|"It's a testament to medical science that he's alive."|
|-- Boston cardiologist, 2004 1|
This page has a few extras:
Major cardiovascular episodes (year and month) Other cardiovascular factors: Other health matters:
- 1978 - Heart attack #1 (age 37)
- 1984 - Heart attack #2
- 1988-06 - Heart attack #3
- 1988-08 - Coronary bypass surgery
- 2000-11 - Heart attack #4
- 2000-11 - Coronary stent placed
- 2000-11 - Abnormal heart function
- 2001-03 - Unstable angina
- 2001-03 - Coronary angioplasty
- 2001-06 - Cardiac defibrillator implanted
- 2005-09 - Popliteal artery aneurysm repair
- 2006-01 - Congestive heart failure
- 2007-03 - Venous thrombosis
- 2007-11 - Atrial fibrillation
Vice President Cheney is a vasculopath with an almost 30-year history of coronary atherosclerosis. His history includes multiple myocardial infarctions, moderate (or possibly worse) left ventricular dysfunction, cardiac electrical instability, and presumed peripheral atherosclerotic disease. The extent of his extra-cardiac atherosclerosis is unknown. His medications are unknown. He smoked heavily from ages 17-37 and takes one or more hypocholesterolemic medications. The control of his cholesterol is excellent, but the control of his blood pressure is unknown. His weight is unknown. He lost 20-25 pounds in the 2000-2001 timeframe 2 3, but he is still appears overweight 1. It is unknown whether he has diabetes, glucose intolerance, or normal glucose tolerance.
A cardiologist in contact with the Vice President's cardiologist 4 has stated 5 that Cheney met the entry criteria of the MADIT I study 6. This implies a two year mortality rate of 15% (with defibrillator) to 30% (without defibrillator) 6.
Of greatest concern, the condition of the Vice President's cerebral vasculature is unknown. Small-vessel cerebral atherosclerosis could produce insidious, difficult-to-recognize degradation of mental faculties.
Cheney described the results of his final general-checkup in office (on July 12, 2008) as "all fine" 7.
Abnormal heart function
Before selecting Cheney as his running mate in July 2000, George W. Bush asked renowned cardiac surgeon Denton Cooley to review Cheney's records and talk with Cheney's cardiologist, Dr. Jonathan Reiner.Atherosclerosis
In a statement, Cooley gave a pseudo-positive report and quoted Reiner as saying that Cheney "is in good health with normal cardiac function" 8 9. ("Cardiac function" refers specifically to the vigor with which the main pumping chamber of the heart (the left ventricle) contracts.)
However, later the same day, Reiner broke his public silence on Cheney's health in order to "correct a mis-statement by Cooley" 9. Reiner disagreed with Cooley's description of Cheney's heart function as "normal," but declined to comment further 9.
It was intially thought Reiner was being a purist, applying a very strict standard of normality 9 10.
However, after Cheney's heart attack #4 in November 2000, it was disclosed that his left ventricular ejection fraction (LVEF) was 40%, consistent with a moderate degree of impaired heart function 11. A later statement suggests that his LVEF was 35% or lower when his AICD was implanted in July 2001 5. Normal LVEF is approximately 65%.
Thus, at a minimum, Cheney in 2000 had a condition known as "left ventricular dysfunction." If symptoms could be ascribed to the sub-normal function of his left ventricle, then he would have "heart failure" (commonly known as "congestive heart failure" in the past). Such symptoms include:
The status of all of these factors was unknown for the Vice President in 2000. It was reported in June 2001 that Cheney had "no evidence of heart failure" 3.
- exercise intolerance,
- shortness of breath,
- swelling of the ankles, and
- difficulty sleeping flat.
Authoritative guidelines 12 changed the definition of heart failure in 2005. Under this definition, Cheney's condition in 2000-2005 was "stage B heart failure."
Events in 2005 and 2006 have made it clear that Cheney has congestive heart failure as defined before 2005, and "stage C heart failure" as defined since then.
