As you probably already know, former president Bill Clinton recently underwent a “heart procedure” upon his return from a visit to Haiti that the press later clarified as angioplasty and placement of a stent.  Mr. Clinton used to have quite a reputation as a man who never met a greasy hamburger he didn’t like and was rewarded for his habits with coronary bypass surgery in 2004.  Nowadays, things are a little different around the Clinton household—from what I can tell he has given himself over to a healthier, more ascetic lifestyle with more time spent on the treadmill than at the drive-through. 

After the procedure the ex-president (and current UN envoy to Haiti) had nothing but praise for his doctors, but reserved his most flattering comments for the technology itself:

"It's miraculous with the stents," Clinton told reporters, referring to the devices used to clear a clogged artery during the operation Thursday.

Clinton, 63, was speaking publicly for the first time since entering the New York Presbyterian Hospital. He was released earlier Friday.

"I didn't (take) any sedatives or anything, so I was alert. I wanted to watch it. I got to watch it on the monitor," he said.

Since catching wind of this story I have tried desperately to find a way to spin this into a clever yet respectful blog topic that would both entertain and inspire my readers.  Something bold, something different—more than just a recitation about the merits of coronary stenting.  Instead of my usual tired commentary I wanted to find a truly inspired angle.

But then I thought, why break with tradition?  So, here you have it—everything you ever wanted to know about coronary stenting but never learned in junior high health class.

First off, a little nomenclature (that I’ve found is frequently misunderstood among non-medical people):

Angiogram (synonyms: heart catheterization, cardiac catheterization, cath) is where we run a small tube (catheter) through the artery to inject dye into the coronary arteries to take pictures.  With this procedure we don’t fix anything.  It’s more or less just a fancy x-ray with dye in the arteries.  That’s the difference between this and . . .

Angioplasty (synonyms: balloon angioplasty, PTCA), where we actually expand a balloon inside a blocked vessel to open a passageway for blood to get down the clogged artery.  Up until about 15 years ago, before the widespread use of reliable stents, most patients had angioplasty alone.  The problem with angioplasty alone, though, was that the vessel frequently closed up again within 6 months and the patient had to return to get the whole thing done again.  While this was good for the cardiologist wanting to make payments on his second home in Aspen, it wasn’t so good for patients.

Angioplasty with stenting is the most common approach today and this is what I’ll explain now.

Have you ever taken apart a ball point pen that has one of those little tiny spring thingies in it?  Now picture the spring, but very small, looking more like chicken wire and made of really, really expensive metal.  Good.  Now that you have that image in your mind click on this hyperlink to see if I did a reasonable job of explaining the appearance of a coronary stent.

To place a stent, the interventional cardiologist first performs angiography to take a picture of the blocked vessel so that he or she can make an estimate of how best to fix the vessel (please click here to see how not to do this).  At this point the operator will thread a very small and flexible wire into the coronary artery and snake it through the narrow center of the blockage.  He* then advances the wire as far out into the vessel as possible. 

Using the wire as a rail the doctor slides a small catheter equipped with an inflatable balloon out to the point of the blockage.  The balloon expands and all the cholesterol and platelet gunk simply gets squished outward into the wall of the vessel (click here for a nice picture or here for brief video).  He will then repeat the process, but this time with a balloon that is wrapped with a non-expanded stent.  The balloon inflates and the stent expands.  The doctor deflates and removes the balloon and the stent stays in place.  If he’s satisfied with the final result he’ll remove the wire and catheter and the patient is returned to the recovery room.  The whole process generally takes less than 45 minutes.

When I first started out in cardiology I was a little surprised to learn that we don’t really clean out the cholesterol build-up from inside the artery when we fix it.  This is not the roto-rooter job you get from a plumber when your pipes are clogged.  All we do is use the stent to compress the unwanted plaque into the vessel wall and pin it out of the way with the stent.

