What Happened To Bill Clinton and His Heart?

What happened to Bill Clinton and his heart condition this week and why was he hospitalized?  What he experienced  was a natural expectation of complications from his history with coronary artery disease.   As you know the former President Bill Clinton underwent open heart surgery several years ago after a brief episode of chest pain and shortness of breath, two cardinal symptoms of coronary artery disease.  In 2004, Dr. Craig Smith performed  quadruple heart bypass on Bill Clinton  at New York Presbyterian Hospital/Columbia  to bypass multiple blocked coronary arteries, some of which were greater than 90% blocked with cholesterol plaques.

I remember back in my pre medical school days always hearing about medical terms on television and the newspaper and never quite understanding what they meant. Some of those terms included atherosclerotic heart disease, heart disease, coronary artery disease.  coronary atherosclerosis.  If you don't know what all these terms mean as a lay person, I'm going to give you a brief physiology  (and pathophysiology) lesson. Refer to the pictures for assistance.  

Our heart and lungs are really nothing more than a fine tuned machine to distribute oxygen to all the cells in our body and to pick up carbon dioxide for disposal.  We breath in oxygen and breath out the byproducts of metabolism, carbon dioxide.   The oxygen we breath in is received by blood as it passes through the capillaries of our smallest lung cells called alveoli (which die and become scared by chronic tobacco smoking).  The oxygen is picked up by the red blood cells circulating in our blood vessels and the blood continues into larger and larger blood vessels as they all meet at the pulmonary veins.  From the pulmonary veins, the red blood cells make their way to the left atrium.  The blood then passes through the mitral valve on its way to the left ventricle.  The left ventricle is the power horse of the body.  It squeezes the blood out through the aortic valve and into the aorta, the main blood vessel of the body, which then carries the blood (which is carrying oxygen) to all the cells of our body.

Pathophysiology Lesson #1:  When you have high blood pressure, the left ventricle becomes thick because it is a muscle itself and in order to squeeze out its blood against a higher pressure (that's what high blood pressure means), it too must get bigger (like the big biceps of a weightlifter).  This thickness eventually causes the left ventricle to fail and that can lead to heart failure (which generally means that the pump has failed).  In this case, we call it left ventricular heart failure.  There are two main kinds, left ventricluar systolic heart failure and left ventricular diastolic heart failure.  A normal left ventricle pushes out about 55-65% of the blood in its chamber with each squeeze.  When the left ventricle becomes thick, it can't relax enough after each squeeze to accept more blood from the left atrium.  It becomes stiff.   And blood can back up into the lungs.  This is called left ventricular diastolic heart failure, or failure during diastole, which is the relaxation period of the left ventricle. 

The other kind of left ventricular failure is called left ventricular systolic heart failure.  Systolic heart failure occurs when the left ventricle  has lost the ability to squeeze blood forward effectively.  The left ventricle usually becomes enlarged (called cardiomegally) and thinned out ("stretched").  A common cause of systolic heart failure is heart attack  (more on that later) .  As a result of systolic heart failure, the left ventricle can only pump forward 5-45% of the blood with each contraction.  That's what it means to have a low ejection fraction.  The left ventricle simple doesn't have the strength or the muscle tissue to squeeze the blood forward.  This is a type of chronic systolic heart failure, or failure during systole, which is the squeezing period of the left ventricle.

When  someone eats a lot of salt or has uncontrolled high blood pressure, the increased volume of fluid in the blood ( water follows salt) and the higher pressure to squeeze against causes the blood to back up into the left atrium and back into the lungs.  Fluid in the lungs is called pulmonary edema which is manifested by shortness of breath with lying down (orthopnea) or coughing when lying down (paroxysmal nocturnal dyspnea).  Sometimes a chest xray will also show pleural effusions, which are a collection of fluid in the pleural space (the outside lining of the lung that separates the lungs from the ribs, muscles and tissues of the thorax).

