After four heart attacks and a spell in hospital this week with a blocked coronary artery, isn't it time that the US vice-president, Dick Cheney, got a slightly easier job? While Dr Jonathan S Reiner, the cardiologist who cleared his blocked artery, cheerily says he's not limiting Cheney's workload, you have to ask whether a 60-year-old who has already had quadruple bypass surgery shouldn't be putting his feet up away from the stress of politics.
Cheney had his first heart attack at just 37 (suggesting that they may run in his family) while campaigning for Congress in Washington. His last heart attack, on November 22 last year, was during the stressful election vote recount in Florida. Yet Dr Reiner is still upbeat. "The symptoms were subtle this time. There is a very high likelihood he can finish out his term in his full vigorous capacity." The Russians, you will recall, used to say the same about President Yeltsin.
But although heart attacks do scar the muscle and reduce its pumping ability, many people return to full work and live long, happy lives. "While no heart attack is minor, some are more severe than others," says Gaynor Dewsnap of the British Heart Foundation. "If there is a blockage higher up in the coronary artery it would mean it was more severe."
On this occasion it seems that Cheney did not have a heart attack (in which the blood supply to an area of the heart is cut off and that portion of heart muscle dies). Instead, the blood vessel in his heart that is kept open by a metal stent (tube) was beginning to silt up, which happens in 20% of people with stents. As soon as he felt pains in his chest - a crucial warning sign - he rushed himself into hospital. The blockage was released using a tiny balloon threaded into the artery.
Like many veterans of heart attacks, Cheney will be on a rehabilitation programme. "When someone's had a heart attack they often get more conscientious about their health - what they eat and the exercise they take. They will have had surgery or be on drugs to reduce the risk of another heart attack," says Dewsnap. "Some people can be healthier than before their heart attack, although four attacks is a lot for anyone, because the muscle can't regrow and every attack you have damages the muscle more."
Although Cheney has had his main coronary arteries operated on, this doesn't necessarily mean that his heart is about to stop. Surgery that restores the flow of blood to the heart reduces the risk of dying from heart disease for at least 10 years after the operation.
The BHF recommends that, rather than retire to bed and wait for further chest pain, heart attack victims should take mild exercise for 30 minutes five times a week. Cheney could do worse than take regular strolls round the White House or play a leisurely round of golf. And he should avoid hamburger joints. Those who have suffered a heart attack should reduce the risk of further coronaries by eating healthily - five servings of fruit and vegetables, less fat, and oily fish once a week.
While Cheney is said to be a perfect patient, how can he reduce the stress of being the vice-president? His working hours are likely to remain long and unrelaxing. The evidence that stress can cause heart attacks is quite compelling. It's known that earthquakes and wars increase the rate of heart attacks, although not in people who don't already have some heart disease. Stress causes a rush of adrenalin that increases the body's demands on the heart and may also tip the heart into an abnormal rhythm. This stress does not have to be acute. A study from Japan of 195 men who had heart attacks found that working for more than 11 hours a day was a risk factor.
Cheney must also be careful not to relieve the stresses of his working day with more than the occasional glass of beer. Research from Finland, looking at more than 1,500 beer-drinking men, found an increased risk of dying in men swigging more than six bottles a session. But most limiting of all, he may need to avoid sports events. A study of Dutch men found that those who watched their football team being eliminated from the European football championship in 1996 had an increased risk of dying shortly afterwards from a heart attack.