We learned from news reports earlier this month that former President George W. Bush was treated with a coronary stent for a blockage in a coronary artery that was discovered during his annual medical check-up. Of course, a great many Americans are treated each day for coronary artery disease (CAD), but Bush's case draws my attention not only because he's the former President but also because he's known to be physically active, especially with cycling.
Bush's Medical History
The fine details of Bush's most recent health matters haven't been made public, and might never be. But we know that while President from 2001 to 2009 he enjoyed comprehensive medical check-ups performed at the Bethesda Naval Medical Center. Each year, short statements were issued by the White House that summarized the President's health. We can take a look back at some of that reporting.
Before taking office, the President received annual medical check-ups from Dr. Kenneth Cooper at the Cooper Clinic in Dallas, Texas. We know that, at the time he took office in 2009, he had no heart problems and no significant family history of heart disease. He occasionally smoked a cigar, did not drink alcohol, and had typical caffeine intake in the form of diet soft drinks and coffee.
From his examination at age 58 in 2004, we know that: he was 6 feet tall, weighing 200 pounds; his body fat was 18.25%; his resting heart rate was 52 and the blood pressure was 110/60; and the total serum cholesterol level was 170 mg/dL, with a decrease in the LDL (bad cholesterol) and increase in the HDL (good cholesterol) from one year previously. He was noted to have mild calcification of the coronary arteries (presumably based on a screening cardiac CT scan) and both aspirin and a cholesterol-lowering agent were prescribed. At the time, he was running 7 1/2 minute miles on the treadmill and was cycling several times per week.
In 2005 we learned that the President's weight had decreased by a few pounds and the blood pressure and resting heart rate remained low. He underwent an exercise treadmill test that was normal and his doctors concluded that he was at "very low risk of coronary artery disease." By 2005 Bush had given up running because of difficulties with knee pain, but continued to be active with cycling and weightlifting.
In 2006 at age 60 he was noted to have an EKG without worrisome abnormalities and a normal stress echocardiogram. Doppler ultrasound studies of the arterial blood supply to the legs was normal and a screening ultrasound of the abdomen showed no evidence of abdominal aortic aneurysm. Laboratory values included: total cholesterol 174 mg/dL, HDL 60 mg/dL, LDL 101 mg/dL, triglycerides 61 mg/dL, and normal values for C-reactive protein (CRP) and homocysteine. Interestingly, it was reported that he was taking no prescription medications despite the 2004 statement about the recommendation for a cholesterol-lowering agent. On the basis of the available information, the President was thought to have "low" to "very low" coronary artery disease risk.
The Coronary Stent
As we all know, Bush left office in 2009. Since then, his medical affairs have been private. So, fast forward to 2013....
We know that Bush went recently for his annual medical check-up at the Cooper Clinic and the following day at Texas Health Presbyterian Hospital was treated with a coronary stent for a blockage in a coronary artery that had been discovered duringn his evaluation. The details have not been made public, but it's probably fair to assume that he underwent a stress test that was abnormal and that coronary arteriography was organized for the following day, with implantation of the coronary stent at the same setting.
The fact that Bush was treated with a stent for the coronary artery blockage has created a bit of a stir in the medical community. For those who are interested you can read more at:
"Did George W. Bush really need a stent?," an article by Larry Huston in Forbes.
"The George W. Bush stent case: An incredible teaching opportunity on the basics of heart disease," a blog piece by Dr. John Mandrola.
"Heart stents still overused, experts say," an article by Anahad O'Connor at NY Times Well.
Basically, the controversy revolves around the appropriate treatment for asymptomatic patients--those without chest pain, heart attack, etc.--or those with so-called "stable" symptoms--for instance, chest pain with exertion--who are found to have blockage(s) in the coronary arteries. In truth, there has been no public reporting on whether or not Bush had any such symptoms, either with exertion or at rest. And there has been no updated reporting on Bush's physical activity level or other relevant risk factors for CAD. But information from the best scientific studies suggests that asymptomatic patients and those with "stable" CAD fare no better, with respect to heart attack, stroke, or death, with a stent than without, so long as the best possible medical therapy is provided.
At any rate, this controversy will be one for our community of heart professionals to discuss and sort out.
What Can We Learn?
From the athlete's perspective, though, Bush's story reminds us of the importance of coronary artery disease as we age, even if we remain physically active. A few thoughts....
1. The discovery of CAD is almost always a surprise....particularly for an athlete. Nobody is immune from this disease, even if remaining physically active helps guard against it.
2. There is a set of well-established risk factors for CAD. I've talked about this issue previously here at the blog. Let's remember that there are some risk factors that, unfortunately, can't be modified: increasing age, being male, and having a family history of early CAD. Other risk factors are under our control: obesity, high blood pressure, smoking, abnormal serum cholesterol and lipid levels, diabetes, and physical inactivity. Adult athletes should know where they stand with respect to these risk factors and work to improve any that can be modified favorably. An ongoing relationship with a healthcare provider will offer the necessary framework for this. Periodic measurement of the blood pressure and testing of the serum cholesterol/lipid levels every 5 years are recommended.
3. Our personal situation with CAD will likely change over time. The process in which plaque builds up in the coronary arteries can begin early in our lives. But this process is often progressive as we age. That's why we say that increasing age is a risk factor. Bush's story illustrates just how this can happen. In 2004-2006 he had very favorable clinical and laboratory data regarding his risk of CAD, including a normal stress echocardiogram in 2006. Yet today we know that an important blockage had formed, or more likely progressed, in the interim. It's important, then, to periodically re-visit our circumstance with CAD.
4. Warning signs are important. Important blockages in the coronary arteries often lead to symptoms of angina--chest pain/discomfort or perhaps difficulties with breathing. When angina occurs with exertion, we call it exertional or stable angina. When angina occurs at rest, we call it unstable or rest angina. Either form of angina should prompt timely evaluation. That evaluation may take the form of stress testing or coronary arteriography to look for blockages in the coronary arteries. Unfortunately, there are some patients whose first sign of trouble is a heart attack, or myocardial infarction. This can occur in athletes and non-athletes, alike.
Related Posts:
1. Coronary Artery Disease: The Essentials
2. Two Stories, Two Endings, a blog post about endurance athletes and CAD.
3. In the News: Coronary Plaque Build-up in Marathoners
