George W. Bush’s Recent Stent Surgery—Two Perspectives

Last week, when former President George W. Bush underwent stent surgery, the procedure was declared a great success.  What is surprising is that not everyone in the mainstream media applauded.  

From Bloomberg News “Former President George W. Bush’s decision to allow doctors to use a stent to clear a blocked heart artery, performed absent symptoms, is reviving a national debate on the best way to treat early cardiac concerns.

“The discussions have been ongoing since 2007, when the trial known as Courage first found that less costly drug therapy averted heart attacks, hospitalizations and deaths just as well as stents in patients with chest pain. The results were confirmed two years later in a second large trial.

“The debate has centered on both the cost of stenting, which can run as high as $50,000 at some hospitals, and its side effects, which can include excess bleeding, blood clots and, rarely, death. Opponents say the overuse of procedures like stenting for unproven benefit has helped keep U.S. medical care on pace to surpass $3.1 trillion next year, according to the U.S. Centers for Medicare and Medicaid Services.

“’This is really American medicine at its worst,’” said Steven Nissen, head of cardiology at the Cleveland Clinic in Ohio  . . .  ‘It’s one of the reasons we spend so much on health care and we don’t get a lot for it. In this circumstance, the stent doesn’t prolong life, it doesn’t prevent heart attacks and it’s hard to make a patient who has no symptoms feel better’” . . .

“’Stents are lifesaving when patients are in the midst of a heart attack’ added Chet Rihal, an interventional cardiologist at the Mayo Clinic in Rochester, Minnesota . . . ‘They allow immediate and sustained blood flow that help a patient recover. For those who aren’t suffering a heart attack, the benefits are less clear   . . . While stents may be used in patients with clear chest pain, there’s no evidence that they prevent future heart attacks.’  A review of eight studies published last year in JAMA Internal Medicine also found no differences.

“Two large-scale clinical trials completed within the last seven years have shown that drug therapy works just as well as stents in preventing cardiac complications. (The three major U.S. heart associations changed their guidelines in 2011 in an effort to reduce excess treatment.  )

[This is important. The major U.S. heart associations have absolutely no vested interest in recommending fewer procedures. When they say “Do Less,” everyone should listen–mm. ]

 

“In Bush’s case,” Freddy Ford, the former president’s spokesman told Bloomberg, ‘he underwent the procedure without any symptoms after a stress test during his annual physical turned up signs of an electrical abnormality on an EKG . . . 

“Paul Chan, an associate professor at the Mid-America Heart Institute in Kansas City, Missouri, questioned why Bush would have undergone a stress test at all if he didn’t have symptoms. While it’s fairly common practice for doctors to put older patients through such tests even without chest pain, Chan said, there’s no evidence showing it’s beneficial. . ..

“The reality is that we don’t know if we can change the trajectory of disease in people who don’t have symptoms, are doing fine and are physically active  . . . There’s no evidence treatment will help them live longer, feel better, or have fewer heart attacks.”

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The Dallas Morning News had a very different take on Bush’s operation. 

From the Dallas Morning News: “Former President George W. Bush’s unexpected surgery Tuesday to clear artery blockage in his heart served as a reminder that even the fittest and most health-conscious must be watchful of cardiovascular disease.

[Translation: Even if you’re fit and healthy, you should worry. You may need surgery tomorrow.]

The Dallas paper continued: “Doctors discovered on Monday the blocked artery during Bush’s annual physical examination at the Cooper Clinic in Dallas. The famously fit 67-year-old then had a stent implanted in his heart Tuesday at Texas Health Presbyterian Hospital.

 “The health scare. . . came as a surprise, given that Bush is an exercise fanatic who showed no outward symptoms of distress. . . .

  “About 600,000 Americans die each year from heart disease, according to the Centers for Disease Control and Prevention . . . many people, like Bush, show none of the common symptoms, such as tightness in the chest and shortness of breath.

“The blockage typically builds up slowly over many years, causing heart disease to sometimes become a silent killer. Experts said that highlights the need for those with risk factors to get periodic screenings.