The process of expanding a balloon is actually quite traumatic to the vessel wall (on a microscopic scale) and triggers a cascade of cellular reactions that makes the body want to heal the vessel with something akin to a scab.  That sort of response is good for a scraped knee, but not so desirable inside a vessel that measures only a few millimeters and provides flow to what is arguably one of the more important organs of the body.  A combination of the metal stent (to prop open the vessel) and the use of anti-clottting drugs such as aspirin and clopidogrel (Plavix) allows the vessel heal without unnecessary narrowing to the artery.

If done right the chance of a modern stent closing down is very, very low.  In my experience a patient with a previous stent is more likely to develop a new blockage elsewhere in the circulation than inside the stent.  Patients also recover very quickly from this procedure.

An article from February 13 reported on Mr. Clinton’s quick recovery and eagerness to get back to full activity.

"I feel great. ... I even did a couple miles on the treadmill today," Clinton said, speaking to reporters in a leather jacket from the driveway outside his home. He said doctors advised him "not to jog but walk. Not to walk fast up steep hills for a week."

While some commentators have suggested that Clinton needs to tame his active schedule I think is the wrong approach.  If I were his doctor—knowing what I do about the success of modern stents—I’d encourage him to get back into life at full speed (especially on the treadmill).  Since he’s become the go-to guy for massive natural disasters I don’t think we can afford to have him sidelined for long.

*Sexism alert:  Please note how I’ve switched from the more correct “he or she” to the less verbose “he” when I refer to the cardiologist.  I don’t mean to denigrate the other half by eliminating the “she,” but since only 17% of cardiologists in this country are women, and of those only 10% specialize in stent placement, I’m probably statistically on safe ground in adopting the masculine pronoun to describe my hypothetical interventionalist.

Last week one of my patients brought his 5-year-old granddaughter with him to his appointment.  When I came into the exam room the child was visibly disappointed to see me and told her grandpa that she didn’t believe I was a doctor because I wasn’t wearing a white coat.  Once I retrieved my lab coat and returned to the room I got a clear nod of approval from my young critic (this is why I didn’t go into pediatrics—way too much pressure).

I really don’t like white lab coats.  They’re hot, they snag on doorknobs and edges of desks, and stuff dumps out of the waist pockets when I sit down.  Moving around the ICU in a long lab coat is like touring a china shop in a poorly tailored trench coat.  Add to this my own perception that with my thin frame I can’t really pull off the “doctor look” in a lab coat. I look more like somewhat trying to look like a doctor—like I’m going to work wearing a Halloween costume.  Some patients also react somewhat unfavorably to the attire.  White coat hypertension is a well documented syndrome of artificially elevated blood pressure in patients nervously sitting in front of their white-clad doctor, and my heart patients don’t need any more problems than they already have.

In training I relied heavily on the oversized pockets as a repository for my many medical handbooks, but the invention of the PDA and smart phone—with their ability to provide immediate electronic access to a library of reference sources—has largely obviated my need for pantry-sized pockets. 

When I started medical school I was pretty excited to get my first lab coat.  Wearing the white coat around the hospital as a third-year student was a pretty big deal.  Nowadays medical schools have managed take this one step further with “white coat ceremonies” where earnest professors robe their medical trainees in the holy white vestiges of Hippocrates (I graduated medical school a few years before this silly trend began).

The white coat has been the visible symbol of medical authority ever since the medical profession hijacked it from their scientific colleagues over a century ago.  Prior to formalized medical training in the United States the early practitioners of medicine were viewed as quacks and mystics and needed a visible display of their new trend toward healing through the scientific method.

The public has come to expect their medical professionals to be wrapped in white cotton, largely thanks to the image of the fictionalized physician that has been formally codified in every movie and television show from General Hospital to Gray’s Anatomy.  Marcus Welby adhered strictly to school of formal fashion and would have never deigned to appear clad only in khakis and a polo shirt.  Outside the world of Dr. McDreamy the reality is not much different: scientific studies on the subject confirm the theory that patients perceive their physician to be more competent and capable if he or she appears in a white coat.