Atherosclerosis is a difficult-to-reverse process that narrows the arteries throught which blood flows. It is more than "hardening of the arteries." It involves the build-up of material inside blood vessels. This reduces blood flow downstream from the build-up. Atherosclerosis may occur anywhere in the body. Mr. Cheney's heart attacks were caused by atherosclerosis in the coronary arteries. The aneurysms behind his knees may have been caused by atherosclerosis in his popliteal arteries. His congestive heart failure indicates difficulties in kidney function (because normally functioning kidneys could dispose of extra fluid). Diminished kidney function could result from atherosclerosis in the renal arteries or from other cause(s). Whether Mr. Cheney has atherosclerosis in his brain is publicly unknown. A betting man would, however, say he does. Atherosclerosis is a systemic disease, and Mr. Cheney's first heart attack is evidence that he has had significant atherosclerosis since 1978. His subsequent heart attacks over the next 22 years indicate progession of atheroscerotic disease. Symptoms of atherosclerosis in the brain may be subtle. Atherosclerosis does not have a single cause. Many factors contribute to, or accelerate, atherosclerosis. These include smoking, diabetes mellitus, hypertension, high cholesterol, and genes.Atrial fibrillation
Cheney had episodes of atrial fibrillation in November 2007 and October 2008 13. Electrical cardioversion at George Washington University Hospital (on Nov. 26, 2007 and Oct. 15, 2008 13, respectively) successfully restored his cardiac rhythm to normal in both cases. In the first case, the rhythym was discovered when Cheney complained of a chronic cough to his physicians 14.Biowarfare exposures
On Oct. 18, 2001, an alarm went off in the White House because a biological warfare agent had been detected. Everyone in the Situation Room that day was thought to have been exposed, and Cheney lethally infected. Cheney calmly reported the incident to the rest of the National Security Council. 15a The alarm was false. It was the day after a white powder sent to Senator Thomas Daschle's office had been identified as anthrax. 15bCardiac defibrillator
In June 2001 (probably June 15-17), a 34-hour Holter monitor showed "some minor periods, very short periods, one to two seconds each, of rapid heart rate." Cheney says:Cholesterol-lowering medication(s)I'm oblivious to these incidents when they occur, and they only last one or two seconds. ... It's not related to physical activity, doesn't appear to be, and just occurs occasionally. I think four times over the course of 34 hours. That's in the press release. They say it lasts for one or two seconds at a time. So there's no outward manifestation of it. I'm totally unaware of it when it happens. 16
This is confirmed by his physicians, who say the Holter showed "four separate episodes of abnormally fast heartbeats amounting to less than 5 seconds in total. That indicated the need for the electrophysiology study" 2. Comment: The fastest ventricular arrhythmias Dr. Zebra has seen were about 200 beats per minute. That works out to about 3.3 beats per second. If Cheney's longest "run" of ectopy was just more than a second, he could perhaps have had a four or five beat run.
The New York Times reported that the ectopic rhythm was ventricular tachycardia 17. The type of arrhythmia was apparently disclosed by Cheney's cardiologist to another cardiologist, Dr. Douglas Zipes 4, or to the press at large -- not sure.
Indication for Holter monitoring was unclear; VP described it as a "routine test" and "For somebody with my history, it's good preventive medicine" 16. His cardiologist reported the Holter was done "to be complete and compulsive" 3. Previous Holter monitoring was "eight or ten" years earlier 16.
Cheney underwent electrophysiology study at George Washington University on June 30, 2001. Femoral venous approach was planned 16. He was inducible; it was only done once [Altman - can't find article anymore]. Dr. Zipes later reported that Cheney fit the criteria for defibrillator therapy used in the MADIT I trial 5. If true, Cheney's ejection fraction is 35% or lower, and his arrhythmia did not respond to an anti-arrhythmic agent during electrophysiologic testing.
Regarding the electrophysiology study, Cheney's cardiologist, Dr. Jonathan Reiner, said "This test today was the result of proactive testing on our part. ... This is about not waiting for symptoms." 2.
The automated implantable cardiac defibrillator was implanted the same day in a one and a half hour procedure. "The implantable cardioverter defibrillator (ICD) was implanted under the skin on the left side of the upper chest. Dr. [sic] says Cheney was sleeping during the procedure." Checked in at 0800, discharged at 1530. Can return to work Monday. 2.
Cheney "was advised to use a cell phone on the side of his head opposite the implant." 2.
The device implanted was a Medtronic GEM III DR model 2. Besides cardioversion and defibrillation, it can also function as a pacemaker 18. The device alone costs about $25,000; the physician fees are extra 3. Before the procedure, Cheney said "I'm not on Medicare, no. (Laughter.) It's Blue Cross, Blue Shield." 16
According to Dr. Reiner "It is very, very likely he will never use this device." 2.
As of July 2005, the AICD had never discharged, indicating that Cheney had not suffered from a significant (detectable) tachyarrhythmia 19 20.
In 1989 Cheney faced Senate confirmation to become Secretary of Defense. His then-cardiologist, Dr. Allan Ross, wrote a letter to the Senate Armed Services Committee. The Washington Post reported:Colds and suchCheney's former high cholesterol has been brought under control with medications, the letter said. It did not list the drugs he is taking, but said none have side effects that would affect his judgment or behavior. 21It is unclear from this language whether Cheney was taking one or more different medications to lower cholesterol.
In June 2001 Cheney's low density lipoprotein (LDL) cholesterol was 72 mg/dl, his lowest recorded value ever 3. This is excellent control.
It is reasonable to assume Cheney is taking a "statin" type of cholesterol-lowering drug, such as Lipitor, Zocor, or Pravachol, given that this class of drugs produces remarkable survival improvements in populations with coronary artery disease. Although widely used, it should be noted that these drugs are suspected to cause subtle cognitive, mood, and behavioral changes in some people 22, including severe irritability 23.
