Treating an Ex-President

Rarely in medical history has a pa tient received such intensive treatment and survived so long after so many heart attacks as Dwight David Eisenhower. To some extent, that endurance could be ascribed to the elusive and in tangible quality that laymen call "constitution." Equal credit must go to the extraordinary assemblage of talent and technology at Walter Reed Army Medical Center. No more than about 20 other U.S. hospitals can boast a comparable cardiology staff and facilities.

After Eisenhower's first heart attack in 1955, the question arose whether he should have surgery. The answer was no, because no surgical treatment of heart disease was considered both safe and effective. That is still true.

When a heart transplant was suggested and a score of Americans offered to donate their hearts, Ike's doctors declared: "Such a procedure is not indicated because of the general's age and the presence of other major medical conditions"--his widespread artery disease might have affected many vital organs.

Management of Eisenhower's arterial difficulties, therefore, has been entirely medical. And treatment methods have improved markedly. Indeed, his long survival in full possession of his faculties would have been virtually impossible only a generation ago. After his first heart attack, Eisenhower regularly took anti-clotting drugs. These did not give him complete protection, as he had a stroke in 1957. But he made a good recovery, and the only long-term effect he noted was a tendency to reverse syllables occasionally in a long word.

No Cripple. Far from making a "cardiac cripple" of their patient, as so many doctors were still doing, Ike's physicians advised him to get all the exercise he could. He did not overeat, and he cut down on hard fats and sweets. This regimen kept Eisenhower's arteries working well for eight full years. Then came his second and third heart attacks, in 1965. Again, Ike recovered astonishingly well for a man then 75 years old. But more episodes were predictable.

The 1968 series of heart attacks be gan in April when Eisenhower was in California. Two weeks later, he was well enough to be moved to Walter Reed, where he soon suffered three more. In their twice-daily reports, cardiologists tried to distinguish between "mild heart attacks" and "myocardial infarctions." At best, the distinction is difficult to make. Infarction is the process in which part of the myocardium (heart muscle) is killed by being deprived of blood. Even a mild thrombosis and occlusion nearly always causes some infarction, though it may be an extension of an old scar.

Each infarct, or area of dead muscle, can interfere with the flow of electrical impulses that serve as the heart's ignition system. Normally, a current is generated for each beat at the "sinus node" (situated where blood enters the upper right heart). The charge then passes through the walls of the two upper chambers (auricles), making them contract. Then the signal is channeled through the auriculoventricular node (where the heart's four chambers meet), and passes through the ventricles' walls.

Wildcat Signals. Ike's heart had so many, or such extensive, infarcts that the original sinus-node impulse could not follow its normal path. Moreover, infarcted areas sometimes develop wildcat electrical impulses of their own, which jam the sinus-node signals. Two deadly consequences may result. The first is ventricular fibrillation, in which the muscles of the main pumping chambers twitch rapidly and uselessly, producing no stroke or beat. The second is what cardiologists call "irritability," in which the heart's electrical system behaves erratically, apparently in response to those wildcat impulses. lice was struck by both.

Hoping to reduce the risk of either reaction, the Walter Reed doctors first tried a British drug, bretylium tosylate, which blocks the action on the heart of noradrenaline, a stimulating hormone in the adrenaline group. This did not work, so they switched to lidocaine (U.S. trade name: Xylocaine), related to procaine and similarly used as a local anesthetic. The Food and Drug Administration has not yet approved lidocaine for general use in heart cases, but the Walter Reed team could use it on an investigational basis. They dripped the solution into one of Eisenhower's arm veins to reduce the heart muscle's reactivity to erratic signals.

That was not enough. In 26 hours, after his seventh occlusion, Ike suffered four periods of ventricular fibrillation and lost consciousness. If these episodes had persisted for four minutes or more, the patient would have suffered brain damage. But the Army team was ready with a defibrillator, a device for giving an instantaneous shock to the heart through electrodes placed against the chest wall, and the beat was restored within two or three minutes.

Pace That Failed. Next, the cardiologists tried to control the faulty electrical system with an artificial pacemaker. Since this w'as not intended to be permanent, it was not implanted in the patient's belly muscle. The doctors used a table model. They threaded an electrode-tipped catheter through Ike's right jugular vein, then through the superior vena cava all the way to a point inside the right ventricle (see chart). Impulses from the catheter were supposed to blanket the node's action and take over its function. They did, for a while. Then the doctors removed the catheter and unhooked the device "because of its demonstrated ineffectiveness after the initial few hours." Evidently the pacemaker current could not safely be made strong enough to overcome the abnormal electrical impulses.

Episodes of ventricular irregularity recurred, some of only a few seconds' duration. Throughout this prolonged, heroic treatment, Ike was not only conscious most of the time, but cheerful. The doctors emphasized that he was not in pain, and rested comfortably. In fact, they said, Ike felt well enough to joke with them about all that electronic equipment to which he was hooked up.

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