What does cause heart disease?

I have danced around this subject for a long time – as regular readers may have noticed. One of the problems in this area is that you have to start with definitions. Which is somewhat tedious, but also rather necessary? Last week, for example, I read someone argue that we should not use the word cancer, we should talk about cancers. Which is true. Multiple myeloma and pancreatic cancer are both usually called cancers, but they don’t have a great deal in common.

Heart disease is also a pretty meaningless term. Do you mean pericarditis, hypertrophic obstructive cardiomyopathy, aortic stenosis, coronary artery disease etc. et bleeding cetera. In fact, in 1948 the World Health Organisation, recognising the need for accurate definitions, made the first stab at creating an international disease classification (ICD) system. Prior to this, for example, Ischaemic heart disease did not exist. Which meant that you could die of a myocardial infarction in the US, but you could not do so in France – because the French had no term for such an event.

Issues such as this mean that trying to look back in time to ascertain death rates from specific diseases in different countries is a fairly pointless exercise. The French, just to pick on them again, did not accept the ICD system until 1968 – typical, you might say. Even when countries do accept the ICD system, it is difficult to be certain that people are using it in the same way. When I started in medicine a very common diagnosis at death, in the elderly, was bronchopneumonia. ‘The old man’s friend.’

Essentially, when an old person died, and you weren’t really sure what they died of, you put down bronchopneumonia. Try doing that today and the local coroner will be on the phone before you can say Harold Shipman. Now you have to die of something rather more specific – even if the patient is a hundred and two and have been going downhill for the last year.

‘I think they died of old age, Mr Coroner sir. But please sir can I write bronchopneumonia.’

‘Bronchopneumonia! You want more bronchopneumonia!’

In the UK we have now conquered bronchopneumonia. Today, the scourge that used to wipe out millions of elderly people, hardly kills anyone at all. Hooray, great celebrations, all around. My goodness it is a miracle of modern medicine… or not.

Yes, be very careful with medical definitions, and not just because they can often just follow the fashion of the day. Also, because, once you think you have defined something this can constrain your thinking to a painful degree.

Ischaemic heart disease would be what most people think of as heart disease. But just for starters, it is not a disease of the heart; it is a disease of the arteries supplying blood to the heart – through the coronary arteries. The ‘disease’ itself is atherosclerosis (thickening and narrowing of the arteries), and the condition underlying this atherosclerotic plaque development.

This is, sort of covered by ICD 414.0

414.0 Coronary atherosclerosis

Atherosclerotic heart disease

Coronary atheroma

Coronary (artery) sclerosis

But is 414.0 what actually kills you? You can have coronary arteries blocked up to 70:80:90 even 100% without having a heart attack a.k.a. a myocardial infarction:

‘We conclude that total occlusion of the major coronary artery occurs commonly in patients with chronic coronary disease, but is associated with myocardial infarction in only 65%.2

On the other hand you can find people with completely clear coronary arteries who have died of – what has been clearly diagnosed as – a myocardial infarction. Here is a paper from the European Heart Journal published last year, entitled: ‘Acute myocardial infarction with no obstructive coronary atherosclerosis: mechanisms and management.’

‘Myocardial infarction with no obstructive coronary atherosclerosis (MINOCA), a syndrome with several causes, is frequent in patients admitted with the diagnosis of M (myocardial infarction ‘heart attack’ my words). An accurate and systematic diagnostic work-up, is crucial for the identification of the cause of MINOCA in each individual patient, and then for risk stratification and for the implementation of the most appropriate forms of treatment. Yet, patients with MINOCA, in particular those with angiographically normal-coronary arteries, are frequently labelled as ‘non-cardiac patients’, thus missing the opportunity to appropriately treat patients with an outcome worse than previously believed.1

In this study they found that about 5 – 25% of those admitted with ‘infarctions’ had no coronary atherosclerosis. So ischaemic heart disease/MI can very frequently occur without the presence of any atherosclerotic plaques at all.

Unfortunately, the plot thickens even further. In many cases it can be found that a large blood clot (thrombus) can form in an artery days or weeks before the myocardial infarction actually occurs.

Here is an interesting little section from an article with a very boring title: ‘The temporal relationship and clinical significance of plaque substrate in healing coronary thrombi from sudden deaths attributed to rupture and erosion.’

‘Although the morphology of the culprit plaque has been extensively studied, especially rupture, relatively little is known about the temporal relationship between the onset of acute coronary events and thrombus maturation. The occurrence of nonlethal ruptures recognized by accumulated fibrous tissue at healed repair sites suggests that healing thrombi represent an episodic cycle of lesion progression. Moreover, thrombi from fatal plaques are in various stages of healing, further suggesting that death might not necessarily coincide with the initial onset of thrombus formation.3

Now, in English.

The thrombus ‘clot’ formation – the thing that is supposed to kill you within minutes of hours after forming – may well not actually occur shortly before you die. It can occur days or ever weeks earlier. Which mean that, in many cases the thrombus forms, the artery blocks, and nothing happens until – in some cases – weeks later.

This does not really fit with the current model of heart disease, which is very simple, and it goes something like this:

  • The coronary arteries gradually narrow and thicken.
  • At some point, a thrombus forms on top of one of the narrowest bits (the plaque),
  • This blocks the artery completely.
  • The heart muscle then rapidly runs out of oxygen and infarcts (dies).
  • In around 50% of cases you die as the heart stops beating, or goes into fibrillation – or suchlike

I call this the plumbing model of heart disease. Pump, pipes, blockage to the pipe in the pump …death. However, you can have final stage 100% occlusive atherosclerotic plaques without an MI. It is also perfectly possible have an MI without atherosclerosis. In addition, the formation of a thrombus does not necessarily correlate in any way, in timescale, with the MI – at all.

Because of all these problems with the current model, it would be perfectly possible to argue that we have the entire process of ‘heart disease’ the wrong way round. Indeed, I regularly communicate with a Brazilian called Carlos Monteiro, a researcher who proposes the myogenic theory of heart disease. He believes that the MI starts within the heart muscle itself, and the clot in the arteries comes afterwards.