It is not necessarily true that Cheney's only lipid abnormality is hypercholesterolemia. Weight gain and/or glucose intolerance, for example, can induce or exacerbate hypertriglyceridemia. The failure to disclose Cheney's total cholesterol level suggests that his high density lipoprotein (HDL) is low. More complex lipid disorders may require classes of medications beyond the statins.
2000-10 - Had "a cold in the weeks before the election" 24.Congestive heart failure
2003-05 - Laryngitis 25.
2004-11 - Severe viral upper respiratory infection. Days after re-election in November 2004, Cheney complained to his cardiologist of productive cough and shortness of breath. After a 3-hour evaluation at George Washington University, the possibilities of cardiac disease and pneumonia were ruled out 19.
2005-01 - The parka mystery. At a somber outdoor commemoration ceremony that attracted world leaders to the site of the Auschwitz Nazi death camp on a cold snowy day, Cheney stood out like a sore thumb among the black-clad, gentlemanly attired heads of state sitting near him. Inexplicably, Cheney was wearing an olive-drab parka with a fur-trimmed hood, hiking boots (of the style known as "shit-kickers"), and a knit cap embroidered with the words "Staff 2001" 26. Mrs. Cheney was dressed in the black style of everyone else. The press was mystified. Even the sober "Washington Week in Review" television show asked viewers for hypotheses to explain Cheney's clothes.
Dr. Zebra wonders if an extended convalescence from the severe "cold" Cheney suffered in November 2004 was a factor. Perhaps the Vice President's handlers decided it was more important to keep the physiologically fragile Cheney warm, dry, and healthy than it was to prevent him from looking sartorially misplaced.
Congestive heart failure is defined (more or less) as the co-existence of a poorly functioning heart plus symptoms or signs of fluid retention.Coronary angioplasty
Cheney has had episodes that are suspicious of fluid retention:
However, in January 2006 he was seen at a hospital because of breathlessness, due to fluid in the lungs. He was treated with a diuretic (fluid medicine) and improved 27.
- An episode of breathlessness in in November 2004 was declared not due to a cardiac cause 19.
- His feet enlarged in November 2005, suggesting foot swelling. No cause was disclosed.
This episode is clearly compatible with heart failure. Although his staff blamed the fluid accumulation on a medication the Vice President had been taking, such medications do not cause breathlessness in persons with normal hearts.
One, and possibly two, episodes of public sleepiness raise the possibility of another consequence of congestive heart failure: sleep apnea.
Note: During the January 2006 episode of breathlessness, the New York Times reported "After performing an electrocardiogram, or EKG test, doctors found no change in the functioning of Mr. Cheney's heart" 20. In the careful, plausible-deniability language of Washington, this is not a helpful statement. It does not say the EKG was unchanged. It does not say there was no change in heart function. It says only that the EKG suggested no change in heart function. This is unhelpful because EKGs are poor at showing changes in heart function.
After presenting with unstable angina in March 2001, Cheney underwent percutaneous balloon angioplasty at GWU Hospital 16. Angioplasty was performed on a focal narrowing in a diagonal branch of the left anterior descending artery. "The angioplasty was necessitated by a common complication of the stent procedure, not a progression of his heart disease." That is, restenosis occurred at the site of the coronary stent inserted into Cheney's artery 4 months earlier. Restenosis is a common complication of stenting -- or at least it was until a new generation of stents appeared in 2003.Coronary bypass surgery
Dr. Benjamin L. Aaron of George Washington University Medical School performed a four-vessel coronary bypass operation on Cheney 21 in August 1988 -- about two months after Cheney's third heart attack. Aaron, by the way, was the surgeon that operated on Ronald Reagan's gunshot wound.Coronary stent
In 1989, Cheney's cardiologist, Dr. Allan Ross, wrote that the operation was not done primarily to increase Cheney's life expectancy, but to allow him "to more safely engage in his rather vigorous lifestyle" 21.
The bypass anatomy is not known. Or, rather, the Washington Post did not know, as of the summer of the 2000 campaign 8. It is presumed that he has a mixture of arterial and venous bypass conduits.
See heart attack #4.Diet
In 2001 Mr. Cheney's physicians appeared satisfied with his diet and exercise compliance, hailing his 25 pound weight loss and calling him a model patient 2.DUI
In June 2001 Cheney stated: "I'm following a fairly rigid diet that's maintained by the Navy stewards out at the house. And as I've said before, my wife is in charge of my food supply. We don't get into that in any great detail" 16.
He maintains a diet that emphasizes fish, buffalo and salad 19.
Without doubt Mr. Cheney's physicians would like him to eat a diet low in sodium. One anecdote, however, describes him carefully salting both sides of his buffalo steak, cut up in pieces 28.
See also: obesity section.
