Stents, Precedents, and Presidents


August 16, 2013

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The title is "Stents, Precedents, and Presidents," and what we are talking about are 2 presidents who underwent cardiovascular intervention.

Let's Go Back to 2004

It's Labor Day weekend, and former President Bill Clinton has presented with unstable angina to a hospital in Westchester and is being transferred to Manhattan to undergo bypass surgery at Columbia. In fact he could have undergone multivessel stenting, which might have been highly effective and preempted a lot of the complications that he had subsequent to the bypass surgery. [Multivessel stenting] could have been done more quickly than waiting for the clopidogrel effect to wear off [before being able to undergo bypass surgery]. Nonetheless he didn't have that -- water under the bridge, so to speak, but interesting to discuss.

More Recently

Former President George W. Bush presented -- reportedly he was asymptomatic -- for his annual physical exam workup at Cooper Clinic in Dallas, Texas. We know he has had that [exam] every year for a number of years, including as the sitting President. This time he had an abnormal stress test, and that led to a CT angiogram, which -- because both of those were abnormal -- led to a transfer to a hospital where he could have a stent placement.

We don't know all the details, and it is not right to second-guess, but there are a lot of instructive points in this case.

Three Comments

First of all, the Cochrane analysis of all the studies relating to annual physical exams has shown that they induce net harm.[1] Randomized studies show that incidental findings lead to net harm of patients and shouldn't be done. We shouldn't be doing annual physicals. That is the general guideline.

Second, the American College of Cardiology, through the [ABIM Foundation's] Choosing Wisely® campaign, has placed stress testing for asymptomatic individuals on the "no go" list.[2]

Third, the former President underwent CT angiography, which would not be conventional for someone with an abnormal stress test. Why not just do an angiogram? Or do a gene expression test. Or various other options. Why expose the patient to a lot of radiation despite more recent efforts to reduce radiation burden (which is substantial)?

Maybe the President had some symptoms, troublesome atypical issues when he was doing 100-mile bicycle rides or his daily rigorous exercise routine. We don't know. Maybe the purpose of doing the screening each year -- and the stress testing -- is because this is individualized care for someone who is so physically active.

Standard of Care

The point being that this is a departure from the standard of care. The precedent in a president is different from what is being advocated for all other people. In this egalitarian world, perhaps we should be thinking of treating someone as an individual. And there is a good rationale for this. We just don't know that for President Bush.

This is an intriguing example. The President is in a fish bowl. Everybody is wondering what would be the best care. But also, the best care "in general" is not the same care for all people. And so there could be rationale [for his treatment].

Perhaps we will find out more about why stenting was performed on President Bush, why there was a CT and an angiogram, why there was a stress test. We may not know any more, but we can learn from this.

I will be very interested in your comments. I have already seen some when the news first broke, with various articles such as the Washington Post opinion piece.[3] I will be looking forward to further thoughts on this important matter. Thank you.


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