’It’s very important for the public to understand that it’s not necessarily pain,’ [that signals a need for stenting] said Dr. Gaurav Gupta, an interventional cardiologist at Methodist Dallas Medical Center.”

[In other words, you shouldn’t wait for “symptoms” before scheduling surgery.

Forget about ‘listening” to your body.  The folks who run the testing facilities will tell you what you need to do.  Just go for the screenings—as often as possible–and they’ll let you know when you should sign up for the procedure.]

The Dallas Morning News concludes:

 “Hundreds of thousands of Americans receive stents each year. And the relatively simple procedure can have a lasting impact: experts said that fewer than 10 percent of patients with stents see re-blockage in the first year.

[Great. What happens to that 10 percent? And what happens after the first year?]

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 The Dallas Morning News story is based on the notion that more care is always better care. This late twentieth-century view of medicine assumes that you can never be too careful. Even if you feel healthy, you should go for screening. Your doctor may be able to find something. 

TIME, like the  Dallas Morning News (and many other publications) stuck with the traditional script, hailing the procedure as one of the mircales of modern medicine:

“Doctors discovered the blockage during Bush’s routine physical, and recommended a stent to keep the artery open.

“That advice has become increasingly popular in recent years to treat chest pain and angina, thanks to advances in stent technology and the fact that the hour-long procedure is less invasive than bypass surgery . . .  the devices are also being recommended in more patients like Bush, who show early signs of heart blockages . . . “:  

                                     A Changing Medical Culture?

 By contrast, Bloomberg expressed a growing awareness that over-testing may lead to over-diagnosis—and over-treatment. (For background on how stenting has been overused in recent years, see this HealthBeat post 

 Health care reform aims is to squeeze some of the waste out of our health care system by reducing overtreatment. But that will require a change in our  medical culture: both physicians and patients must begin to realize that, as California governor Jerry Brown tried to tell us back in 1974: “Less is more.”

For years, Americans  have resisted this idea. Until very recently we tended to think that “Plenty” is never enough. Whether we were talking about the size of a restaurant meal, a McMansion or a car, “More” was always better

But in the past decade attitudes have been changing –and nowhere is this cultural change more important than in medicine.   

Five years ago, if a former president underwent heart surgery that appeared successful, I very much doubt that we would have read anything like the Bloomberg story in the mainstream media.

But today, more and more doctors have been speaking out about the excesses. And some in the media are printing their objections. Regarding Bush’s operation, USA Today quoted Nissen, saying that “Bush ‘got the classical thing that happens to VIP patients, when they get so-called executive physicals and they get a lot of tests that aren’t indicated.’”

Meanwhile CNN reported that a 2006 medical examination revealed that Bush had no signs of hypertension or other modifiable risk factors and that he had a “low” to “very low” coronary artery disease risk profile.

This reflects a critical change in how some reporters cover medical care. Healthcare reform is beginning to open minds.  Rather than simply interviewing the doctors who treated former president Bush, the Bloomberg reporter sought second opinions from leading medical experts. Not only that, he assumed that his readers would be interested in what skeptics had to say. (Ten years ago, I can imagine an editor saying: “Our readers don’t want to hear this.”)

16 thoughts on “George W. Bush’s Recent Stent Surgery—Two Perspectives

  1. The next logical step would be to redo the stress test which showed the “electrical abnormality” to see whether it is still present, and to report the result.

    • Edward–

      Thanks for commenting.

      Or just don’t do a stress test on an asymptomatic patient in the first place?

      Some months ago, my husband refused a stress test (along with 3 hours of other cardiac testing.)

      He has no symptoms–no angina, no history of heart disease.

      He later learned that his doctor owned the testing facility.

      This is the sort of thing that worries me.

      People with symptoms should be tested—but asymptomatic patients? All tests carry risks. . .

