A National Journal article published Oct. 11, two months after President George W. Bush underwent a heart catheritization to have a stent clear and open a blocked artery, says his heart health was more serious than first believed – potentially life-threatening. The 95-percent blockage that sent the former Commander-in-Chief known for his regular runs to a Texas hospital was first discovered during a routine stress test. President Bush was not experiencing any symptoms of a heart attack. A subsequent CT angiogram revealed the extent of the blockage, leading to the decision by his medical team to proceed with the stent procedure. Since then, the media has debated whether or not that was the right treatment and if it was really as serious as an impending heart attack.
Director of the Cardiac CT program at Oklahoma Heart Institute Dr. Victor Cheng, who was not involved with President Bush’s care, says there are times when a stent is correctly indicated, but using a stent to open up heart artery blockage is often not needed in an asymptomatic patient.
“Clinical trials so far have not proven reduction in heart attack risk when angioplasty and stenting is done in truly asymptomatic patients,” he says. “Because of this, media coverage has reported dissenting opinions on whether angioplasty should have been done at all for the former president. Several expert physicians have publicly weighed in on the debate, but unless they have been personally taking care of the former president, these opinions are educated guesses based on population-wide data, and we need to keep that in mind.”
What are some circumstances that would lead to a procedural intervention in someone who doesn’t have symptoms and was found to have severe heart artery blockage on cardiac CT? Dr. Cheng recommends revisiting the patient’s activity level and symptoms, such as shortness of breath or chest pain. “Some folks will realize they were indeed having symptoms, or had modified their lifestyle to keep symptoms from occurring,” says Dr. Cheng. “This has happened in our promotional CT population. If the individual confirms that he or she was actually symptomatic, then procedural intervention with angioplasty or bypass graft surgery is effective in resolving symptoms when medications do not work.”
High Risk Coronary Artery Disease
When identifying heart disease through methodologies such as a cardiac CT scan, cardiologists can diagnose the severity of the coronary artery disease if present. “Certain types of severe coronary artery disease are considered very high risk even if the patient is asymptomatic, and procedural intervention is generally preferred,” says Dr. Cheng. “These include severe disease in the left main coronary artery and severe disease in all three major coronary arteries.” (The three major coronary arteries are the left anterior descending, circumflex, and right coronary arteries.)
However, if severe coronary disease is discovered in an asymptomatic patient, Dr. Cheng says a procedure is not always imminent and other factors need to be evaluated. “Some of these include evidence of heart muscle oxygen deprivation, reduced heart pumping function, presence of other medical conditions, and even occupational demands,” he explains. This is the time Dr. Cheng advises patients to have an earnest discussion with their cardiologist about their risk of a future heart attack and if measures such as lifestyle modifications or medication therapies should be adopted to reduce that risk.
“The issues brought up by former President Bush’s case illustrates how medical decision-making for the doctor and patient can be quite complex when someone asymptomatic is found to have severe heart artery disease,” adds Dr. Cheng. “There are situations in which opening up the blockage should not be done, because it is not likely to help the patient live a longer or higher-quality life. The doctor and patient can only figure this out after thorough consultation and should avoid immediately reacting to the picture of the severe blockage alone.”
Photo: Associated Press