As a youth Cheney had two arrests for drunken driving 29, one in November 1962 and one in July 1963, both in Wyoming 28.Esophagitis
An upper gastrointestinal endoscopy performed in July 2005 showed mild inflammation of the esophagus, i.e. esophagitis 30. No further information was released.Exercise program
It's likely this is "reflux esophagitis," caused by stomach acid leaking backwards into the esophagus. Upper endoscopies are not performed during routine physical examinations, so it is also likely that Mr. Cheney was having symptoms of the condition.
Reflux esophagitis is more common in the obese and in people with obstructive sleep apnea.
A colonoscopy was also performed during the July 2005 physical, and was normal 30.
It has been reported that between 1988 and 2000 Cheney exercised only twice a week and gained 40 pounds 1.Exercise tolerance and Angina pectoris
During the 2000 campaign, however, it was reported that Cheney regularly exercised for 30 minutes on a treadmill 31.
And by 2001 his physicians appeared satisfied with Cheney's diet and exercise compliance, hailing his 25 pound weight loss and calling him a model patient 2.
On the day before implantation of his AICD in 2001, Cheney said: "I exercised this morning for 30 minutes on my Schwinn Airdyne bicycle, as I do several times a week. I've experienced no symptoms of any kind." 16
During the 2004 campaign, Cheney used an elliptical trainer. Sometimes the exercise machine was seen being unloaded from Air Force Two, and sometimes it was ready for him in his hotel room. 19.
Angina pectoris is chest/arm/jaw discomfort arising from inadequate blood flow to the heart muscle. Classically, angina occurs during exercise or other periods of higher-than-normal demand for blood by the heart.Gout
Angina may exist in stable or unstable patterns. When angina occurs at a consistent level of exercise, it is called stable. Stable angina is not generally an emergency, and people may coexist with it for years.
A June 2001 report disclosed that Cheney then had "no symptoms" 3; it is difficult to know exactly what symptoms were being referenced.
It is unknown whether Cheney currently has stable angina. His statements about his exercise program are only moderately informative. They have disclosed his exercise method and duration, but omitted the key variable: intensity. A person with significant angina may be able to "exercise" for a relatively long time if the intensity is low enough.
Thus, it would be interesting to know more about Cheney's skiing. Dr. Zebra has run across two descriptors:
Unfortunately, from these fuzzy data it is not possible to tell how vigorous Cheney is today.
- Sometime before July 2000, Senator Trent Lott went skiing with Cheney.As the others eyed a "very steep" ski run, Lott remembers Cheney taking off "like a bat." "All I could see was [his] red scarf flapping down the mountain. ... He's a very aggressive, competitive skier." 29.
- Sometime after January 2001, Cheney told Ski Magazine 32 that he is now "a fair weather skier" more likely to "ski with the grandchildren." He continued, "I've got bad knees at this stage so I'm much more modest in my approach."
Another clue to Cheney's exercise tolerance might come from noticing if he curtails his workouts on the stationary bicycle when at home in Jackson Hole, Wyoming. If so, it could be a sign that exercise at altitude provokes angina. (Breathlessness would be expected, of course.)
Finally, Dr. Zebra has always wondered if Cheney experienced angina on Sept. 11, 2001. When radar showed hijacked United Airlines flight 93 heading toward the White House:Secret Service agents burst into Cheney's West Wing office. "Sir," one said, "we have to leave immediately." ... Before Cheney could respond, the agents grabbed the vice president under his arms -- nearly lifting him off the ground -- and propelled him down the steps into the White House basement and through a long tunnel that led to the underground bunker. 33Talk about heart-pounding....
It has been reported that Cheney travels with a suit to protect him in the event of attack with chemical or biological agents 28. Perhaps it is a deluxe model with air conditioning and its own oxygen supply. If, however, it is the type issued to military members, then it seems unlikely Cheney's precariously compensated cardiovascular status could long endure the heat stress, breathing effort, and rapid dehydration that invariably attends wearing of the suit.
"Episodes of gout in his foot" 31. (Does not say when, or if in one foot or both feet.) A photograph printed in October 2005 showed Cheney walking with a cane 34. This may have been due, however, to an invasive procedure he had undergone the month before on the arteries behind his knees.Heart attack #1
This June 1978 heart attack occurred at age 37, during his first campaign to become Wyoming's lone member of the House of Representatives 8 35.Heart attack #2
It was an inferior wall infarct. Cardiac catheterization afterwards disclosed "moderate coronary artery disease" 36 ("moderate" is not defined). Unlike the description of Cheney's second and possibly third heart attacks, this one is not described as "small" by his current cardiologist 36.
Until this heart attack, Cheney had been a smoker for 20 years. He has said he gave up smoking after the attack and went on a strict dietary and medical regimen 21. There are indications, however, that his change in lifestyle was neither so dramatic nor whole-hearted 1.
