George W. Bush’s angioplasty: Did he receive the best care?

George W. Bushs angioplasty: Did he receive the best care?

Former president George W. Bush underwent an angioplasty recently, and the details sparked a public debate about the controversies of heart disease treatments.

His spokesman stated that he underwent a routine physical exam and had no symptoms of heart disease. A stress test showed EKG changes and a CT angiogram found a blocked artery. He was transferred to another hospital and underwent an angioplasty, a procedure in which a stent (a wire mesh tube) is inserted into the blocked artery and pushed against the artery walls to prop it open.

Before delving into the details of the ensuing controversy, let me make clear that we don’t have enough details about Bush’s care to make any judgments about it, and the rest of the post will be about angioplasties in general, and not about Bush’s case specifically.

Whenever a public figure undergoes a medical procedure there is a concern that the public will misunderstand the details and assume that the procedure is also right for them. (A recent example is Angelina Jolie’s revelation of her double mastectomy.)

The controversy regarding Bush’s care centers on the fact that while angioplasties are known to be lifesaving during or immediately after a heart attack, in patients with stable heart disease they have no advantage over medications other than for relief of chest pain. We are told that Bush was not experiencing chest pain, and he is known to be an active athlete, having hosted and participated in several lengthy bicycle rides since leaving office. So the justification for the angioplasty is unclear.

Our best evidence comparing angioplasty to medications in patients with narrowed coronary arteries comes from the COURAGE trial which published its findings in 2007. The trial showed that rates of heart attack and death were the same whether patients with blocked arteries underwent angioplasty or were put on optimal medications.

This is where the media sometimes distorts the story. The press coverage of Bush’s angioplasty had frequent questions about the necessity of the angioplasty and the cost of such a procedure. That is precisely not the point, and gives the public the incorrect idea that angioplasties are expensive and beneficial luxuries. BMWs, after all, are unnecessary and expensive, but very nice. And if a VIP gets something unnecessary and expensive, shouldn’t I want one too? The point of the evidence about angioplasties is that in most patients they have no benefit. Focusing on “necessity” misses that point.

It is entirely possible that Bush’s care was flawless. One possibility was that his stress test was extremely abnormal. Such very abnormal tests were excluded from the COURAGE trial, and we have no definitive evidence whether medications or stenting is best in those cases.

The important thing for the public to understand is that VIPs sometimes get terrible care. I’ve personally seen that myself. Physicians often over-test and over-treat celebrities, wrongly thinking that this will protect them from blame for any adverse outcome later. It’s much easier to tell a prominent patient that we will fix your problem with a high-tech and very expensive solution, rather than taking the time to educate the patient that we should start a few very old and very inexpensive medicines which have been proven to save lives. Paradoxically, we’re frequently much more comfortable doing the right thing for patients who will not draw public attention.

I wish the former president continued good health. I wish the rest of us a careful review of the evidence before we burst into our doctors’ office demanding a stress test.

Albert Fuchs is an internal medicine physician who blogs at his self-titled site, Albert Fuchs, MD.

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  • buzzkillerjsmith

    Didn’t the USPSTF recommend that most asymptomatic pts not have routine treadmills? I realize that sometimes cardiologists and generalists are behind the 8 ball on this with the medicolegal risk of missing something, but perhaps W would have been well advised to stay out of the damn doctor’s office in the first place.

    • Albert Fuchs

      Yup. (Except for showing up at the darned doctors office for occasional blood pressure and cholesterol checks.)

      • Alice Robertson

        LOL Wait a minute…Buzz….are you really a doctor? Or the enigmatic type that can read data and clinical trials and go….holy cow….going to the doctor is dangerous at times? Enigmas are simply refreshing at times…oh I know…they are an acquired taste:). So, the question begs….you gonna shoo shoo some of those patients outta your office and tell them to go home and have their wife sit on their shirt tail to keep them from leaving ….and ah….I mean ya’ know….doctor’s orders…..could keep ‘em healthier than the medical profession? I’m sure he would thank you for it:)

        • buzzkillerjsmith

          I really am one but I do limit the things other docs try to do for me–no PSA or “just to check” treadmills for this guy. I will concede Dr. F’s point about bps and cholesterols, and I do get a flu shot every fall.

