My take: Tim Russert

WSJ Health Blog: “Russert’s doctor Michael Newman said the tough-questioning but congenial host of NBC’s ‘Meet the Press’ had been under treatment for asymptomatic coronary disease, but that it was under control with medication. He was carrying excess weight, Newman observed, but he got regular exercise and he performed well on an exercise stress test in April.”

GruntDoc: “I therefore propose a new sign in medicine, the Tim Russert sign: death (or MI) shortly after a negative stress test.”

I don’t have all the medical information, so I’m speculating.

From what I heard last night, Mr. Russert was urged to lose weight and had previously diagnosed coronary artery disease. It would not be unreasonable to assume that he was already on a statin, aspirin, and blood pressure medication (as his enlarged heart can be caused by chronic hypertension).

A point of debate is his negative stress test 2 months ago. It is unclear what type it was – an exercise stress test, stress echocardiogram, or nuclear stress test? This matters, as the sensitivity would vary from 80 to 90 percent.

The gold standard to determine the extent of coronary artery disease is a cardiac catheterization. However, this is not typically done in an asymptomatic patient with a normal stress test. No doubt there will be calls to do so in light of Russert’s death.

Did he have any symptoms prior to the MI? Colleagues said he did not “feel well” in the days prior to the event. Was this his anginal equivalent?

Finally, it is likely he collapsed from ventricular fibrillation, which is a shockable rhythm. Did the Washington bureau have an AED? Was it used? Even so, Mr. Russert’s chances of survival would still have been slim.

A sad day indeed and a tragic loss in the world of journalism and politics.

Update:
Further reading has revealed that Russert had diabetes, and the autopsy revealed significant left anterior descending coronary artery (LAD) atherosclerosis (the so-called “widow maker”).

He passed his exercise stress test “at a high level of exercise.” Hypertension and cholesterol were reported to be well-controlled.

Still can’t find whether the stress test was with imaging or not. It makes a difference in the detection of Russert’s plaque:

Imaging tests are more sensitive than the exercise ECG in the detection of severe (three vessel and left main) disease . . . the sensitivity for severe disease was 93 to 98 percent with planar thallium imaging, stress echocardiography, and SPECT perfusion imaging compared with 86 percent for exercise ECG testing.

Given his risk factors, I would not be surprised if Russert’s PCP will take heat (or even be vulnerable to a malpractice lawsuit) if the stress test was ordered without some kind of imaging.

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  • Kirsten

    my husband passed an exercise stress test with flying colors but failed the nuclear test miserably which had him in quad-bypass 4 days later. Another friend of mine passed an exercise stress test and was told what great shape he was in and died the very next day… don’t these doctors know the nuclear test is the only true test for any man over 40??

  • The Happy Hospitalist

    Even a nuc test can be interpreted negative in the setting of multivessel CAD. When all the vessels are blocked, horribly abnormal heart can be interpreted as a normal nuc med. When will America learn that no test is 100%

  • Diana Lee

    Thank you for sharing your perspective. We don’t know much, but it’s clear that we’ve lost an excellent journalist and an important man.

  • Anonymous

    Can I ask the question – how does so much information about famous patients like Tim Russert and Ted Kennedy make it into the media? Isn’t that what HIPPA laws are for? From a family and patient’s perspective, I would have a difficult time with so many swirling media takes about his previous condition, primary doctor’s recommendations (followed and unfollowed), compliance and possible legal ramifications. Agree with the happy hospitalist – sometimes patients die even when the doc has done the best job he/she can do. My thoughts to the Russert family.

  • Mike Donovan

    Regarding the death Of Tim Russert:

    In the new issue of Newsweek, Dr. Steven Nissen, chair of cardiovascular medicine at the Cleveland Clinic told the magazine when asked about the role of STRESS and heart attacks:

    “Most of us do not think it is terribly relevant,” and explained this with a shocking lack of logical thinking: Newsweek writes, “After all, he notes, “many people in this world have stressful jobs,” and they don’t all die of of heart attacks.

    Time Magazine named Dr. Nissen one of the 100 Most Influential People In The World in their “Scientists and Thinkers” section.

    Think about that.

    Now, consider the completely illogical statement from Dr. Nissen bolded above. One thing should be made perfectly clear in light of this statement: He believes cholesterol as very relevant to heart attack risk. Yet, to turn his Newsweek comments around, “many people in this world have **high cholesterol**” and they don’t all die of heart attacks.

