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Text: George Washington U. Doctors Brief Media on Richard B. Cheney's Condition
Wednesday, November 22, 2000

Following is the transcript of George Washington University doctors Alan Wasserman and Jonathan Reiner second media briefing on Richard B. Cheney's condition.

WASSERMAN: Thank you.

We passed out the results of the cardiac enzymes that were obtained, and I'd just like to give you a little bit of an addition to what we passed out.

The first value was obtained at approximately 8 a.m., and the values are completely normal. The second set of values were available to Dr. Reiner some time after noon today, while he was in the catherization laboratory. The second of values show an elevated level, a minimally elevated level, that shows that there was a very slight heart attack. The third set of values shows that a level has basically tapered off, and have not continued to increase.

To put this into some perspective: In someone that has had a significant heart attack, the levels would be somewhere 20 to 50 times higher.

Approximately a year ago, the American Heart Association established a definition for a heart attack that encompasses any enzyme elevation. Over a year ago, this amount of enzyme elevation would not have been considered, by most people, signs of a heart attack.

I want to also tell you that Secretary Cheney is continuing to do well. We continue to expect a full recovery, and to see him back to normal activity, very shortly.

Dr. Reiner, who performed the catherization, is here with us and will be ready to answer some questions for us.

Dr. Reiner?

Are there questions for Dr. Reiner?

REINER: Good afternoon.

Yes, ma'am?

QUESTION: Can you tell me what is his ejection (ph) fraction, the level of the his heart's efficiency?

REINER: You know, we actually didn't quantify it this afternoon, but I would estimate it at around 40 percent.

QUESTION: And what does that mean in layman's terms? Is that good or bad?

REINER: It's moderately impaired.

It's consistent with his history of prior heart attacks. I would leave it at that.

WASSERMAN: There has been no change.

REINER: Yes, really, it really remains unchanged.

QUESTION: Dr. Reiner, at this point can you anticipate any additional procedures?

REINER: No, none at all, actually.

QUESTION: For the immediate future, or can you go out on a limb? Is it possible to say that we could categorically rule out, for example, a coronary bypass?

REINER: Well, actually at this time, for a patient like Mr. Cheney, our traditional pathway would involve probably an exercise stress test in three to four months. But really no other procedures are performed. And it would be exceedingly unlikely for him to require a repeat bypass operation.

QUESTION: When do you expect him to be released?

REINER: Well, you know, we're still evaluating that. He's doing extremely well. I just spent a little time with him after he had some lunch.

I would say probably conservatively speaking some time over the next 48 hours or so.

QUESTION: Can you talk in layman's terms about what the catheterization is and then putting in the stent? What that means? And is that known as angioplasty? Is that different than angioplasty?

REINER: Sure. The term cardiocatheterization is fairly synonymous with the term coronary angiography. And what we do during this procedure is we inject dye directly into the arteries that supply blood to the heart muscle. And using X-ray imaging techniques, that gives us a very clear picture of the coronary artery anatomy.

We do this through a blood vessel that is accessible to us at the top of the leg.

Angioplasty is a technique which has been around for about 20 years--it's been refined greatly over that period of time--in which balloons and various other devices can be advanced across blockages in these heart arteries, and then the blockage is relieved by expanding the balloons and using other devices.

This morning, we deployed what we call a stent in Mr. Cheney's diagonal artery. A stent is a stainless steel mesh. It's crimped onto a balloon, and when the balloon is expanded, the stainless steel mesh is also expanded, and is essentially embedded into the wall of the artery, and it acts like a tiny stainless steel scaffold, to, sort of, buttress the wall of the artery and keep the artery open. And that's the procedure he had this morning.

Yes, sir?

QUESTION: Was the stent in the same location as the bypass surgery (OFF-MIKE)

REINER: No, the stent was in an artery that was not by-passed.


QUESTION: Dr. Wasserman said earlier, repeatedly, that Secretary Cheney did everything he could to keep his health well, and, yet, this still happened to him.

Two questions: Why did it happen to him now? And is this something Secretary Cheney can look forward to in the future?

REINER: Well, you know, I think, you know, one of the first things I told Secretary Cheney is that the news actually is extremely good.

His coronary anatomy has been stable for many years. And I think it's really a testament to many of the things that he's done, in terms of, you know, cholesterol reduction and exercise.

And I think it really shows how far we've come in, now the 21st century, in managing patients with coronary disease.

I think the actual results of his tests today were very encouraging.

And, you know, as to what to expect in the future, you know, I would expect him to return very rapidly to a normal and vigorous lifestyle without really restrictions, and I would be exceedingly optimistic.