Clinical findings of heart failure also include jugular venous distention (JVD) where by the jugular veins in the neck become engorged with blood from the higher pressures of blood backing up into the lungs. Leg swelling is also a very common finding.  As the blood backs up into the lungs it increases the volume of fluid in the right side of the heart, or the venous system, and that causes swelling.  On occasion, fluid can also increase in the belly and that cause the belly to swell with ascites.

What is Bill Clinton's ejection fraction? I don't know if Bill Clinton has heart failure or not.  I couldn't find any source that disclosed that information.  He was not noted to have a heart attack before his 2004 operation.  If the pump has not failed prior to bypass surgery, the ejection fraction is usually preserved after.  If there was no heart attack preceding his original surgery, his pump is probably squeezing just fine, which explains his ability to keep up a rigorous schedule.  However, I don't know what his original left ventricle was like.  I don't know if he had signs of left ventricular hypertrophy (thickening) from high blood pressure or not.

Once the blood is pumped into the aorta and out to the rest of our body, the oxygen in the red blood cells is picked up by all the tissues in our body from  capillaries.  Blood vessels (arteries) get smaller and smaller eventually becoming capillaries.  On a cellular level, all the tissues in our body get the oxygen they need and get rid of their carbon dioxide at the capillary level. The deoxygenated blood after passing by all the cells in our body is then returned to the heart by way of larger and larger veins (artery=oxygen, high pressure, vein=deoxygenated, low pressure).  All the blood returns to the right side of the heart by way of the large blood vessel  returning blood from the body (inferior vena cava) and the large vein returning blood from the brain (superior vena cava), both of which enter the right atrium of the heart (see the first picture above).

Once the deoxygenated blood enters the right atrium, it passes through the tricuspid valve into the right ventricle which then pumps the blood through the pulmonic valve and into the pulmonary arteries.  From the pulmonary arteries the blood enters the network of capillaries in the lung  and picks up the oxygen from the lung tissue and drops off the carbon dioxide (the byproduct of cellular metabolism) which you breath out.  And that's the lifecycle of a red blood cell.  Your red blood cell will last approximately 120 days before it dies.  Your body is constantly making new red blood cells in your bone marrow and spits them out according to another entirely complicated hormonal feedback system.

Pathophysiology Lesson #2: As a hospitalist, I am keenly aware of the increased risk almost all medical and surgical patients have for the development of deep venous thrombosis, which are blood clots in the deep veins of the body (the deoxygenated, low pressure system).  Usually blood clots will form in the leg veins and travel up through the inferior vena cava, into the right atrium, pass through to the right ventricle and into the lungs by way of the pulmonary arteries.  When the blood clots get lodged into the pulmonary arteries, or smaller branches out in the lung periphery, they can prevent the lungs from exchanging oxygen.  If you lose a large portion of your blood vessels in your lungs (which is also what happens in smokers), there is no way for your body to pick up the oxygen in the lungs.  As a result, you are required to wear oxygen, forever.  

Clinically, a pulmonary embolism can cause pain with inspiration or coughing, coughing up blood, tachycardia (fast heart rate) and increased pulmonary artery pressures.  They may cause your right ventricle to acutely dilate (the low pressure right ventricle now has to pump against a higher pressure caused by clots blocked in the pulmonary arteries) and that can cause you blood pressure to plummet because your right ventricle can't handle the load and can't overcome the high pressure acutely causing an acute shock like state.  And death.

If you can't get blood to the left heart because it's all blocked up in the lungs, you can die.  This is why massive   pulmonary emboli can also cause sudden death.  It's also why folks who are morbidly obese, who smoke or who have obstructive sleep apnea all have a form of right sided heart failure.  The normally low pressures of the venous system become elevated. Why?  Because the right side of your heart, your right ventricle, is not used to pumping against high pressures.  It was not made to do so.  Sleep apnea, obesity and emphysema from chronic smoking all cause the pressures within your pulmonary arteries to increase which causes the right ventricle to work harder.  What is the side effect of such a process?  Right heart failure  which causes swollen legs.  Sometimes painfully swollen.  And there isn't a lot doctors can do to fix the problem.  It also significantly increases the chance of oxygenation problems and increases morbidity and mortality.  The solution is weight loss, weight loss, weight loss.

