Yeltsin's Fitness at the Heart
of Russia's Political Future

By David Brown and David Hoffman
Washington Post Staff Writers
Tuesday, February 20 1996; Page A01

Boris Yeltsin has heart disease. That much -- and very little else -- is certain about the health of the 65-year-old president of Russia.

His physical condition has been the subject of news reports, rumor and scandal. His five years as president have been punctuated by episodes of illness, peculiar behavior and unexplained retreats from public view. The announcement last week that he is running for reelection has revived speculation about his fitness for the job.

Yeltsin has cast himself as a bulwark against Russia's resurgent Communists and potent nationalists. Despite his current unpopularity, his power as the incumbent might well propel him into a second-stage runoff campaign this summer, most likely against the Communist Party candidate, Gennady Zyuganov. Thus, riding on Yeltsin's uncertain health could be the hopes of many Russians for an alternative to a Communist leader.

Moreover, though Yeltsin has experienced two episodes of heart trouble in less than a year, the Kremlin has gone to great lengths to hide details of his illnesses, leading to speculation in Russia and abroad that his condition is more serious than has been disclosed. Should Yeltsin die or be impaired by ill health while in office, the Russian constitution provides that he would be temporarily succeeded by the prime minister and that an election to replace him would be held within three months.

Official reports say that Yeltsin suffers from coronary artery disease, the most common heart ailment -- and most common cause of death -- in both the United States and Russia. Almost certainly, he has had one heart attack, and possibly two.

As far as can be determined, he has not undergone angiography, the key diagnostic procedure that most Americans and many Europeans with his medical history would receive. Nor has he had bypass surgery, a treatment for severe coronary artery disease that is performed about 485,000 times a year in the United States and less frequently in Russia.

The questions about Yeltsin's health overshadow the facts. Among the more important unanswered questions are these:

Why has treatment of Yeltsin's ailment not been more "aggressive," assuming that coronary artery disease is the correct diagnosis? Has the president turned down procedures and treatments his physicians favor? Has politics or concern for his image affected medical decisions?

What explains the sporadic facial puffiness mentioned in news reports? Is Yeltsin sometimes unsteady on his feet? If he is, what is the cause? Does he have pain from a 1990 back injury that he underwent surgery for in 1993? Does he take painkillers that may have a sedative effect? What medications does he use regularly?

Only Yeltsin or his doctors can answer these questions with certainty, and they seem unlikely to do so publicly. Andrei Vorobyov, a physician who treated Yeltsin in October, said in response to questions from The Washington Post that he "was not authorized to speak about the president's health. You have to ask him." A written request for information submitted to the president's press secretary, Sergei Medvedev, was not answered.

Without answers, discussion of the Russian president's health must rely heavily on inference and speculation. Nevertheless, a rough medical portrait can be sketched from Russian and Western news reports, observations of the president, Yeltsin's writings, expert opinion and epidemiological data.

Yeltsin was hospitalized in November 1989 -- during the Soviet era shortly after he was dismissed as head of the Moscow Communist Party organization. In his autobiography "Against the Grain," Yeltsin described his symptoms as "headache and chest pains" and added: "I had suffered a physical breakdown."

Soon after he was admitted, however, he was summoned by Soviet President Mikhail Gorbachev to appear at the offices of the party's policy-making Central Committee in Moscow. Yeltsin was under sedation, and in his book he bitterly recounts being helped from his bed and ushered to a waiting car: "My head was spinning, my legs were crumpling under me. I could hardly speak because my tongue wouldn't obey."

Yeltsin returned to the hospital after a meeting with the ruling party Politburo. Emotional turmoil and headaches are the main symptoms he mentions in his description of the remainder of his stay. There are no more references to chest pain and none to heart disease.

On July 11 of last year, however, Yeltsin was admitted to Moscow's Central Clinical Hospital with chest pain specifically attributed to problems with his heart. Official pronouncements included two important words -- "ischemia" and "angina." Neither ischemia nor angina, however, is a medical diagnosis. Instead, they are terms describing the results and symptoms of a disease.

Ischemia is a deficiency of blood flow to living tissue or an organ. Many things can cause ischemia. Pinching, cutting or plugging an artery can each cause ischemia by robbing tissue of oxygen-rich blood.

Angina is short for angina pectoris, the term for chest pain that arises from insufficient blood flow to the heart muscle. That muscle is continuously active and, consequently, has a large appetite for oxygen. Even a brief reduction of blood flow to it causes pain in most people.

The blood vessels in question are called the coronary arteries, which deliver blood to the heart muscle; they are not the vessels that carry blood into and out of the heart's pumping chambers. Ischemia in the three coronary arteries is usually caused by the accumulation of cholesterol, calcium and excess cells on the vessel's inner walls, a process called atherosclerosis.

Prolonged or severe ischemia can lead to death of the heart muscle served by the narrowed artery. That is called a myocardial infarction, or, in more common parlance, a heart attack.

Several days after Yeltsin's July hospitalization, a medical official announced the president had suffered a "surface myocardial infarction" -- one that does not extend through the entire heart wall. These are less damaging than full-thickness infarctions and often leave a patient with a normal electrocardiogram, or EKG. According to his press secretary, Yeltsin's EKG was normal. Yeltsin spent two weeks in the hospital and another two weeks recuperating at a government resort.

