Former President Bill Clinton's heart disease and its treatment have been in the headlines of late, and no wonder: heart disease due to atherosclerosis (fatty deposits also containing cholesterol) is the leading killer of Americans, with a death toll of over one-million annually. But for many of us in his age range, the reasons we are so interested are complex: aside from humane concern for his health, we also think: if heart disease can sneak up on an apparently healthy and robust ex-president, who among us is immune?
We all want to know, "what caused it, what were his risk factors?" The media (and even the president himself, when he called in to the Larry King Show from his hospital bed) have expressed a simple cause: too many cheeseburgers. The truth is much more complicated. In the large majority of Americans who are not unusually susceptible, dietary intake of fats and cholesterol plays only a minor role in the genesis of coronary heart disease such as Clinton's (see ACSH's classic publication on preventing coronary heart disease:
Chemoprevention of Coronary Heart Disease.).
His medical history, not well-publicized until now, shows more of the relevant precursors: a family history of sudden premature death (an important predictive factor for heart disease), elevated blood pressure, cigar smoking, and especially, elevated cholesterol and other lipid abnormalities. (Cigarette smoking is a major risk factor for heart disease, but Mr. Clinton did not smoke cigarettes. The causal relationship between occasional cigar smoking and heart disease is not as well established).
Since he was not a cigarette smoker, the lipid abnormality is likely the most important of the factors under his control, aka "modifiable" factor (as opposed to non-modifiable factors such as being male, and family predisposition to heart disease). Apparently, he was discovered to have moderately high total cholesterol in association with high "bad" cholesterol (LDL) while he was still in office. Amazingly, while he was put on appropriate therapy with a lipid-lowering statin drug, this treatment lasted for only a brief period. When he lost some weight, we are told, he made the decision to stop the medication.
Of course, this may be an incomplete picture of Mr. Clinton's medical history. Furhter, his current situation may not have been prevented had he stayed on the cholesterol drug continuously. But, as a rule, elevated lipids are not a transient phenomenon--once present, life-long treatment is almost always needed as a preventive measure against atherosclerosis. It seems to me that if he had reasons to be started on a statin, such treatment should have been continued--especially given his other known risk factors.
Bill Clinton's case also illustrates the emergency physician's devilishly difficult task of evaluating a middle-aged man with vague symptoms. We are now told that he had had complaints of "indigestion" and "heartburn" at times, which may well have been atypical symptoms of developing heart trouble, "atypical angina" as it's called medically. This often occurs without hard evidence, such as abnormal EKGs or even with a negative exercise stress test. It's not possible to hospitalize and do an angiogram on everyone who comes to the ER with indigestion, so some, like the ex-president, are turned away with only symptomatic treatment. Some of these folks go on to develop complications, including heart attack and even death.
Mr. Clinton was indeed fortunate that his discomfort became severe enough to warrant urgent evaluation and treatment, yet did not progress to serious heart damage. He would be well advised to continue to lose weight, and quit smoking entirely. He will likely be treated long-term with statin drugs, as well as aspirin to prevent clots in his arteries, and other drugs to relax the heart and reduce his blood pressure.
We should all learn a lesson from his example: even moderate elevations of cholesterol and LDL should not be ignored, borderline high blood pressure should be treated. His occasional indulgence in "fast food" was not what put him in jeopardy, despite this being the easy answer for the news media.