His reasoning – following on from the work of his father in Law, the cardiologist Dr Mesquita is, as follows:

  • Clinical observations showing the absolute lack of efficacy of anticoagulants in the treatment of unstable angina pectoris. Unstable angina is considered to be a stage leading to myocardial infarction
  • The strong correlation of myocardial infarction with stress or unusual physical activity
  • Frequent coronary angiographies showing no obstructions in the presence of myocardial infarction
  • Many anatomic-pathological studies have demonstrated no relationship between thrombus and infarction, which led many authors since the 1940s to consider coronary thrombosis—the clot in the arteries—as a consequence of acute myocardial infarction, not its cause
  • The development of coronary thrombus after a heart attack, demonstrated experimentally4

True or false, right or wrong? Can the myogenic theory explain more of what we actually see? Yes, no, maybe. Personally, I don’t think his theory is correct in totality, although it has many correct bits in it. Causality is always a bugger, which way round do things go? This before that, or that before this? Are things actually related at all?

Sorry to say that I provide no further explanations. Or this blog would end up three hundred pages long, and I will not impose such a thing on anyone. What I hope to have made clear is that we have models and definitions of heart disease/IHD/MI that cannot be considered even remotely adequate. Whatever is going on, it is a far more complex and interesting thing than the plumbing model.

Which boils down to one simple thing. Namely that to ask the question, what causes heart disease, is easy. But in order to try and answer it we have to establish, as clearly as is possible, what the bloody hell is this disease? If find that you cannot find the answer to anything whilst sinking into a bog, or staring into the fog. Both of which seem the activities of choice of my cardiology colleagues.



1: http://eurheartj.oxfordjournals.org/content/early/2014/12/12/eurheartj.ehu469

2: http://onlinelibrary.wiley.com/doi/10.1002/clc.4960060203/pdf

3: http://dare.uva.nl/document/2/106726

4: http://www.westonaprice.org/author/cmonteiro/

107 thoughts on “What does cause heart disease?

  1. Sulamaye

    Having two weeks ago watched my mother die from internal bleeding and a massive bleed in her brain just 24 hrs after a change in her anti coagulant, I do find myself wondering if she’d still actually be alive if she’d just relied on the pace maker and a bit of aspirin. No way of finding out now though is there? They don’t tell u there’s no antidote to these modern ones unlike warfarin. What are ur views on these anti coagulants I wonder?

  2. Gretchen

    “you could die of a myocardial infarction in the US, but you could not do so in France – because the French had no term for such an event.” Is this the cause of the “French paradox”? Someone in Paris dies from an MI and they call say he died from a crise de foie or something?

    1. Anne

      Crise de coeur (literally heart crisis) – my mother died in France (2002) and that’s what the doctor told me she’d died from.

    2. David

      Yerushalmy and Hilleboe were among the first to dispute Key’s notion. Part of their refutation was an analysis of the French methods of reporting, allegedly they had more deaths in ‘other diseases of the heart’ and less in atherosclerosis.

      However they also point out that Keys’ definition of relevant heart disease omitted an unusual number of heart deaths which was attributed to eating fish and not dodgy stats.

      1. David

        I should have mentioned that the fishy bit referred to Japan where they recorded many heart attacks in a category not used by Keys.

  3. Professor Göran Sjöberg

    Interesting reading for an almost dead man since 16 years now. Perhaps I have reincarnated.

    I am also slightly sold on your friends idea of a myogenic or myopathic origin. That goes well along with your idea of the importance of enjoying life and increasing the activities in the parasympathetic part of the autonomous nervous system.

    Though there is a great ‘quack watch’ warning on the Weston Price foundation. I just now happen to read a very interesting book about the 25 years of rigorous research this great dentist, one of the most respected in his days, conducted on teeth infections and the connection with diseases in other organs, like the heart, in our bodies. The sad thing is that his findings was covered-up.

    1. Mary Richard

      Professor Goran,
      One of the most enlightening stories I ever heard came from a medical documentary here in the U.S. a few years back. It was hosted by a coroner and was to me like a medical “who done it!” It was my first aha moment about the role of bacterial infection in the mouth and its connection to an MI. His family reported he just said he did not feel well (tired mostly) and just wanted to rest on the sofa. He died in his sleep of a heart attack. On coroners exam, he was found to have EVERY major artery in the heart blocked. Yet, there was no heart tissue death at all. On even closer exam, she noted a very extensive collateral blood supply this man had or developed over time (she did not know obviously) which actually kept his heart in tip top shape. The heart tissue was not compromised at all and he had never complained of any angina. As she delved further examining this man’s jaw, neck and oral cavity, she noted extensive signs of infection. The source? A bad tooth. That was where this all started from… one abscessed tooth he had not attended to, but which caused the infection to manifest in his jaw, his neck and in the tissue surrounding the heart. It killed him. So if we assume that any kind of infection be it bacterial or viral is capable of an inflammatory response, it is not a big stretch to conclude that your heart can just give out for more than just atherosclerotic plaque build up as we have commonly been taught. Perhaps systemic infection or a simple tooth left unattended to can cause an domino effect that does not have a happy ending. I am trying to find some studies on this as I think some can be found by looking at periodontal disease and heart health. This goes to show that any infection in close proximity to the heart can be quite dangerous. Take good care of those pearly whites. The coroner stated that a course of antibiotics could easily have saved this poor gentleman’s life. He was in his forties.

      1. Mary Richard

        I think Georgie boy there is a bit of a renegade! You are much smarter than he. So, it can be taken either way, but being the positive person I am…I would take it as a compliment.

  4. Jo


    My mum had a heart attack about 10 years ago. When they wheeled her in to study her arteries they found them pristine. No furring at all. After many tests and long periods on a monitor when she could barely move because of exhaustion, she was given a pacemaker. She’s fine now and her consultant is impressed that it hardly ever comes on, suggesting that her heart has got better. The consult thinks it might be hereditary (her father died of a sudden heart attack in his 50’s) or the result of a viral infection. Nobody really knows. I would, of course, be quite keen to know if it is hereditary!