So now I've talked about the life cycle of the blood cell as it travels from the left side of the heart to the tissues and back to the right side of the heart.  What does this have to do with Bill Clinton and his heart and his recent hospitalization?  For that, you now have to understand what a coronary artery is. The aorta is nothing more than the giant artery coming out of your heart to carry oxygen to all the organs of your body.  It splits into smaller and smaller and smaller arteries, each with their own name.  The carotid artery takes blood to your brain.  The renal artery takes blood to your kidneys.  The femoral artery takes blood to your legs.  The coronary arteries take blood to your heart.

You can see from this picture that there are three main coronary arteries that receive their blood from the base of the aorta.  The three main coronary arteries of the heart are the right coronary artery (RCA) the left anterior descending (LAD) and the left circumflex artery (LCx).  The left main coronary artery is the stump that divides into the LAD and the LCx.  When you have a blockage here it's called the widow maker.  Why?  Because, as you can tell, the LAD and the LCx provide blood to the left ventricle, the main pump of your heart.  You lose that and you're a dead man.  That's the main anatomy of the coronary arteries.

Coronary arteries are subject to the same stresses as all the arteries of the body.  If you are sedentary, obese, have high cholesterol, smoke and choose to become a type II diabetic your arteries will suffer.  All of these actions are toxic to your blood vessel endothelium ( the inside lining of your blood vessels).  As a result of that constant toxic irritation, cholesterol and lipid plaques develop on the inside lining of your arteries.  Over years, that plaque gets bigger and bigger, eventually leading to signs and symptoms of blockage.

When blood can't pass through the blockage, any exertion (which increases the need for blood and oxygen at the cellular level) causes the pain, shortness of breath and  nausea  known as angina.  When the angina comes on only during exertion, it's known as stable angina.  When the angina comes on at rest it's known as unstable angina.  When the artery is 100% blocked, that represents a myocardial infarction (MI), also known as a heart attack.  What turns a stable plaque with angina into an unstable plaque with an MI?   A stable plaque "ruptures" (I don't think anyone knows why) and a clot of blood and cholesterol and lipid forms in the artery turning what was once a stable 60% lesion into an emergency.  That's why we use clot busting drugs for acute MI.  While the plaque can be there for years, it's the rupture of the plaque and clot formation that will kill you.

As physicians we can differentiate between different arteries undergoing angina/ischemia (ischemia ST segement changes on an EKG are depressed and T waves are often inverted indicating a lack of oxygen) or full thickness heart muscle death of an MI (ST segment elevation on an EKG).  There are generally 12 lead patches that are placed on your chest wall when doing an EKG. The leads on your chest  correlate with your EKG which correlate with the anatomy of the blocked artery.    For example, look at this normal EKG below.  ST segment changes in lead II,III or aVF will often indicated inferior ischemia, or blockage or the right coronary artery.  ST segment changes in the V2-V4 leads can often indicate anterior ischemia or LAD coronary distribution blockages.  ST segment changes in lead I or aVL or V5, V6 can often indicate ischemia or infarction in the lateral distribution, or left Circumflex (LCx) artery.  That's the simply skinny on coronary artery disease.

Using a combination of your clinical symptoms, your risk factors, your history, your ECG changes and your serial blood markers such as troponin, CK or CK-MB your hospitalist, internist, family medicine doctor and cardiologist can risk stratify you into an urgent or watchful waiting scenario and decide whether you should undergo urgent heart catheterization, stress test or nothing more than medication management.  Or nothing at all.  Perhaps all you need is a Green Goddess.

