October 15th, 2013
Questions Remain About George W Bush’s Stent
L. David Hillis, MD
The National Journal reported yesterday that “George W. Bush’s recent heart problems were far more dangerous than generally believed — potentially life-threatening, in fact.” The Journal cited “an authoritative source”:
“He was more than 95% occluded. With a blockage like that in a main artery you’re supposed to die. He was pretty lucky they caught it.”
On the Nightly News” broadcast Brian Williams said that NBC news had “confirmed” the report.
But it is impossible to know for certain precisely what Bush had. I am assuming that he was discovered to have a positive exercise test at the Cooper Clinic in Dallas. First, what are the details of the supposedly “worrisome changes” on the electrocardiogram? Was the test, in fact, markedly positive, or just positive? Positive at a low workload or at a high workload? Symptomatic during the test or not?
Second, what coronary artery had the 95% stenosis? They imply that it was his left anterior descending, but I can’t be certain. Was it his left main (in which case PCI or CABG would be appropriate even in the absence of symptoms)?
I don’t think news organizations should report “new” information like this that doesn’t really help us better understand the indication for the procedure. What do other CardioExchange members think about this issue?
9 Responses to “Questions Remain About George W Bush’s Stent”
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I am amazed that with 7 randomized controlled trials demonstrating no benefit from elective stenting with respect to future heart attack risk or coronary death that the experts are still reporting that stenting of a single vessel lesion “saved a life” from a “ticking time bomb”.
Based on Fame II, I think we can comfortably state that by placing 100 elective stents in symptomatic subjects with tight stenosis, you prevent the need for 12 “urgent stent”. However if you live in Canada or go to the VA, you only prevent about 4 “urgent stents” by placing 100 elective stents. How this gets translated into a life saving procedure continues to amaze me.
In an interview given by George W. Bush at a charity golf tournament in Texas, he mentions that the infamous stent was indeed placed in his LAD. (Video available at http://thehill.com/video/in-the-news/319573-bush-feeling-pretty-good-after-heart-surgery)
Not having any other details on the case, I do not think one should jump to the conclusion that his PCI was inappropriate.
I believe there is still equipoise in choosing between an invasive or conservative strategy in asymptomatic patients with a large ischemic burden as would be expected with a functionally significant proximal LAD stenosis. This is precisely the population targeted by the ongoing ISCHEMIA trial.
I certainly agree with Drs. Blanchet and Paixao. However, we must respect our colleague who made the decision to intervene upon the left anterior descending coronary artery lesion. This was, I believe, triggered by a non-invasive evaluation that plausibly demonstrated high-risk features. Also, we do not have any details about the area of myocardium at risk, and type of lesion that was intervened upon. We will perhaps continue to debate upon this controversial topic until we have the results of the crucial ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) trial (http://clinicaltrials.gov/show/NCT01471522). Until then, it will have to be a risk:benefit ratio discussion with our patients, giving them all the data we have when moving forward with intervention in stable and/or asymptomatic epicardial coronary artery disease, with decisions based on the foundations of physician-patient partnership, and shared decision-making.
A few random thoughts (and to play the devil’s advocate a bit):
1. Would most of us really feel comfortable not intervening on a 95% LAD stenosis? As Drs. Paixo and Kalra states, the equipoise underlying ISCHEMIA trial is that revascularization could be beneficial when a large amount of myocardium is at risk. Similarly, even if we conservatively interpret FAME II’s results, is it fair to extrapolate the group-averaged benefit in FAME II to individual patients with very tight stenoses?
2. Perhaps it was the exercise stress test that was inappropriate. Without knowing the full context, though, it’s difficult to judge. Were there any symptoms that he was concerned about? Decreased exercise tolerance? The nuances of clinical decision-making can be hard to capture, which was part of the reason why ACC recently changed the terminology from “inappropriate” to “rarely appropriate”.
3. As Dr. Andrew Einstein pointed out a while ago, in the context of President Obama getting a coronary calcium scan, there are also considerations beyond the purely clinical: the tolerance for uncertainties and health risks ought to be lower for presidents, given their responsibilities (albeit in this case it was after Bush has left public office).
To get back to Dr. Hillis’ initial question, I’d say that these kinds of complex issues are often fumbled in media coverage, with its tendency to play up controversies (“he was pretty lucky they caught it” vs “American medicine at its worst”). But good reporting and balanced perspectives are possible. For instance, I found this earlier report that interviewed Dr. Nissen and Dr. Jessup to be fair and informative (http://www.cbsnews.com/8301-204_162-57597191/why-george-w-bush-might-have-needed-a-stent/).
“Would most of us really feel comfortable not intervening in a 95% LAD stenosis?” Therein lies the rub.
By the way – 95% based on CASS criteria, or as loosely interpreted in everyday use? But that is a topic for another day…
In a case that you have a combination of privacy, politics and national security the only thing you can be sure is “I only know that I know nothing” Socrates.
Lisa Rosenbaum’s blog in the New Yorker talks more about this subject:
http://www.newyorker.com/online/blogs/elements/2013/10/the-most-slandered-treatment-in-medicine.html
I think her main point is a good one:
“If, however, we make room for the tremendous uncertainty upon which most of medicine is practiced—an uncertainty that eludes hard and fast rules governing appropriate use—then we are left with a more truthful tale, albeit one that offers a less clear path to a happy ending.”
But I think the tricky part is to both honestly acknowledge the uncertainty, while also be careful to not use uncertainty as the rationalization for inappropriate / low-value / wasteful care.
It is interesting to use the SCAI QIT tool (http://www.scai-qit.org/) in this case to see the appropriateness of PCI given different clinical scenarios for the former president.
Given what we know, most permutations will result in uncertain benefit for PCI. The exception, for what I assume is CCS I angina not on anti-anginals, would be a high risk stress test, where PCI is appropriate for 1v CAD. Almost everything else yields uncertain benefit.
Another interesting exercise would be to imagine that the patient is not the former commander-in-chief, but a Vietnam War veteran presenting at the local VA. What are the chances his consulting cardiologist would push for PCI in that vet’s case? Are we consistent in our advocacy for medication (COURAGE) vs PCI (FAME II)?
I don’t have all the details of the former president’s case but what I have read he had a 95% left main stenosis for which they performed PCI. If that’s the case, I don’t think there would be any argument that revascularization was indicated. Without knowing specifics about his anatomy, it is difficult to debate the choice of PCI vs. CABG. However, assuming the anatomy is suitable, there are those, myself included, that believe PCI has achieve a degree of equipoise with CABG in patient’s in the extremes of risk. In other words, PCI in a young patient with a low STS score would probably be a reasonable option that should be discussed with the patient. How do we know that this was not in fact discussed with Mr. Bush and he opted for PCI.
You’re comments regarding the VA would seem to suggest that you have not rotated in a VA. I am not sure what you are implying but as a practicing interventionist at a VA, I am almost takingoffense at your comment that implies the care at VAs are somehow inferior or that we somehow value our veteran patients less. I will tell you that we probably perform more high risk procedures than our counterparts in the community. I myself have performed more than 100 left main interventions.