    In fact, study after study shows countries with the highest rates of fat intake and the highest average cholesterol rates have the lowest incidence of heart disease. Imagine that!

    Dr. Nissen’s irresponsible and illogical comments in Newsweek shows – again – the complete bamboozlement the cholesterol hypothesis has on western medicine just because, “everyone knows,” high cholesterol causes Coronary Heart Disease. How do they know this? “Because everyone knows.” Ad nauseum. With a little research, the facts show this is simply not true.

    What Dr. Nissen said about stress can be said about high cholesterol. Plenty of people live with both without having heart attacks.

    Maybe Mr. Russert’s death can help in bringing us back to real science as opposed to what Big Pharma dictates as what is science – and what is not. Follow the money.

    How ironic that it was Dr. Nissen who made such a horrible misstep in logic with his comments to millions of readers in Newsweek.

  • Anonymous

    Denial for most males is the principal factor for fatality.

    Common symptoms are indigestion, feeling of malaise (sometimes for weeks), lethargy, heaviness in the arms, aching in the neck, tooth or wrist (often thought to be muscle pain by patient’s)

    Stress tests are variable nuclear scans can be normal with multi-vessel disease.

    Tim’s most likely pathophysiology was the disintegration of a placque with either downstream embolization to a critical arteriole and ventricular fibrillation. The autopsy did not describe in any great detail what the CADs revealed (maybe that was just media ignorance.

    I am sure Ted Kennedy did release his doctor’s to speak about his condition….Mr. Russert was dead. Not sure what that means in terms of releasing information. Does a wife have to release it??

  • kirsten

    well thank you to those that addressed my comment. I thought the “widow maker” was easier to detect placque than most, and also, i wonder why, if he were diagnosed with heart disease, he wasnt ordered to undergo an angiogram. I am not a doctor, i am not even in that field, but as i previously stated my husband had quad bypass and the widow maker was 90% blocked. What a shame that was missed on such a wonderful and notable man as mr. russert…

  • J Craig MD

    Think about it. His MD said he was being treated for “asymptomatic CAD”. The only way to make that Dx is a positive CT, positive thallium GXT, or a cath. If he had the first 2 tests, no way they would have held out on the cath. My bet is that he had a cath which showed non-obs disease. So, that plus probably a negative GXT (plus or minus imaging) = medical therapy. Interesting that there was no AED in the Washington bureau of NBC. I bet there will be now.

  • Ziffie Loo

    Big bucks for a high stress job and the reward is CV disease.

    Was it worth it?

  • Mike

    “Little Russ” threw a bunch of softballs at a bunch of political cronies. No wonder Bush praised him. Nice guy to fish with, but not a “great man”. Just a guy on TV.

    Mike Donovan clearly is another person who hates science. How many studies showing high LDL and increasing heart disease does someone need to see. Of course it’s not the only risk factor. Of course everyone knows the “butter paradox”in the French. But those treated with statins DO have less MI/death.

    So get your head out of your rear and stop being part of the problem.

  • Anonymous

    The surest way to discredit oneself and the profession in general is to speak out when one doesn’t have all the facts and don’t even know which ones are missing—and that applies to sideline comments when regarding someone who you have not examined and have not read the entire medical record.

    I was an expert in a med mal case that was filed as a result of a statement made by an academic consultant who DID see the patient–but didn’t have all the records.

    Tens of thousands of dollars later, he is presented in deposition with the records that he didn’t have when he say the patient and told her that she was a victim of malpractrice, and retracted his statement then and there–after a great deal of harm had been done, including to the patient who had lived with a sense of injury and grievance for years rather than going on to accept and cope with her misfortune.

    The problem is just compounded when the statement is public, not private, and made with even less information.

    It is frankly unprofessional.

  • shadowfax

    The confounding factor is that I read (I forget where) that he had a ruptured plaque. Small atherosclerotic plaques, which are non-obstructive, can exist in the setting of a negative nuc stress. When an acute thrombus forms on the plaque (i.e. “ruptured plaque”) then you get occlusion and ischemia.

    This is why a lot of cardiologists are doing in-vessel ultrasound these days, to detect the non-occlusive disease, and this is also why I’ll still admit someone with chest pain even if they have had a recent negative nuc stress.

