HEART OF THE MATTER

July 26, 2000
		Dick Cheney has suffered several heart attacks and undergone quadruple bypass surgery. Margaret Warner talks with Dr. David Meyerson, a cardiologist with Johns Hopkins University. The Health Unit is a partnership with the Henry J. Kaiser Family Foundation.

Heart Health Special May 5, 2000: New standards, old practice. March 23, 2000: A simple test Nov. 11, 1999: Ramipril for preventing heart attacks and diabetes. July 20, 1999: Aldactone found surprisingly effective. May 27, 1999: Seeking hospitals for heart care. Nov. 11, 1998: Gains in the fight against Heart Disease. April 13, 1998: Smoking and Heart Disease. June 19, 1997: Estrogen and Heart Disease. April 3, 1997: Heart disease risks. The NewsHour's Health Spotlight. Browse the NewsHour's coverage of Health   Article in the New England Journal of Medicine Brigham and Women's Hospital American Heart Association	MARGARET WARNER: Dick Cheney suffered his first mild heart attack in 1978, when he was just 37 years old. Two more followed in 1984 and in 1988, and that year, he underwent quadruple bypass surgery. Since then, Cheney's doctors say he's been in good health. Yesterday, the Bush campaign released a statement from Cheney's cardiologist describing his history of heart procedures, and stating that Cheney leads "an asymptomatic and extraordinarily vigorous lifestyle." To help us understand heart disease and the latest advancements in treating it, we're joined by Dr. David Meyerson, a cardiologist with Johns Hopkins University and national spokesman for the American Heart Association. Welcome, Dr. Meyerson. DR. DAVID MEYERSON: Margaret, a pleasure. MARGARET WARNER: All the descriptions of what Dick Cheney had is always that he had three mild heart attacks. What is a mild heart attack is that a medical term? DR. DAVID MEYERSON: Can I say briefly I'm not his cardiologist, nor do I have the benefit of examining him, nor do I have any political agenda so you've asked me to talk about the science. Heart attacks come in all shapes and sizes. You can take out a large amount of heart muscle, for example, if it was a car engine, you can destroy three or four cylinders worth of power. Minor heart attacks or mild ones may destroy half a cylinder of power or none at all. They literally come in all shapes and sizes. MARGARET WARNER: All right, and so - but in a heart attack describes what happens. DR. DAVID MEYERSON: Heart attacks are often caused by blockages that nourish the muscles. Over time, because of high cholesterol, high blood pressure, smoking, diabetes, and many other causes that narrow the red lines here, which are coronary arteries, the ones that nourish the heart muscle, those begin to block off over time. Finally what can happen is that a blood clot can form in one of those arteries. And if the artery - you can see -- the artery up here, if this gets blocked up here, then all of the downstream muscle can be in jeopardy and a heart attack means that a segment of heart muscle dies and gets replaced by scar tissue but if the heart attack only happens down here, only a tiny amount of functional heart muscle. So, again, heart attacks come in all shapes and sizes.
	Coronary artery bypass surgery
	MARGARET WARNER: All right. Then it's said after the third one he had what a called coronary artery bypass graft surgery and in the quadruple form. Explain that. DR. DAVID MEYERSON: Well, the number of grafts that you have is a little bit like saying -- bragging rights on a park bench. For example, what I mean by that is that the difficulty is getting there. If you have to drive to the supermarket in a snowstorm, you have to dig the car out and drive safely and it's treacherous to get there. When you're there, you buy what you need to buy. When the surgeon is in there, they bypass what they need to do to give the best blood supply to different areas of the heart muscle. Most of the time this is the left anterior - descending coronary artery -- they put a special artery in here, called the international mammary artery, which runs inside the chest wall. MARGARET WARNER: They take it out of you in another area and put it in here -- DR. DAVID MEYERSON: They don't even take it out all the way. They take it out from its pedicle so that it actually -- its blood supply is there -- they replug it in down here. It's a wonderful graft. It lasts almost forever; it does not have the tendency to block down. It's a terrific graft. For areas that that can't reach we take veins out of the leg called safinous veins, and the vein would go up from the aorta where the blood is plentiful. If there was a blockage here, the vain could go from here to beyond the blockage. You bypass the blockage; hence the term, coronary bypass grafting. MARGARET WARNER: So how long does bypass surgery last? DR. DAVID MEYERSON: A wonderful question. When we first began to do bypass surgery in this country in 1969, and '70 and '71, we didn't know to pay as much attention to preventing the second recurrence. Diabetics needed to have the blood sugar controlled. We can drive the cholesterol into the basement with wonderful medicines. We get people to stop smoking. In the early days they would last a few years and we would wonder why they were breaking down again or clotting off again. It turns out that if we pay meticulous attention to blood pressure and cholesterol and diabetes and keep people active and keep them on the right medicines we can make those grafts last almost indefinitely. MARGARET WARNER: So how much of this is under an individual's actual control? DR. DAVID MEYERSON: The individual has to sign on 110% with the doctor. In the year 2000 we are more responsible for our health care than ever before in the history of medicine. You must work with your doctor, with your cardiologist, with internist. And, you know, it's very interesting, things that are borderline, borderline cholesterol, borderline blood pressure,, tobacco smoking a little bit-- when you say you'll cutting down, it's like saying I'm only going to drive 135 miles an hour two or three days a week. So that when we pay attention to all those things we can make people last longer and do enormous levels of activity. And when people go back to work after bypass surgery, believe it or not, you know what the most compelling reason for them to go back to work -- if they worked before, they can go back to work Generally, if they didn't, they are unlikely to go back. But we can maintain a very high level of function in people who are well treated.
