Triumphant Procedures in Cardiology-Lessons from Dick Cheney

• Vice President Dick Cheney’s 33-year battle with heart disease illustrates the evolution of triumphant advances in cardiology that evolved over the past half century that allowed him to serve the nation for 40 years, albeit controversial. He has had five heart attacks, one bypass surgery, several angioplasty/stents, implanted cardioverter defibrillator, and finally a left ventricular assist device (LVAD) implantation. Cheney’s medical history is a fascinating tale of the combination of perseverance, technology and unprecedented cardiovascular innovation.

• As Cheney recounts in Wall Street Journal (July 9, 2011), life-saving techniques for heart attacks were non-existent back in the 1950s, when his grandfather died from one before reaching the hospital. The vice president is a recipient of virtually all cutting-edge cardiac procedures throughout the years that have kept him not only alive but working fulltime at the highest levels of the government, up until his recent retirement.

• Cardiology has improved more in the six decades since his grandfather died than all of previous history. A new advance, often unavailable even a few years before, has always outpaced the progress of his heart disease and of his career. “I’ve been extraordinarily fortunate to live in a place and a time when all that was going on,” Mr. Cheney says.

• In 1955 when President Eisenhower suffered a heart attack the standard treatment was six months of bed rest. Dr. Paul Dudley White, the father of modern cardiology, was criticized for allowing him to return to the White House after seven weeks of bed rest in the hospital. He was not even allowed to see a cabinet member for 17 days after the heart attack.

• President Lyndon Johnson also had a massive heart attack in 1955 at the age of 46 and died in 1973 at the age of 65 from advanced heart disease (two main arteries completely blocked and the third one narrowed by 60-80%). Despite repeated chest pains (angina), he was told that the digitalis he was taking regularly, and nitroglycerin “on demand,” represented the best that medicine could do for him. Both these presidents did not have the benefit of the innovations in cardiology that VP Cheney and President Clinton received.

• Mr. Cheney had his first heart attack at age 37 in 1978, when he was running for the congress for the first time, and was complicated by loss of consciousness. Despite his parents having a family history of early heart attack, and warning from his doctors, he had smoked for 40 pack-years and had other unhealthy habits that put him at greater risk.

• The future vice president received good medical care and even better advice from the internist who served as a cardiologist (there weren’t any cardiologists in Wyoming in those days). His doctor advised against giving up his political aspirations with the comment “hard work never killed anybody”. Had he been advised otherwise, most Americans outside Wyoming would have never heard the name Cheney.

• A vast improvement in the standard of cardiovascular care was well underway, as new treatments like coronary artery bypass graft surgery (introduced in the 1960s) were being refined. Yet to emerge were new classes of drugs like statins to lower cholesterol (circa the late 1980s), ACE inhibitors to lower blood pressure (circa the early 1990s), and beta blockers to reduce stress hormones (circa the early 1980s).

• Since midcentury, the heart-disease death rate has fallen by nearly 2% annually; though progress seems to have slowed in recent years it remains the leading killer in the U.S. Most of the decline can be explained by a greater awareness of prevention and the decline in tobacco use. Mr. Cheney quit smoking after the first heart attack and never had another one after that dreadful night.

• Still, he had his second heart attack in 1984— again during election campaign —and his third four years later, “the most serious” requiring a quadruple bypass surgery, where surgeons rerouted blood vessels around his arteries. Within a few months, he became active and started skiing again.

• He had a silent heart attack during the now infamous 2000 Florida recount ─ his fourth one. He was indeed the beneficiary of diagnostic improvements to detect a heart attack with blood tests that was not available when he had his first one. The recent diagnostic improvements meant the ability to detect the enzymes and proteins released into the bloodstream when heart muscle cells are injured. A generation ago, Mr. Cheney’s fourth heart attack, wouldn’t have been detected at all.

• Over the next year, Mr. Cheney’s doctors took advantage of the new cardiology arsenal. They gave the vice president a balloon angioplasty (c. 1980s) to reopen an artery and two coronary stents (c. 1994), metal sleeves, to prop it open.

• Mr. Cheney suffered his fifth heart attack in February of 2010, and by spring he was “in steady decline, less and less stamina and energy, approaching end-stage heart failure.” No matter how minor, each heart attack does more and more damage, leaving behind heavy tissue that cannot contract.

• The most important procedure from the West Wing period was the installation of an implantable cardioverter defibrillator (1985), a battery-powered device about the size of a pocket watch that continuously monitors heart rhythm and delivers a corrective electric jolt if it recognizes an abnormality. He wore that about five or six years, then got it replaced when a newer model came along.

• The defibrillator saved his life in late 2009, when Mr. Cheney went into ventricular fibrillation and lost consciousness while backing out of his garage in Jackson.

• The dramatic improvement of survival following a heart attack has contributed to having a large population of patients with chronic heart disease, often with late-stage heart failure. Between 60-70% of patients with late-stage heart failure have hearts that were damaged by one or more heart attacks.

• As Mr. Cheney’s condition deteriorated, he and his physicians considered a heart transplant but opted for the LVAD. The surgery was a huge risk given his age, sickness and the logistical fact that his surgeons would need to “go right back in exactly the same location” as his bypass 20 years before. “Cutting through all that scar tissue, that’s tougher in a sense than actually installing the LVAD, or so they tell me.”

• Three days before the operation was scheduled all his systems started to crash—kidneys, liver; blood flow just wasn’t adequate to keep him alive. He was dying!  He had an emergency LVAD implantation the very same night at Inova Fairfax Hospital in Falls Church, VA. He was in the intensive care unit for about five weeks, most of that on the respirator and developed pneumonia that delayed his recovery.

• He spent months in cardiac rehabilitation program. “When you get to the point where you spend that much time in an ICU, you just totally waste away,” he says. “Muscle mass is all gone—you can’t open a tube of toothpaste, can’t get in and out of the bed, need help with absolutely everything you do.” 

Economic Implications of Advances in Technology

• Economists agree that the spread of such technological change accounts for most of the climb in U.S. health-care costs—currently 17% of the GDP and nearly double that of other high income countries. Heart disease accounts for about a third of what Medicare spends merely on hospitals, not counting drugs or other charges.

• The US has had a system that provides for the kind of research and innovation that has provided these tremendous capabilities. That automatically raises questions about how to deliver it to everybody who needs it.

• The health economists are looking to find ways to deliver the quality care that everyone expects and that the health system is capable of providing to the maximum number of people.

• As with any other new medical technology, these advances come at a price. With health care costs escalating each year, and cardiology accounting for a significant portion of the Medicare budget, there is much debate about how widespread innovative cardiac devices and procedures, such as LVADs, should be. For patients who return to productive lives with an LVAD, the overall cost may well be reasonable considering the return to productivity and the reduced long-term cost of care for severe heart failure.

• As more patients who will not receive a heart transplant are provided with destination LVADS, the cost analysis is likely to be favorable for LVAD use. However, they are still likely to generate considerable debate on the ethics of their use in an already overburdened health care system.

• Given the fact that most of the patients who need an LVAD have hearts damaged by coronary artery disease, we may see a push to reduce demand by achieving higher levels of prevention.

Dick Cheney becomes “The Million Dollar Man”.