In the case of Bill Clinton, he had multiple blocked arteries diagnosed in 2004.  There are several options on how to handle blocked coronary arteries.  The deciding factor on which option to pick is supposed to be decided by how many blocked arteries there are, the degree of blockage in the arteries, whether the patient has any symptoms or not and whether they have diabetes or not.  Options for blocked arteries include
  • Ballon Angioplasty A catheter is placed from the groin into the heart (that's why it's called a heart catheterization) and dye is delivered which lights up the coronary arteries under a special fluoroscopy machine.  Once a blockage is visually determined, a ballon is opened up in the blockage, crushing the cholesterol and lipid plaque against the side of the blood vessel wall and opening up the artery.  The procedure often takes less than an hour.
  • Stenting  In the same type of procedure as a ballon angioplasty, a catheter is guided from the groin into the coronary arteries dye is used to find the offending blockage and stent is deployed over the lesion from the tip of the catheter.  Recent stents are coated with medication which prevent them from clotting up again.  They require the use of Plavix, a type of super aspirin ( and super expensive), and nobody knows exactly how long you need to be on the drug.  Plan on at least a year, perhaps longer.  That's $1,500 a year , just in medication costs for the stent.  The other option is a bare metal stent (prior to the drug coated stents).  Which to use and when, I have no idea.  Ask a cardiologist!
  • Coronary Artery Bypass Surgery. That's why it's called a CABG, not cabbage.   That's what Bill Clinton had done.  The surgeon takes the artery from inside your chest wall (LIMA or left internal mammary artery) or veins from your leg (SVG or saphenous vein grafts) and sutures them into your coronary arteries on either side of the blockages, thereby bypassing your coronary arteries containing  the blockages.
  • Lifestyle and Medication Management  Sometimes no procedures are necessary  and the blockages are treated with lifestyle modifications and medications such as diet, exercise, stopping smoking, statins, aspirin, and depending on the left ventricular ejection fraction, beta blockers and ACEi  may also be added. 
With all that said, I think it's safe to say I know what happened to Bill Clinton and his heart and why he was hospitalized?  Here's the answer.  Six years ago he was diagnosed with multiple blocked arteries in his heart.  He underwent bypass surgery on four coronary arteries to bypass the blockages in his native vessels.  He lost weight as is clearly evidenced by his before and after pictures.  I assume he exercises and doesn't smoke, unlike our current President who double talks about the mandate for insurance while catching drags of cigarettes in the Oval Office.  As far as I can tell, Bill Clinton has done everything he needed to do to fight his disease process.  So what happened to Bill Clinton?

It looks like he was hospitalized this week because of chest pains.  He did not have a heart attack (damage to his heart muscle).  He had chest pain related angina ( a warning sign) .  MSNBC reports that one of his bypass grafts was completely occluded.  Instead of trying to open the bypass graft, he got two stents placed in the native coronary artery that was occluded years ago.    I heard on the news last night that the failure rate of the grafts is about 10% or so after 5-6 years.  So what Bill Clinton experienced was a natural expectation of the limitations of modern medicine.   Vein grafts aren't like arteries.  They have different biological expectations when placed in an environment they were never meant to be placed in.  Remember veins are part of the low pressure right heart system.  When you try and turn them into surrogate arteries in the coronary system, they are bound to suffer under the stress.  That's the limitation of our 2. 5 trillion dollar health care system.

What happened to Bill Clinton?  Why is he doing everything right and still experiencing complications?    He's suffering the fate he sealed years ago with his daily jogs to McDonald's.  The key to preventing heart catheterizations and bypass surgeries and clogged arteries and stenting and hospitalizations is not to find the motivation to change after you're stricken with illness.   That's like telling an alcoholic with end stage cirrhosis that if they quit they're liver will be normal again.  Or telling an oxygen dependent COPDer who smokes that quitting will make their lungs normal again.   It doesn't work like that.  Once you chose the lifestyle you choose, your consequences are often times irreversible.  Coronary artery disease is no exception.  Coronary artery disease is not curable.  It can only be managed.

The key is to prevent it from ever happening in the first place.  If Bill Clinton had found the motivation to live right in his early years he would, in all likelihood not be in the situation he is today.  Modern medicine is more like a band aid.  A very expensive band aid.

And now for a little Bill Clinton humor.  What would he have said if we was actually a doctor or nurse?  "I experimented with albuterol a time or two, and I didni't like it and I didn't inhale and I never tried it again."  See other famous quotes by famous people, had they been a doctor or nurse instead!

I experimented with albuterol a time or two, and I didn't like it.  I didn't inhale and I never tried it again.  Bill Clinton ecard humor photo.

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