  2. “The health scare. . . came as a surprise, given that Bush is an exercise fanatic who showed no outward symptoms of distress. . . . ”

    That was me pretty much. My Elk Hound and I would be out walking the hills of upstate New York of the dirt roads of Michigan. I would be kayaking the Finger Lakes or the Michigan water ways. I was a runner too. I kept my diet reasonable and ate the fruits, dietary fiber, fish, etc. My cholesterol was good and LDLs minimal.

    This operation came as much of a surprise to others as it did to me. Occasionally, I would still get a mild pain where the incisions were made for the bi-passes. The same and low caliber pain I had when I drove myself to the ER. It came when I was working a little harder than normal in Cardiac Rehab. Back for another stress test and it came on again. Another catheterization or walk-about to look around. No stents as he felt they would not add a day to my life. I just need time to let my heart repair itself and get stronger.

    My heart attack in the beginning was so mild, I thought it was the onset of a cold.

    • run–

      I’m glad they didn’t use stents. They can lead to problems down the road . . .

  3. Maggie,
    I am shocked….shocked that the ‘free market’ could do such a thing ;^)
    I’m not sure of the best solution to ‘accommodate’ people who want/are offered this kind of care. Perhaps an alternate, private insurance segment, vs upgraded, non-fee-for-service Medicare for those of us (any age) who would prefer to not step into the rarefied territory of well-promoted quackery (such as performing stress tests and stenting on asymptomatic people).
    There is a systemic solution: Medicare-for-all, alongside private insurance (such as in Australia, UK, Norway, Sweden, Israel, New Zealand, Canada) as an alternate option. Everyone is free to choose, but universal care is a constant availability.

    Ruth

    • Ruth–

      In a way we already have healthcare for the rich– concierge medicine, provided by doctors who don’t take insurance.
      People pay out of pocket for the services. If they want full body scans, stress tests and stenting (even though there are no symptoms to justify the procedure) they can have it. But the rest of us aren’t paying for it.

  4. Most of the writing and commentary on this topic is idiotic and done by people who have not a shred of clinical insight. No one writing here or elsewhere has any clue as to: the magnitude of the electrical changes; whether he has serious symptoms during the test; and, which artery was blocked or the % blocked. In the real world, where actual clinicians interpret these signs and symptoms (yes, those are two different things), the decision making is far more complex than allows for Monday morning quarterbacking.

    As for people who point to the President’s fitness habits and suppose that they should have provided some kind of blanket immunity, your stupidity is showing, not his. Everything done in pursuit of health is simply a hedging of bets. Even someone with ideal cardiovascular health has an 80% lower risk of mortality in a given period that someone who has none of the 7 habits that comprise it. It is likely the case that without his diligent pursuit of fitness, Mr. Bush may have had earlier or more severe symptoms leading to disability or early death.

    • Vik–

      Apparently you think that Dr. Steve Nissen, head of the cardiovascular dept. at the Cleveland Clinic and other physicians Bloomberg quotes have “not a shred of clinical insight.”

      I’m curious about your credentials.

      Also it’s worth noting, as Nissen points out, “Stress tests often leads to procedures that are not indicated. “Procedures such as a stent are only useful in people who have symptoms. If you do a stress test in somebody who doesn’t have symptoms, it doesn’t lead to a benefit.”

      Bush’s spokesperson says that he was not experiencing symptoms.

      “In people who are not having symptoms, the American Heart Association says you should not do a stress test.” http://www.boston.com/lifestyle/health/blogs/daily-dose/2013/08/12/was-george-bush-stent-surgery-really-unnecessary/DzklhNCGVlgriNxgpKZtuO/blog.html

      Presumably, the AHA doesn’t know what it is talking about.

      20 years ago, stress tests were routine. Today, they are not. Every test carries risks.

      Without seeing Bush’s medical records, it’s impossible to know with certainty that the stent procedure was unnecessary.
      But since so many doctors have questioned it, I’m surprised that the doctors who performed the procedure have not come forward to reveal exactly why they thought it was necessary.

