Election day has come and gone. Next up we will be voting for the White House occupant for the following four years. As a group, the Presidents have generally been healthier than the average American. However, as Bernie Sanders’ recent heart attack made clear, the Presidents are not immune to heart disease and stroke. What is the history of Presidential heart disease and what lessons can the average citizen take from history?

We’ll start our Presidential heart history with Woodrow Wilson. In 1919, during his second term, Wilson suffered a stroke. Despite being paralyzed on his left side he was able to complete his term.  Warren Harding was President from 1921 to 1923. He died of an apparent heart attack and cardiac arrest while in office in 1923. The man who took over for Harding, Calvin Coolidge, was President from 1923 until 1929.  He died from a heart attack in 1933. During Franklin Roosevelt’s third term in office, in 1944, he was diagnosed with high blood pressure, coronary artery disease and congestive heart failure.  At the time, there were no effective blood pressure medications so his systolic blood pressure was routinely over 200 and often 250.  Despite his health problems, he won a fourth term, but died from a massive stroke in 1945.  1955 was not a good year for Presidential heart disease. Dwight Eisenhower suffered a heart attack while in office and future president, Lyndon Johnson, also had a heart attack that same year.  Both men were treated, as was the custom at that time, with one month of bed rest. Both men were heavy smokers at the time of their heart attacks. Eisenhower would go on to have seven heart attacks and one stroke. He died from congestive heart failure in 1969.  Johnson had another heart attack in 1972 and died from a heart attack in 1973.  During his term in office, in May 1991, George H. W. Bush was diagnosed with atrial fibrillation (an irregular rhythm from the upper chamber of the heart).  His heart was electrically shocked back into rhythm.  Bill Clinton started having chest pain three years after leaving office and ultimately underwent open-heart bypass surgery.  Lastly, George W. Bush was found to have a blocked heart artery in 2013, four years after the presidency. He was treated with an angioplasty. 

In all, nine of the last eighteen Presidents suffered from heart disease or stroke, a prevalence of 50%, which is much higher than the average rate of heart disease in Americans. Why is this? Many of the Presidents had risk factors for heart disease such as high blood pressure, high cholesterol or diabetes. Many were noted heavy cigarette smokers.  In addition, one can imagine that these men were under a tremendous amount of mental stress.

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Mental and emotional stresses have long been associated with heart disease. When these stressors occur, there are a number of physiological changes that are detrimental to the heart.  These changes include an increase in heart and blood pressure, as well as an increase in the heart’s demand for oxygen and blood flow. The heart arteries can close down or spasm, reducing blood flow to the heart. There is increased inflammation and various clotting factors are activated. In addition, mental stress causes behavioral changes. Under stress, patients may go back to smoking, consume extra alcohol, not follow a prudent diet and stop exercising.  Cardiac hyperresponsiveness from mental stress has been associated with an increased risk for high blood pressure, atherosclerosis, heart attack and cardiac death.  Patients experiencing mental stress can have chest pain, but more worrisome, mental stress is often present without symptoms. The medical term for this is “silent ischemia” (ischemia is lack of blood flow to the heart). Ischemia from mental stress can be detected with an EKG monitor or during a mental stress test. A mental stress test is performed by applying EKG leads and, instead of walking on a treadmill, the patient is asked to perform a task such as solving a tough math problem, or public speaking, or naming all of the Presidents. The mental stress test can be combined with nuclear or echo imaging as well. 

So how can the average American citizen avoid following the Presidents down their adverse heart heritage trail? First, take care of risk factors. Avoid smoking, exercise regularly, follow a good diet, keep weight down and treat high blood pressure, diabetes and high cholesterol. As difficult as that is, managing stress may be even more problematic. There is a lot of stress in our daily lives. From small stressors (for example, traffic congestion) to larger issues (such as job or family stress), stress is ubiquitous and nearly impossible to avoid.  That is why stress management is such an integral part of cardiac rehab programs for patients with heart disease.  Interventions need to be long term (over at least 6 to 12 months), be conducted in groups and use techniques that alter the stress response including behavioral training, biofeedback, meditation, relaxation techniques, regular physical exercise and yoga. Lastly, don’t run for President.