Heart: An American Medical Odyssey (16 page)

Finally, I emphasized that I had not been vetted in the conventional sense and that I needed a day when I could meet with him and lay out all the reasons I wasn’t the right choice.

A few days later, I flew down to Austin and met with Governor Bush and campaign strategist Karl Rove at the mansion. We discussed the vice presidency, and Karl and I made essentially the same arguments against my candidacy, pointing out that I was not a good choice from a political standpoint. I underscored my misspent youth just as I had done with his father ten years before when I was under consideration for secretary of defense. I repeated that I had twice been kicked out of Yale and twice arrested for driving under the influence in my early twenties.

Finally, I focused on my history of coronary artery disease. I told him that I had to be aware at all times of my heart condition and that if I ever felt so much as a twinge, I would have to have it checked out immediately to determine whether I was having another heart attack. I said if it happened in the middle of the vice-presidential debate, I wouldn’t delay until the debate was over. I would, without hesitation, seek the nearest emergency room for the appropriate tests. The governor took all this in, and we arranged to have his physician, Dr. Denton Cooley, talk to my cardiologist, Jonathan Reiner, about my fitness to run and serve as vice president.

It soon became clear that Rove and I hadn’t been very persuasive. I received a call from the governor telling me that Dr. Cooley had reviewed my medical situation with Dr. Reiner and concluded that there was no health reason that I couldn’t run for and serve as vice president. A few days later the governor posed the question formally, asking me in an early-morning call to be his running mate as the GOP candidate for
vice president of the United States. That afternoon, Lynne, Liz, and I flew to Austin, and George Bush announced me as his choice for vice president on the GOP ticket.

I have never regretted my decision to accept his offer. I had been able to think of many reasons that it wasn’t a good idea, but in the end, there were two basic considerations that I found persuasive. First, I fit the profile of what he was looking for in a running mate because of my previous experience, especially in national security matters. Second, I was persuaded it would be a consequential vice presidency. He made it clear I would be an important part of his team, not just a typical vice president relegated to attending funerals and fund-raisers. President Bush kept his word throughout our eight years in the White House. He did not always follow my advice, but he always gave me an opportunity to tell him what I thought on important issues. I was able to play a significant role because that is what he wanted.

Some of my critics have suggested that I “manipulated the process” to get selected as vice president. That proposition is simply not supported by the facts. If I had wanted to be vice president, all I had to do was say “yes” the first time it came up with Joe Allbaugh.

In the end, I agreed to become vice president because George Bush persuaded me I was what he was looking for and that my experience would be a valued addition to this ticket. When you are asked to do something on behalf of the country, you have an obligation to try to do it. Looking back now some thirteen years after I made that decision, I am deeply grateful for the opportunity I had to serve during those difficult and challenging years. And I owe President George W. Bush a deep debt of gratitude for having made that possible.

The pink “While You Were Away” note said simply, “Dick Cheney called.”

A little annoyed to discover the message so late in the day, I asked my assistant,
Yaa Oforiwaa, why she didn’t page me when Cheney called hours earlier.

“He didn’t want to bother you,” she said.

For many years, Cheney’s cardiologist had been Dr. Allan Ross, an internationally renowned clinician and researcher. Allan was chief of cardiology at GW when I began my fellowship in 1990, and he quickly became a mentor. Allan brought me into his research group when I was a first-year fellow and later, when I completed my training, he gave me a job. After Allan’s retirement in 1998, Cheney’s internist, Gary Malakoff, asked if I would assume Cheney’s care. Gary told me that Secretary Cheney was now CEO of Halliburton, a Dallas-based company, but he still came to Washington periodically for checkups. I had met Cheney a few years earlier when he came in for a catheterization, and I told Gary I would be happy to see him.

Mr. Cheney’s most recent clinic visit was in November 1999, at which time he seemed to be doing pretty well. In spring 2000, Cheney had been in the news a lot. He was vetting potential vice-presidential running mates for Governor Bush, and the press was speculating that an announcement was going to be made soon. The Veep sweepstakes is a quadrennial DC obsession, and the spotlight at the time seemed to be focusing on Pennsylvania governor Tom Ridge.