On Oct. 26, he was flown by helicopter from his country residence to a Moscow hospital, again suffering from chest pain. This bout was more serious than the earlier one, according to numerous reports. At a news conference, the president's top aide, Viktor Ilyushin, said "the president's condition does not call for great optimism" and added that "it is unlikely he will be back at work in the near future."

Official pronouncements again referred to "acute ischemia." Vorobyov, the physician, appeared on Russian public television and said Yeltsin's EKG "showed little change" from his previous ones -- which suggests he had not had a myocardial infarction.

Some observers, however, are skeptical. Mikhail Alshibai, a cardiologist at the Institute of Cardiosurgery in Moscow, was asked in a recent interview with New Times magazine if Yeltsin had suffered a heart attack in October. He replied: "It is possible. We know very little about it, only that it was much worse than his first one. And it took a great deal longer to treat it."

Jerrold M. Post, a physician and professor at George Washington University and coauthor of the book "When Illness Strikes the Leader," recently wrote an article about Yeltsin's health and personality in the journal Problems of Post-Communism. In it, he states that Yeltsin "suffered a heart attack" on Oct. 26. Last week, Post said sources familiar with the Russian president's health are certain of that diagnosis, though he would not identify them.

Yeltsin stayed out of public view for a longer period this time. Several reports said he received "active therapy," although details of that treatment were not specified. It is not known what, if any, medicines he is taking. In the West, aspirin and a class of drugs called beta blockers are recommended therapy after myocardial infarction.

Several reports suggest his treatment has emphasized non-pharmacological interventions. Yeltsin is on a low-salt diet, and his spokesman said he lost about 22 pounds by mid-December. He reportedly also has quit drinking, though excessive alcohol intake is not a major factor in the course of atherosclerotic coronary disease.

It appears, however, that he has not undergone angiography, a procedure in which the coronary arteries are momentarily filled with an opaque dye and X-rays are taken. This process outlines the inner contours of the vessels, revealing the location and size of blockages. If coronary artery bypass surgery is contemplated, angiography must be performed.

Leo Bockeria, a distinguished Russian heart surgeon and chairman of Moscow's Bakoulev Institute for Cardiac Surgery, said in a recent interview that, although he was not consulted in Yeltsin's case, he was certain that angiography was not performed. "The people taking care of him are the best cardiologists in our country; I am sure they do not see the necessity," he said.

Cardiologist Alshibai said: "The question that troubles me most is that none of the official reports said that a coronograph [angiography procedure] was done on the president. Today, this is the only test that can give a complete picture of an ischemia patient with respect to treatment methods and prospective life expectancy."

Duke University Medical Center maintains an international database of people who have survived 30 days after a heart attack. It gives some indication of Yeltsin's risk -- assuming he had a heart attack.

European men roughly his age have about a 3 percent risk of dying in the first year after a heart attack. The risk persists at 3 percent to 4 percent a year for the subsequent four years. Bypass surgery lowers the risk of dying in the first five years by roughly one-third.

In the United States and most European hospitals, a person's chance of dying in surgery, or immediately afterward, is 2 percent to 5 percent. A more precise estimation depends on details of a patient's health, which in Yeltsin's case are not known; nor could the operative mortality in Russian hospitals be determined, although Yeltsin presumably would get the best treatment the country could offer.

It is not known whether Yeltsin has a medical condition that would complicate heart surgery, or even preclude it. His autobiography, however, contains a description of an illness he had as a young man that could conceivably complicate bypass surgery now.

Yeltsin describes a bout of tonsillitis and high fever that was followed by a transient heart ailment. Doctors advised him to stay in bed for four months. Yeltsin rebelled against this treatment, escaped from the hospital on a rope made of sheets and recuperated at home.

Yeltsin does not name this illness. However, it bears some resemblance to rheumatic fever. A minority of people who have had that illness later develop disease in the heart's valves. Sometimes this requires surgery to replace the valves. The operation occasionally is done simultaneously with bypass surgery, although the combined procedure carries a risk of dying that is 1.5 to 2.5 times higher than the risk for bypass surgery alone.

Many people have speculated that Yeltsin simply does not want surgery, either because of personal preference or because he feels it might accentuate his political vulnerability. Seeking treatment overseas could similarly hurt his image.

There is even less information with which to judge other concerns about Yeltsin's health. Rumors of heavy drinking have dogged him from the start of his term, bolstered by peculiar behavior, such as his seizing a band leader's baton during a visit to Berlin in August 1994 and then attempting to lead the band himself. Another time, he failed to leave his plane for a planned airport meeting with the Irish prime minister, inviting suggestions that he was drunk.

Not all of Yeltsin's troubles may be linked to alcohol. As he addressed parliament in March 1993, for example, many observers noted a disheveled appearance and slurred speech. Immediately after the speech, however, Yeltsin gave an interview to an American reporter, in which he talked of the extreme emotional turmoil caused by the death of his mother a few days earlier. The correspondent smelled no alcohol on Yeltsin's breath.

Other observers have speculated that Yeltsin may periodically be taking painkillers and muscle relaxants -- both of which can cause grogginess -- for a back injury he sustained in a rough helicopter landing in 1990.

Yeltsin says in his autobiography that in times of crisis "people often seek solace in God; others seek it in a bottle. Neither of these escape routes interested me."

Brown reported from Washington, Hoffman from Moscow.