The Experts Speak Interviews
Coronary Angioplasty, Restenosis
Mark Goodman, Ph.D., M.A.
West Orange, NJ 07052
“Pilot Findings of a Percutaneous
Transluminal Coronary Angioplasty Restenosis Prone Prevention Program,”
Mayo Clinic Proceedings, May, 1997;72,487.
“Hostility Predicts Restenosis After
Percutaneous Transluminal Coronary Angioplasty,”
Mayo Clinic Proceedings, August, 1996;71(8),729-734.
“Identification and Treatment of
Psychosocial Risk Factors for Coronary Artery Disease”
Mayo Clinic Proceedings, (Editorial, August 1996;71(8),817-819).
Can you please share with us your educational background
and current position?
Mark Goodman: I am one of approximately
12 individuals in the United States who have earned an accredited
Ph.D. in Behavioral Medicine (with specialization in clinical
neuropsychology) from the University of Maryland/Baltimore.
Behavioral Medicine is a new interdisciplinary specialty
combining cross-training in behavioral psychology, neurosciences,
physiology and medicine. My externship and internship/residency
were completed at Johns Hopkins and The Union Memorial Hospitals
in Baltimore, MD. At the time of these two angioplasty restenosis
risk-factor and intervention studies, I was attending clinician
and faculty preceptor on the neurology/psychiatry rotation
for internal medicine and family practice residents with
consultation/liaison assignments to cardiology, open heart,
geriatrics, CCU, and general medicine services. I was also
the principal investigator conducting this grant-funded
clinical cardiac research. I am fully licensed, and practicing
in New Jersey-U.S.A. providing angioplasty restenosis-prone
behavior modification interventions (and dementia diagnostic
2nd opinions), and continuing clinically relevant research.
I am Clinical Associate Professor affliated with the University
of Medicine and Dentistry of New Jersey-SOM, and am a part-time
Medical Director for an automobile insurance company.
KH: When did you get interested
in the role of behavior and coronary restenosis?
MG: My clinical
assignment to open heart surgery service made me acutely aware
of the now well-documented temporary and permanent mental
status/neurocognitive/personality changes and long post-op
recuperative period that accompany coronary artery by-pass
grafting (CABG). Simultaneously, I also attended to many post
percutaneous transluminal coronary angioplasty (PTCA) patients,
many of whom, like my post-CABG patients, were also in their
third to sixth decades of life. Obviously, the difference
in post procedure sequelae were formidable. However, as the
literature documents, I saw about 35% of our post-PTCA patients
returning with angiographically documented repeat same-site
restenosis despite repeat PTCA’s. The fate of multiple
same-site PTCA restenosis is typically CABG. PTCA is a virtually
painless, elegant, and beautiful procedure which immediately
improves quality-of-life for those who are suitable candidates.
I thought if there were a way to prevent restenosis, one could
perhaps avoid CABG. However, you can’t prevent something
unless you know what places one at risk for the disorder.
At the time I embarked upon the risk factor intervention study
in 1993, little was know about restenosis risk-factors. My
research training in behavioral cardiology studying risk-factors
for heart disease partly focused on Type-A coronary-prone
behavior where certain predisposed individuals exhibit exaggerated/fluctuating
sympathetic nervous system hyperreactivity in response to
environmental stimuli. This mechanism appears to be vagal
nerve mediated and an old vestige of the “Flight-Fight”
phenomenon. For want of a better term, some identify this
pervasive response style as “hostility.” Forty
components make up Type-A behavior pattern which is typified
by being easily frustrated when one’s goals are thwarted,
rapid speech, impatience, cynicism, feeling time pressured,
surliness, rudeness, disagreeableness, antagonism, loud
voice style, etc.. Large National Institute of Health studies
ultimately demonstrated that it is this “hostility”
component of the Type-A behavior which is cardio-toxic and
coronary-prone. I am the first in the world to have studied
the role of “coronary-prone behavior” as a risk
factor for PTCA restenosis. My hypothesis was an outgrowth
of my experiences attending the post-PTCA patients with
persistent same-site restnosis whom I was requested to consult
on initially because of their demanding, caustic personalities/behaviors,
which were disruptive and a nuisance to the nursing and
supportive staff during their in-patient admissions to the
Can you tell us a little about your research and results?
MG: My Restenosis-Prone Prevention Treatment
Program (May, 1997) is based upon my original risk-factor
study (August, 1996) which found that individuals who have
coronary-prone behavior are almost 2.5 times as likely to
experience restenosis or re-narrowing of the previously
balloon-dilated site within 6 to 26 weeks post-PTCA. This
risk-factor is assessed by using the Type-A Structured Interview
(SI), a verbally administered interactive set of pre-determined
questions. The scores from the "Structured-Interview",
which has been used since the 1980’s, are highly correlated
with the physiologic and hemodynamic consequences associated
with hostile/coronary-prone behavior responses which are
antecedents to cardio-toxic blood pressure fluxuations and
catecholamine cascade secretions. Currently, 4 of 5 reported
pilot study volunteers are free of restenosis and other
clinical cardiac events at 24 months after their final PTCA.