  5. Roy

    Interesting but also a bit confusing and also worrying for me. I was told by an optician I had a vein on the photo taken that indicated silver wiring , does this mean I have atherosclerosis as he said and should avoid strenuous exercise?

  6. Flyinthesky

    Cancer, I do speak from experience here, is a generic term for various diseases with various causes that we may or may not be able to effect a cure. A lot like the term CVD with it’s inherent vagaries but we mustn’t actually say we don’t understand, with it’s attendant disempowering connotations.
    We know but there are some areas that need refinement.
    My personal treatment plan was based on, quote: ” basically we’re going to throw the kitchen sink at you and see what happens” As I’m still here, fingers crossed, it would appear, again fingers crossed, it has worked. It wasn’t knowledge or skill it was fortuosity what done it.
    I remember, vividly, the fight between the two factions, surgery and chemo and radio.
    Fortunately “I” made the right choice, the abomination was not clearly defined and had spread locally into surrounding areas so I thought surgery wasn’t an option. I was at stage four and palliative was the only option. Had I followed the surgical advice I am pretty sure that I would no longer, as an irritant, be here. I, unlike most, am prepared to accept the consequences of my own decisions, I must admit there are some fine, very fine, people out there but they do not convey their own realities but someone else’s.
    My position, I may be wrong about, well, almost everything, I don’t think but I am but I’m prepared to put my life on it, to discuss reality with anyone so long as you talk to me as opposed to talk at me, that, in these times seems to be off the menu.
    Certainty is empowering Uncertainty isn’t, so despite uncertainty we’ll go with the winner. That’s where we are.

    1. Dr. Malcolm Kendrick Post author

      Sorry, but I absolutely disagree with you. Uncertainty is science is critical, and empowering; whilst certainty is utterly inimical to progress and disempowers all but those who rule the current citadel.

      1. Sula Maye

        I’m not sure but I think Flyinthesky was actually agreeing with you – saying modern medicine shies away from uncertainties because they are not ‘viewed’ as empowering, rather than because they are not.

      2. Flyinthesky

        I really, really don’t want to disagree with anything you say here, I think we’re talking semantics here, to know and to declare knowledge here is power, to espouse uncertainty is diminishing.
        There is no argument here about the citadel I embrace and concur with almost every word you utter. The thrust remains, I am no literary orator and no literary genius, I do try my best, horses for courses et al, The reality remains, we know jack about cancer and jack about, you do but you’re off message, CVD but there is no gain or future to be gained by admitting it. It’s very near absolute.
        Without the definitive there is no power and it is a power game, I don’t dispute for a moment your position, even if you were wrong, I don’t think you are, you should be commended for your questioning of the narrative.
        Unfortunately the consensus, bought and paid for, rules. It’s an uphill struggle to break it.
        There are a lot of people who post on your threads who are far superior to me in academia and literary eloquence but I try my best. It doesn’t always come across as I intend it.
        Core issue reiterated, uncertainty maybe critical but it isn’t empowering. Nobody is categorically saying, I don’t know but you may need statin therapy. They’re saying they know.

      3. Flyinthesky

        An aside, I have recommended your site and writings to numerous people with cholesterol issues to very little avail
        The consensus and status quo are very powerful forces to address. my primary interest is politics and democracy, whereas most people I interact with will question political agendas and express the absence of democratic accountability, the viability of scientific opinion AGW, GMO et al, they accept the word of the GP as the word of God himself. It beggars belief but it is an irrefutable phenomenon.

      4. Leaf Eating Carnivore

        I agree with you. Science knows nothing but various degrees of probabilities. It cannot exist without an open mind.

        Preconception is the death of inquiry.

        One surprisingly happy result of my quite random childhood is that I never knew what might happen next. I’m even unsure that the sun is going to rise tomorrow – although I will admit to the overwhelming likelihood thereof. Precarious, but liberating.

        Beware the person of firmly made-up mind – neat, complete, and utterly closed. Bounce a quarter off it, you can…

        Then run like Hell.

      5. Professor Göran Sjöberg


        I think it was very good of you to clarify your point and I think all of us agree with you, not least myself.

        The medical ‘consensus’ business is all about getting to the power and to the money by the dogmatic ‘knowing’. This is exactly why I consider medicine more as religion than any science. If a religion finally admits that the dogmas it treasures are wrong it doesn’t exist anymore.

      6. Stephen Rhodes

        I have a feeling I a version of this in one of your responses on another thread – buy I may be wrong. It is a 1959 translation by Justin O’Brien from a 1952 work by Andre Gide;
        “I resist giving advice; and in a discussion I beat a hasty retreat. But I know that today many seek their way gropingly and don’t know in whom to trust. To them I say: believe those who are seeking the truth; doubt those who find it; doubt everything, but don’t doubt of yourself.”

    2. Mary Richard

      If I had stage four cancer…depending on the type and location, I think I would let a house fall on me if thought it might be a cure. You did the right thing. Did not know this about you. So happy you are still here!

      1. Flyinthesky

        Thanks Mary, so am I. Cancer is a strange phenomenon, in a lot of cases, I wouldn’t like to put a percentage on it, if you tell someone they have cancer you have effectively killed them. The people who live the longest see it as a task and not a sentence.
        My consultant was telling me about the surgical options he had in mind, all of which I declined.
        I approached my task with mirth and humour, it kept me going, much to his consternation.
        Hello doctor, you didn’t expect to see me did you, I’m still here! After 6 years of monitoring he was probably glad to see the back of me I expect, snigger.
        I often wonder if cancer screening has an overall positive effect, we are induced to be almost permanently worried about. It’s the empowerment engine that drives the health care profession.
        You may avoid cancer but you might get CVD or other conditions worrying about it.