          • Alice Robertson

            Ack…not the freakin flu shot. Cochrane did the data on it and it’s useless. But that’s okay….I still have hope for ya! Ha!

        • Guest

          Alice, those of us in the medical field avoid docs as much as possible. It’s nothing personal. It’s just that they cannot fix what may be broke by lifestyle.

          Screening finds problems which may be real or may be false positives. Interventions carry risk. Just take care of yourself and be ready to die when it’s time. It’s ok.

          • Alice Robertson

            Well that is refreshingly honest of you to share that. Honestly, I think it’s quite truthful (I have a daughter with cancer, so I understand the limitations all too well…those limitations break my heart at times). I appreciate this type of self-reflective honesty.

          • Guest

            I’m sorry to hear about your daughter. My thoughts are with you.

          • Alice Robertson

            I am grateful you took the time to say that….you recognize that emotional pain is worse and harder to treat than physical pain at times….realizing pain is still pain and it hurts no matter what the source (I love CS Lewis’ writings on The Problem with Pain…surely his philosophical pleasurable pinings could help heal a heart:)

      • elizabeth52

        Great advice, couldn’t agree more.

        I have my blood pressure checked every year or so, and usually my cholesterol…and that’s about it. My doctor has checked my Vitamin D levels as well.

        Recently I read that high cholesterol is not linked to heart disease and strokes, but low cholesterol is linked to cancer. What?
        Apparently the Swiss have the highest cholesterol levels in the world, but also, have the lowest number of heart attacks and strokes. The Australian aborigine has the lowest cholesterol levels in the world, but the highest number of strokes and heart attacks.
        I haven’t had time to do any research yet…fortunately, my cholesterol levels have always been normal.

        I also, heard at a conference earlier this year (evidence based medicine) that most people are taking statins unnecessarily.

        I have rejected cervical and breast cancer screening, both informed decisions. When I heard about the American well-woman exam it made me shudder, I’d never permit it, it’s not evidence based and carries risk, even unnecessary surgery. It’s concerning that many women are coerced into this exam or they’re denied birth control pills.
        I don’t understand how that can be permitted…when our informed consent is ethically and legally required for all cancer screening.
        Bowel screening: the latest “offer”…

        I agreed to the FOBT, but have declined a colonoscopy. (at this stage) It will be interesting to see the results of the randomized controlled trial being conducted by Dr Gil Welch and his team at Dartmouth, comparing the FOBT with the more invasive and expensive colonoscopy. (that carries serious risk)

        I firmly believe we should do our own research and make informed decisions about cancer screening. in my opinion, it over-promises and risk is rarely mentioned, we should understand what we’re agreeing to before we hand over our precious symptom-free body. More and more I feel like I stand protector over my body from the medical profession and the never-ending “offers” of screening. If it doesn’t pass my risk v benefit assessment, the answer is NO. So often we forget we can say NO, thank you.

        • Alice Robertson

          It’s the type of foods you are eating that are linked to cancer. I follow this stuff because my daughter is a vegetarian with cancer and diet plays a huge role in prevention.

          I really liked the honesty here but it appears the readers don’t appreciate it! Ha! I keep getting dislikes anywhere I post. I’m thinkin’ there are some darling, demented, disliking docs who are in sore need of therapy. But oh my if their peers are giving out such bad counsel should they dare expose themselves? Hmmm…..:) And for those haters well they need to know that diet and exercise is really helpful for anger management, refusal to read newer medical evidence (that’s coded now:), anonymous irate hatin’ online over a disagreement that causes you to make up “Guest” accounts…um…..I need to find that peer-based review and post it to help those poor suffering souls before another doctor gets to them:) *wink*

          • elizabeth52

            In my opinion, diet and exercise are more likely to extend your life than screening. I think the latter provides false reassurance in most cases.

            I think too many now forget the basics and think that a pap test and mammogram will cover them. I think screening provides huge profits for vested interests and it’s a great political tool, but the benefits have largely been exaggerated and the risks with testing go unmentioned or are downplayed. Too many women are pushed or coerced into testing with no informed consent. (or even consent)

            We’re extending our breast screening program here in Australia to include those aged 71-75 even though there is no evidence of benefit, will it just add to the number over-diagnosed and over-treated?
            We should be reviewing the evidence on breast screening: do the risks exceed the benefits?

            I think so.