Well, times may be changing.  It turns out that the white coat is coming under increasing scrutiny and criticism, and not just by people like me whose complaints are more of a sartorial nature.  Numerous reports in the last decade demonstrate that the lab coat—with its oversized sleeves and overcoat design—tend to make more contact with our patients than we’d like.  Resourceful microbiologists and infectious disease specialists have taken to culturing the garment and finding a frightening world of microbiological flora that we are dragging from patient to patient.

In one such study researchers randomly sampled the lab coats of dozens of attendees at medical and surgical grand rounds at a large academic hospital.  After culturing the sleeves of these residents, interns and medical students, they found that 23% of the 149 volunteers were contaminated with Staph aureus, a common but problematic pathogen that is currently to blame for many hospital-acquired infections.  A significant 18% of white coats were colonized with the far more virulent and difficult-to-treat multi-drug resistant variety.  You can find public restrooms more sanitary than this.

Just last summer the American Medical Association voted on a motion to recommend banning the venerable white coat from use inside hospitals.  They cited numerous studies (like the one above) that show that we practitioners could cut back on the rate of hospital infections if we’d just give up our Typhoid Mary attire (oh, and do a better job of washing our hands—but that’s another story).  If they follow through with their recommendation they will be taking a cue from our relatives across the pond who’ve already banned white coats as part of their far more aggressive “bare below the elbows” campaign than prohibits coats, long sleeves, watches, jewelry, and neckties. (Neckties?  Sure.  According to one study half the ties worn by doctors in one New York City hospital contained bacteria known to cause hospital infections.  And how often do you send your ties out for laundry?)

So, are white coats destined to suffer the same fate as nursing capes and fade into extinction?  Despite my personal fashion and comfort misgivings and the dire warnings from our microbiology colleagues, I actually hope not.  Somewhere we have to find a compromise between the science of antisepsis and a respect for tradition and image.  For, like the child in my office, when I see physicians sporting well-pressed, bright white coats I have to admit they look wiser, more capable, and, in the end, more doctorly.

“What’s his condition? Is it serious, or critical, or what?”

I got this question last week from the family member of a man who was resting in the ICU in the early stages of a stroke. I had come out to update the family on the patient’s condition and was answering questions from what must have been about 20 people. Most of my answers were some permutation of “I don’t know” (unfortunately, when it comes to strokes, “I don’t know” is most often the only honest answer—will they recover? will this happen again? how much strength will come back?).

I never quite know how to answer the question about “condition” when it comes to medical illnesses.  When I was younger and barely into my internship I faced this issue with similar bemusement and figured I must have simply missed that day in medical school when this vernacular was explained.  If I’d only paid more attention in my classes I might know the meanings of descriptors such as critical, serious, grave, serious but stable, extremely critical, etc.

I’m now pleased to say that this particular subject is not one of the many that I missed in medical school while I was snoring in class or out skiing (my medical school is located less than 30 minutes from several very tempting ski resorts).  The use of these terms is actually never taught in medical training.  Why?  They don’t really have much meaning and we don’t use them.

We doctors favor more specific phrases to categorize a patient’s condition, such as septic shock, multi-system organ failure, cardiogenic pulmonary edema, and acne vulgaris (that last one’s for my brother’s benefit—dermatologists shouldn’t feel left out just because they don’t know how to find the intensive care unit).  We’ll use the term stable somewhat frequently, especially with individual disease states, but try to avoid pigeonholing patients into grave, critical and serious.

Members of the media have popularized this system of grading a patient’s condition and it has caught on among the general population.  You can’t listen to a news report about a hospitalized famous person without hearing the reporter make a declaration about the patient’s level of stability: “Doctors have upgraded the patient from critical to serious.”  (You can bet the doctors had absolutely nothing to do with upgrading anything).