      2. Flyinthesky

        There’s always the afterthought: No Mr Jones of course you don’t have cancer…………..but while you’re here………..

  7. Leaf Eating Carnivore


    I agree with Malcolm. Within science, uncertainty rules. Necessarily.

    As Flyinthesky points out, however, in the whack-’em bash-’em world of (insert discipline name here), certainty, like any bully, usually has it’s way.

  8. Leaf Eating Carnivore

    Um – did I say something unacceptable in my now-deleted comments? Please enlighten, as I do not wish to deliberately offend…

    1. S Jones

      Leaf Eating Carnivore – posts on this blog are moderated. As far as I know the moderator is Dr Kendrick himself, but I could be wrong. Posts appear when he has the time to do his stuff, they don’t appear immediately they are submitted.

      1. Dr. Malcolm Kendrick Post author

        Correct, I am the moderator and I get round to things as quickly as I can. I try to allow almost everything to go up – excluding adverts, complete rants and things that are so far off topic that I cannot see any relationship to what is being discussed. Sometimes I completely miss things, because I get around six hundred e-mails a day and things can get deleted by mistake.

  9. Luigi

    Do we need really need to know the medical or biochemical answer to the question of what causes heart disease. History has the answer; how much heart disease was there at the end of the 19th century? What did they eat? End of discussion! Do we run our petrol fueled cars on diesel?

  10. Robert Brain

    In his fine book on the history of cardiac care (https://jhupbooks.press.jhu.edu/content/broken-hearts), David Jones explores the controversies and utter lack of agreement about the causes of heart disease. One of the most telling remarks in the book comes in the Introduction, where he says that he interviewed some forty leading researchers in cardiology in recent decades, not one of whom was willing to be quoted on the record!

    1. Dr. Malcolm Kendrick Post author

      I recommend that everyone should read it, as I just have. Most interesting and makes many very good points about how atherosclerosis may start. I don’t think it is fully correct, but I don’t think such a thing is yet possible

      1. David Bailey

        I couldn’t make sense of the title or the abstract – is there any chance you might give us an executive summary!

      2. Mary Richard


        I think this is a very interesting read for those of you who might want to examine the role of stress in acute myocardial infarction. It mirrors a lot of what Dr. Kendrick tried to explain in both Statin Nation I and in both of his books. He knows what he is talking about. I witnessed this first hand and can tell you…these tragic stories went on for years.

      3. David Bailey

        I had another shot at that paper, and further in it becomes more readable after GOOGLEing a few expressions like “tunica intima”! This paper really seems to contain the last part of the theoretical collapse of medical theory in this area:

        Saturated fats don’t cause heart attacks.
        Cholesterol levels in the blood don’t correlate with heart attacks.
        Heart attacks aren’t caused by simple blockages of arteries, but maybe cause them.
        What next?

        I think everyone would love to read a blog by you about that paper!

        Presumably despite that paper, strokes must be caused by clots physically blocking the blood vessels, or is that idea under threat also?

        It strikes me that someone should think really hard about what makes the French different apart from diet. I mean, are they all more laid back, or less competitive, or do they just enjoy more sex?

    2. Gretchen

      Fascinating article. Unfortunately, author says he doesn’t see any practical way to reduce CVD because of the new model, so I hope Dr. Kendrick does blog on this.

    3. Mary Richard

      I think this is a very innovative perspective and theory. It certainly gives us hope in thinking about risk identification far beyond what we have commonly been taught. The cell proliferation theory certainly gives us some glimmer of hope in identifying and hopefully finding a cure for or at least a better chance at halting the progression earlier on in the disease process. The interventions we have thus far seem to be merely bandaides, not cures.
      More importantly, how do you feel about it? And, in your mind, what would be the logical next step? I am thinking in terms of research.

  11. sultan4swing@aol.com

    Dr Kendrick.

    Hi. How does the artcile below square with your book where you believe the evidnece shows the major cause of artherosclerosis is stress.. ??

    Rhod Tibbles

    1. Dr. Malcolm Kendrick Post author

      It doesn’t, at least not fully, but that doesn’t stop it from being interesting and valuable. I still think my hypothesis works better than anything else, but who knows. I could be barking up the wrong tree.

      1. Mary Richard

        I agree with you Dr. Kendrick. I talked to a cousin (in law) last evening. She told me she cannot walk any longer without heaviness in the legs and pain. When she sits down, it goes away. She saw a doctor and they confirmed it appears blood flow to the legs is compromised. She has diabetes, has fought cancer and won for the time, but still smokes. She has also been on Simvastatin 40mg. for five years. I begged her to quit (the cigarettes and the statin). She told me her brother has just had major bypass surgeries in the peripheral arterial system. PAD or peripheral arterial disease is at an all time high. Younger and younger people are being plagued by it. And the bypass surgeries and stents are just awful. She has to have an angiogram to see where the blockages are. I fear that she will go through an awful, painful surgery. The best she can hope for is just stenting. PAD is nothing more than angina of the peripheral arterial system. When it hits you, it is the most painful disease one can imagine. Your legs feel paralyzed and the more you try to walk or function, the more the pain and feeling of paralysis persists. So your efforts to walk through the pain make one less active and the disease takes its toll. It is a vicious cycle. It is running rampant.

        I think your theory about smoking, stress, inactivity, diabetes etc., is right on. And, as I told her, if the statin truly was the wonder drug purported to be, why does she have PAD anyway? I just told her that it is lifestyle changes that will keep this disease at a distance. It makes me sad that all these pain management and lifesaving techniques to address PAD are just not working. It is a waste of people’s time, money and health. It is certainly a waste of resources. And why and for what?

        I hope we can broach this subject as well when we speak of coronary arterial disease, let us not forget that for whatever reason, many are experiencing these attacks of the peripheral arterial system as well. The numbers are growing. And…it is not pretty.

