Feb. 13, 2010 -- After Thursday's heart surgery, Bill Clinton is out of the hospital and back on his feet, but cardiologists say his battle with heart disease is far from over.
"This is not a problem just in that one area. You have to treat the whole person to reduce the risk," says Dr. Sharonne Hayes, director of the Mayo Clinic Women's Heart Clinic, adding that if whatever led to blockages in two of Clinton's arteries isn't addressed, it's "quite likely" that he'll have more blockages in the next couple of years.
Released in "excellent health" Friday morning from NewYork-Presbyterian Hospital after stent surgery, the former president will be back to the work of his foundation in the next couple of days, Clinton spokesman Douglas Band said in a statement.
Considering Clinton's notoriously demanding schedule, will a return to work mean there will be enough time for the cardiac rehab strongly advised for patients who have repeat cardiac events like this?
In September 2004, Clinton underwent quadruple coronary bypass surgery. He was notorious for his fondness of fast food and donuts -- and the high cholesterol, 223, to match. After the surgery, he lost weight and improved his diet.
But after Thursday's surgery, cardiologists say Clinton's heart disease may not have been sufficiently managed.
"The simple fact that someone has a development of new blockages despite treatment…would tell me that I have a patient that is still at risk," says Hayes. "[It] means we're not doing enough -- something's got to change."
Hayes says that after a repeat event like this, it's necessary to "relook at what we need to do" to lower the risk of heart trouble -- diet, physical activity levels, medications, and any other risk factors all have to be re-examined to see what may have led to the new blockages.
Post-Op Analysis – What's Up With Clinton?
In Clinton's case, the problem may go beyond diet and exercise. His cardiologist, Dr. Allan Schwartz, told ABC News' John Berman in an interview Friday that Clinton was doing all the right things behaviorally, including monitoring his diet and working out every day.
But reducing stress is one lifestyle change that Clinton may have a hard time sticking to.
Clinton is known for his hectic life -- and the grace with which he handles it -- but even for those accustomed to it, high levels of stress can wear on the heart.
"We do know that acute stress can trigger, in someone that otherwise is doing well, a heart event," Hayes says.
Hayes adds the earthquake in Haiti may have put a lot on Clinton's plate. In the past month alone, Clinton has travelled to Haiti twice to oversee relief efforts, to the United Nations twice to coordinate Haitian relief, and to Switzerland for the World Economic Forum in Davos.
Even as he was wheeled into surgery Thursday, Clinton was still working -- he was on a conference call for Haitian relief.
"Everyone has stress in their life; stress per se isn't the risk factor, it's how we respond to the stress," Hayes says. For some high-functioning individuals, if they're handling that stress well, "it's not necessarily harmful."
Another aspect of Clinton's case is his family's history of heart disease, which he acknowledged to an interviewer in 1988.
Theoretically, if a patient had "perfect care," was handling stress, diet, and exercise and still had a recurrence of blockage, the cause could be partly genetic, says Dr. Randal Thomas, director of the Mayo Clinic Cardiovascular Health Clinic and president of the American Association of Cardiovascular and Pulmonary Rehabilitation. But in Clinton's case, he says he'd be "surprised if it were all genetic."
Thomas says studies show that patients can further lower their risk if they "adjust treatment with medication to be even more aggressive, have even lower targets for cholesterol, and really ratchet up the intensity of therapy."
This therapy includes the ABCs of heart disease, Thomas says: aspirin, beta blockers (to lower blood pressure), cholesterol medication (usually statins), diet, exercise, and fish oil.
For someone with coronary artery disease, Hayes says -- which Clinton's "got it in spades" -- statins play a key role in post-op care. "Current guidelines say [these patients] should be on statins indefinitely."
But according to a report from the New York Times, while Clinton had been on the statin Zocor to lower his cholesterol before his 2004 surgery, he did not remain on it.
Road to Recovery -- Cardiac Rehab
Whether it's medication management, stress, or genetics at the root of Clinton's arterial blockages, cardiologists say that Clinton should go into cardiac rehabilitation -- a program of education, monitoring, and cardiac care -- in order to unearth exactly what needs to change.
"After a stent procedure," Hayes says, "[rehab] has been shown to decrease risk of a patient coming back with a heart attack. It's an underappreciated, very underutilized [tool]."
Cardiac rehabilitation is a comprehensive program that provides patients with emotional support, education about lifestyle, and supervised exercise training, as often, even previously active patients are fearful of working out after a cardiac event.
These programs reduce mortality following a cardiac event by 25 to 35 percent, Thomas says.
But this therapy is time-consuming: programs generally consist of three hours of monitored exercise and three hours of group sessions a week, Thomas says -- a time commitment that may be hard to squeeze into the former president's booked-solid schedule.
"I would hope that [Clinton] finds some time to continue the care that's going to help [his heart]," Hayes says.
But coronary artery disease is a lifetime commitment, Thomas says. "[Surgery] is a good short-term solution [but] it's temporary; in the long term, the most powerful thing we can do is adjust lifestyle and medication.
"Unless we get rid of the underlying problems," he says, the problem will come back.