Heart Trouble

08.06.13

George Bush Gets a Heart Stent—and a Close Brush With Our Broken Health-Care System

The 67-year-old former president had a heart stent placed this week. Dr. Kent Sepkowitz explains the procedure—and why the whole affair exposes what’s wrong with the politics of medicine.

He may be one of only 43 men to have served as president, but George W. Bush yesterday joined 500,000 other Americans  by having a coronary artery stent placed.

As a 67-year-old man known for jogging and biking—as commander in chief, he famously exercised six days a week—as well as the son of a skinny, ageless father, the development is something of a surprise. But then, alas 67 is 67. And further alas, W.’s latest foray into the world of American medicine has landed him in the awkward position of illuminating everything that’s wrong with his party’s position on health care.

The procedure W. received is one of three main treatments, along with medication or coronary artery bypass graft (CABG), used to manage coronary artery disease. Coronary artery disease, or “hardening of the arteries,” is the cause of most heart disease, including heart attacks and heart failure. The stent procedure involves threading a drug-coated mesh into a coronary artery; there, a long, thin balloon is expanded against the narrowed coronary artery wall and the stent is left in place to continue to pry open the artery.

The main danger of a stent is that clots may form within it, provoked by the body’s inflammatory response to the presence of this new piece of foreign material. To suppress the inflammation, drug-eluting stents are now used; these are much more effective than the bare metal stents from a decade or two ago. The drug embedded in the stent may be one of a few different classes—either an immunosuppressive (also used in transplants to prevent organ rejection) or a cancer chemotherapy agent that has a similar impact, namely to calm down the body’s immune response at a microscopic level and prevent the series of events that can lead to clotting. 

From available reports, the former president was seeing his doctor for a routine check-up when the “problem” was noted and soon after addressed. However, assuming that what we have been told by his press office is accurate (never a safe assumption), the procedure the 43rd president received is not really indicated for the condition he has, which is to say none at all.

The drug-eluting coronary stent has been well demonstrated to help those with more severe and symptomatic coronary disease—though it may be less effective than the more dramatic and painful procedure, the CABG. But no study has concluded that drug-eluting stents are indicated for a patient such as Bush 43, who we are told had no symptoms of severe coronary disease. "In medicine, we apply therapies to patients for two reasons,“ notes Dr. Robert Minutello, a cardiologist and expert at stent placement who is an associate professor at Weill Cornell Medical College. “To make them feel better or live longer." If indeed the ex-president had no symptoms, he could have no improvement; and no study has shown mortality benefit for the drug-eluting stent outside of those with more severe coronary disease. 

What do you know—minding his own business, staying busy in Dallas, W has stepped into some of what his father might have called deep doo-doo. He now finds himself stationed in the battlefield of America’s rip-roaring health-care debate about who should get what. Study after study has shown that America spends the most for health care and still finishes a dismal 15th or worse in most health indicators. Ever the leader, W (and Warren Buffett and countless others) now shows us why. In addition to the skimming off the top created by our byzantine system of payment and repayment, which is a topic for another day, we have costly health care because we treat countless people who reside in the gray zone of clinical uncertainty. They have early prostate cancer, early coronary disease, early breast cancer, early this and early that. We don’t know if they need treatment or not—but we can’t stand to do nothing. Waiting is for wimps. So we treat.

Our ability to detect disease has sprinted far past our ability to manage it, and the trend shows no signs of letting up.

The problem extends to the vocabulary of illness as well, where radioactive terms have conferred fear and loathing to conditions that actually aren't so bad. Our ability to detect disease has sprinted far past our ability to manage it, and the trend shows no signs of letting up.   

But it gets worse: it turns out the only way to better health, even for swank ex-presidents, is to illuminate the shady areas with research. Which costs money. Taxpayer dollars. Taxpayer dollars that the unconscionable sequester is now withholding to the tune of 5 percent of the National Institutes of Health budget, or $1.55 billion.

W and his aging ilk soon may find that all those sequestered dollars actually are used to help doctors study a problem, not to those vaguely assigned “bureaucrats” who want to make you fill out a form. With fewer dollars, there will be fewer people studying fewer problems—and just maybe no one will be around to help with a study that addresses the next health problem of a former president.

But actually it gets even worse yet. Bush 43 won't necessarily need a million-dollar heart transplant like his old sidekick Dick Cheney or even a $200,000 left ventricular assist device (which Cheney also had, pre-transplant), but he now is officially a health-care consumer like so many other 67-year-olds. 

And the health-care system that will care for him has been developed not by private companies, though they have contributed greatly to it. Rather, Medicare and Medicaid provide the support of the medical schools and the hospitals in urban areas and the salaried doctors and nurses and health professionals—Medicaid dollars Bush’s governor, Rick Perry, has opted to refuse as a way to demonstrate his manliness for a potential 2016 presidential run.

The organized and thoughtful health-care system that moved George W from a doctor’s office in Dallas to a catheterization table somewhere was built by tax dollars. And, unless they are slowed, the near-sighted, panic-stricken, anti-tax ranters of his party will cripple a true life-saver: the American health-care system.