A heart attack attaches several diagnostic labels to a patient. They are subtly different, in ways that rarely matter to laypersons. By virtue of having a garden-variety heart attack, Cheney (or anyone else) would carry the following diagnoses:
- myocardial infarction, history of
- coronary heart disease
- coronary atherosclerosis
- coronary artery disease
- atherosclerotic cardiovascular disease
- arteriosclerosis (a word little used by medical people)
This 1984 heart attack has been described as "small" 36.Heart attack #3
This 1988 heart attack has also been described as "mild" 35, but the wording of Cheney's current cardiologist's description is ambiguous 36.Heart attack #4
Coronary arteriography at this time showed "an increase in the extent of his coronary disease" 36 (presumably compared to 1978 or 1984). Thus, Cheney underwent a coronary bypass operation about two months later.
At 3 am on November 22, 2000 -- hours after the Florida Supreme Court backed recounts in Florida 35 and put the Bush-Cheney election "win" in grave jeopardy -- Cheney awoke with chest and shoulder discomfort 11 37. He asked Secret Service agents to drive him from his townhouse in MacLean, VA to a hospital 35, arriving about 4:30 am at George Washington University Hospital 37."Metabolic disorders"
He was admitted to the coronary care unit. Initial tests were normal, but at about 7 am an EKG was suspcious for a heart attack. Cheney therefore underwent coronary angiography at about 8 am 11. It showed 90% occlusion 35 of a diagonal branch of the left anterior descending artery 38. The rest of Cheney's coronary anatomy was unchanged from that shown on his most recent prior angiogram -- in 1996 38.
At about 10:30 am, Cheney's cardiologist performed balloon angioplasty of the LAD diagonal and also placed an intracoronary stent at the site of the obstruction 11. The result was good 38.
At the time Cheney presented to the hospital, it was not clear whether this was a heart attack or an episode of unstable angina. Over time, blood results showed that it had been a small heart attack 38: total CPK was normal, but there were "minimal" elevations of CPK-MB and troponin-I 11.
Dr. Zebra read somewhere that Cheney had had a normal exercise stress test in July 2000, just three months before his heart attack. This sort of thing (infarct soon after a normal treadmill) happens all the time.
Cheney later said that the controversial election of 2000 was not as stressful an experience as managing the first Gulf War, which he did as Secretary of Defense in 1991 37. The recount decision was ultimately reversed by the United States Supreme Court.
The one reference 10 that mentions metabolic disorders offers no additional details. This does not appear to be a reference to gout or allergy, as those are mentioned in the reference as separate entities. Diabetes mellitus is a common metabolic disorder, but there is no public suggestion that Mr. Cheney has this condition.Mischaracterizations of Cheney's health
This section necessarily includes both opinion and fact.Obesity
In 2000, Dr. Gary Malakoff (director of internal medicine at George Washington University Hospital and Cheney's personal doctor since 1995) said Cheney is in "excellent health" 31. Alas, his patient in excellent health had a heart attack the next year. Instead of enthusing about the present, perhaps the good doctor should have been a little more forthcoming about the future. (In 2004 Malakoff was dropped from Cheney's medical team because of addiction to prescription drugs 39.)
By contrast, renowned cardiac surgeon Dr. Denton Cooley was more clever in his assessment. Before announcing Cheney as his running mate in 2000, Bush asked Cooley to review Cheney's medical records. Cooley reported: "Mr. Cheney's health problems in the past should not interfere with a strenuous political campaign" 8. That's nice to know, but it's not very helpful. In fact, it's a really weird thing to say. Obviously, it's more important for the electorate to know whether Cheney's past health problems would interfere with his Vice Presidential duties if elected. Perhaps Cooley, who has redone many a failed coronary bypass, was unwilling to predict something positive about a longer period of time. Even so, Cooley was barely correct -- Cheney's November 2000 heart attack (#4) occurred literally days after the campaign ended.
Cheney takes a "long list of medications" 36. Dr. Malakoff's 2000 statement that Cheney "has shown no side effects of any of these medications which would alter intellectual performance or impair his judgment" 36 is not as strong as Dr. Ross' 1989 statement that, of Cheney's medications, "none have side effects that would affect his judgment or behavior" 21. Perhaps this weakening reflects a recognition that "statin" cholesterol-lowering drugs can, at least in some patients, provoke "severe irritability"
Furthermore, it is well known in the medical profession that studies of drug interactions are extremely limited. So, given that Cheney is taking multiple medications, it is certainly true that no one has a scientific basis on which to say his medications do not interact to produce (possibly subtle) cognitive effects. His physicians have not put this caveat in their public pronouncements.
There have been accusations that, early on, Washington doctors and politicians deliberately down-played Cheney's November 2000 heart attack #4 as a non-heart-attack 40 41. Dr. Zebra doesn't buy this. Distinguishing the various types of acute coronary syndromes can be difficult in some cases, and it sounds like Cheney was simply one of those cases 11 38.
However, Dr. Zebra does find ?willfull incongruities in descriptions of Cheney's health by administration officials.