      But the consensus is that stenting is over-used, and that too many doctors and patients view it as a “quick fix”

      A couple of days ago, the NYT offered a good summary of current thinking:

      But far too often, studies show, stents continue to be implanted in patients who stand to gain little if any benefit. Last month, two of the country’s largest medical organizations identified the procedure commonly used to place a stent — called a percutaneous coronary intervention, or angioplasty — as one of five highly overused medical interventions.

      Their report focused only on elective procedures performed on patients with stable coronary artery disease, a type that can cause chest pain and other symptoms during physical exertion but generally not at other times. Studies show that in these particular patients, inserting a stent is generally no better at preventing a heart attack or an early death than taking medication alone.

      And yet many patients continue to undergo such procedures, even when there is the prospect of harm and the unlikelihood of benefit. The two groups that issued the report, the American Medical Association and the Joint Commission, said that roughly 1 in 10 elective angioplasty procedures performed nationwide may be “inappropriate,” and another third questionable. The operation typically costs around $30,000, and in rare circumstances it can cause tears in blood vessel walls, major bleeding and other problems.

      “Major complications are not very common,” said a member of the panel that issued the report, Dr. Stephen D. Persell of the Northwestern University Feinberg School of Medicine. “But when it does occur, it can be catastrophic.”

      One recent recipient of a coronary stent was former President George W. Bush. Few facts are known about his case, but a spokesman said Mr. Bush had a stent inserted at a Dallas hospital last week after a blockage was discovered during his annual physical.

      In some cases, experts say, doctors are motivated to use stents for financial reasons, because of the large revenue streams that stent procedures can bring hospitals. But some experts say that part of the problem is simply that many patients, and even some doctors, incorrectly regard coronary artery disease as a plumbing problem.

      According to this view of the disease, cholesterol is slowly deposited in an artery wall, creating a lesion that grows and clogs the artery like a pipe, eventually rupturing and causing a heart attack. In theory, propping the artery open with a mesh stent where this stenosis, or narrowing, occurs should reduce the likelihood of a heart attack.

      But plaque does not work that way, and the plumbing analogy does not account for crucial factors like inflammation, said Dr Michael B. Rothberg, the vice chair for research in the medicine institute at the Cleveland Clinic. Researchers have found that most ruptures occur at lesions that appear otherwise mild, in some cases so small that they do not limit blood flow and may be invisible to cardiologists, he said. Vulnerable plaques often cannot be identified or stented before they rupture and lead to blood clotting – a thrombus – that completely obstructs an artery.

      Dr. Rothberg recently published a report that described what he called two of the leading myths about coronary artery disease. One is that dietary fat creates plaque and clogs arteries. In fact, studies show that diets that include fats like the monounsaturated and polyunsaturated kinds found in nuts and olive oil can protect against heart disease. The other widespread misconception about coronary artery disease, Dr. Rothberg said, is that narrowed arteries are the problem.

      “If you have a clogged sink, you call a plumber and he cleans out your sink and it’s fixed; that’s the analogy people have in their minds,” he said. “But that’s not how angioplasty works. They’re not cleaning out the whole pipe. They’re just going to this one small area where there’s a stenosis. But the rest of the artery could be full of inflammation and other plaques.”

      For some doctors who see an isolated narrowing or blockage on an angiogram, it can be hard to resist the urge to fix it, a phenomenon medical journals call the “oculostenotic reflex,” said Dr. Grace A. Lin, an associate professor of medicine and health policy at the University of California San Francisco School of Medicine.

      In a study published in The Archives of Internal Medicine, Dr. Lin found that some doctors performed elective angioplasty procedures because they believed it would alleviate a patient’s anxiety. Others felt that new and better stents would make a difference, or they worried they would feel guilt if they did not operate and a patient had a heart attack down the line. But some simply could not accept the idea that opening a narrowed artery would not be helpful.

      “One of the beliefs among primary care physicians and cardiologists is that if you see a blockage and you open it, it must help in some way even if the data suggest otherwise,” said Dr. Lin. “If you’re thinking of the arteries as plumbing and you see a narrowing, then your response is to try to open it.”