            When we push screening and ignore the basics, people make poor decisions, their perception of risk changes. (for example: a woman once proudly told me she never misses her pap test while lighting a cigarette, she’s been trained to believe that cervical cancer is a huge threat and the pap test is the most important healthcare decision…little does she know that smoking and lung cancer is a MUCH greater threat to her life)

        • Guest

          It’s always a good idea to be informed about anything related to your health, so props for that. But the Pap smear for cervical cancer screening has reduced mortality from cervical cancer by 50%. That’s nothing to pooh pooh at.

          • elizabeth52

            Sure some women are helped by pap tests, but it’s a rare cancer so the chance of benefit is low. The risk of a false positive, excess biopsy or over-treatment is MUCH higher, and made worse by inappropriate and excessive screening. (and both the States and Australia are guilty of that)
            The lifetime risk of cervix cancer is 0.65%, it was always a rare cancer in the developed world and in natural decline before testing even started. (Those factors would still be having an effect – more hysterectomies, fewer women smoking, better condoms, less STD etc.)

            It was the numbers that didn’t work for me, as a low risk woman my risk of cervix cancer is near zero, while the lifetime risk of referral for colposcopy (and a biopsy and perhaps, a “treatment”) is a whopping 77%…the risks were too high for me. The States would have similar referral rates if not higher with the practice of testing women not yet sexually active and some women still being tested annually and into old age.

            If I were worried about this rare cancer, I wouldn’t even think about a pap test anyway, until I’d established I was HPV+ and at risk of cervical cancer. Most women are HPV- and cannot benefit from pap testing. The American practice of adding HPV testing TO pap testing is pure excess, causes confusion, and simply generates the most over-investigation.

            For those women interested, in my opinion, the best screening program in the world for cervical cancer is the new Dutch program. They’ll scrap their 7 pap test program, 5 yearly from 30 to 60, and offer instead 5 hrHPV primary tests at ages 30,35,40,50 and 60 and ONLY the roughly 5% of women who are HPV+ and at risk will be offered a 5 yearly pap test. (until they clear the virus) This will save more lives and take most women out of pap testing and harms way. (damage to the cervix can mean miscarriages, premature babies, c-sections etc.)

            Those HPV- and no longer sexually active or confidently monogamous might choose to stop all further testing. Dutch women are already using a HPV self-test option/device, the Delphi Screener. (also, available in Singapore and elsewhere)
            I’ve also, declined breast screening even though that cancer is far more common. Weighing up the risks and actual benefits, it doesn’t get over the line for me. (The Nordic Cochrane Institute brochure on breast screening and Professor Michael Baum’s informative articles and lecture helped me make an informed decision to decline testing)

            Speaking generally:

            We need to stop telling women what to do and start respecting informed consent. Give women real information on risk and ACTUAL benefit, respect them as competent adults/individuals and offer evidence-based testing that focuses on what’s best for them AND, leave the final decision to women, to accept or decline screening as they see fit.

          • Peta

            It’s almost as though you want doctors to start treating women like grown-ups, Elizabeth. That won’t do, that won’t do at all! ;-)

          • elizabeth52

            I know, but let me dream.
            To be fair there are doctors out there just as concerned, it’s worth our time to find them. I have enormous respect for the handful of doctors who keep pushing for change and take the time to educate and warn us. People like Dr Gil Welch, Dr Margaret McCartney, Prof Michael Baum, Peter Gotzsche and a few others. It really is important to find a doctor where it’s possible to have a respectful two-way relationship, not dictator and subject or guardian and child.

          • Alice Robertson

            And pap smears are better than the Gardasil shot. Now the rough crowd here can dislike this because I would relish a conversation on this.

          • elizabeth52

            The fact is almost all women are HPV- and cannot benefit from pap testing. HPV primary testing and self-testing “used the right way” takes 95% of women aged 30 to 60 OUT of pap testing. A small risk has been turned into a highly lucrative industry in the over-treatment of CIN.
            There was never a need to worry and harm so many, to help so few. Since the 1960s the Finns have had a 7 pap test program, 5 yearly from 30 to 60, they have the lowest rates of cc in the world and refer FAR fewer women for colposcopy/biopsy/treatments. Australia also, seriously over-screens women, we “treat” more than 10 times the number of women than a country like Finland.

