Just How Bad Was It?

Dick Cheney's heart condition has been the subject of speculation and controversy from the moment George W. Bush picked him as his running mate. Cheney had suffered three heart attacks in 10 years, his first at age 37, and in 1988 underwent quadruple-bypass surgery to relieve blockages in his coronary arteries. From a medical perspective, the news last week that he had suffered a fourth heart attack wasn't all that surprising.

Indeed, Cheney is so attuned to the vagaries of his heart that when he was awakened last Wednesday around 3:30 a.m. by a discomfort in his chest, he realized at once that he couldn't dismiss it as simple indigestion. It wasn't intense pain, Cheney told the press two days later. But, he said, "it lasted long enough, it was steady enough, it didn't change when I breathed deeply or moved around" that he decided--correctly--to have it checked without delay. (See this week's Personal Time: Your Health.)

Cheney arrived at George Washington University Medical Center at 4:30 a.m., and shortly afterward, doctors performed an electrocardiogram and a blood test. The ECG, which looks at how well the heart is beating, showed no change from Cheney's previous ECGs. The blood test, which measures the presence of special enzymes released by the heart during a heart attack, showed no evidence yet of any damage. But doctors know it often takes several hours for cardiac enzymes to show up in the blood after a heart attack, so follow-up tests were ordered.

After a second ECG at 7 a.m. revealed minor abnormalities, Cheney's doctors decided to take a closer look at his coronary arteries. A dye was injected into his blood vessels and an X ray delivered the bad news: a branch of Cheney's left descending artery--one of the three main arteries in the heart--was about 90% blocked.

The next step was to thread a tiny surgical balloon and a thin stainless-steel stent into the artery to forcibly widen the passage. After the balloon was deflated, the metal mesh of the stent was left in place to keep the artery open. During this procedure the results from Cheney's second blood test became available. It showed a slight increase in the cardiac enzymes, indicating that Cheney had suffered a mild heart attack after all.

Based on everything that's known so far, it seems Cheney is in pretty good shape for someone who has had four heart attacks; there is no reason to think he wouldn't be able to serve one or even two terms. Over the long haul, says Dr. Christopher Cannon of the Brigham and Women's Hospital in Boston, the goal should be to prevent future episodes through more aggressive lowering of cholesterol and treatment with more anticlotting agents. But it's hard to know how much more Cheney's doctors can do, since basic questions about his treatment have not been answered.

Despite repeated requests for information, his doctors have declined to say much about the four bypass grafts that were stitched into Cheney's heart 12 years ago. Typically, such grafts last 15 years or so before they have to be replaced. Cardiologists trying to read between the lines of the press releases assume his grafts must be holding up, because the stent was not placed in a bypassed artery.

Cheney's cholesterol level has never been disclosed; doctors have said only that it is being treated. His estimated 40% "ejection fraction," a measure of how efficiently his heart is pumping blood, suggests that Cheney's heart is "moderately impaired," according to Dr. Roger Blumenthal of Johns Hopkins Hospital in Baltimore, Md., and it places him at somewhat higher risk for another heart attack.

But, Blumenthal is careful to add, it doesn't preordain another heart attack. "He should look at this episode as a wake-up call," Blumenthal says. Losing weight, eating right, keeping his blood pressure low and exercising more are all steps that should help. Most doctors also advise heart patients to minimize stress, but stress is one thing Cheney will have a hard time avoiding--at least for the time being.

--By Christine Gorman. Reported by Alice Park/New York