      Dr. Rothberg said that patients with stable disease who are told they have a blockage naturally assume that angioplasty must be lifesaving, unless their doctor explains to them otherwise.

  5. At the start of a recent annual physical at my local hospital-owned primary care practice, I told the physician’s assistant that I didn’t want an EKG to be part of this exam. I explained that in the Choosing Wisely program, the American Academy of Family Physicians says an annual EKG or any other cardiac screening as likely to be more harmful than beneficial in an asymptomatic, low-risk patient. I’m a 61-year-old male whose 10-year risk of a heart attack per the Framingham risk assessment method is 6%. The PA didn’t argue but said she needed to ascertain that they had a “baseline EKG” on file in case I ever had symptoms and needed an EKG (not that the US Preventive Services Task Force reports underlying the AAFP recommendation support that practice, either). Since they had previous EKG results on file, there was no further discussion. However, the printed summary of the visit said, “Patient refuses EKG today.” Well, yes he did, but he thought he had a good reason. Further, if the practice endorsed the Choosing Wisely program, there would have been no reason for them to insert such a note into my record. I look forward to declining the EKG again next year, assuming I even keep the appointment for the annual physical.

    • Jack-

      Good for you! (and thanks for commenting).

      And good for the American Academy of Family Physicians. When it comes to being patient-centered, they are one of the very best physicians’ associations. If only more patients were aware of their “Choosing Wisely” program.

      I should write about it.

      You end your comment saying “assuming I even keep the appointment for the annual physical.”

      There is actually quite a bit of research showing that an annual physical does no good unless you go in to tell your
      doctor about specific symptoms.

      In that case you don’t need a “physical per se” (a battery of tests, etc.) — you need doctor who will listen carefully while you explain the how, where and when of your symptoms, and then decide what tests he may need to do to try to pinpoint the cause.

      At the same time, there is a good argument to made for touching base with your family doctor once a year–just to tell him how you are doing. One of my favorite doctor/readers says that good PCP’s ask two questions: “How is everything at work?”
      and “How is everything at home?”

      Sometimes, the answers that come in response to those questions alert the doctor to problems . The patient extremely stressed at work, and hate your boss. A doctor might well counsel you to try to change jobs and even suggest you see a counselor who specializes in helping people make job moves). Or, you and your wife and fighting, and she’s drinking too much (your PCP would probably recommend that you might need marriage counseling, and that your wife definitely needs to talk to a doctor about her drinking (he might well recommend someone who is very good in this area) –or consider joining AA.

      If you have a doctor (or a PA or a NP) you like and trust, to me these are good reasons to see him or her every year.

      But it’s not at all clear that most of us need expensive “physicals”. It’s just a ritual left over from 20th century medicine.

    • Jack, that “Patient refuses EKG” is doctor speak for, “if he has a heart attack tomorrow, it’s not my fault.” The PA wasn’t trying to be a jerk. He was CHA.

      • Panacea–

        I agree– the PA wanted to document that he had refused an EKG in case he had a heart attack and someone asked “Why didn’t he have an EKG at his last regular appointment.”

  6. A lot of this unwarranted inteventional medicine comes from defensive medicine by primary care physicians, who fear not getting consultation will leave them at risk. Once we send patients to a specialist who makes everyone happy by offering to perform a highly profitable series of tests and procedures to reassure our patient that they are OK or find yet more interventions they can profitably do we have failed our patients from the start.

    • Dr. Pullen–

      Thanks for your comment.

      I totally agree– PCP’s who just pass patients off to specialists are failing their patients.

      If a patient is worried–and insistent that he get a referral–perhaps you could refer him to a specialist who you know is conservative?
      (There are some out there.)

  7. Nice Information !! known as Courage first found that less costly drug therapy averted heart attacks, hospitalizations and deaths just as well as stents in patients with chest pain. It doesn’t prevent heart attacks and it’s hard to make a patient who has no symptoms feel better.