Yaa told me that Mr. Cheney needed to schedule a clinic appointment in the next week or so, but he wanted to have a stress test first.

Why does Cheney need a stress test now?
I wondered.

I walked over to the clinic and tracked down Gary and asked him if Cheney was feeling all right. Gary told me that as far as he knew, everything was okay.

“Gary,” I said, “I think Cheney is going to run for vice president!”

•  •  •

Stress testing has been used for decades as a noninvasive way to assess the adequacy of the heart’s blood supply and is based on a fairly simple principle. Progressively vigorous exercise, usually walking on a treadmill
with increasing pace and incline, results in a rise in blood pressure and pulse, and consequently increases the work required of the heart. If the blood supply to the myocardium is intact and unimpeded, the continuously monitored EKG reveals only a faster heart rate. If a coronary artery contains a narrowing restricting blood flow, characteristic changes are often evident in the EKG tracing and patients may also develop chest pain. Ironically, this abnormal result is called a “positive” test (positive for whom?) whereas a normal result is referred to as “negative.”

If a patient has had a prior heart attack or has an otherwise abnormal baseline EKG, a standard stress test can be difficult to interpret, and myocardial perfusion imaging is often performed instead. At the outset of this procedure, commonly called a nuclear stress test, patients are injected intravenously with either the radioactive isotope thallium-201 or technetium-99m, agents that are avidly absorbed by the heart as long as the muscle is alive and the blood supply to it is unobstructed. Images of the heart are acquired while the patient lies under a gamma camera, essentially a digital detector of radioactive particles, a technology that was invented in the 1940s during work on the Manhattan Project. The patient then exercises, is injected with a second dose of radioisotope, and again is imaged under the camera. The entire process takes about two hours.

Normal heart muscle absorbs the tracer homogeneously, which the computer displays as color-enhanced, cross-sectional silhouettes, and the pictures at peak exercise should be similar to those obtained at baseline. If there is a blockage in one or more of the coronary arteries or the patient has had a prior heart attack, a defect is apparent in the digital images. A nuclear stress test is more sensitive and specific for detecting the presence of coronary disease than is a regular stress test, raising the precision of the exam. It does, however, expose the patient to a significant amount of radiation, about the same as a CT scan, equivalent to about 850 chest X-rays, enough to set off the radiation detectors at federal buildings like the White House. Still, for patients with a prior heart attack, known complex coronary disease, or women in whom the false-positive
rate for a regular stress test is quite high, nuclear imaging, can be quite useful.

•  •  •

Dick Cheney arrived unaccompanied for his stress test at George Washington University Hospital on July 11, 2000. He was able to exercise for nine minutes on the treadmill (about average for a fifty-nine-year-old man) and had no chest pain. Not bad. The nuclear images, however, were a mixed bag. While the test was unchanged compared to the prior year’s exam, with no signs of new ischemia, there was clearly evidence of significant damage from the old heart attacks involving both the lateral and inferior walls of the heart. Overall it was a stable but definitely abnormal test.

The next day, I stopped by Cheney’s internist’s office, and together Gary Malakoff and I walked over to the clinic to see Cheney. After brief pleasantries, Cheney almost matter-of-factly said, “It looks like I may be asked to run for vice president.”

I think Gary might have actually said, “Oh my God!” but I forced myself to channel some of Cheney’s preternatural calmness and tried to act as if patients tell me that all the time.

“What will you be able to say about my health?” Cheney asked.

I began by reviewing the results from the stress test and echocardiogram. I told Cheney that although the two studies clearly showed impairment of his cardiac function, a consequence of his three heart attacks, the results appeared to be stable when compared to tests performed a year earlier. It was a good sign that Cheney continued to lead an energetic life, with a very demanding job, and was able to ski at high altitudes and hunt, reassuringly without signs of clinical heart failure. I told Mr. Cheney that I felt his cardiovascular status was sufficient for what I could only imagine would be a remarkably fatiguing and stressful job, but although I thought he would do well, there was obviously no way I could predict the future. Cheney never really asked whether we thought he was physically fit to be vice president. I don’t think he intended the meeting to be the political version of preoperative clearance.
He simply wanted to know what we would be able to say. Before leaving, Cheney asked us to keep the news confidential until an announcement was made and told us that at some point, Gary and I would need to put together something in writing. At no time did he try to suggest what we would or wouldn’t be able to talk about.

