Heart: An American Medical Odyssey

by Cheney, Dick

  Overall, the vice president has felt well. He recently completed a long overseas trip which covered approximately twenty-five thousand miles and sixty-five hours of flight time. Two days ago after arriving back in Washington, DC Mr. Cheney began to note some mild discomfort in his left calf, extending up to the back of the knee. The vice president did not note any swelling in the ankle. There was no chest pain or shortness of breath.

  On examination the left calf is subtly larger in diameter and mildly more tense than the right calf. The left leg has a mildly positive Homans” sign [pain in the calf when the foot is flexed]. The DP and PT pulses are 2+ bilaterally.

  Arterial and venous ultrasound of the right leg revealed no evidence of DVT and the popliteal stent graft is widely patent. Venous ultrasound of the left leg shows a prominent thrombus in the left popliteal vein extending into the TP and tibial and peroneal veins. Arterial imaging of the left leg was not performed.

  In summary, Vice President Richard Cheney has developed a left lower extremity DVT [deep vein thrombosis] most likely caused by his recent extensive plane travel. We have begun enoxaparin 100mg SC q12 hours (first injection given at the time of this examination) and warfarin 5mg qd [blood thinners]. . . . I told Vice President Cheney not to perform his usual exercise regimen. We will plan to repeat the venous imaging study in 1 month’s time.

  Jonathan S. Reiner, MD

  Blood returns to the heart from the long and capacious veins of the legs aided by periodic propulsive compression of surrounding muscles that essentially “milk” the veins of their blood. Clots can form anywhere blood pools, and it has long been recognized that prolonged immobilization, such as that which occurs in a bedridden patient or a long-haul traveler, can lead to the development of thrombi in the legs. In 2003, David Bloom, a thirty-nine-year-old NBC reporter covering the invasion of Iraq, who had spent several days riding in a cramped position inside a tank recovery vehicle, died from a pulmonary embolus that originated in a DVT in his leg.

  It has been estimated that 1 in 4,600 people who fly will develop a DVT within two months of travel, a condition erroneously referred to as “economy class syndrome.” While there is no evidence that sitting in economy class increases the risk of developing a DVT, the likelihood of developing a clot does increase with flights of more than eight hours and also with assignment to a window seat. Vice President Cheney traveled on Air Force Two, a spacious Boeing C-32 (a modified 757), but even with plenty of room to move around, long flights equal long sedentary stretches. Risk factors for the development of a DVT other than prolonged immobility include a genetic or acquired predisposition to clotting, smoking, cancer, oral contraceptive use, age greater than sixty, and congestive heart failure.

  In isolation, the vice president’s DVT was a fairly common and very treatable condition, but its occurrence did leave me with some concern about the general trend in his health.

  Medical Faculty Associates

  The George Washington University

  June 6, 2007

  Dr. Lew Hofmann called this afternoon and relayed a message that the vice president needed to talk with me. I called Mr. Cheney and he stated that he has felt more fatigued recently. We saw the vice president 1 week ago for a device check and to discuss plans for routine follow-up. At that time Mr. Cheney stated that he had no chest pain, shortness of breath, palpitations, edema or change in his exercise tolerance. Today Mr. Cheney noted that for the last week to week and a half he has felt more fatigued. He stated that he has been having difficulty keeping the RPM of his exercise bicycle above 60. He notes that he may be a little more short of breath climbing stairs. He has not had any chest pain and . . . has not been short of breath at night. He has not had edema. His weight is down somewhat and is currently around 210.

  I told Vice President Cheney that we should proceed with our planned echo and nuclear stress test earlier than July and we agreed to have the vice president return on June 8, 2007 for testing. I discussed this plan in detail with Drs. Hofmann and Bosch.

  Jonathan S. Reiner, MD

  Two days later, the vice president returned to our offices for a comprehensive cardiovascular examination that included an EKG, an exercise stress test with myocardial perfusion imaging (nuclear stress test), and an echocardiogram. Although both the EKG and stress test were unchanged and showed the effects of the earlier heart attacks, the echocardiogram revealed that the vice president’s heart function had declined. Prior echos had estimated Cheney’s ejection fraction about 30 percent (normal ejection fraction is greater than 50 percent), but now it was closer to 20 percent, a significant drop. In my note summarizing the vice president’s evaluation, I wrote:

  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 f
ew 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.

  CHAPTER 12

  Slippery Slope

  VICE PRESIDENT CHENEY

  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.