Heart: An American Medical Odyssey (30 page)

Mr. Cheney’s increased fatigue is likely the
result of a decline in his
left ventricular contractility.
Although he is remarkably well compensated, he has little reserve. The stress test
shows no evidence of active ischemia but he was able to do less exercise compared
with his last exam 2 years ago. While the vice president is currently class II, I do
believe he would benefit from addition of spironolactone to his regimen. We will
also increase the dose of his Cozaar from 50 mg to 100 mg. As he does not get angina
I think we can stop the Imdur. This should give us a little more room in terms of
systolic blood pressure for maximizing the doses of his heart failure meds. We will
start by increasing the Cozaar and then in 1 week add spironolactone 25 mg
qd. . . .

The vice president’s ICD is now near end-of-life
and we will plan to have him return in July for elective replacement of the device
by Dr. Cindy Tracy.

•  •  •

Nearly seven years had elapsed since Dick Cheney first told Gary
Malakoff and me that he was going to run for vice president, and during those
twenty-five hundred days, Cheney’s overall health had been stable, although far
from uneventful. Now we were beginning to see a not-so-subtle decline in his
cardiovascular status. I still had no doubts whatsoever about the capacity of the vice
president to perform the duties of his office, but his care was becoming more complex.
Congestive heart failure (CHF) is defined as the inability of the heart to maintain an
adequate output of blood, and it was becoming abundantly clear that Dick Cheney had
CHF.

A few days after the testing at the MFA, Lew Hofmann drafted a summary
for the vice president:

The Naval Observatory

June 11, 2007

Mr. Vice President

I know that we threw quite a bit of information at you
in a
short period of time on Friday. I thought I would take a
moment to review our findings and recommendations. . . .

Your Heart

There is no way I can improve on Dr. Reiner’s
lucid description of the current status of your heart. Both your symptoms and the
imaging confirm that there has been some decrease in pumping function. There was no
evidence of new blockage.

The Plan

Dr. Reiner would like to make medication adjustments
which should help preserve your heart’s ability to pump
effectively.

Cozaar
is a drug called an “ACE Receptor Blocker” which has been
shown to preserve and sometimes improve heart function. You were on a middle-sized
dose of 50mg; we will increase it to 100mg. Cozaar is also used to treat high blood
pressure, so there is a small risk of lowering your blood pressure to the point
where you might feel lightheaded when we make the dose increase.

Imdur
is a drug in the class of “nitrates” which are used to
treat angina. Dr. Reiner started you on this as a precaution when you had a fleeting
episode of chest pain some years ago. You have been free of chest pain since. Imdur
can lower your blood pressure as well, so we feel that stopping the Imdur may
counterbalance the blood-pressure-lowering effect of the higher dose of
Cozaar.

Inspra and Aldactone [spironolactone] are medications
which are also beneficial in preserving heart function. Once you are stable on the
new dose of Cozaar, Dr. Reiner may decide to add one of these medications to your
regimen.

One of the earliest things which will change if your
heart is having more trouble is your weight. You will probably gain a few pounds
before you begin to develop shortness of breath or changes in exercise tolerance. We
want you to
record your weight daily
from now on, and let us know right away if you experience unexpected
weight gain.

Your ICD

We are proceeding with plans to change out the ICD in
July,
most likely on a Saturday morning. This will take place
in the main hospital. The new ICD will include the ability to do a very sensitive
check on your fluid status. . . .

. . . And Some Good News

Your cholesterol numbers continue to be
excellent:

Total cholesterol 171 (normal less than
200)

HDL (“good cholesterol’) 58 (desirable
greater than 40)

LDL (“bad cholesterol’) 61 (desirable less
than 100)

Triglycerides 259 (desirable less than
250) . . .

Drs. Reiner, Bosch and I are all devoted to not only
helping you be the very best vice president you can be, but also to securing for you
the healthiest possible future.

Very Respectfully

Lewis A. Hofmann, MD, FAAFP

White House Physician

The data from the vice president’s ICD in June had shown that the
battery in the six-year-old device was nearly depleted. Implantable defibrillators have
sealed titanium cases, and when the battery is exhausted, the entire “can,”
electronics and all, must be replaced. The procedure, referred to in cardio slang as a
“gen change” (generator change), can usually be accomplished in a
thirty-minute outpatient surgical procedure with sedation and local anesthesia, during
which the subcutaneous pocket is opened, the old device is unscrewed from its leads, and
a new device is inserted. The fact that the old ICD had never been called on to treat a
dangerous arrhythmia did not in any way affect our decision to replace it, and one could
argue that the decline in the vice president’s heart function made a defibrillator
even more imperative. Since the original implant, new features had been introduced, and
I was particularly interested in its ability to detect the onset of congestive heart
failure.

Fluid accumulation, particularly in the lungs, is one of the hallmark
features of congestive heart failure, and it often has an insidious onset. Engineers at
Medtronic, the Minneapolis-based biomedical
device manufacturer,
leveraging the fact that an ICD is essentially an implanted electrical circuit,
developed a method to detect the early warning signs of CHF by monitoring changes in
intrathoracic impedance. Electrical impedance is a measure of the resistance to the
passage of current through a circuit and is reduced by the presence of fluid in the
chest. One of Medtronic’s new ICD models had a feature that they called OptiVol,
which had the ability to track daily intrathoracic fluid levels, and I thought this
would be useful for monitoring the vice president for incipient heart failure.

ICDs with OptiVol are produced with a usually helpful capability enabling
wireless interrogation and programming without the traditional need to rest a mouse-like
programming head on the skin above the device. I had learned a lesson from the original
implant experience, and since that time had tried to tailor data-driven treatment
recommendations to the unusual work and lifestyle of this particular patient. After the
vice president received the ICD in 2001, we searched, after the fact, for potential
sources of electromagnetic interference in his residence, office, limousine, helicopter,
and airplane, and thankfully found none.