      2. Jim

        If one were to have a blocked Iliac artery to the point of total blockage and assumed calcification but was able to walk at a reasonable pace, and didn’t cause too much hindrance to overall quality of life other than no longer being able to take part in anything more demanding than walking as mentioned above; would a stent be a reasonable long term option (min 40 years) or would there be a strong likelihood that the blockage would reoccur in relatively short time due to the stent’s damage to the endothelium?

  12. mikecawdery

    Very interesting but confusing. Does Collins know about this? I was under the impression that the science was SETTLED and AGREED by the X-spurts and CHD, CVD, CAD etc., were all caused by cholesterol and treated “successfully” by statins.

    What a shock.

    The strong correlation of myocardial infarction with stress or unusual physical activity

    I would certainly go with this as the first (stress) was involved with my “heart attack” and the second with my father’s. We both survived to live for several years.

    1. Mary Richard

      When I read Dr. Kendrick’s first book “The Great Cholesterol Con”, it opened my eyes to this often overlooked fact of life that long term stress can and does kill. After the category five storm Katrina devastated the LA and Miss coast, it looked like a war zone. Everywhere you looked in that cities whole neighborhoods were decimated to the point that they were unrecognizable. People were engaging in heavy manual labor they were not accustomed to trying to clean areas and manage the debris for months on end, sometimes years. The number of heart attacks soared as the stress and as you say “unusual physical activity” took its toll on thousands. I had never heard of so many fatal MI’s in all my life. Unrelenting stress devastates the body, I am convinced of that.

    2. Mary Richard

      My husband died two months to the day after Katrina struck the Gulf Coast area. I have no doubt that the unusual manual labor along with acute stress in the aftermath, contributed greatly to his untimely death. He was not an old many by any means. I do, in fact, believe that stress or post traumatic stress can kill.

  13. Mary Richard

    I think these studies are most fascinating. Dr. Mesquita makes an interesting argument about the percentage of patients who have no atherosclerotic plaque but yet die of MI. It certainly needs further study. And…without more demographics, how do we know what caused the heart to just stop beating, leading to death? What might have “interrupted” the damage/repair process that many of us have come to believe can reverse plaque? What, therefore, is the definition in the context of what Dr. Mesquita has explained to us, an MI? We have all known or been taught for years that someone without blockages can, in fact, die suddenly of an MI. And if it is collateral blood flow that can save a blocked heart from sudden death, why do some people have them in plentiful supply and others do not? What, in fact, is the structural composition of these collateral arteries? Can they become overwhelmed and if so…how? What causes them to form in the first place or are we born with them…some of us. I would love to know that. That is a study worth delving into.

  14. Jennifer

    I feel inadequate to respond to Dr K’s new topic, and all the interesting responses. I feel that we have a long way to go to fully describe and understand coronary disease/malfunction. In the mean time, after reading the article about the 30 golden years of optimum Victorian nutrition,( which we are now learning actually existed, contrary to incorrect propaganda), I maintain that good nutrition is the basis for good health….be it coronary, hormonal, mental, intestinal, etc etc.
    I would so like to see an improvement in nutritional content of our diets, and untimately witness a substantial reduction in preventable conditions. Then we could leave the medics to concentrate on conditions of unknown origin…..blimey….that should concentrate the old brain cells.
    The system is overwhelmed by the costs of preventable conditions, along with prophylactic meds for ‘possible’ diseases that may occur in the crystal balls of the future.

    1. Mary Richard

      Beautifully stated. What else do we have other than to look to the past prior to the overwhelming attempts to use pharmacology to “prevent” and treat. It will be lifestyle changes, diet and further research into the origins of heart disease or vascular health in general that will give us the answers we need. You have heard the definition of insanity is to continue to do the same thing over and over again expecting a different result.

      1. Jennifer

        Mary, I had a discussion with a person who revealed that butter is no longer bad for us, suggesting that something in its make up must have dramatically changed recently. ( a fair assumption, after having been told it was so bad for the last 40 odd years)
        My response was…”it never has been bad for us”. Yet, despite this new found knowledge, their shopping list still includes soft margarine, skimmed milk and white sliced bread, along with the bag of repeat prescriptions.
        Many poorly people are terrified to change their life-long eating habits of the last 50 to 60 years, to that which we know are the essential components of foods eaten by our forebears. And the same folks will rarely relinquish the bags of medications dished out by well meaning, but ignorant medics, having been brainwashed into believing such concoctions come from a superior planet to our earth’s good old, dependable, natural foods.
        There may always have been congenital malformations of bodily systems of unknown cause, which I trust do benefit from medical/nursing interventions. However, my worry is, that abuses (i.e. excessively preserved foodstuffs and mountains of toxic medications) inflicted on human beings during the last century, will manifest as tragic genetic changes in future babies. Or am I getting a bit paranoid these days?

      2. Jo

        This is a reply to Jennifer. It’s nice to see the return to sensible dietary guidance (i.e. not low fat) but what concerns me is that many people alive today will have no comprehension of what normal fat is. I see people thinking that they no longer eat low fat but still taking the skin off their chicken and using low fat milk. They add a thin smear of butter to their toast and think they are eating a normal fat diet. I’m over 50, and I remember, but anyone younger will not.

        1. Jennifer

          Jo, I feel that I am talking to a brick wall at times, as family members think I have taken leave of my senses taking on the low carb, high fat regime. ..BUT… to be honest, even I, through fear from time to time, curtail my excessive fat intake, and increase my newly limited carbohydrate intake. Now why should that be? Silly me! I fully understand why my health has improved immensely since eliminating most carbs and adding large amounts of sats, and yet…..the temptations and indoctrination of 67 years is so hard to fight. I am not without sin.
          But, tomorrow is the first of my future….and as I do now know what is correct, I intend to forgive my misdemeanours of recent weeks and follow the best regime I have discovered in recent years.
          NO meds, Very Low Carbs and healthy fats and proteins. Fandabidozie.

  15. Brian Wadsworth

    Your line of thinking is superb. Now, if only you could dream up a way for a drug company to make money from the hypothesis you would get all the support in the world for testing it!

