Politicians, especially US presidents, are involved in the harsh, palatable realities of politics, activities that lead not only to headaches but to heartache as well. Once someone in power presents with cardiovascular disease, its management becomes the subject of debate among the medical community and the media; it boosts heart disease awareness and opens our eyes to the variety of treatment modalities. Although he did not present with symptoms of coronary artery disease, this past summer former US President George W. Bush received a stent after a blockage was discovered during a routine physical examination that included a stress test. An abnormal finding on electrocardiogram led to a computed tomography angiogram where the coronary lesion was detected. That lesion was treated with a stent as first-line therapy. Immediately after implantation, a ferocious debate arose. So what provoked this debate?

Throughout the years, there has been a movement to minimize the use of stents as first-line therapy for the treatment of patients with significant coronary disease even when symptomatic; medical therapy was historically advised as a first-line therapy in this population, especially within asymptomatic subjects. How will stent implantation improve symptoms for symptomatic and asymptomatic patients? The American Heart Association states that in asymptomatic individuals, a stress test should not be part of routine screening. Dr. Steven Nissen (Cleveland Clinic, OH) recently stated in an interview that routine stress testing in patients without symptoms can lead to non-indicated procedures. He added that Bush likely, “…got the classical thing that happens to VIP patients, when they get so-called executive physicals and they get a lot of tests that aren’t indicated. This is American medicine at its worst.” In contrast, in a video statement from the president of the Society for Cardiovascular Angiography and Interventions (SCAI), Dr. Ted Bass recognized that heart disease treatment is complicated and admitted that medications are the first line of therapy while stents are secondary, both to failure of the drugs to relieve symptoms or when the drug is not well tolerated. In his recorded video message Dr. Bass recommend that patients consult with their physicians for optimal, individualized therapy.

When a recent poll on www.crtonline.org asked whether asymptomatic patients with positive stress tests and significant lesions should undergo coronary stenting, physicians answered: yes, 70%; no 24%; and unknown, 6%. So why the controversy? Is it because medical therapy has historically been considered adequate for these patients and that stents do not prolong life or reduce heart attacks in stable angina patients? Is it cost driven? Or is it due to fear of complications, such as stent thrombosis and restenosis? With recent improvements in stent technology that mitigate complications and improve efficacy, and with the introduction of bioabsorbable scaffolds, which are completely reabsorbed within a few years, it is time to be open minded and consider a paradigm shift; a shift that accepts stents and equates their usage with medical therapy for stable angina treatment. In consideration, none of the recent studies, including COURAGE, has shown superiority of medical therapy over stenting. Although stenting did not demonstrate superiority over medical therapy with respect to death and myocardial infarction, stenting often resulted in immediate elimination of the blockage and rapidly resolved the anginal symptoms and ischemia, which was driven by the blockage.

It is conceivable that stent placement can alleviate angina and ischemia almost immediately. This information should be presented to stable angina patients as they weigh their treatment options, similarly to the way the heart team discusses revascularization options. I can only assume that such a discussion was conducted with former President Bush who was fully informed of the appropriateness criteria and of the value of stent placement versus medical therapy in his condition.

Over the past 70 years tremendous progress has been made in the prevention and treatment of cardiovascular disease, resulting in a 60% decline in heart disease and a nearly 70% decline in stroke rates. To further expound on this progress, let us have a look at four former US presidents and one vice president. When “I like Ike” Eisenhower suffered an anterior wall myocardial infarction in 1955, the then-president called it indigestion and blamed it on onions. With delayed and limited treatment at the time, he suffered from severe congestive heart failure but his ambulation was aggressive. Instead of being kept in bed for 6 months, his doctor ordered Coumadin, a low fat diet, and maintenance of a healthy weight. Although he ultimately died of heart disease, his recovery from this first attack was rapid and changed the way infarct patients were treated thereafter. That same year, then-Senate Majority Leader Lyndon Johnson spent 6 weeks at Bethesda Naval Hospital following a serious heart attack. It proved impossible to keep Johnson away from the action he thrived on. Doctors lifted the news blackouts and gave up on limiting visitors, since too little activity, they concluded, was more likely to cause a second attack. Fast forward 50 years, and although former President Bill Clinton did not have a heart attack, he underwent quadruple bypass in 2004 and percutaneous coronary intervention in 2010. This intervention included the implantation of two stents to open narrowed arteries for the treatment of unstable angina and to prevent a heart attack from occurring. This same year, Mr. Clinton became a vegan. Additionally, former Vice President Dick Cheney has suffered from five heart attacks since the age of 37, has undergone coronary artery bypass graft surgery and implantation of defibrillator, and by 2012—after a long struggle with heart failure and after undergoing a series of progressive treatments, including left ventricular assist device implantation—he finally received a heart transplant.

Clearly, the case of former President Bush is different and speaks more toward the value of primary prevention in an asymptomatic, physically active individual, who was found to have a significant lesion in his coronary arteries following a routine stress test. The two issues subject to controversy include whether a healthy, asymptomatic individual without traditional risk factors should undergo routine stress test and whether stenting should be the preferred treatment if a blockage is found on angiogram. Heart disease detection and prevention became most effective in heart disease eradication and impact the way we screen and treat our patients. Nevertheless, it is estimated that more than 600,000 Americans die each year from heart attacks. We often see in our practices or on the news individuals who experience sudden cardiac death as their first manifestation of coronary artery disease. Most likely, appropriate screening and preventative measures could have prevented these heart attacks and, ultimately, cardiac death. The value of routine coronary artery disease screening via stress testing or other noninvasive tests (calcium score, computed tomography angiogram or carotid intimal thickness measured by ultrasound), in addition to an annual physical examination for healthy individuals, is the subject of ongoing research. Meanwhile, it is important to recognize that traditional risk factors are no longer sufficient to detect significant coronary artery disease. Further, significant plaque development is a dynamic process and passing one’s stress test is not a lifelong guarantee for clean coronaries. Stents are an easy fix for coronary blockage; however, stents have nothing to do with prevention, which requires an adequate diet, exercise and optimal medical therapy with continued screening for patients at risk. Stents alone cannot prevent heart attacks, but that does not mean we should not use them to open severe blockages, even in asymptomatic, stable patients.