This time I wasn’t concerned about accidental interference causing
the ICD to malfunction; instead I was worried that a sophisticated attacker might
wirelessly access the device, reprogram it, and potentially kill the vice president. I
broached my concerns with Dr. Cindy Tracy, and she said she would look into it.
Medtronic told Cindy that the feature was not customizable, and if she wanted OptiVol,
it would also come with wireless. After confidentially disclosing to the company the
background for our request, Medtronic agreed to create a one-time change to the new
ICD’s firmware that disabled its wireless functionality. Medtronic no doubt
thought I was paranoid or had seen too many episodes of
24
,
but in 2013,
a computer hacker disclosed that he had
reverse-engineered a device programmer and showed that it was “100 percent
possible” to load compromised firmware into an implanted device using a laptop,
exactly the way the fictional terrorist Abu Nazir killed the vice
president on
Homeland
.

As we approached the end of our second term in office, I was aware that my coronary artery disease was progressing. Some days I had trouble walking up the stairs in the vice president’s residence to the second floor. I had had occasional episodes of atrial fibrillation, which caused excessive fluid buildup and sometimes made breathing difficult.

Nevertheless, my health still was not interfering with my ability to do my job. In September 2008, we took our last major international trip to Georgia, Azerbaijan, Ukraine, and Italy. One of the most significant historical events during my years in public office had been the collapse of the Soviet Union, marking the end of the Cold War, the withdrawal of Soviet forces from Eastern Europe, and the liberation of the former Soviet Republics in the “near abroad,” the independent republics that lie near to or border Russia. Vladimir Putin once referred to the collapse of the Soviet Union as “the greatest geopolitical catastrophe of the century.” In my opinion, he never accepted the notion that former Soviet Republics such as Georgia, Ukraine, and Azerbaijan should be free of Russian domination. In 2008, he used military force to reassert Russian authority in the Near Abroad.

My trip came in the aftermath of the invasion of Georgia by Russian forces. Georgia’s president, Mikheil Saakashvili, whom I had known previously, contacted me and told me how deeply concerned he
was about what was happening to his country. At one point, the Georgians were convinced the Russian tanks were only a few miles from the capital of Tbilisi. My trip was meant to reinforce the proposition that the United States was committed to the freedom and independence of those states that had gained their freedom when the Soviet Union went out of existence. Ukraine had been threatened by a Russian attempt to install a pro-Russian candidate in the presidency. The people of Ukraine rose up in the Orange Revolution, which led to a second election and the presidency of Viktor Yuschenko. During his campaign he had fallen seriously ill, apparently the result of having been poisoned by pro-Russian elements. Azerbaijan incurred the wrath of the Russians when it tried to build a gas pipeline to southern Europe that would compete with the monopoly the Russians enjoyed as purveyors of natural gas supplies to Western Europe.

The year 2008 was also a presidential election year. I was not actively involved in the campaign, in part because Senator John McCain, the Republican candidate for president, was trying to put as much distance as possible between his campaign and the Bush-Cheney administration. That fall, our administration was also dealing with the global financial crisis. I sat in on many of the meetings and was asked by the president to work to build support for our position among House Republicans. The major responsibility for monitoring developments and developing and implementing the president’s policy fell to the secretary of the treasury, Hank Paulson, in close consultation with the chair of the Federal Reserve, Ben Bernanke.

At one point during the fall campaign, McCain asked the president to convene a meeting with the congressional leadership to discuss the economic crisis. McCain suspended his campaign and returned to Washington to attend the meeting organized at his request. When first called on by the president, Senator McCain had nothing to say. When the president called on Harry Reid, majority leader, for his views, he indicated the Democrats had agreed that Senator Barack Obama would speak for all of them. It was clear the Democrats had their act together
and the Republicans didn’t. After the meeting, it wasn’t at all clear why McCain had asked for it in the first place.

As our administration drew to a close, Lynne and I moved from the vice president’s residence to a new home in McLean, Virginia, just outside DC. The weekend before the inauguration, I was lifting a box and injured my back. The injury put me in a wheelchair and eventually required surgery to repair a herniated disc.

During the early months of 2009, we adjusted to being private citizens once again as we split our time between our house in McLean, Virginia, and our home in Wyoming. We took the entire family on the vacation of a lifetime: a week cruising the coast of Alaska from Ketchikan to Juneau. Although I had no major problems on the trip, I did have certain limits. When everyone got off the boat to hike to a special area to observe Alaskan brown bears, I had to stay behind because I was concerned the hike would be too strenuous.

For several years in the 1990s, I traveled every year with a group of friends to British Columbia to fish for steelhead, one of the world’s great challenges for fly fishermen. I had to give it up when I was vice president because all of the security and logistical arrangements when I traveled involved the use of US governmental resources. I couldn’t justify doing so just so I could go out of the country to fish.

October 2009 was the first chance I had to go back, but it required a long, complex trip on commercial flights. When I got to the Babine River in northern British Columbia, I found I had difficulty spending a full day on the river. Steelhead fishing requires wading in fast, often deep water. All I could handle was a couple of hours a day. I spent the rest of my time next to a fire in the lodge. On my annual pheasant-hunting trip to South Dakota, I wasn’t strong enough to stay in the field all day with the rest of the party.

A major factor in the transition back to private life from being vice president is the loss of the tremendous support mechanism that surrounded the person who is in that office. Lynne and I lived in the vice-presidential residence that used to be the quarters of the chief of naval
operations. For a long time, vice presidents lived in their private homes, but in 1974, Congress decided to provide quarters and moved the chief of naval operations to other facilities. To this day, the Navy provides the personnel who operate the residence, and they are superb.