  16. gollum

    I highly recommend Peter D’s blog. Here on hearts burning carbs


    (don’t heart attacks often occur at 4am in perfect bed rest but at hypogly time?)

    That blog is a gold mine, here he explains in 3 pages why i.v. insulin cannot be as good as your own:


    Also demolishes the myth that insulin is needed to “use” glucose (tip those scales into equilibrium and keep pharma happy)

    1. Professor Göran Sjöberg


      Interesting reading!

      I read somewhere that when the activity of the relaxing part of the autonomous nervous system, the parasympathetic, goes down to zero typically at 4am, while the sympathetic stressor part is working at a high level pounding your heart (‘Get up! Time to work and earn a living!), the glycolysis turns on full force in the heart muscle and producing lactic acid, ischemia, locally. The acidic state, thus created, presumably then disturbs the special nervous signalling system in the heart.

      Well I have now quite a few demolished myths along my road into medicine but still believe that I understand much more of it today than when I was living with the myths.

  17. Olga

    Hi Dr. Kendrick,
    Could athrosclerosis and the myogenic theory of heart disease be in fact describing two different diseases? Are there any differences in frequency of cardiac failure with and without athrosclerosis seen between different ethnicities, geographies, socioeconomic status? Also, is one associated with blood pressure and the other not?
    I’m curious because my family has FH with high Lp(a) and we typically get heart disease around 55-65 years of age, unless you have been treated with a statin, and then it has shown up as early as 47 years of age! We all get athrosclerosis, and have low to normal blood pressure. As always thanks for the informative post.

      1. Olga

        My dad, a very heavy smoker, who ate a high saturated fat diet, chain smoked, and had never heard of a statin died at the age of 56 with heart disease. Contrast this with my brother who never smoked, eats a “heart healthy diet f(tongue in cheek here),” exercises regularly, and took statins for 10 years before requiring a 5 artery by-pass surgery at the age of 47. Something is clearly amiss.
        My family is of Portuguese decent. I can’t help wondering if the high Lp(a), which makes one more prone to clotting, was a mutation providing an adaptive advantage to those who lived near the coast and ate mostly sea food, sparing them the fate of the Innuit, who suffered from hemorrhagic stroke. Take the Lp(a) carrier away from the ocean and the Lp(a) becomes a liability. Perhaps the increase in many diseases have happened as a result of the ability of peoples to more easily move around the globe. Not just because of cultural displacement stress but because of genetic discordance with the environment. Something to think about.

        1. Dr. Malcolm Kendrick Post author

          Lp(a) is used to patch up and protect blood vessels in those with vitamin C deficiency. Humans are one of the few animals that cannot synthesize vitamin C. Fruit bats, hedgehogs, other great apes and a couple of others. So, nothing directly to do with living near the sea. More, living near to fruit trees I suppose.

          1. Jo

            Hmmm… there’s more vitamin c in liver than in an orange. All the good stuff is in the organs generally. Possibly a contributing factor to the Victorian scenario posted earlier.

      2. Professor Göran Sjöberg


        Now Lp(a) pops up as a new item in my ignorant medical world and I am again immediately lost. First I thought it had something to do with ‘signalling’ as with the ApoB on the LDL.

        Trying to ‘educate’ myself by quick-reading Wiki this knocked me down as usual. It is now an evident fact that I am getting more and more ignorant the more I try to understand but still I claim my one-liners.

        As when I now visited my woodchopping diabetic friend to help with my chainsaws this afternoon. Then he told me that he had met with his GP who had ‘found something’ with his heart and mentioned a catchword. So he asked me if I had any idea as an ‘expert’ on ailing hearts. which I didn’t have.

        Instead he had a one-liner from me.

        “Don’t listen to the docs, don’t eat any carbs and keep chopping the wood.”

        “You will soon die – he is almost 80 now – and why not die happy without cutting and medicine?”

        He is to my opinion very impressive at chopping the wood but very bad at not listening to the toutings from the health service.

      3. Professor Göran Sjöberg

        This is an add-on to my previous comment about my growing ignorance.

        I am not only an admirer of Malcolm’s fighting spirit but I also keep an eye on other “fighters”. One of those is Dr. Mercola, though with an Achilles heel of being a ‘peddler’ of all kinds of supplements on which he is said to make a fortune which is probably also true. His earnings must anyway be just a trickle of what Big Pharma is squeezing out of us poor people with ailing hearts and things like that. And, as always, big profits is a taint that sticks and reduces the credibility of your message.

        Anyway, among the ads on his blog (he is very active!) I read a lot of interesting tales of “failures”, with proper references, within the school medicine tradition and of alternative ‘integral’ healing procedures. Perhaps worth checking out!

        On his latest thread I was again shocked and knocked down reading about the futility of metal knee replacements (and this is about my own superalloy metal stuff!) in controlled randomised trials. It seems to be all about placebo effects. (Probably also true for my E-vitamine supplements and me now not being disturbed anymore by the unstable angina.)


      4. Mary Richard

        Dr. Kendrick,
        There are several studies or inquiries into the relationship between sleep apnea and MI without vascular obstructions. I have researched pubmed and found many fascinating and thought provoking articles on MI and sleep apnea. Could we be overlooking a vast area of study that gives us a correlation between MI and stroke without vascular abnormalities or blockages?
        If you research the “risk factors” as listed by our American Heart Association, there is no mention at all to sleep apnea as being a “risk factor”. However, there is no doubt in my mind that when you look at the physiologic changes that take place in the body during sleep studies afterwhich a diagnosis is made of sleep apnea, it is certainly worthy of scrutiny and consideration.

        When Professor Goran mentioned the autonomic nervous system and its two functions in the parasympathetic and sympathetic regions, it made me wonder how those autonomic functions can indeed become dysfunctional although to maintain homeostasis, they have to work in tandem with each other. So, perhaps that one much over looked and underdiagnosed condition holds clues. Hmmmm!