  • Retired Hospital CEO

    On four occasions I have had negative stress nuclear tests however on the basis of other signs and symptons my cardiologist has sent my for a cardiac cath. Three of the four caths have revealed an 80 – 90% blockage in a different artery requiring angioplasty. I am fortunate to have a great cardiologist
    who takes the time to understand my subtle changes in addition to the test results and uses his gut instincts and knowledge of me to complement the science. I hope that Tim had been followed closely by a competent cardiologist in addition to his internist.

  • Anonymous

    Reitired Hospital CEO,

    4 nuc’s and 4 caths?? I hope you are paying those out of your own pocket and not soaking the taxpayer (medicare) or spreading to other policyholders that happen to be healthy

  • Frank Drackman

    Where was Hilary Clinton Friday afternoon? Funny how Russert drops dead the week after Clinton suspends her campaign. People have a strange habit of getting dead around her. If shes VP she’s in the Oval Office within 6 months guaranteed.

  • Anonymous

    One thing a great number of people don’t realize is the inadequate care and cardiac prevention many people are getting at the hands of their internists. Some do a great job but many don’t. Many are doing and reading cardiac tests in their offices when this is best left to a cardiologist. What does it do, it provides poor quality testing to make money for the person who really isn’t adequately trained to do the right test or to interpret it. These plain stress tests are just money makers for these internists. The majority of people should have a nuclear or echo test with the stress test and they should have it under the supervision of a reputable cardiologist. I went to a cardiologist once who couldn’t repeat my test because my internist had just done one, which was probably substandard. I paid out of pocket for a repeat test with my cardiologist and it was amazing how much more information was gathered. I suspect Tim’s relationship was too tight with his internist and he would have been better off in the hands of a cardiologist. Since there appears to be none involved you’ve got to think his internist didn’t refer him or if he did he took over the care. Such a shame…

  • Alison

    I don’t understand why Tim Russert did not have a angiogram. I recently had one and it showed 100% occult in the same artery “widow maker” One stent and I am back to normal. His doctors should be sued!!! The doctors generally don’t take their patients seriously!! Our lives are in their hands when we go to them for help. They need to take responsibility for their mistakes!

  • Anonymous

    None of us have all the facts, meaning all kinds of possibilities exist: maybe Tim was urged to have an angiogram and declined it. Maybe he did have a nuclear scan that was normal. Maybe his internist made a mistake. We should all be careful to keep our eyes on the ball and never forget we are taking care of people, not categories of risk, and act accordingly.

  • Anonymous

    How many studies showing high LDL and increasing heart disease does someone need to see. Of course it’s not the only risk factor. Of course everyone knows the “butter paradox”in the French. But those treated with statins DO have less MI/death.

    How many studies of LDL effect on heart attack risk came from studies done on statins and how many from other sources? How many of these other studies show causation? Do statins work because they reduce LDL or because they reduce inflammation? How come in recently published statin+Zetia vs statin trial higher reduction in LDL didn’t translate into additional benefits? I think not that long ago, kevin, dinasaur, and other MD bloggers were questioning LDL effect on heart desease? Are they also anti-science? Why didn’t you argue with them the same way you do with someone who may be a layperson.

    Don’t know anything about mike donovan, but it seems like a double standard to me. Also, mike was simply commenting on someone’s interview discounting the effect of stress yet AHA seems to think that stress may be a risk factor – http://www.americanheart.org/presenter.jhtml?identifier=4750

  • Anonymous

    Do statins work because they reduce LDL or because they reduce inflammation?

    Bingo. THE question.

  • Anonymous

    More than enough epidemiological studies have demonstrated a direct, unequivocal relationship between cholesterol levels and incidence of MI. 50 years worth of studies, including some long before statins were developed. This is no longer disputed.

    Second, a person can have totally normal cardiac tests, no vessel occlusion, and STILL be at risk for sudden cardiac death. How? Some plaques do not encroach into the lumen of the vessel and thus are not visible unless intravascular ultrasound (IVUS) or other techniques are used. However, these plaques may be extremely vulnerable to rupture. It’s the worst case scenario in a way: no symptoms to warn of a problem, no narrowing of the lumen, no obstruction, and yet, tremendous risk for sudden death.

    Stop badmouthing Steve Nissen; he’s the one who pioneered IVUS and championed its use because he recognized that conventional imaging was missing a lot of the problem.

    Last, previous posters are right: we can be on all the medication in the world, have expert care, and tragedy can still strike. Prevention measures on the part of the patient are a big area for improvement if we want to make a real difference.

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