- In November 2000 Cheney woke up in the middle of the night with chest discomfort and was rushed to the hospital. The dullest doctor in the world would recognize this immediately as either a heart attack or unstable angina -- either of which could have been rapidly fatal. Yet, Karen Hughes, press secretary for the Bush-Cheney campaign, said the trip to the hospital was a "precaution" 41.
- In November 2000, when Cheney was in in a coronary care unit, Governor Bush declared: "Dick Cheney is healthy" 42.
- In March 2001 Cheney developed chest discomfort again. The Secret Service rushed him to George Washington University Hospital where he underwent immediate coronary arteriography 35. Yet, Cheney's office described this urgent, invasive procedure as "a non-emergency precautionary procedure" 43.
It has been reported that between 1988 and 2000 Cheney exercised only twice a week and gained 40 pounds 1.Orthopedic issues
By 2001 his physicians appeared satisfied with his diet and exercise compliance, hailing his 25 pound weight loss and calling him a model patient 2.
Mr. Cheney's current weight is unknown, but an in-depth magazine profile in 2006 described him as "easily 30 pounds overweight" 28.
See also: diet section.
Cheney has had surgery on his right knee because of an old football injury 36 31. (What year? Arthroscopic or open?) More recently he has noted that his "bad knees" (plural) make him ski more modestly 32.Pomegranate allergy
In June 2005 Cheney consulted orthopedic surgeon Dr. Richard Steadman in Vail, Colorado because of "an old knee injury" 44. Rumors quickly 45 46 suggested that this was a cover story for an evaluation of a cardiac problem, angina pectoris. However, the editor of the Vail, Colorado newspaper has found inconsistencies in some details of the rumor 47 48.
Given that aneurysms in Cheney's knee arteries were discovered "during a routine examination in July" 2005 49, more credible hypotheses are that early symptoms of the vascular problem were initially thought to be orthopedic, or the story about an old knee injury was a cover.
In January 2006 Cheney was using a cane in public. His office stated this was a flare-up of a recurrent problem in his left foot that was being treated with rest and anti-inflammatory medication 20. They would disclose neither the condition nor the medication. Tendonitis has occurred in that heel, and there is a question of osteoarthritis and/or gout in the big toe 27.
Cheney has a history of anaphylaxis to pomegranates 36 10.Popliteal artery aneurysms
Aneurysms of the arteries behind both knees (the "popliteal arteries") were discovered on a "routine examination" in July 2005 49. It is unclear whether Cheney's evaluation for "an old knee injury" in Vail, CO in June 2005 contributed to the diagnosis.Presumptive list of Cheney's medications
The popliteal artery may become aneurysmal (swell like a balloon) for several reasons. The most common reason is atherosclerosis 50. Cheney has a history of orthopedic problems with his knees, so it's also possibe that could be the cause of the aneurysms. However, having aneurysms in the arteries behind both knees 49, strongly implicates atherosclerosis.
Cheney had endovascular treatment of both popliteal artery aneurysms on Saturday, Sept. 24, 2005 at George Washington University Hospital 51. Originally, the right and left sides were to be repaired on two different occassions 49. According to Cheney's office 52:Using local anesthesia, two overlapping Viabahn stent grafts were implanted in the right popliteal artery. The implanted device consists of a flexible, self-expanding stent covering a thin walled graft composed of polytetrafluoroethylene. Placement of the device in the right knee artery went exceedingly smoothly, and an intraoperative decision was made to repair the aneurysm behind the left knee using a similar technique. The procedure lasted six hours and there were no complications. [Full statement]This was a non-surgical procedure done under local anesthesia. There was speculation that this relatively new procedure was used instead of performing a popliteal artery bypass because (1) compared to surgery, it is less of a stress to the cardiovascular system 51, and/or (2) Cheney did not have a vein available to become a bypass conduit. The trade-off is that the long-term results of endovascular repair are not known.
Dr. Zebra is not sure, but it appears this was an off-label use of the grafts
Ironically, the manufacturer of the Viabahn graft is Gore Inc.
Until proven otherwise it is reasonable to assume that the anuerysm is another manifestation of Cheney's long history of atherosclerosis. So, while not a serious health threat in itself, the appearance of atherosclerotic popliteal aneurysms would be highly significant because it would:
A photograph printed in October 2005 showed Cheney walking with a cane 34.
- Be another sign that, despite aggressive treatment, Cheney's atherosclerosis is not quiescent;
- Be the first public admission that Cheney's atherosclerosis is systemic (i.e. involves more than his coronary arteries); and
- Raise the question whether Cheney has a claudication syndrome. (Dr. Zebra read somewhere that, as of about 2005, he did not have claudication. Would love to have a reference...)
