World Class Prevention Part 2: Plaque and Heart Attack – What Really Happens

This is part 2 in the Personal
Prevention Experience series. This is another Bale/Doneen slide. It's talking-
there- it makes a couple of good points. The first one is the focus on education.
Again, education is the biggest part of this. It's like the old Sims commercial
and many other commercials. The best customer, the best client, the best
patient is clearly somebody that knows what's going on- is the educated, smart
consumer. Now, another thing that's very helpful to see on this slide is
something that you wouldn't notice unless it's pointed out or you're
already aware of it. This is- a picture of an artery with blood flow going through
it. Now, this middle one is the best one to look at and the bottom one is- has got
a couple of problems; but the middle one is- shows the blood going through the
artery and it shows that the plaque is not in the lumen. The plaque is inside
the artery wall itself; and in fact the vast – the vast majority of that plaque is
LDL. So that's what leads to a lot of the misperception that cholesterol in your
diet or LDL is what causes plaque. Again, that's wrong. Here's what actually
happens. You get inflammation of that lining right there, which you can hardly
see. It's a single cell layer. It's called the intima or endothelium of the artery.
When you get inflammation of that, you get holes and nicks in it. Then, LDL,
cholesterol that's in the blood actually goes through those holes and nicks and
lodges in that artery. Let's go to another issue- event reality. Here's the
major point that- that this makes- that 99% of all plaque is going away from the
hole, in other words in the artery itself. Now, most heart attacks and strokes are
caused by plaque that is not blocking the flow of blood. Again, we- the obvious
common logic is that it's like hair clogging the drain of a shower or a
bathtub. It's inside the lumen. That's not what happens. It's inside the- the artery
wall as we just showed on the last slide. That's why you can't predict a heart
attack or a stroke. As we've said many times, half of heart attacks- the patient
first finds out about it by dying. Now, here's a picture of- a diagram of a clean
artery with no disease. The major areas that we want to look and think about are
the intima or that endothelial layer. It's what keeps things like cholesterol
from soaking into the artery- the artery wall itself. Then the media is the second
layer, it's a muscle layer that provides strength to keep that intima layer,
which is so thin it would blow apart with the pressure that's inside a
typical artery. We don't worry about that adventicia. It just keeps the artery in
place. It's when this intima gets- irritated and burned and has holes in it
that cholesterol starts to seep through those holes. The cholesterol then, can't
go on through the media, so it gets stuck between the intima and media layers. Here
are a couple of images in these next two slides- of the progression of this
disease. The first slide just- I mean the first on the left, basically shows a
normal artery, an artery without plaque. Each successive cut shows more and more
plaque. It also talks about some of the enzymes that you start to see. On the
inflammation panel, for example, you'll see LP PLA 2 / plaque-2. If you haven't
taken the course, the free inflammation course, go back to our videos, just google
Ford Brewer inflammation course. It should come up. If
you haven't, make a comment below and I'll help you find the- find the course;
but LP PLA 2 is that one of the labs that we look at in the inflammation
panel. That starts to happen along this area as shown here. It's- it's an enzyme
released by the immune system, is it's trying to get this plaque out of here.
Your immune system recognizes that plaque and knows this should not be
happening. It's when this happens over on the right that you get a heart attack or
stroke. You get damaged- the- the immune system attacks this plaque; that's where
you start to see these little red spaces and actually it's green, some enzymes
called MPO, just like plaque 2. I'll show you that in
the next slide; but you start getting this what we call necrotic or dead
material because the immune system is releasing enzymes which degrade and
dissolve this plaque, trying to get rid of it; but here's the problem.
That and that necrotic material, if it releases out into the bloodstream as
this has in this diagram, will cause a clot. So it's not- in the clot- the clot,
if it's big enough and goes to the heart, caused a heart attack. If it's big enough
and goes to the- to the brain, it causes a stroke. Now, so it's not the plaque itself
that's blocking off the artery wall and causing the heart attack like so many
people think, again, just using common logic. That's why you can't predict it by
doing a stress test or angiograms. You cannot predict this. It's because of
this acute episode where you get the leak. Now that's called- and you'll hear
it multiple times, we call it a hot plaque. Let me go back to a comment, well
actually we'll make that. We'll go back to it a little bit later.
I mentioned that some of the- the drawing in the artery wall is a little bit