            I’d approach Gardasil with caution, there are far better ways to deal with the small risk of cc. I wouldn’t be prepared to accept much risk at all to protect me from a rare cancer. Gardasil should only be administered with informed consent, consent should never be assumed as so often happens in women’s cancer screening.

            A 5 yearly pap test offered to the 5% who test HPV+ (aged 30 to 60) would produce better outcomes and see over-treatment rates plummet. (not good news for everyone…)

            Why would 95% of women want to have a lifetime of unnecessary pap testing with the high risk of a false positive, excess biopsy or over-treatment?

            This program made it over the line in the Netherlands because experts were asked their PERSONAL opinion on the best evidence-backed program for women, NOT as a representative of a medical association or specialty, therefore vested interests did not win out over the evidence and what’s best for women. I fear the huge profits made from over-screening and over-treatment will mean non-evidence based screening and excess will be protected in some countries well into the future.

            What was the motto? First do no harm…well, that doesn’t apply to women.

          • Alice Robertson

            A quick quote from a longer article in a pathology review (I am friends with a Coroner who thinks this stuff is great late night reading:)
            Frequent and regular pap smears are a highly effective weapon against cancer.


            In the war on cancer, the Papanicolaou (Pap) smear has been our most effective weapon. Among women who are screened regularly, the Pap smear has reduced cervical cancermortality by as much as 99%.* Richard M. DeMay, MD (citations are included in the article)

            I believe you are wise to approach Gardasil with much apprehension. The shot needs boosters every five years and isn’t as effective as the makers shared. You have probably read what one of the articles CBS news did titled something like Gardasil Researcher Speaks Out? And there is so much more (the shot was over-promoted and just not the magic weapon it was sold as and it’s been pretty harmful to the girls it killed). Just the reporting at VAERS is scary, but there is evidence based medicine at PubMed about it too. I am keeping this short on purpose because I am unsure how many doctors or readers actually care. They feel it’s too scary not to get their daughters the shot not even realizing their young daughter will need it again and again and maybe even again before she is old enough for the shot to not be given. Sadly moms think their doctors actually studied it before shooting it in their daughter’s arms and actively purporting that a mom is a great and wise mom for getting it. It’s one thing to actually understand a topic but it’s quite another to tell your patients a load of bollocks.

          • elizabeth52

            Hi Alice,

            Richard DeMay also, wrote an excellent article, “Should we abandon pap smear testing?”.
            The point is: few women can benefit from pap testing, (fewer than 0.65%…the lifetime risk of cc minus false negatives) and we know large numbers will end up in day procedure having unnecessary and potentially harmful procedures after false positive pap tests. (made worse by over-screening)

            If women make an informed decision to test, they should be offered evidence based testing, not over-screened with the pap test…they should not be tested too early, too often and for far too long or screened inappropriately. It’s the reckless use of the pap test that has always concerned me and the complete lack of respect for informed consent and consent itself.

            I can understand why a women who is HPV+ and aged 30 or older might want to have a pap test every 5 years, and before we fully understood the significance of HPV…if a high risk woman or someone risk averse might want to have 6-7 tests, 5 yearly from 30 to 60.

            It’s been known for a long time that 2 and 5 yearly pap testing provides the same benefit, but 2 yearly produces far more false positives. Also, no country in the world has shown a benefit pap testing those under 30, but this group produce the most false positives.

            It’s the way the pap test has been used, not the pap test itself. My younger sister had a excess cone biopsy after a false positive pap test, colonoscopy/biopsy, it was a devastating experience.

            Had she known that 1000 women need to be tested regularly for 35 years to save one woman from cc, and that a false positive and over-treatment was MUCH more likely…she would have declined pap testing. No one respected her right to choose, she was told all women must have pap tests with no real information. That’s not fair or ethical.

            There appears to be no concern about the huge number of women who end up over-treated, and some go on to have premature babies, miscarriages, high risk pregnancies, need cervical cerclage or c-sections. Most of this damage is avoidable with evidence based screening and informed consent.

            I care about all women, the small number at risk from cervical cancer who might benefit from pap testing and the vast majority who can never benefit and should be protected from this testing.
            I agree with you about Gardasil. It’s so important to do our own research and make an informed decision. Women’s healthcare is loaded with vested and political interests, add high emotion and it’s a toxic mix.
            I say to women…read, read and keep reading, knowledge will protect you.