When Cheney was selected as Bush's vice presidential nominee, the Bush campaign refused to disclose a list of all the medications he was taking 41. It has been admitted that Cheney takes "many drugs for heart disease and other medical conditions" 10.Shot in hunting accident
It is possible, however, to make a reasonable guess at the medicines he takes. Heart attack survivors generally all end up on the same classes of medications, and there are few medicines available for gout. Additional medications for heart failure are doubtless taken.
Other possible medications include more aggressive anti-coagulation, e.g. with warfarin (Coumadin). If Cheney's "metabolic disorders" are related to glucose intolerance, he may be taking oral anti-diabetic medicines.
- Medications for heart attack survivors:
- ACE inhibitor such as lisinopril (Zestril), or AR blocker
- anti-cholesterol "statin" such as atorvastatin (Lipitor)
- beta-blocker such as atenolol (Tenormin), metoprolol, or carvedilol (Coreg)
- fish oil capsules
- nitroglycerin prn
- ? second lipid-lowering medication
- ? second blood pressure medication
- For generalized atherosclerotic disease:
- pentoxifylline (Trental)
- sildenafil (Viagra) prn
- For left ventricular dysfunction or heart failure:
- furosemide (Lasix)
- beta blocker as noted above (esp. carvedilol)
- ACE inhibitor/AR blocker as noted above
- ? digitalis (Digoxin)
- ? aldosterone blocker such as spironolactone or eplerenone (Inspra)
- For gout:
- allopurinol (Zyloprim)
- indomethacin (Indocin) prn
Anyone close-by to Cheney when he belches may be able to confirm the use of fish oil by smell (the "fishy burp").
Dr. Zebra would not be surprised if Cheney has sleep apnea and uses a positive pressure breathing mask when he sleeps (e.g. CPAP, BiPAP, or AutoPAP). Does anyone know his collar size?
Cheney was pelted by a shotgun blast while hunting in southern New Mexico in the late 1990s. Cheney was not hurt, but was "offended" and "miffed" with the hunting party, exclaiming "You guys watch where you're shooting!" The shooter was either Bob Forrest or his twin brother Dick -- it was unclear who fired the errant shot. 53Shoots in hunting accident
This is pure speculation. The widely reported accident in which Cheney shot a fellow quail hunter in early 2006 could have had medical aspects.Skin cancer
(1) There are reports Cheney had a beer before-hand. It's possible that his metabolic and cardiac illnesses could lower his tolerance to alcohol, such that some impairment was present at a time and a dose that ordinarily would not cause problems in a healthier person. (2) After a lifetime of hunting and almost a lifetime of atherosclerosis, Cheney's hearing may be poor, such that he did not hear another person nearby, whereas another person would. Perhaps the victim was making noise to the point that he thought Cheney would hear him. (3) It was reportedly a very hot day. Heat dissipation is an energy-requiring process. Persons with heart failure do not function well in the heat. This could affect his senses and/or his ability to process information rapidly.
Conspicuous by it's absence is an objective report of the distance between the victim and Cheney's gun. A standard forensic technique calculates this distance based on the separation of the buckshot impacts on the victim's skin. The distance from one buckshot pellet to another increases, according to the laws of physics, as the pellets travel further from the gun. The technique is limited because the "choke" of individual shotguns can differ 54a, but in this case the weapon would have been available for analysis.
A "small spot" of skin cancer on his face was surgically removed 31. (Does not say what year or what type of skin cancer. Statistically, it is most likely to have been a basal cell skin cancer.)Sleepiness
In April 55 and May 56 2006, the press published photographs purporting to show Cheney asleep in two meetings. Video aired Oct. 25, 2007 on Good Morning America caught him dozing while in an emergency meeting in which the President was discussing wildfires blazing in California. It was claimed that in the first meeting Cheney was merely reviewing his notes. Dr. Zebra disagrees. A careful analysis of the photo provides ample evidence he was asleep [photo and analysis]. The other picture is inconclusive.Tobacco history
Sleepiness is a major finding in a patient with heart disease, as it raises the possibility of sleep apnea, specifically Cheyne-Stokes respiration and central sleep apnea. Daytime sleepiness occurs in everyone at some time, of course. Still, sleep apnea can never be ruled out in patients with heart disease unless there is a formal sleep study.
Central sleep apnea, more so than obstructive sleep apnea, can be difficult to treat. Cheney's obesity increases his risk of obstructive sleep apnea.
Quit 20-year smoking habit in 1978 after his (first) heart attack 21 -- maybe.Unstable angina pectoris
He had started smoking in his teens, and had consumed as many as three packs of cigarettes a day. But unlike Dwight Eisenhower's remarkable kicking of a similarly intense habit, it is not clear that Cheney quit smoking quickly or completely 1.
Vice President Cheney developed unstable angina in March 2001. This is a medical emergency, much like a heart attack.Venous thrombosis
The chronology of events, according to 35, was:
Note: Dr. Zebra cringes whenever he sees discussions of chest "pain." The sensation of myocardial ischemia is typically "pressure" or "squeezing" and is rarely "pain."
