Clinton - Atherosclerosis can be relentless

From: Dr. Jai Maharaj (usenet_at_mantra.com)
Date: 09/06/04 

Date: Mon, 06 Sep 2004 21:30:44 GMT

Clinton - Atherosclerosis can be relentless

Forwarded message from fidyl@yahoo.com

[ Date: Mon, 6 Sep 2004
[ From: fidyl@yahoo.com
[ Subject: Clinton/ Atherosclerosis can be relentless

Clinton Operation Aims to Restore Blood Flow

By Lawrence K. Altman
September 4, 2004

http://www.nytimes.com/2004/09/04/national/04heart.html

The major heart operation that former President Bill
Clinton is to undergo early next week restores blood flow
around blockages that prevent coronary arteries from
nourishing the heart, allowing the vast majority of
patients to lead normal lives.

In past interviews, Mr. Clinton said he has long been
concerned about developing heart disease because it runs
in his mother's family. But even people like Mr. Clinton
who exercise, adhere to healthy diets, take statin drugs
and get regular medical checkups may eventually need
surgery because the underlying disease - atherosclerosis
- can be relentless.

As Mr. Clinton's case illustrates, the need for such
surgery can come unexpectedly at any time. Although it
takes years for fatty deposits to build in the arteries,
chest pain can come on in an instant if a fatty deposit
ruptures and blocks the artery. The blockage can cause
the pains of angina, an insufficient supply of oxygen
rich blood to the heart, or a heart attack, destruction
of heart muscle.

Mr. Clinton and his doctors released no details about
what kind of surgery he will undergo or its timing. But
one doctor said that his heart function was normal and
that he had not suffered a heart attack.

But Mr. Clinton's doctors are recommending bypass rather
than an increasingly common procedure of inserting a
balloon to open a blocked artery and then a stent, a
mesh-like tube, to keep it open. This suggests that
either he is unlucky in having ill-placed blockages or
has extensive coronary artery disease.

In a coronary bypass operation, cardiac surgeons open the
chest. Though procedures vary according to different
factors, surgeons in many cases then isolate one or two
internal mammary arteries from beneath the breastbone and
connect the cut end to a point beyond the blockage in a
coronary artery. In addition, the surgeons may take a
vein or artery from elsewhere in the body, connect one
end to the aorta, the main artery emerging from the
heart, then connect the other end at a point beyond the
blocked coronary artery.

During the operation, surgeons may stop the heartbeat and
temporarily connect a patient to a heart-lung machine to
nourish the body. Studies have shown that some patients
can suffer some memory loss and other brain damage after
being on a heart-lung machine.

Cardiac surgeons describe the bypasses by the number of
coronary arteries that are detoured in this way. A friend
of Mr. Clinton who asked not to be identified said Mr.
Clinton said it would be "a triple or quadruple bypass."

These bypass connections restore blood flow but do not
cure the disease.

The best therapy is prevention, and Mr. Clinton had long
taken steps to avoid heart disease.

In an interview with this reporter in 1996, Mr. Clinton
said he had asked his doctors in Arkansas to perform
treadmill tests nearly every year - even when he was in
his 30's - because of a history of heart disease on his
mother's side.

Mr. Clinton said he "just wanted to know what kind of
health I was in" and "if any problems were developing."

Mr. Clinton has said that he tried to exercise before
going to bed but at times his duties as president did not
allow him to be as physically active as he would like.
Still, he performed very well on exercise treadmill
tests, reaching an impressive Stage 6 with a normal
electrocardiogram.

But at the time of his exit physical examination as
president in 2001, blood tests showed he was at increased
risk of heart disease. His cholesterol was 233, with a
low-density lipoprotein level, the so-called bad
cholesterol, of 177. That was considerably higher than
the 137 of the previous year's examination.

So White House physicians began prescribing a statin
drug, Zocor, to lower his cholesterol and other lipid
levels.

The news yesterday about Mr. Clinton's heart condition
surprised many people because he looked trim and well
when he spoke at the Democratic National Convention in
July and signed copies of his autobiography in recent
weeks. Indeed, Mr. Clinton was active until he
experienced mild chest pain and shortness of breath and
sought medical care at Northern Westchester Hospital on
Thursday afternoon, said Tammy Sun, a spokeswoman for
him. Initial testing was normal and he went home, only to
undergo additional testing yesterday morning at
Westchester Medical Center.

There, doctors advised him to undergo bypass surgery
after he underwent a procedure known as a coronary
angiogram. In it, doctors insert a thin tube into an
artery near the groin and thread it up to the coronary
arteries. Then doctors inject a dye to determine the
contour of the coronary arteries and the location of any
blockages.

If the blockages are small enough and easily reached
through the tube, doctors may insert a balloon to open
the artery and also insert stents, metal cylinders to
keep the vessel open. Use of stents has led to a decrease
in the number of coronary bypass operations.

But whether the stents can be inserted depends on a
number of factors like the number and extent of blockage
and whether they can be reached by the catheter. In
addition, bypass is usually recommended if there are
blockages in the left main coronary artery, a critical
region. If a stent is used there and the spot becomes
blocked again, which can occur, the patient can die.

Cardiologists not connected with Mr. Clinton's case said
in interviews yesterday that they presumed his doctors
rejected the possibility of using stents because of such
factors.

Dr. Robert O. Bonow, chief of cardiology at Northwestern
Medical School and a former President of the American
Heart Association, said it was common for patients
experiencing chest pain to come to a hospital and then be
sent home if initial testing does not show evidence of a
heart attack, with instructions to have further testing
in a day or so and to return sooner if the symptoms
recurred. Doctors also admit such patients to a coronary
care unit.

"A lot involved in the decision has to do with what a
patient wants to do," Dr. Bonow said.

Dr. Bonow also said that "unfortunately, it is not that
uncommon for individuals with good exercise performance''
to have a heart attack or need bypass surgery. Such a
patient could have significant undetected heart disease
or the disease could progress rapidly or in spurts, Dr.
Bonow said. "The rate of progression can be difficult to
predict and there are various ways it can play out," Dr.
Bonow said.

Mr. Clinton lost weight recently, at least 20 pounds,
which he credited to the South Beach diet, a popular low-
carbohydrate plan. Experts not involved in his care said
they doubted that the diet had any effect on his heart
problems.

"I think it's unlikely the diet would have had any major
impact on his developing the coronary artery disease,"
said Dr. Robert Robbins, director of the Stanford
Cardiovascular Institute in Palo Alto, Calif. "Obviously,
it's been developing over a period of many years and is
related to his genetic predisposition for coronary artery
disease and environmental factors such as his heavy
weight and his proclivity for McDonald's and junk food."

The South Beach plan would have been an improvement over
Mr. Clinton's well-known fondness for doughnuts and
hamburgers, Dr. Robbins said, but the diet may have come
too late.

"I think he was trying to do all the right things but his
past ways caught up with him," Dr. Robbins said. "But
some people have such a strong genetic predisposition
that no matter what they do they end up with pretty
severe coronary artery disease."

End of forwarded message from fidyl@yahoo.com

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