a very-low–fat diet and stress reduction as alternate approaches to the management of coronary artery disease, especially stable disease. We are in an ideal position to educate and support the patient in making lifestyle changes. As Ornish states, “... it's actually easier to make big changes than small ones.”5 This is especially true when one's life is on the line. With this approach, the potential benefits include not only reversing coronary disease, but also normalizing cholesterol, weight and blood pressure, all of which help our patients to achieve excellent health.

in reply: Dr. Scherger's point regarding aggressive dietary therapy for patients with coronary artery disease is well taken. Indeed, all patients with atherosclerosis should be educated and encouraged in all aspects of risk factor modification. This represents a mainstay of the physician's approach to coronary disease, not an “alternate” approach. We did not intend to deemphasize dietary therapy in the treatment of coronary disease. Rather, as it states in the introduction, our review is intended as a guide to help the physician decide when to consider revascularization rather than medical therapy alone, and to identify the procedure that is most appropriate to prolong survival.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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