different. May not all be red, as you start getting into some of the release
of these enzymes. In fact, some of them are green.
Pardon the- what's the word I would use- maybe ugly imagery. I'm gonna- but I'm
gonna connect a couple of dots here. We're talking about MPO here- Myeloperoxidase. It's another enzyme, another lab test. It's green and you may
recognize this when you have a cold or a child has a cold and and they have mucus
coming out of their nose. It's got a greenish tint to it. That's Myeloperoxidase; and it's the same thing. It is enzymes that are released by white cells.
A certain type of white cell releases MPO. Another type of white cell releases
plaque 2. So those are some of the key tests within the inflammation panel; and
as you see in this image, again, it's the release of this liquid plaque with all
of these inflammatory markers in it, that causes a clot, which causes the heart
attack. Now, that was all images. Let's just look at the- the reality. This is-
this is an artery. This is- and this is a picture of a real one. It's on a
microscope. They've cut it sideways like this. So you can see the lumen, which is
inside. This is where the blood flows. You can see this red tint. That's that media
layer that we talked about earlier. That's the muscle. That's the structure
that holds holds the artery. Now, this thin layer right here is the
intima. You can barely see it, but right here you can see it very well. In fact,
there's nothing but intima right here, between this area- this light colored
area, and this lumen where there- where the artery blood flow is. All of this is
plaque; but we can tell by looking at it, it is state- this part of
the plaque is stable. It's a waxy substance. It's not going to
break loose but look again and let's look deeper at this- inflamed plaque. This
was liquid. It's inflamed plaque and the reason we know that is- that it's liquid,
is it has retracted some away from the rest of the tissue, when you put it in
the- on the slide preparation. So now you begin to realize, you've got hot liquid
plaque with those inflammatory immune cytokines biomarkers in the- in this
plaque right here; and the only thing standing between that and the flow of
the blood is that intima layer. Now if that breaks through, it can cause a clot.
And that's exactly what happened here. This is a different type of preparation
but as you can see it's a- it's a real artery. In this one, the- the muscular or
artery wall, the media layer is this more clear looking area. This yellowish waxy
looking stuff is stable plaque. These brown areas are hot liquid plaque areas.
And look what happened here. Again, as you can see this is a Bale/Doneen
slide. Brad and Amy tend to call this "intima," the tennis court, because your
body has several- has the equivalent of several tennis courts; but here's the the
most important part. Look at how that has cracked. This area used to look like this
one; and the intima cracked and this liquid came out. Now, that's not the
liquid. That black thing is a clot. The clot formed when that hot liq- liquid
plaque- when this crack happened in the intima
layer, and the hot liquid plaque touched the blood stream, therefore, causing the clot.
That clot went on back up into this area and in fact as you can see,
well you can't see, the reason they were taking this artery out, is because this
patient has died. He's died from a heart attack and it came from the clot that
was formed here. One other thing to note, is that you've got this brown spot up
here. As you can see, this inflammatory process is a systemic process. If you
find it in one place, you'll find it in a bunch of others. Now, that's a logically
very helpful for us to remember and here's why: We take a look for hot plaque
in the neck using the CI-MT (Carotid Intima-Media Thickness Test). So what
we're looking for on the Carotid Intima-Media Thickness Test is the
thickness between this intima and media area. And as you can see in different
parts of the artery, it too varies. So that gives you some of the clue
regarding some of the challenges in getting an appropriate and accurate CI-MT.
Another thing that the you see, when we're looking for CI-MT, is we're looking
for these hot liquid plaque areas. On this- on this image again, we're looking
for that CI-MT, the intima-media thickness area, and we're also especially
looking for these hot liquid areas. When you get a normal carotid ultrasound, they
would show- this would show as negative; because it doesn't really- a normal
carotid ultrasound, as opposed to a CI-MT, the normal one, the routine one that 99%
of them that are done out there, is only positive if you have obstruction of the
flow. And that create- that takes up to two-thirds of the decrease of the size
of the lumen. So these are some of the things that help you understand, a little
bit more about what's going on with a Bale/Donee type of evaluation, some of
my preventive evaluations, and it starts to get into
what actually causes a heart attack. If you've made it this far, as usual, thank
you so much for your interest! Thanks and if you hit that subscribe or like button,
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Thank you again!