          • Alice Robertson

            Hi! I think it’s neat you checked out the article. If you include a URL it usually gets moderated, so some people bust them up or do as I do and leave them out. It’s nice to talk to you!

            I have four daughters who aren’t interested in Gardasil (it’s a moral judgement on their part and they believe sex is for marriage. So it’s good they choose the best and safest road [I know that leads to their husband’s past experience…but that’s an add-on[). But my married daughter gets her pap smears.

            We just feel the pap smear every three years is better than the Gardasil shot and it’s boosters every five years. Eventually they all need to give up the false security of the shot and get the pap smears anyways. The shot has a timeframe of recommendations so women end up having get pap smears anyways.

            There are tons of newer articles on the pap smear for those interested. It’s a quick google search. Time usually tells exactly what’s up with a shot…then the shots are tweaked and the public mislead.

          • elizabeth52

            Hi Alice, Actually I found the article by DeMay many years ago. I’ve been researching this topic for decades…constantly amazed at the screening “story” pushed at women and comparing it to the evidence.

            One thing to consider: if your daughters want the best protection from cervical cancer, HPV primary testing (or self-testing) provides the best protection both from the cancer and the much higher risk of potentially damaging over-treatment. The pap test misses many adenocarcinoma of the cervix, it was designed to prevent/detect squamous cell carcinoma, but HPV testing is more likely to detect/prevent these cancers.

            Pap tests therefore, produce false negatives as well as false positives.

            I’m 55 and have never had a pap test, an informed decision, as a low risk woman the risks of over-treatment were too high for me.

            I respect the screening decisions of other women, but it’s a tragedy the profit motive means over-screening with the pap test is the norm or ADDING the HPV test to the pap test, when simply offering women an opportunity to test for HPV means we can identify the small number at risk and leave other women alone.

            HPV Today, Edition 24, sets out the new Dutch program. There are lots of articles and studies on the HPV primary test, it outperforms the pap test. Delphi Bioscience can provide info on HPV self-testing.
            Nice chatting to you…we have to share information and experiences, personally, I simply don’t trust the medical profession to be honest with us and put us ahead of their own interests.

            Many will curse the day when HPV primary testing (and self-testing) finally takes over, they’ll keep women in the dark for as long as possible, but as more women become aware, HPV primary testing will take over…and that will take most women out of pap testing and see excess biopsies/over-treatment rates plummet, that’s a lot of money lost to vested interests. In my opinion, that’s why the true significance of being HPV- is never mentioned to women…these women are having unnecessary pap tests that simply risk their health.

          • Alice Robertson

            Hi! It’s really nice you have studied so much. I appreciate your willingess to share so openly. It’s always good to read another viewpoint (and we know top-notch docs disagree all the time so it’s important to be able to disagree)

            About my daughters ( have four and two sons)…. we are Christians who homeschooled so that cut way down on problems. My daughters were able to get local sport’s volleyball and academic scholarships so they lived/live at home during college…again cutting down on temptations. So for us the best choice was purity, but we know for most young women they firmly believe the shot will give them immunity from cancer (they claim it helps the guys now too).

            Anyhoo…..if you would like to chat outside of this board on FB I am there (wish you could post URL’s here but I can’t without moderation and sometimes that is the kiss of death to a post). On FB I am at their URL then slash arobert6

  • drgn

    Wasn’t he the one that started this whole RUC process with the AMA by declining the government from taking over that job or was that Daddy Bush? No matter. He is probably not smart enough to figure that connection out. Who knows if he is one of the many patients that had a unnecessary procedure? Least of all him.

    • Guest

      It’s sad that you still have Bush Derangement Syndrome well into his successor’s second term. I hope you get over it soon.

      • drgn

        glad you are not a physician. will not be responding to anymore of your antics.

        • Alice Robertson

          Drgn….oh please don’t go…stay and play for awhile:) Admittedly this is a rough crowd. I am a conservative and they don’t like you or I:) What’s wrong with these twits! Ha!

