Medical Mystery: A president’s love of exercise reveals an issue

Editor's note: Allan B. Schwartz, M.D., a professor of medicine in the Division of Nephrology & Hypertension at Drexel University College of Medicine, is looking at the health of U.S. presidents. On the eve of the Republican National Convention, his subject is the 41st president, George H.W. Bush.

A World War II Navy pilot and star baseball player at Yale, George H.W. Bush brought his love of fitness to the presidency, with Secret Service agents along for his usual runs.

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George H.W. Bush was a Navy pilot and star baseball player at Yale.

On May 4, 1991, during the entourage's usual Camp David route, Bush developed shortness of breath, chest tightness, and a general feeling of fatigue. An irregular heartbeat was detected on physical exam by the White House physician.

Bush was rushed to Bethesda Naval Hospital by helicopter. Able to walk into the hospital on his own power, the president was completely alert and otherwise stable with no other complaints. But the irregular heartbeat persisted and was extremely rapid - his ventricular heart rate was 150 beats per minute on arrival at the hospital. The electrocardiogram showed no other abnormalities except atrial fibrillation. An ultrasound examination of the heart showed no structural abnormalities and otherwise normal heart function.

On admission, doctors prescribed digoxin, a drug used to slow the heart rate, and procainamide, used for arrhythmias. A heart defibrillator machine was placed nearby, in case of an emergency, to restore heart rhythm to normal.

Vice President Dan Quayle was notified to stand by, as he would act in Bush's place if the president needed general anesthesia. That had the press corps reeling in a different form of shock.

By 10:25 p.m. on May 5, the president's heart was back in normal sinus rhythm. But the next day at 5 a.m., the atrial fibrillation recurred. Cardiology consultants hovered over the president, and decided he could go back to the White House.

The digoxin and procainamide were continued, and doctors prescribed warfarin to prevent blood clots from forming in the heart. Bush was given a defibrillator device and monitor to wear, which transmitted a continuous record of his heart rhythm as he moved about his activities.

Over the next days, Bush began feeling increasingly tired. A fine hand tremor and a slight neck enlargement had occurred. His weight decreased 13 pounds over a few weeks.

What diagnosis could explain all his symptoms?


Solution:

Test results from earlier blood work started to give an explanation for the atrial fibrillation, fatigue, hand tremor, neck enlargement, and weight loss.

About two weeks after the atrial fibrillation event, the White House announced: "Mr. Bush began a series of tests today to determine how to treat an overactive thyroid that his doctors say led to an erratic heart rhythm."

The president himself made the next announcement. "The good news is that once the thyroid is corrected, that means there's no problem on the heart - the thyroid is connected to the heart bone, you know, and I think it's going to be all right."

The president was readmitted to the hospital and treatment for Graves disease, also known as hyperthyroidism. His treatment started with an oral dose of radioactive iodine targeted to directly decrease thyroid gland activity. Two days later, he began a 10-day course of saturated solution of potassium iodide (SSKI) to prevent a rare complication of radio-iodine therapy called "thyroid storm" (extreme hyperthyroidism).

The radioactive iodine treatment worked a little too well, and within a few months Bush's thyroid hormone level was too low. He was started on synthetic thyroid hormone, which would be required for life.

Eighteen months earlier, first lady Barbara Bush also was diagnosed with Graves' disease, though in her case the autoimmune condition had the additional complication of making her eyes appear more prominent.

An even more startling occurrence was noted when Mildred "Millie" Kerr Bush, the first family's pet English springer spaniel, developed another autoimmune disease, lupus. Was there something in the White House environment causing these problems? After an investigation, physicians concluded it was simply coincidental that the first couple and their dog all developed autoimmune conditions.


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