It turns out I’m not the only doctor confused by this and I had to look to other sources to learn more about these descriptors.  The American Hospital Association has actually published guidelines to help us all understand what a “critical but stable” patient is.  Here’s the skinny:

Undetermined - Patient is awaiting physician and/or assessment.

Good - Vital signs are stable and within normal limits. Patient is conscious and comfortable. Indicators are excellent.

Fair - Vital signs are stable and within normal limits. Patient is conscious, but may be uncomfortable. Indicators are favorable.

Serious - Vital signs may be unstable and not within normal limits. Patient is acutely ill. Indicators are questionable.

Critical - Vital signs are unstable and not within normal limits. Patient may be unconscious. Indicators are unfavorable.

Clinicians find the "critical but stable" term useful when discussing cases amongst themselves because it helps them differentiate patients who are expected to recover from those whose prognosis is worse.  But a critical condition means that at least some vital signs are unstable, so this is inherently contradictory.  The term "stable" should not be used as a condition. Furthermore, this term should not be used in combination with other conditions, which by definition, often indicate a patient is unstable.

This is not the only popular system of measurement that we doctors don’t really endorse.

How do you measure how big a skin cut is?  The number of stitches you get in the ER, of course.

What about the seriousness of heart surgery?  It’s the number of bypasses at the time of coronary bypass graft surgery.  A triple bypass is more serious than a double, and a quadruple is near death.  The famed quintuple bypass trumps them all. 

And how much bigger, exactly, is a massive heart attack than a regular one?  And what exactly is a double pneumonia?

When I finally reached my ER rotations in medical school I was surprised to learn that the number of stitches a doctor uses has more to do with size of the suture, type of suture technique used, and how much time he or she has to close the laceration than the size of the cut itself.  In bypass surgery, the number of grafts used in the operation often depends as much on surgeon preference and style as it does on the seriousness of the patient’s underlying condition (incidentally, you won’t hear terms like triple or quadruple bypass among cardiologists—we’ll call it three-vessel or four-vessel).  And I still don’t really know what constitutes a massive heart attack or double pneumonia (see previous blog on this subject).

The last one I really have trouble with is the issue of “how many years do I have left?”  I’ve been out of medical school for 16 years and I’m still baffled about how this prediction is made.  Perhaps doctors of television and movies have particular insights that allow them to predict a patient’s remaining breaths with stopwatch accuracy.

Maybe someday I’ll learn this whole vernacular and, if ever I happen to attend to a hospitalized celebrity, be able to better provide reporters a measurement of the patient’s condition. “After his massive heart attack and double pneumonia he was in grave condition with only 4 weeks to live.  Thanks to the sextuple bypass with a hundred stitches we’ve upgraded him to critical-but-stable condition.”

As for now, I’m simply stuck with taking my best guess and relying heavily on “I don’t know.”

This week marks the one-year anniversary of this cardiology blog. Now that 2009 has come to an end I’d like to take this opportunity to summarize the best pieces of the previous 52 weeks. It seems every other publication from Time magazine to Mad magazine allows themselves the luxury of taking a week off by recycling a year’s worth of previous material, so I figure “Why not do the same?”

Below you’ll find links to all sorts of useful information and answers to nearly every important question in the world of cardiology.

Does elective coronary stenting decrease your chance of a future heart attack?  See the entry from March 18.

What’s the best dose of aspirin for you?  June 22

Are women more or less prone to strokes than men and how do they fare when they suffer a stroke?  February 11

What causes palpitations in healthy people?  August 24

What does “Do Not Resuscitate” (DNR) mean and how does it affect end-of-life care in the hospital setting? March 2

What are the best internet sites for medical information?  December 7

What do you do if you have symptoms that no one can figure out?  October 19

What can you conclude if you have chest pain that is relieved in the emergency room with a dose of nitroglycerin?  April 6

Do we really use rat poison to prevent strokes in humans? February 23

Is marathon running dangerous?  October 26

What kind of influence do drug companies have on our prescribing practices? May 11