        Here are just three:
        Cellular mechanisms associated with intermittent hypoxia
        Oxidative stress in the systemic and cellular responses to intermittent hypoxia
        Pathophysiologic mechanisms of cardiovascular disease in obstructive sleep apnea

  18. Mary Richard

    I think you are close to a reason the French have low numbers of cardiovascular disease. However, it may be that they engage in more “guiltless” sex and probably take off down the street running afterward while lighting a cigarette. You know…exercise is the key!!!

    1. David Bailey

      Yes, the fact that the French also smoke quite a lot, makes their low heart disease quite incredible.

      Maybe a study of disease patterns in Bonobo monkeys would be illuminating!

  19. Flyinthesky

    An interesting snippet from the papers today:
    Pills used to treat depression also help mend ailing hearts, a study has found.

    Seroxat, a widely used antidepressant, worked ‘far better’ than the standard treatment for heart failure. The so-called happy pills not only stopped the heart from deteriorating – they actually helped mend it.
    Taking on face value it reinforces Malcolm’s perspective on the role played by mental state on heart disease.
    If we accept that stress is a major causational factor in heart disease being informed you have heart disease accelerates the process. Catch 22.

    1. David Bailey

      Maybe the seroxat relaxes them so much, they forget to take their statin pills!

      We seem to be hearing more and more about drugs being used for quite different purposes – I think I heard of statins being used to fight dementia, for example.

      To be honest, having read about how the evidence for various drugs is distorted in so many ways, I don’t trust any of this – it is just an effort to increase profits! I have also read that SSRI’s perform little better than placebos (which possibly contradicts my first sentence), but I guess if people are realising that your drug doesn’t do much, one strategy is to claim it is brilliant at doing something else!

  20. Jean Humpreys

    Off topic, but was very pleased to see Dr James Lefanu calls the new book “obligatory reading” in his column in tody’s Telegraph.

      1. David Bailey

        I have bought a copy and read it once – but it is one of those books that I will certainly read again, and recommend to others.

    1. Flyinthesky

      There’s the dilemma, do you allow others to read your copy to spread the message or persuade others to buy their own copy to support the author.

  21. Professor Göran Sjöberg

    This thread is about ‘What does cause heart disease?’

    It could have been about any other disease and I would have been in the same state of confusion as now. Is it the ‘life’ that cause heart disease? (Or any other disease!) I wonder if this is the reason why inheritance and genetics has such an allure in the ‘science’ of medicine.

    I wonder now if I, as a metallurgist, am ‘sick’ in my trying to understand the basics involved in medicine. Just now, e.g., I happen to read the “Molecular Biology of THE CELL” for the third time and by a coincidence has arrived at ‘DNA, Chromosomes and Genomes’. And the cruel, blunt fact, as I read it clearly stated in the book, is that we don’t understand ‘how it works’ not even in the simplest cell.

    How can we then even claim that we should be able to ‘understand’ what causes our ‘higher level’ diseases?

    Perhaps the best we can hope for is to ‘corroborate’ whatever. “May the best hypotheses be the dogma for ever!”

    Although I just feel as healthy as ever nowadays, working my chain saws, this insight makes me ‘sick’.

    1. Dr. Malcolm Kendrick Post author

      Do not look for the cause, or a cause, for that is a blind alleyway. You may look at a beautiful painting and try to analyse why it is beautiful – and in so doing, destroy its beauty. I know this is not exactly what you are saying. The greatest error of science, and particularly medicine, is trying to grab at the answer too early. Whilst it is often the path to fame, and riches, it is also the path to ruin and destruction. Sadly, humans need and crave certainty, and if you can dangle that in front of them…. The great beauty of science is the journey.

      1. Professor Göran Sjöberg


        I think you frame my present dystopic thoughts about medicine quite well.

        If a patient expects to meet a God when he consults his GP there must be a pressure on the GP to live up to that expectation and ‘dangle’ that certainty in front of them. But if a patient instead challenges the GP by asking inconvenient questions about any practice, as my student about the vaccination of his child or myself with the cardiologist, the ‘vanity’ of the GP, and even more of the ‘expert’, might come at trial and he really dress up in his official ‘garments’.

  22. Fiona

    I can’t find James LeFanu’s column of 9 March on line yet. Could someone please tell me the name of his book that is being so highly recommended so I can rush out and buy at least one copy?

  23. Stephen Rhodes

    Moving on from what causes heart ‘disease’ to the thing that probably worries most people, I came across http://circres.ahajournals.org/content/95/8/754.full.pdf+html . I haven’t read it properly yet – I don’t think I understand half of the words involved so will need to bone up – but it does reinforce Dr Kendrick’s view (if I don’t misrepresent him) that there is no simple cause and effect as far as heart disease and heart attack are concerned.

    The paper considers how various particular pre-existing conditions (substrates?) might trigger potentially fatal cardiac arrhythmias, and concludes the following;

    Sudden death in patients with HF is a complex phenotypic
    expression of a systemic disease that most often results from
    the unfortunate confluence of a number of factors. These
    include, but are not limited to, a hospitable substrate, the
    result of remodeling of active and passive membrane properties
    of the heart, altered neurohumoral signaling, in many
    cases myocardial ischemia, and perhaps an underlying genetic
    predisposition to electrical instability. The risk of SCD (sudden cardiac death)
    is highly time-variant, reflecting temporal heterogeneity of
    both the myocardial substrate and triggers. This minute-to minute
    variation in the risk makes SCD prediction in individual
    HF patients an enormous challenge.

  24. Laurie

    ‘All models are wrong, but some are useful’ George Box.
    Prevention isn’t profitable but it sure is more comfortable, and comforting and less stressful…….than treatment.

    Correlation is not causation, but non-correlation can be used to reject a (wrong) cause- and help with deciding a course of action. Heart attacks and high-cholesterol are NOT even correlated…..Lowering cholesterol with statins won’t prevent heart attacks.
    You can never bridge non-correlation to what the cause is….but there is the possibility that something that IS correlated will lead to discovering the cause. But suffering ‘patients’ cannot afford to wait around for the studies to further connect symptoms with cause, etc…….Established correlation can be useful right now…even if it cannot prove cause…..