•  •  •

Five days later, on Monday, July 17, my assistant Yaa called the cath lab to tell me there was a Dr. Cooley on the phone from Texas.

“Dr. Denton Cooley?” I asked.

“Yes, Denton Cooley.”

I didn’t know Dr. Cooley personally, but I certainly knew who he was. Dr. Cooley was one of the pioneers of cardiovascular surgery, and at eighty years old, he was still one of the world’s preeminent heart surgeons. Cooley’s career had been filled with legendary accomplishments. He was the founder of the Texas Heart Institute and its chief surgeon, and in 1968, he performed the first successful heart transplant in the United States. The following year, he implanted the world’s first total artificial heart, a gutsy attempt to save the life of a dying forty-seven-year-old man using an untested and unapproved device. In 1984, President Ronald Reagan presented Dr. Cooley with the Medal of Freedom, the nation’s highest civilian award.

“Do you know what he wants to talk about?” I asked.

“He didn’t say, but Dick Cheney called earlier and said it was okay for you to speak to him.”

I moved to a phone where I could talk in private and called Dr. Cooley in Houston. He was cordial but got right to the point. He told me that Governor Bush had asked him to review Dick Cheney’s medical history, and Cooley asked me to summarize it for him. After a quick, slightly uncomfortable flashback to medical school and my first day on cardiac surgery, I launched into a long, detailed, and comprehensive review of Cheney’s history.

I told Dr. Cooley about Cheney’s three prior heart attacks, the first at age thirty-seven and the most recent twelve years before, in 1988.
I discussed Allan Ross’s decision to send then Congressman Cheney for coronary artery bypass surgery and the details of the operation performed by Dr. Aaron. Following surgery, Cheney had undergone cardiac catheterization twice in the 1990s, both of which I had participated in, revealing that two of his bypass grafts had closed. One of these grafts, the left internal mammary, was not functioning, likely because all of the blood flow to the front of the heart was going through the relatively little diseased, “native” left anterior descending coronary artery that the graft was intended to bypass. The second graft undoubtedly had failed because Aaron had attempted to bypass the artery that caused the 1984 heart attack, which he described in his op-note as an “unfilled, unused, and atrophied vessel.” I went on to review the results of Cheney’s recent stress test and echocardiograms and his lack of symptoms or congestive heart failure. After I had spoken uninterrupted for several minutes, Dr. Cooley asked me if Cheney was ever in cardiogenic shock.

Cardiogenic shock is a critical condition defined as the inability of the heart to provide the bare minimum amount of blood necessary for organ function. If it is not quickly rectified, death usually follows.

“No, sir,” I replied.

“Well, then, I will call and reassure the governor,” Cooley said, thanking me for my time before ending the call.

Governor Bush later said, “Dick had talked to his doctor and then I got Denton Cooley to call Dick’s doctor to discuss the record, and I talked to Dick extensively about his health.” Mr. Bush went on to say that when Dr. Denton Cooley told him Mr. Cheney “was suited to be the vice president,
I felt that was good enough for me.”

Later that day, I wrote a letter to Gary Malakoff that reviewed the events of the prior week and summarized what I thought about Dick Cheney’s cardiovascular fitness to serve as vice president of the United States. I concluded the letter in this way:

Today I spoke with Dr. Denton Cooley after this was requested by Mr. Cheney. I reviewed Mr. Cheney’s medical history essentially as
I outlined it to you above. Later I spoke with Mr. Cheney. During that conversation I clearly reviewed what I consider to be key elements of his cardiovascular status; that his heart shows the effects of at least 2 prior MI’s, that his left ventricular performance is impaired but he has no symptoms c/w CHF [congestive heart failure] and has no angina. I stated that his risk of an adverse event is higher than a person of similar age without heart disease but that his short-term and long-term risk is not quantifiable. I also mentioned that his current vigorous lifestyle is in many ways very reassuring.