All Americans should have concerns about heart disease. Yet when the heart that is diseased resides in the second most powerful man in the world, we need to understand what is actually happening beyond the press releases and news conferences. Although the vice president is officially number two, he is likely de facto the most powerful man in the world.

Mr. Cheney is only sixty years old, but has had four heart attacks, quadruple bypass surgery, and now two percutaneous procedures to open closing coronary arteries. He fortunately had symptoms that allowed him to recognize the problem and seek appropriate medical attention. Clearly this is a patient with premature coronary artery disease, related to genetic and environmental risk factors. From the genetic category, his cholesterol and blood fats have been significant contributors to his condition. Whether more esoteric genetic risk factors are active cannot be determined from available public data, but you should know that other factors determined by your chromosomes are not routinely examined, yet play perhaps even more powerful roles in determining cardiac risk than cholesterol levels. Other environmental factors include his smoking (which he stopped after he had his heart attack), suboptimal dietary habits seen often in wealthy executives, a history of minimal exercise which he has now begun to do regularly, excessive caloric intake which contributed to his overweight status, and stress.

The procedures used to treat the vice president represent the technological equivalent of locking the barn door after the horses are out. Great to have them. Too bad we need them. Very active prevention strategies are mandatory if we want to keep Mr. Cheney's experienced hand on the tiller. From the genetic side, identification of all known risk factors and their aggressive management is absolutely required. This doesn't just mean being on the right drugs, but having the targets hit, i.e., blood fat, blood pressure, and other factors lowered to ranges that have been shown to reduce the risk of recurrent disease. These values are known; they just have to be met.

From the environmental side, absolute dietary control of fat, caloric and salt content would go a long way to supplement the benefit of his medications and reduce his weight. This would reduce the workload his damaged heart has to do, and help protect the diseased arteries that are trying to nourish his heart. His exercise program needs to be aerobic to help build up cardiac reserve and encourage collateral blood vessel growth, should he suffer another closure of a major artery.

All of the above are feasible and achievable, not just for Mr. Cheney, but for anyone who has had a heart attack. The one factor, which is problematic in this unique situation, is the vice president's stress load. Stress. Now that's a problem for all of us, but that's a real problem for this talented and bright man in the pressure cooker environment that is the White House. The schedules, the meetings, the crises are all additive in an environment that taxes a healthy heart, much less a diseased one. The only way to be unaffected is be detached or protected by circles of aides. Somehow, Mr. Cheney strikes me as a hands on executive who has thrived on the turmoil and excitement. Indeed, that characteristic may have contributed to his current situation. But the dilemma he faces after this most recent event is that the environment that molded him may be the one that may prematurely kill him. To resolve this paradox, his family, his doctors and his closest colleagues need to advise this First Advisor. I, for one, need him to stay on the job at the White House. After all, someone needs to be awake.