  1. Thi video is the best yet on tying in what the various tests you recommend actually tell us. Now its the search for the right tests. Example: my cardio wont order a CIMT, so my family doc orders it. I get a call from “the hospital heart lab” explaining my costs @ $500 which seems like a lot for a carotid arterial blood flow test, but i have to pay it because I’m not diagnosed with a carotid blood flow restriction. Seems odd, so i ask for some details on what this CIMT is? So staff cardiologist takes the call and in an irritated manner asks “WHAT do i mean when I keep saying CIMT?” I explain. He has no idea what I’m talking about! He’s talking about an arterial ultrasound, that’s not CIMT! This is an advanced, new, regional Heart center in central Florida. State of the art technology! In the heart of the heart attack capitol of the world!!! They have no idea what a CIMT is!! You cant make this sh-t up! They don’t even know where to get one! I’d be lost without Dr brewer and these videos!!!

  2. Another fantastic video, thank you! I read that doctors listen to the blood flow in carotid arteries to check for a swirling sound. I actually had one doctor listen to the blood flow in my carotid arteries. I asked him if he was listening for a swirling sound and he was amazed that I knew about it (he didn't pick up any swirling sounds in my carorids). Is it a raised plaque that causes the whirlpool effect (like a rock in a river) on the flow of blood? And can the whirlpool cause the blood to clot even without the plaque rupturing? My neighbor had a stroke in his late 30s and was left permanently paralysed on one side. They discovered that he had a hole in his heart that had caused blood to swirl and maybe caused the clot that caused the stroke.

  3. No glycocalyx in your photos?

  4. Super informative and clearly articulated. Thank you.

  5. I have had a 0 CAC and a Normal CIMT. So I guess My chest pain is anxiety/stress or muscular? Doctor says angiogram not worth risk since above are all good?

  6. Brilliant as always Dr Ford Brewer. You are a huge inspiration for lots of phisicians. Regards from São Paulo Brazil.

  7. What nutrients help keep the Intima layer strong and healthy? I noticed Collagen made the veins in my hand big, green, and healthy looking. Can diet affect the formation of liquid plaque?

  8. Looking at the progression of atherosclerosis chart, at 99% blockage in the artery (LAD) I see I wasn't far from a heart attack, or even sudden death. Still do not get how I wasn't having any real outward symptoms. Maybe the varying systolic hypertension. I was already taking a few things that thin your blood though. Thanks!

  9. great video Doc – im taking a supplement called "endothelial defense" from life extension I know you cant specifically comment a whole lot without scientific research, id appreciate your 2 cents even if not very in depth.

  10. Excellent presentation Dr. Brewer! Viewing those slides showing plaque build up, it would appear that once the build up gets past a certain point, there would be very little that could be done to reverse it. That's why prevention is so important. So, when the blood flow is cut off enough by the expanding plaque, that's when an MI event can occur secondary to lack of blood supply to the muscle tissue. Therefore, it would seem to me that having a stent implanted into the artery to expand it so that more blood can flow to the tissues is just a "stop gap" measure. The plaque lodged in the wall remains there intact I presume? So, how does one go about removing the "hot plaque" naturally, or can it eve be done at that point? Anyway, I am rambling again….Thanks for your videos!

  11. Another excellent presentation!

  12. So the plaque forms to fix the damaged intima and seeps in to fix the hole but then the intima becomes weak and the plaque breaks through into the blood flow creating the stroke causing clot? I really need to study your course. I'm determined to understand this.

  13. Dr. Brewer-thank you for the excellent explanation of what goes on in the arteries and plague.

  14. Ironically, I had my heart attack ON the tennis court, playing tennis.

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