	Lifestyle changes
	MARGARET WARNER: Now the letter from Cheney's doctor talked about the exercise he does and he had quit smoking and a lot of personal changes, and they talked about medications. Cheney himself has admitted that he's gained quite a bit of weight, substantial bit of weight in the last few years. Setting his case aside specifically but is overweight itself a factor, a risk factor? DR. DAVID MEYERSON: Overweight by itself is a little bit of a risk factor. It's pale in comparison to smoking and very high untreated cholesterol, high untreated blood pressure and untreated diabetes. It really pales in comparison. But inactivity and obesity do predispose the higher blood cholesterol and higher blood pressure. We'd like to see if we can get people to be more active in our society. We are as a society very much overweight. MARGARET WARNER: How does stress affect a person's vulnerability if they have heart disease? DR. DAVID MEYERSON: It depends. If a person is not used to stress, if they're in an environment that is totally foreign to them, then stress may be an important issue into triggering episodes of heart dysfunction at times. But people who are well treated, who have been doing their stress tests with their doctors, and with nuclear stress tests, which are better, because they tell us where the blood is flowing and where it's not - people who are on the proper medications, they want to be able to handle stress pretty well. MARGARET WARNER: All right. Bottom line, if someone has had two or three mild heart attacks, has had bypass surgery 12 or 15 years ago, are they at a greater risk of a recurring heart attack, another heart attack, than someone of their age in the general population? DR. DAVID MEYERSON: You would have to say that they are at somewhat higher risk but I would also at the same time say that those people, if they have signed on to the program with their cardiologist, they are being watched much more carefully; they are being treated. The person in the general population may not know that they have a problem with high blood pressure or high blood cholesterol until they present either with the first fatal heart attack or something terrible to them, so that, again, when you're being watched and being tested, we think we can predict who is at high risk and who is at low risk very well. MARGARET WARNER: So, in other words, some of these early warning heart attacks can actually be beneficial in an odd way? DR. DAVID MEYERSON: In an odd way if it tells you that must toe the line early, it's a godsend. MARGARET WARNER: Rather than waiting. Now, what have been the advances in the treatment? For instance, bypass surgery he had 12 years ago -- has the technology advanced since then? DR. DAVID MEYERSON: Bypass surgery can be -- is still the treatment of choice for certain groups of narrowings. For other groups of narrowings we can treat them aggressively with medicine and they may not need surgery. Yet, for other people we can do what's called angioplasty and put a stent in. A stent looks like a little meshwork cylinder, that can go in on a little balloon; the balloon goes into the coronary artery - it inflates - it deploys the stent, again, which looks a little bit like a spring inside a ballpoint pen. The balloon is deflated, withdrawn, and what we have left is a patent or open coronary artery with a little metallic bridgework thing inside. And that only takes 20 minutes to put in. MARGARET WARNER: So are you saying that some of the people who might have had bypass surgery say a decade ago might not -- today might just have an angioplasty? DR. DAVID MEYERSON: They might only have an angioplasty, but prevention is still the name of the game. Nobody that I know would prefer to trade a well treated heart attack or a well treated stroke for never having had one to begin with you. So if you really want to do yourself and your family a favor, keep your cholesterol in the basement, know what your blood pressure is -- you must not smoke. If you are a diabetic, you have to watch doubly; if you're a member of a family that has early heart attack and early stroke in your family, be checked. There is a lot that we can do. There are wonderful medicines. Prevention is the name of the game. MARGARET WARNER: Well said. Thank you, Doctor, very much. DR. DAVID MEYERSON: Thanks, Margaret.