Former President George W. Bush received an angioplasty and stent this morning at Texas Health Presbyterian Hospital Dallas. The stent was recommended by Bush’s doctors to open a blockage in one of his coronary arteries, found yesterday during what was described by Bush spokesman Freddy Ford as his annual physical exam at the Cooper Clinic in Dallas.
According to Ford, and as reported by Liz Szabo in USA Today, Bush experienced EKG changes during his exercise stress test and so was given a CT angiogram to determine whether these irregularities were the result of a coronary blockage. (CT angiograms seem to be somewhat of a feature at the Cooper Clinic — the photo on their home page pictures Dr. Cooper — the founder of “aerobics” — sitting in front of a multidetector CT scanner.) Indeed the CT angiogram revealed a blockage, so Bush was transferred to Texas Health Presbyterian, an angioplasty-capable hospital, where he had the stent procedure (a.k.a. PCI) this morning.
Although Bush is known for leading long bike rides at his ranch near Dallas (he had just completed a 100 km ride) he reportedly had not been experiencing any of the usual symptoms of coronary artery disease, such as angina or shortness of breath.
Which brings up the whole question of whether this stent was necessary — at least this was an issue buzzing around Twitter all morning long.
Some sample tweets:
Richard Besser @DrRichardBesser (ABC News Chief Medical Editor):
Frmr Pres GW Bush had stent placed in heart artery after “routine physical exam.” Not indicated if no symptoms. Overtesting? Overtreatment?
Eric Topol @EricTopol (World-renown cardiologist, Editor-in-Chief of Medscape, author of The Creative Destruction of Medicine):
Relative to Pres Bush, here are the @ACCinTouch recommendations against stress testing http://www.cardiosource.org/News-Media/Publications/Cardiology-Magazine/choosing-wisely.aspx
Larry Husten @cardiobrief (Forbes medical journalist):
Was Bush offered optimal medical therapy? Did he undergo ad-hoc stenting? http://www.forbes.com/sites/larryhusten/2013/08/06/questions-about-president-george-w-bushs-stent/
David Filmore @DaveFilmore (Exec Editor of The Gray Sheet & The Silver Sheet):
Bush Doctrine supports preemptive strikes
And there are hundreds (by now thousands) more. The questions are important because when a high profile individual, such as a former President, gets a medical procedure done, it becomes a kind of popular guideline for “best practices.” And in the past few years, the questions around “unnecessary stenting” have been the subject of numerous articles in both the lay media as well as professional journals.
Are annual stress tests a good idea?
As Dr. Eric Topol points out in his tweet, the American College of Cardiology specifically recommends against the annual use of the kinds of tests done for Bush — in patients with no symptoms, that is. So did President Bush have symptoms? One would think that after a 100 km bike ride, such symptoms would show up. Did they? We’re not being given those types of details. And it’s debatable as to whether an exercise stress test alone can predict an adverse event. I think back to Tim Russert (who interviewed Bush several times) — he had a stress test, which was negative, and died of a massive heart attack only a few months later.
Was a CT angiogram necessary?
This test is not currently covered by Medicare or most insurance providers for this indication, mainly because it’s considered one of those “over-used unnecessary tests.” We at Angioplasty.Org have written extensively about CT angiograms, because they are in fact very useful, when performed in the correct circumstances. If the stress test shows irregularities, then a CT angiogram, which is non-invasive and takes only minutes to perform, can be used to rule out coronary blockages in 98% of cases, saving those patients from having an invasive cardiac catheterization to find out the same information (37% of caths show no disease). However, in Bush’s case, a blockage was revealed on the CT, so a stent was recommended.
Was a stent necessary?
Or could Bush’s coronary artery disease have been managed with optimal medical therapy. This is a debate that has raged since the COURAGE trial showed that patients with stable angina did as well on medical therapy as they did with angioplasty and stenting. Or perhaps, President Bush’s angina was not stable. We don’t know. Was Fractional Flow Reserve (FFR) used during his diagnostic angiogram to measure whether or not the blockage was “ischemia-producing?” We don’t know.
PCI (stents and angioplasty) is recommended for symptom relief in stable patients, when medications don’t solve the problem. If the blockage is severe and potentially life-threatening (unstable angina, infarction, etc.) then a stent can be a life-saver. For example, President Bill Clinton had two stents placed a few years back because his bypass grafts had closed up. Suddenly feeling quite poorly, he went to see his cardiologist who immediately took him to the cath lab. This was not a stable, “annual physical” type situation, but an urgent revascularization.
Was Dave Filmore correct when he called Bush’s procedure a “preemptive strike?” We shall see….
Meanwhile I’ll be reporting more on this issue in the near future because, no doubt, more information will be coming out…hopefully. And once again, the debate over the role of medical procedures such as PCI has been rekindled.
And, of course, for extensive information on angioplasty, stents and more, visit Angioplasty.Org.