QUESTION: But you said he's done everything he can that's (inaudible) to the procedure. But, you know, if he's done everything he can yet he still has this, is this something that he's going to have to be aware of and look out for in the future, constantly?

REINER: Well, let me say this in another way. You know, because he's done all he can and he has had exceedingly little progression of his coronary disease, you know, we sometimes see patients who have had, sort of, an explosive, you know, worsening of their disease. And I think it's very reassuring that we have absolutely not seen that.

He's really been exceedingly stable for--you know, for over a decade.

QUESTION: He obviously had a blockage in his--in the coronary artery. Could you describe the level of that blockage? Was that artery completely blocked, partially blocked, et cetera? How would you describe it? Halfway?

REINER: Yes. You know, these events are caused not just by these fixed blockages, but also by blood clots that become sort of superimposed on top of these blockages. And Secretary Cheney had about a 90 percent, 95 percent blockage in the artery that we repaired this morning.

WASSERMAN: And the artery now looks...



REINER: Yes, sir, 9-0.

WASSERMAN: I was just asking Dr. Reiner how the artery looked when he finished with the procedure.

REINER: Yes. At the end of the procedure there is no residual narrowing in the artery.

QUESTION: And so you said there was a minor heart attack? So that technically you would say that (inaudible) the American Heart Association standards, he's now had four heart attacks? Has he had three in his prior history? And so are you saying he had a heart attack based on the American Heart Association standards?

REINER: You know, what I would say is that, you know, this would be the smallest possible heart attack that a person can have and still have it classified as a heart attack. You know, his cardiac enzymes were just minimally elevated.

Yes, sir?

QUESTION: Given that blockage, would he have died if you hadn't opened the artery?

REINER: Well, you know, I don't think the situation was even close to being that dire. You know, he had a change in his symptoms, he had some pain last night and...


REINER: Right. And, no, I would say he was absolutely never at risk of dying from this.

QUESTION: Is this induced by stress, or it was something that would normally happen since that artery was 95 percent blocked?

REINER: No. I don't think this was--you can really tie stress to, you know, stress to this. This is really caused by, you know, biochemical factors, some of which we understand, some of which are really still being worked out. It's really hard to pin, you know, stress on this.

You know, I will say that, you know, this is a man who's had probably a stressful, you know, last several months, and he really has not had an event like this. And I would be very hard-pressed to link stress to this kind of event.

QUESTION: And he didn't report any previous symptoms in the last few months or the last year or the two years, similar symptoms to this?

REINER: Mr. Cheney's been essentially--has been essentially asymptotic for about a decade.

QUESTION: What about visitors? I mean, is Governor Bush coming or anybody?

REINER: I have no knowledge of that.

QUESTION: (inaudible)

WASSERMAN: No, we don't at this stage.

Yes, sir?

QUESTION: For most people out there who are not in the medical profession, the, quote, "very slight heart attack," close quote, and the, quote, "smallest possible heart attack," close quote, remains a heart attack.

And in the case of this particular patient, is there any change--a question that was asked earlier, is there any change in his ability to serve as the vice president of the United States or, if he should be called on, to serve as president of the United States?

WASSERMAN: I would say, none at all.

QUESTION: Dr. Wasserman, this morning you refrained from using the word "heart attack"; why was that? And as we left the briefing having no idea that he had suffered a mild heart attack until we talked to other cardiologists, did anyone connected with the Cheneys ask that that word not be used?

WASSERMAN: Of course not. The end of my statement this morning you see--if you go back and look at it--it specifically mentioned the elevation in enzymes. I assumed that most people would understand that that meant a small heart attack. There is no other definition of this.

What we did say was that in previous years this may not have been called a heart attack, but clearly this is a small heart attack.

QUESTION: Sir, but the campaign told us directly that he has been assured that he did not have a heart attack. It's by...


WASSERMAN: The only thing...

QUESTION: ... his doctors that he was assured that he didn't have a heart attack, and now your telling us he had a heart attack.

WASSERMAN: Let me clarify. When he came in at 8:00 this morning, he was first seen, and we got the first set of enzymes and the EKG, there was no evidence of a heart attack.

Up until approximately sometime after noon today, when we got the second set of enzymes, was the first time that we could say that we would define this as a small heart attack.

So everything...

QUESTION: But you told us this morning that at 8:30 a.m. you had done the catheterization.

WASSERMAN: No, I said at 8:30 this morning we decided to take him to the cardiac catheterization laboratory. We did not take him to the catheterization laboratory because he was having a heart attack. We took him to the catheterization laboratory to look at his anatomy because he had a change in symptoms.