- Thursday (March 1) - Resting EKG on Cheney, taken at the White House for "routine" follow-up, is normal.
- Saturday (March 3) - Cheney feels a "minor twinge in his chest" as he got off an exercise machine at home.
- Saturday (March 3) - evening - Party with Washington lawyer Roderick Hills 40.
- Sunday (March 4) - time? - Appears on CNN "Late Edition" and tells Wolf Blitzer: "I feel great."
- Sunday (March 4) - time? - Appears on "Face the Nation" [?]
- Sunday (March 4) - afternoon - Felt another pang.
- Sunday (March 4) - evening - Party with Federal Reserve Chairman Alan Greenspan 40.
- Monday (March 5) - morning - Felt a sharper pain, lasting three to five minutes, while dressing. Called and talked to his cardiologist, Dr. Jonathan S. Reiner, who did not "insist" that Cheney be examined.
- Monday (March 5) - 7:30am - Arrives, as usual, at his West Wing office.
- Monday (March 5) - lunch - A working lunch with television commentators and newspaper columnists. Ate a chef's salad.
- Monday (March 5) - after lunch - Meetings with Portugese foreign minister and his (Cheney's) senior staff.
- Monday (March 5) - about 2:00pm - Cheney again calls his cardiologist, complaining of more chest pains. Cardiologist insists Cheney be examined.
- Monday (March 5) - "afternoon" - EKG performed at the White House is normal 43
- Monday (March 5) - about 3:30pm - Secret Service agents rush Cheney to George Washington University Hospital. Cardiac angiography showed 90% occlusion at the site of the stent placed in the left anterior descending diagonal artery the previous November. Urgent coronary angioplasty is performed.
- Monday (March 5) - White House issues three-sentence press release:Vice President Cheney checked himself into George Washington Hospital for a repeat cardiac catheterization after experiencing two brief, mild episodes of chest discomfort. This is a non-emergency precautionary procedure. An EKG obtained at the White House this afternoon was unchanged from one obtained last Thursday. 43
- Monday-Tuesday (March 5-6) - Diagnosis of unstable angina pectoris can be made because there is no evidence of myocardial infarction (heart attack): "Three sets of cardiac enzymes are normal indicating no damage to the heart muscle. Multiple EKGs have been unchanged." 57
On March 5, 2007, five days after arriving home from an extended air trip (including Australia and Central Asia), Cheney consulted his physicians for pain in his left calf. The physicians found a blood clot known as a DVT (deep venous thrombosis) in a leg vein. Cheney was started on an anti-coagulant, then returned to work 58 59. A repeat ultrasound on March 21 showed no extension of the clot 60. Comment: Media coverage of this event has connected Cheney's prolonged flying time to the clot, then moved on to the next story. This is not, however, a run-of-the-mill post-airline-flight DVT because:
Other causes of DVT cannot, therefore, be dismissed. Most worrisome in anyone Cheney's age is cancer. A spontaneous thrombosis associated with cancer is known as Trousseau syndrome. It can be the first sign of cancer. It is also possible this clot reflects a "hyper-coagulable state." Congestive heart failure is a classic hyper-coagulable state. Certain gene variants may also cause hyper-coagulability. This is fascinating to consider in light of his long history of atherosclerosis. The major point is that Cheney should undergo a diagnostic evaluation to determine the cause of the clot. For someone in Cheney's high office, this should include colonoscopy, upper endoscopy, full body imaging, a complete dermatological examination, and various blood tests. He will likely continue taking an anti-coagulant medication for at least three months. At least initially, this will involve frequent monitoring of the medication and perhaps dietary change.
- Cheney was not jammed into an airline seat. He was in a small office and bedroom that happened to be in an airplane.
- Cheney was certainly taking anti-platelet drug(s) because of his coronary artery disease. This should have offered some protection against a clot (unless he has been non-compliant).
"I've got a doc with me 24 hours a day who watches me very carefully. There's one outside there now," he said, pointing to a nearby door. "He's part of the entourage that supports me. The president has one and I have one. So everything looks good to go." 25.
"...and my capacity to function in this job, if the doctors ever conclude I can't, obviously I'd be the first to step forward and say so. That's not in my interest or anybody else's interest to have me continue in the job if I were not capable of preforming it. And so I'll follow my doctor's advice in that regard." 16.
"if there were any inhibition on my ability to function, if it were the doctors' judgment that any of these developments constituted the kind of information that indicated I would not be able to perform, I would be the first to step down. I don't have any interest in continuing in the post unless I'm able to perform adequately, and the doctors have assured me that is the case." 16.
"If I ran into problems where I felt I couldn't serve, I'd be the first to say so and step down." 25.
Comment: These phrases sound sincere and magnanimous, but note: (1) The Consitutional duties of the Vice President are few, and (2) What Cheney doesn't say, or even imply, is that he would step aside if he or others saw his capabilities diminishing.