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Heart Health

November 22, 2000 at 12:00 AM EDT


RAY SUAREZ: GOP Vice Presidential Candidate Dick Cheney checked himself into George Washington University hospital this morning in Washington, D.C., complaining of chest and shoulder pains. Cheney has a history of heart problems. He suffered the first of three heart attacks in 1978 at age 37. Cheney underwent quadruple bypass surgery in 1988 and had reported no problems since. This morning doctors said Cheney had not suffered a heart attack, but took some precautionary procedures.

DR. ALAN WASSERMAN: A decision was made to perform a cardiac catheterization. The results of the catheterization showed an increased narrowing in a side branch artery, specifically the diagonal branch of the left anterior descending artery. The rest of his coronary anatomy is completely unchanged from the previous study, performed in 1996. A decision was made to place a coronary stent in that area that showed some additional narrowing. After placement of the stent, the artery now appears normal. Mr. Cheney has returned to his hospital room and is doing well.

RAY SUAREZ: From Austin, Texas, George W. Bush made a public statement concerning his running mate’s condition. Bush said he spoke to Cheney this morning.

GOV. GEORGE W. BUSH: This morning I talked to Secretary Cheney, we had a very good conversation. He sounded really strong, and he informed me that as a precautionary measure he went into the hospital, he was feeling chest pains, and it turns out that subsequent tests, a blood test and the initial EKG, showed that he had no heart attack. I’m pleased to report that.

RAY SUAREZ: Late this afternoon doctors at George Washington University Hospital updated Cheney’s diagnosis and said he, in fact, had suffered a very slight heart attack.

DR. ALAN WASSERMAN: Let me clarify. When he came in at 8:00 this morning he was first seen, when we got the first set of enzymes and EKG, there was no evidence of a heart attack. Up until approximately sometime after noon today when we got the second set of enzymes was the first time that we could say we would define this as a small heart attack.

DR. JONATHAN REINER: This would be the smallest possible heart attack that a person could have and still have it classified as a heart attack. His cardiac enzymes were just minimally elevated.

RAY SUAREZ: I’m now joined by Dr. David Pearle, professor of medicine at Georgetown University and director of the coronary care unit at Georgetown University Hospital.

Well, Dr. Pearle, by revising that diagnosis, by conceding that, yes, Secretary Cheney did have a very slight heart attack, what are they saying this afternoon about what happened to his heart that they weren’t saying earlier in the day?

DR. DAVID PEARLE: Well, the fact that he has had a little bit of an enzyme elevation, a small heart attack, is worse than if there had been no heart attack at all. A heart attack usually is caused by blockage of one of the coronary arteries, and that’s presumably what caused the symptoms this morning. The fact that Secretary Cheney did what all doctors advise, come promptly to the hospital, had what sounds like outstanding medical care, George Washington University Hospital, the blocked artery was promptly opened with angioplasty and placement of a stent, means that the long-term outlook is still good, but it would have been better if there were no enzyme elevation whatsoever.

RAY SUAREZ: There they are again, those enzyme elevations. We’ve heard several references to that now. What is that telling you in your blood that happened to your heart perhaps 12, 14, 16 hours ago?

DR. DAVID PEARLE: Enzymes are substances found within the cell, and when a cell dies, these enzymes leak out or are released from the dying cell. That’s what we mean by a heart attack, a certain number of cells have died. It’s of coursed encouraging that it was a very minimal enzyme elevation, presumably a very, very small heart attack, but nevertheless there was some tissue damage.

RAY SUAREZ: Is this made more significant by the fact that we’re talking about a man who has had three heart attacks in the past?

DR. DAVID PEARLE: It is. The damage to the heart is cumulative. The test results that were released when Secretary Cheney was first named vice presidential candidate suggested that his heart muscle overall was almost normal so that the amount of previous damage was minimal, and it sounds from all reports – of course, I’m not involved in his care, and like everybody else as well, it sounds like the amount of damage to the heart this time was again very minimal.

RAY SUAREZ: And they put in a stent. What is that and how is it put in?

DR. DAVID PEARLE: A stent is a modification of the balloon procedure, or angioplasty that’s been around for about 20 years now. When an artery is blocked off, we can pass a small balloon down that artery to the point of blockage, inflate the balloon, and open the artery so blood flow is returned throughout the artery. One of the problems with the balloon procedure, though, was that over time, if we opened the artery with a balloon, there was a 30 to 40% chance that in the process of healing that artery would tighten down. And what we have learned is if we use these little metal scaffolding devices which stay in place permanently after the procedure, the chance that the artery will tighten down over the next few months is much less, instead of 30 to 40%, somewhere in the range of 10 to 20%, depending how large the artery is.

RAY SUAREZ: So it, in effect, holds the walls open?

DR. DAVID PEARLE: Exactly. There’s still a healing process, it’s still possible that that healing process will reocclude or reclose the coronary artery, but it’s much less likely.

RAY SUAREZ: Well, the doctors made some mention of where this happened in the secretary’s heart — the diagonal branch of the left anterior descending artery. I just said it, I don’t know what I just said, but I said it. Is it significant that this is an original part of his heart, rather than one that was grafted or reconstructed during by-pass surgery 12 years ago?