Should someone with heart problems get the flu shot?  October 5

How much sedation are you really going to get with that medical procedure?  May 18

What constitutes adequate exercise for your heart?  May 26

What’s the latest thing in cardiac imaging and what are the risks?  November 23 and January 11

What are the treatment options for atrial fibrillation?  December 21

How can you best prepare for your next visit with your doctor so that your important questions will get answered?  March 23

Should you limit your peak heart rate when you exercise?  June 1

What are the characteristics of a good doctor?  September 14

How important is quitting smoking? August 10.  What’s the latest on smoking cessation products?  July 13

How useful is it to ask your surgeon how many times he or she has performed the procedure you’re scheduled to have? April 20

How can you stay in good shape as you age?  August 3 and September 28

What can you and your doctor do to cut your pharmacy expenses?  August 17

What’s the latest on the defibrillator ex-president George Bush received to protect his heart from the trauma of his pending divorce?  Oh, wait.  That wasn’t my blog.  That little pearl of scientific insight comes from The Globe.  No wonder their readership is bigger than mine.

A few weeks ago I happened across a news release from the American Heart Association that caught my attention. On an annual basis the AHA publishes its own top ten list (who doesn’t?) of the most influential research publications of the year. This year’s registry included the usual basic science papers with names that range from the arcane (“Circulating transforming growth factor-β in Marfan syndrome”) to the nearly unpronounceable (“Functional cardiomyocytes derived from human induced pluripotent stem cells”). In case you missed the purpose of the latter study, the authors package it up for you in a tidy soundbite: “The aim of this study was to characterize the cardiac differentiation potential of human iPS cells generated using OCT4, SOX2, NANOG, and LIN28 transgenes compared to human embryonic stem (ES) cells.” Oh, so that’s it?

I’m not knocking these studies—I’m not sure I’m even smart enough to read them—I just found that I gravitate more toward research that has direct application to my daily patient interactions.  One study in particular caught my eye and I was pleased to see it make the AHA’s top ten.  I had read it when in was published in September and was somewhat surprised at the findings.

Researchers studied the rate for heart attacks in three separate communities in the United States: New York state, Bowling Green, Ohio, and Pueblo, Colorado.  As far as I can tell, the only thing these three locales had in common was the precise reason they were put under the microscope: within the last few years their local legislators had passed strong laws that limited smoking in public places such as restaurants and places of employment.  The authors observed a 15% drop in the number of heart attacks in the first year after the smoking ban was put into effect and this decline only steepened with time.  After three years the rate of heart attacks among the general population had plummeted by 36%.

Didn’t we already know this?  Is this really news?  After all, the National Health and Nutrition Examination Survey measured nicotine levels among nonsmoking adults and found that only 13% of those living in regions with smoking bans tested positive compared to 46% living in jurisdictions without smoking legislation.  In 2006 the Surgeon General’s office devoted an entire annual publication to exposing the deleterious effects of secondhand smoke.

What’s different about this study, and why it is so important, is that this is the first real proof we have directly linking treatment (banning smoking in public places) to effect (decreasing heart attacks).  Yes, indeed, curbing the freedom of smokers to light up within the confines of an office or a restaurant not only enhances the pleasantness of the environment, it also directly impacts the health of those nearby.  And passing a law that pushes the smoker into the well-vented outdoors produces a real, measurable, and immediate effect on the risk of heart attack among the broader population.  It’s this kind of direct evidence that really moves the opinion of those in a position to enact public policy.

In June of last year Omaha enacted its own ban on smoking in public confines.  The local paper’s editorials were filled with tirades about the loss of freedom imposed by this draconian edict.  These letters came from tobacco’s most valued customers who vow to never give up the habit and don’t see the problem with the rest of us sucking in a few fumes now and again.

But I maintain that freedom from undeserved heart attacks and death is more important to our society than is the freedom to light up whenever and wherever you’d like.  It sounds like communities in New York, Ohio and Colorado believe the same and are now reaping the rewards of their decision.