    Stress, leaky gut, infections, metabolic syndrome, cholesterol-sulfate deficiency, in my humble understanding, are all problems…….Low-fat diets, grains, vegetable oils, sugars, cholesterol-phobias are all implicated…..You decide for yourself…..I choose to eschew foods that don’t help and are correlated with symptoms that lead to heart disease…however you define.

  25. Professor Göran Sjöberg

    Mary Richard

    First now I noticed your serious interest in the subject of infected teeth as the interesting response to my input on March 1. I apologise.

    I just happened to have an infected root canal filled tooth extracted yesterday which had been annoying me for some months. This was also the reason for my ‘research’ (you tend to solve your own problem first hand 🙂 ) and reading the book I mentioned in passing. The title of the book is “ROOT CANAL COVER-UP” and was written by an American root canal specialist Dr. George E. Meinig who is also associated with the Weston Price Foundation.

    In this book he has brought forward, from hidden files, the extensive experimental work on test animal during 25 years and which work Weston Price headed. From what I read it is definitely scientific work we are talking about and it is as surprising as it is today that the medical establishment can cover-up and hide this kind of work for so many years – and it continues.

    Well – Weston Price was definitely a LCHF advocate and this is just against the grain a hundred years ago as it is today.

    Still – according to the dentist I met yesterday the connection between infected teeth and other ailments is today well recognised and extensive research is ongoing.

    1. maryl2015

      Professor Goran,
      You got my attention. I think I will read that one indeed. I am so glad you took care of that awful tooth. My own brother died very young of a heart attack. Just days prior, he had finally gotten a bad tooth taken care of. It had plagued the poor boy for a while. I am not sure now if he had it pulled or filled or had a root canal. But, I recall he was in quite a lot of pain since he avoided doctors of any kind until he was in crisis mode. He had a heart attack on Christmas day, was in the hospital, but apparently they did not order any interventions of any kind. After a two week stay in hospital, he was released and told to follow up with the clinic. He died on his way to the first post hospitalization clinic appointment with a heart specialist. He was both talented and loved so much. I miss him always.

      Thanks again, Professor.

    2. BobM

      I recommend this book for you:


      (It’s called “Kiss your Dentist Goodbye”, by Ellie Phillips.)

      I had my dentist and the hygienist getting on my case about my teeth, even though I brushed three times a day and flossed 1-2 times a day. They had me coming in for cleanings every three months. Using the techniques in this book, my teeth are much improved and feel dramatically better.

      1. Fiona

        BobM and others: I’ve never had to have a professional clean by the hygienist since I was given a really good electric toothbrush. I was told only recently by a dentist not to clean my teeth immediaely after a meal while there might still be acid on them: now I eat fruit as a starter instead of as a dessert

  26. corporal collinCarol

    I, it would appear am something of a challenge, I had my heart attack aged 56 I was slim, fit, very active and a vegetarian who didn’t eat fatty foods or cheese, I ran five days a week walked two dogs two miles each up steep hills….. I was however very stressed, my husband had recently died of cancer I had a legal case in progress, and work was very stressful. Then Bingo! I had an NSTEMI which resulted in a stent to RCA drugs for the rest of my life and much head scratching by cardiologists – my own view is inflammation caused by stress?
    Two years later no longer on Beta blockers I was readmitted to hospital, eventually after many tests it appears my Stent had broken in two and the RCA was almost closed, restented sent home on new drugs regime, I remain ok.

    Satins have so far given me three lots of jaundice and the last one made my leg muscles disintegrate, I have now recovered my legs muscles and can no longer take statins. Estimebe has been prescribed and tolerated but doesn’t make a scrap of difference to my stubborn 6.8 cholesterol numbers as it only tackles the cholesterol I eat, and I don’t eat much, so the aspirin and Candesartin seem to be keeping me alive????

    Seriously though I am worried, I have so far been told I have CAD but no damage to my heart because of my healthy lifestyle however my cholesterol needs to be under 4 and there are no drugs I can take that will not harm me, so at the ripe old age of 60 I am awaiting the grim reaper, my mother was somewhat similar and died following her third heart attack at the age of 70, that was ten years ago and it looks to me like nothing much has changed.

    1. celia

      Corporal Collin, if you really think your cholesterol needs to be under 4 read “Fat and Cholesterol are Good for You” by Uffe Ravnskov. I think you might change your mind!

  27. corporal collin

    I, it would appear am something of a challenge, I had my heart attack aged 56 I was slim, fit, very active and a vegetarian who didn’t eat fatty foods or cheese, I ran five days a week walked two dogs two miles each up steep hills….. I was however very stressed, my husband had recently died of cancer I had a legal case in progress, and work was very stressful. Then Bingo! I had an NSTEMI which resulted in a stent to RCA drugs for the rest of my life and much head scratching by cardiologists – my own view is inflammation caused by stress?
    Two years later no longer on Beta blockers I was readmitted to hospital, eventually after many tests it appears my Stent had broken in two and the RCA was almost closed, restented sent home on new drugs regime, I remain ok.

    Satins have so far given me three lots of jaundice and the last one made my leg muscles disintegrate, I have now recovered my legs muscles and can no longer take statins. Estimebe has been prescribed and tolerated but doesn’t make a scrap of difference to my stubborn 6.8 cholesterol numbers as it only tackles the cholesterol I eat, and I don’t eat much, so the aspirin and Candesartin seem to be keeping me alive????

    Seriously though I am worried, I have so far been told I have CAD but no damage to my heart because of my healthy lifestyle however my cholesterol needs to be under 4 and there are no drugs I can take that will not harm me, so at the ripe old age of 60 I am awaiting the grim reaper, my mother was somewhat similar and died following her third heart attack at the age of 70, that was ten years ago and it looks to me like nothing much has changed.


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