DR. DAVID PEARLE: It is. Of course it’s a little discouraging he would have any progression of disease at all. But their statement was there’s been not much progression elsewhere. The fact that it was a branch of a major vessel, rather than a major vessel itself, is also good news; presumably this is a relatively small artery that’s occluded. What I think most of us would have expected going in is a problem in one of his grafts, which are now 12 years old, and problems in those grafts are a little harder to treat than problems in your own native coronary arteries, the coronary arteries you were born with.

RAY SUAREZ: Could you show us on your model?

DR. DAVID PEARLE: This is a model of a heart and, of course it’s not totally accurate. But the heart is a muscle, like other muscles, and like other muscles it needs its own supply of oxygen and nutrients. And that supply of oxygen and nutrients comes through the coronary arteries, shown here in red, so that it is blockage within these coronary arteries that deprives the heart of sufficient nutrients and causes a heart attack. It’s a little hard to see in this model, but the specific artery that was involved in Secretary Cheney’s event this morning is probably this one, although it’s, again, this is very schematic. But it’s one of these coronary arteries running around the outer surface of the heart that was blocked off or partially blocked off.

RAY SUAREZ: Now, we’ve just come through a process that most American men never face: A national presidential campaign. Do we understand well enough the link between stressful interludes in your life and this kind of event?

DR. DAVID PEARLE: Well, the short answer is no. Of course it doesn’t usually happen in this setting, but this is the number one cause of death in the United Sates among both men and women. It seems sort of intuitively obvious that stress would be bad for your heart and would contribute to the buildup of atherosclerosis. The scientific literature on that is not absolutely conclusive, so that in general most doctors try to tell people to avoid stress; that’s a hard thing to do in daily life. The scientific evidence is equivocal. And such evidences we do have suggests it’s not just stress per se, it’s more frustration and anger, it’s not so much working hard because you choose to work hard, but working hard because someone else told you to do it and you don’t like it.

RAY SUAREZ: What’s the short term prognosis for men in this kind of condition? The doctors earlier today said that in air matter of a couple of days, Secretary Cheney can be home and resuming normal activity.

DR. DAVID PEARLE: Well, I think that’s probably accurate. There are complications of the angioplasty and stenting procedure that have to be followed carefully. There are complications when there is even a small heart attack. It has to be followed carefully, and that may slow the process down just a little bit. But assuming there are no short-term complications, I think it’s probably realistic that someone like Secretary Cheney would be fully active within a week or two, maybe even sooner, certainly able to talk to people as soon as tonight.

RAY SUAREZ: Well, what are the kinds of things that doctors would be looking for in the next 24, 48, 72 hours?

DR. DAVID PEARLE: Well, in the short term, the artery that has been fixed could get into trouble again. That’s much less likely to happen with a stent. I think the chance of that happening is very small. Sometimes even a small heart attack can cause irregular heart rhythms; that’s the kind of thing that would be watched for and might keep until the hospital a day or two longer than he would be with a conventional angioplasty. Usually when we do an angioplasty or stent the patient is out of the hospital within 24 to 48 hours. If there’s been a small amount of heart damage, that may be delayed an extra day or two. But from everything that has been announced so far, I think it’s realistic that he’ll be back at work within a week or two.

RAY SUAREZ: Now, reiterating that you are not Secretary Cheney’s doctor —

DR. DAVID PEARLE: Absolutely.

RAY SUAREZ: Let’s discuss the overall outlook for men who are at his age who have had three heart attacks in the past, and now have another episode, admittedly this one is small. Does the outlook over the long haul change very much, by this new episode?

DR. DAVID PEARLE: Well, I think the long-term outlook is good. I mean, our treatments are superb, particularly for people who follow the advice. I mean, people who are able to avoid the things that we know make further events more likely, for example, avoiding cigarette smoking, keeping the cholesterol low, which can be done with a combination of diet and drugs, keeping the blood pressure under control, really makes a major difference in the long-term outlook. There are several issues. Anyone who has had an angioplasty is at risk of that artery tightening down again in a timeframe of several months. And the chance of that, depending how big the artery was, is proposal on the order of 10 to 20%. We do know that the by-pass grafts that are placed have a tendency to deteriorate a little over time, and someone who has 12-year-old by-pass grafts, we want to monitor very carefully with regular exercise tests. But, nevertheless, with contemporary medical therapies in a patient who adheres to a healthy lifestyle, the long=term outlook is good.

RAY SUAREZ: And the short term-return to daily activity, I mean, are you really suggesting that Saturday he could run around the block if he wanted to?

DR. DAVID PEARLE: Well, of course I’m not involved in his care, and there are a lot of things that make one person different from another. Assuming the amount of damage to the heart is small, I think he will be, the likelihood is to be back to pretty much normal activities within a week or so. We usually advise people to take it easy a little bit for maybe a week or so after an event like this. Some do, some don’t. There will be some restrictions in terms of heavy lifting, and climbing Mount Kilamanjaro and running and that sort of thing, but I think in terms of normal activities of a busy executive, whatever job Secretary Cheney is going to have a couple of weeks from now, he will be able to return.

RAY SUAREZ: Dr. David Pearle, thanks a lot.

DR. DAVID PEARLE: My pleasure.