          Now that said…your last comment was a knee-jerk because surely it just promotes the stereotype that only doctors should be at the table. To be glad a conservative challenging you isn’t a doctor (actually one or more of the “Guests” here are your colleagues). Since I only use the Cleveland Clinic I am not versed in other hospital systems but they are mostly conservative there and they used to like stents a whole lot (my husband’s stents were billed at close to a six figure amount. And they were sued by a sport’s figure who was outraged that the doctor’s there were investing in apparatuses and then placing them in heart patients during surgery. Way to make sure your investment portfolio thrives? Anyhoo they were forced to cough up a ton of money and quit the practice that never should have been allowed… it’s just a conflict of interest….and more widespread at one time….and, yes, I realize our Congressmen do it and we have had little luck with the Stock Act).

          It’s hard to know if Bush had old school docs, or narrow-vision docs or omgoodness conservative docs:) Specialists disagree all the time and even famous doctors get bad counsel. Hindsight is 20/20 and nervous patients often make terrible blunders when they listen to bad medical counsel.

          • drgn

            oh no my comment was not meant that way. i enjoy reading both patient and doctor posts here.
            That is truly amazing about Cleveland Clinic. That really is a conflict of interest from what you describe. Is there a news clipping on that? I looked it up on a search and couldn’t find it. But there are plenty of lawsuits including a Baltimore doc in 2010 that put in 30 stents in a day. What was funny was in that article was a quote fromCleveland Clinic cardiologist talking about how excessive this problem is. When did this lawsuit occur?

          • Alice Robertson

            I tried to repsond but I used a “.com” and it is moderated.

          • Alice Robertson

            All my posts are in moderation, but if you find the article before me could you send it to me at: Realizing docs often like to stay anonymous but some are very open. I did think this article about Eric Topel was a bit alarming and can understand the problem the Clinic had with his financial ties (which I believe he lived and learned and changed from). I sure hope I can find that article but I can’t remember the guys name who sued (and a generic search on who sued the Clinic would take a lifetime to hunt down). My neighbor was an editor of The Cleveland Plain Dealer so I am going to grab him and see if he remembers because that’s where it was covered.

            Title of interesting article (I am glad things changed because it was worrisome for a patient):

            Patient Care vs. Corporate Connections


          • Alice Robertson

            Well none of my moderated posts made it and the one had pertinent info in it. I hate to backtrack. I will try to get it. I had no idea it would be so hard to find. I liked the NY Times article about the conflict of info with the Cleveland Clinic and why they are now being more transparent (not transparent enough for the NIH though:)

          • drgn

            oh no worries on that. Thanks for sharing that about the Cleveland Clinic. That’s really spot on with this topic isn’t it?

          • Alice Robertson

            I agree, but it’s problematic that the moderator isn’t releasing moderated posts. It feels like censorship and since censorship is a huge problem in medicine (for both doctors and patients) I guess that sorta figures in with the topic because we are discussing what happens when patients don’t get full disclosure and can’t make decisions based on a full view….only a partial view of what medicine can do.

  • Chiked

    Well since inflammation and not cholesterol deposits cause heart attacks, it is not wonder that medications are just as good as angioplasty Both are a waste of time and do not deal with the REAL cause of heart attacks.

    • Albert Fuchs

      Ummm… No. Statins and aspirin have been proven to prevent strokes and heart attacks and save lives. So they’re not a waste of time or money.

      Except for infectious diseases and genetic diseases caused by a single gene, the cause of virtually all diseases is very difficult to sort out scientifically, since it’s unethical to do experiments in which we try to give people diseases. In the absence of definitive evidence, I like to keep an open mind.

      • Chiked

        Nope. Statins only work in young/middle aged men with pre-existing heart disease. So if you are a healthy man, elderly or female of any age group, they are a waste of time and money.

        I agree that asprin works…probably by its anti-inflammatory effects and it is a heck of lot cheaper than statins or angioplasty.

        • Mengles

          idiots like you keep the money flowing

  • Guest

    Bill Clinton also had two stents in 2010. Was he retarded too, or are we just too invested in the BUSH IS DUMB!!! narrative to bring that up?

    • Guest

      If he got them without a clear indication then yes, he was an idiot too. Stop trying to turn this into a red vs blue political argument. Nobody cares.

    • drgn

      Bill Clinton had chest pain and got a stent. Sounds like a very different situation.

  • David Mokotoff

    If he did not have a moderate to high risk nuclear perfusion test, and had no symptoms, then his procedure would be denied payment by Medicare and most insurers under the present rules. The only other way around this would have been if an intra-procedure IVUS or FFR showed a high grade lesion.

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