While these results seem
impressive, “selection bias” is present in that
I chose only those with the greatest amount of hostile/coronary-prone
risk-factor behavior and at least two same-site PTCA (balloon-dilation)
restenosis. The biofeedback component of my program has
been successful controlling systolic hypertension, thereby
reducing pharmacotherapy which may carry sexual dysfunction
and depression side effects
. Patients whom are mostly
male, report better frustration tolerance (especially driving
in traffic), weight loss via diet compliance, smoking/caffeine
intake reduction, and a reported increased sense of control
and calm. Patient’s spouses verify that they are easier
to live with at home and experience less conflict at the workplace.
KH: What type
of patient is most suitable for your program?
MG: If the individual has elevated risk-factor
scores via the Type-A SI, then they are eligible as a candidate
in the intervention program. I should state at the outset,
this program is NOT psychotherapy. It initially consists
of an educational component, explaining the results and
meaning of an elevated risk-factor score on the Structured
Interview, as well as the physiologic consequences of their
behavioral responses to environmental challenges. Biofeedback
is an integral part of the program. It is used to educate
the patient with objective concrete data on how to circumvent
and control the cardio-toxic/pathophysiologic consequences
of PTCA restenosis-prone behavioral responses. My goal is
to train the patient in techniques (non-pharmacological)
that they like, can master in several hours, and which are
consistent with their lifestyle, giving them the ability
to control hemodynamic/blood pressure, sympathetic nervous
system/adrenaline hyper-reactivity. This is coupled with
easily implemented pure behavioral strategies customized
to each patients’s traditional cardiac risk-factors
(i.e. smoking reduction/cessation, weight loss and easy
ways to increase compliance with lipid-lowering diets, etc.).
KH: Can you share other lifestyle
modifications that may be of benefit in reducing restenosis?
MG: Lifestyle modifications
are the goals. Research has shown us that a biological risk-factor
may be modified/reduced as much as 20% through behavioral
change. Smoking, the choice to consume high fat vs. a low
fat diet, exercise, alcohol consumption, hypertension control
as well as compliance with risk-factor reducing pharmacologics
are all behaviors. Behavioral medicine has to do with changing
behaviors to achieve a beneficial medical outcome. Behavioral
medicine’s concerns are health promotion and disease
prevention. Having multi-disciplinary training, one area
I always address is quality of sleep. Sleep-wake cycles
disorders are common in these patients who are so success
driven, and this disorder negatively affects diet, mood,
compliance, immunocompetence, and strains interpersonal
relationships. In reqard to diet, I teach my patients how
to shop for healthier foods in the supermarkets, and even
how to determine healthier alternative when dining out or
eating fast foods!
KH: How do you determine
if your program is successful and what is the time frame
of this determination?
MG: Restenosis following PTCA-balloon
dilation is most likely to occur within 6 months, according
to the literature. I waited 18 months before reporting my
restenosis prevention findings because I believe this was
the minimum time necessary to demonstrate clinically useful
significance. Cardiologists and other physicians (as well
as my PTCA patients who have not progressed to CABG) tell
me they consider these pilot results to be a very positive
finding. Statistically, my results are even more impressive
given the small sample size, thus attesting to the “robustness”
and large “effect size” that this behavioral
measure has in capturing and predicting a disease hard-endpoint.
I would arbitrarily set a time limit of 3 years without
restenosis in evaluating whether treatment has truly been
successful. Patients consider my prevention program successful
even if they are able to postpone CABG and further clinical
KH: What are the side effects of your
program, if any?
MG: None, other than restenosis, which
might have occurred anyway.
KH: What is the cost of this behavioral
MG: The assessment identification of this
risk-factor via telephone or in-person interview using the
same verbally administered assessments as I used in the
August, 1996 Mayo Clinic Proceedings article is $300
for a 1-hour consultation. This allows adequate time to
respond to questions and provide explanations and, of course
education. The Restenosis Prevention Program, at $300/ per
hour is comprised of approximately 8-12 hours. The fee can
range from $2400-$3600 depending upon the number, and degree
of severity of cardiac risk-factors requiring treatment
modification intervention. The Restenosis Prevention program
can be compressed into a weekend, if necessary. I am not
a participating provider with any health care insurance
companies, and require pre-payment in advance to reserve
treatment Program time. However, my fee may potentially
be reimbursable directly to the patient.
KH: What study needs to be done next
to confirm your findings?
MG: A prospective study with treatment
cases matched to controls on all demographics (i.e. age,
gender, race, body mass index, traditional risk factors
and hostility scores) including degree and site of arterial
restenosis with my intervention program manipulated as the
independent variable. It would be important to verify a
dose response linear relationship between more intervention
and more resistance to angioplasty failure for those identified
with this risk-factor. Moreover, unlike in pharmacologic
studies, blinding subjects to the hypothesis and covarying
out variable rates of human learning are difficult in pure
behavioral interventions. I am certainly amenable to suggestions
from other clinical researchers.
KH: Are there any other factors,
especially nutritional, that may help reduce the likelihood
of restenosis after percutaneous angioplasty?
MG: Absolutely! Clinical Pearls News
had a brief article in 1997 on the protective role of vitamin
C in preventing PTCA restenosis. My Prevention Program includes
consultation with each of my patients cardiologist regarding
the latest in nutritional pharmacology with antioxidants,
fish oils, parasympathomimetics, etc..
(New Jersey License Expired)