QUESTION: And at 10:30 a.m., you did this test. So you knew like 10:30 a.m. that he needed...

WASSERMAN: At 10:30 a.m., we started putting the stent in.

The two are unrelated. Having an enzyme bump and having a small heart attack is unrelated to the procedure that we did.

QUESTION: But you just told us a second ago that at noon you had the elevated levels. We didn't do our (inaudible) until after then. You knew at noon there were elevated blood levels.

WASSERMAN: That's right. I said after noon we knew that there were elevated levels. And in the statement that I gave you before lists the facts that he had elevated enzymes in that statement.

QUESTION: But you did not indicate to us that that was the lowest level--that was the smallest possible level for a heart attack.

WASSERMAN: I think I said that there were minimal enzyme elevations, yes.


WASSERMAN: I'm sorry?

QUESTION: Wasn't your previous statement misleading? It led with a sentence that said he didn't have a heart attack. And then...

WASSERMAN: I'm sorry. I don't remember ever saying he didn't have a heart attack. I said that he had enzyme elevation.


QUESTION: Excuse me. You said that you did a stent at 10:30.

WASSERMAN: No, I said we started the stent procedure around 10:30.

QUESTION: The stent procedure at 10:30. Why did you do the stent procedure at 10:30 when you did not know that he had elevated enzymes until noon?

WASSERMAN: OK. Dr. Reiner can answer that question for you.

REINER: First of all, first thing when Mr. Cheney was admitted to the hospital, the initial set of cardiac enzymes that were obtained early this morning were negative. And based on that, I think was the--you know, the statement early on that there was no evidence for heart attack at that time.

When we started our procedure--actually probably midway through our procedure this morning, we obtained some blood for a second set of enzymes, and those were the enzymes that have come back minimally positive.

Now, as for the question about the--you know, the stent, the stent procedure is done following the diagnostic angiogram, which defined his anatomy. And the stent procedure would have been performed whether or not there were any enzyme abnormalities.

QUESTION: Can I follow up on that? So it sounds to me like what you are saying is that you're doing the stent to relieve the blockage (inaudible) to prevent a heart attack from occurring, which, in fact, then occurred.

REINER: No, sir. The enzyme tests reflect the state of the heart muscle over the past several hours. So the blood obtained during the cardiac catherization procedure, you know, reflects what has happened to the heart over the past several hours. It does not...

QUESTION: (inaudible)

REINER: Yes, sir.

QUESTION: So do you think he had it at home or in the hospital...


REINER: I think he had this very small release of cardiac enzymes at the time he had this episode of pain in the middle of the night.

QUESTION: Sir, maybe it would help--two things if you could. Explain to people what elevated enzymes mean, that there's been some damage to heart muscle, explain that, what the enzymes mean. And then also maybe you should just go through and refresh for us starting doing the timetable again and when you got the--when the blood was taken, when it came back, because there seems to be some discrepancy there and there's just some question as to the credibility of the information we got.

REINER: We have biochemical markers that enable us to determine whether or not there has been any damage at all to the heart muscle. And over the last several years, you know, we've had some new tools, much more sensitive markers which weren't available several years ago which enable us to detect extremely small levels of heart muscle damage.

You know, two or three years ago we would simply--based on the biochemical data available then, we would simply have classified this event as just angina. But because we have more sensitive markers, we can detect extraordinarily minute elevations in these markers of heart muscle damage. So, you know, we've had really to rethink what a heart attack is.

And while most people think of substantial, you know, disability following a heart attack based on, sort of, old criteria, we're now able to detect these tiny little elevations in the--in the enzymes which have a much different, you know, prognostic effect than much more substantial elevations.


QUESTION: ... your statement that there is evidence of any new hot muscle damage, is incorrect?

REINER: No, that's correct from the standpoint--the statement was that on catherization or on EKG could we see any heart muscle damage, that's still correct. What tells us there was some heart muscle damage was the enzyme elevation.

WASSERMAN: Let me just go on record, as saying, first of all, we never attempted to mislead the press or the American people. We were working with the best available information. We have to analyze the information as it comes to us.

The reason why we're having this update right now is, because we have new information and we want to make sure that the American public is getting honest information. So I want to go on record so that all of you understand it was never an attempt to mislead anybody. We were all interpreting the information as it came in, OK.

QUESTION: Let us go on record that you stopped the press conference so we couldn't ask the questions to clarify it at that time. Why did you?

WASSERMAN: Because we needed to get back and get more information so that we can give you the most up-to-date information that we took.

QUESTION: We were told there'd be no more briefings.


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