The recent medical treatment of former US President George W. Bush has received huge media attention. More interestingly it has raised a debate among cardiologists and medical professionals on how to treat asymptomatic coronary heart disease.
All the frenzy made me recall the famous words of US Secretary of Defense, Donald Rumsfeld who served under president George W. Bush between 2001 and 2006:
There are known knowns; there are things we know that we know.
There are known unknowns; that is to say, there are things that we know we don’t know.
But there are also unknown unknowns – there are things we do not know we don’t know.
The known knowns – What we know that we know about the treatment of Mr. Bush
According to press releases, former US President George W Bush received a stent at Texas Health Presbyterian Hospital in Dallas on August 6, 2013 after a blockage was discovered in a coronary artery during a routine physical examination. The blockage was found during his annual physical exam Monday at the Cooper Clinic in Dallas. After the blockage was uncovered, Bush agreed to receive a stent at the cath labs of Presbyterian Hospital, where the procedure went smoothly and without complication.
A Bush spokesman has revealed that Bush had not had symptoms prior to the examination, “but the stent was necessary. His annual physical includes a stress test. EKG changes during the stress test prompted a CT angiogram which conformed a blockage that required opening”.
The coronary arteries supply blood to the heart muscle. If there is a narrowing or blockage of one of those arteries people often experience chest pain on exertion, commonly known as angina pectoris. A sudden blockage of a coronary artery, may cause damage to the heart muscle, a condition known as an acute myocardial infarction. However, a narrowing or blockage of a coronary artery sometimes causes no symptoms at all. This is commonly referred to as asymptomatic coronary artery disease.
The so-called COURAGE trial published in 2007 found that less costly medical therapy averted heart attacks, hospitalizations and deaths just as well as stents in patients with stable coronary artery disease. According to the press releases, Bush’s coronary disease was defined as stable. So, why wasn’t he given medical therapy which has been proven just as effective as a stent, and is much cheaper?
“This is really American medicine at its worst,” said Steven Nissen, head of cardiology at the Cleveland in Ohio, in a telephone interview. “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.”
Nissen said that routine stress testing in patients without symptoms can lead to procedures that are not indicated. He added that Bush likely “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. This is American medicine at its worst.”
“Stents are lifesaving when patients are in the midst of a heart attack, said Chet Rihal, an interventional cardiologist at the Mayo Clinic in Rochester, Minnesota, who has studied use of the devices. They allow immediate and sustained blood flow that help a patient recover, he said.
For those who aren’t suffering a heart attack, the benefits are less clear, according to Rihal. While stents may be used in patients with clear chest pain, there’s no evidence that they prevent future heart attacks, he said.
So the message from the media and the cardiology community is quite clear; Former president Bush had a VIP treatment. As far as we know, unnecessary stenting may have been performed. According to current medical knowledge and clinical guidelines, he would have done as well with much cheaper medical treatment. Some might call this bad medical practice.
The known unknowns – What we know we don’t know about the treatment of Mr. Bush
The treatment of former President Bush takes on a different perspective when we realize that we know what we don’t know about his treatment.
We know for example that we don’t know about the extent of his coronary artery disease. It is quite possible that Mr. Bush had a severe narrowing of the proximal left anterior descending artery which supplies blood to a large part of the heart muscle. In that case it would have been very appropriate to insert a stent into the artery. To not treat a severe narrowing of the upper part of this artery would not be considered good clinical practice.
So why all the media fuzz about Bush being given inappropriate treatment when we don’t have the necessary information. The curtains are closed, we don’t know the details. We even know what we don’t know.
Jumping to conclusion with limited information, and not realizing that we know what we don’t know may be called bad journalism.
The unknown unknowns – What we do not know we don’t know about the treatment of Mr. Bush
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