⬅ Donald Trump: Coronary Artery Disease

Trump has calcium deposits in his coronary arteries. They are extensive enough to exceed a common threshold for the diagnosis of coronary artery disease 1 SEE BELOW. The calcium was detected on CT scans over a number of years, with the amount of calcium increasing each time. (Results tabulated here: MORE) Trump's risk of arterial disease progression seems to be driven mainly by his age, cholesterol, and obesity MORE.

Trump's secretiveness around his health makes it impossible to say whether he has had direct complications of the disease in his coronary (and other) arteries. Indirect complications may have attended his covid-19 illness.

Diagnosis & Prognosis

Trump's diagnosis of coronary artery disease is not a surprise. Although he does good things for his arteries by avoiding tobacco and maintaining a low blood pressure, anyone living in the modern world is at risk for atherosclerotic arterial disease, of which coronary disease is the deadliest type. Thus, news outlets intone that Trump "has a common form of heart disease" 1 2, but of course it is more complicated than that.

First, a little background:

Coronary artery disease causes symptoms when pathological narrowings in an artery limit blood flow through that artery. Based on the laws of hydraulics, a single lesion in a coronary artery has to obstruct about 60% of the arterial diameter in order to cause symptoms. When obstruction is 100% or nearly so, a heart attack will occur.

Coronary artery disease is a concern because it can lead to heart attack, heart failure, effort intolerance, and arrhythmias including sudden death. It can also can herald disease in other important arteries, such as those in the brain.

What does a coronary calcium score of 133 tell us about blockages in Trump's coronaries? Only probabilities, which can be expressed several ways.

1. A calcium score between 100 and 300 raises the risk of heart attack or coronary death by a factor of 7.7 as compared to people having no coronary calcium 3. Comment: That sounds grim, but this is only a relative risk. The next item discusses absolute risk, which is more important.
2. For Trump as an individual, his calcium score, blood pressure, cholesterol level, etc. translate to a predicted 9.5% chance of a "CHD event" in the next 10 years, using the MESA model 4. (See screenshot at bottom of this page→ MORE) In the MESA model, a "CHD event" (coronary heart disease event) is defined as any of: myocardial infarction (heart attack); resuscitated cardiac arrest; death from coronary heart disease; or, in persons with angina, coronary revascularization ("revascularization" = bypass/angioplasty/stent) 5. A different, unnamed model has been reported to yield a 17% risk 6. Comment: The difference between the models could be explained if they use different endpoints. For example, the MESA model does not consider angina pectoris as a "CHD event," but another model might, and so its predicted "risk" would be a higher number. Other models for persons aged 70+ generally do not factor in coronary calcium levels. The MESA output for Trump MORE shows that considering his calcium score does not markedly change his risk prediction.
3. At the level of single obstructions in the coronary arteries, it can be said, on the basis of one study 7, that Trump has a 95% chance of being free from a coronary obstruction of more than 50%. Comment: There is no question, however, that Trump should continue to take a statin, as figure 1 in another study shows 8.
4. Compared to the typical 17% annual increase in calcium score 9, Trump's increase in annually compounded calcium score was quite high from 2009 to 2013 (went from 34 to 98 = 188% rise in 4 years = 30% increase per year), but has been slow from 2013 to 2018 (went from 98 to 133 = 35% rise in 5 years = 6% increase per year). Comment: This is hard to interpret. The recent slow-down could be good, or it could be bad (because one benefit of statins seems to be conversion of dangerous non-calcified atherosclerosis into less dangerous calcified atherosclerosis). Such uncertainty highlights limitations of the coronary calcium score as it is understood today. New scanning techniques are available, but are not as well studied.

Although putting numbers on serious events can be comforting, it is important to remember that the predictions are not really individual predictions, and that arterial disease has a large, unpredictable component. No physician would be surprised if Trump had a heart attack or stroke tomorrow. Comment: It's this unpredictability, plus Trump's age, that make the effusive prognoses of the White House physicians unsupportable. For example, arterial narrowings much less than 100% often cause heart attacks, not because they limit blood flow, but because they are metabolically active or physically unstable and thereby incite formation of a blood clot at that spot (which then causes 100% obstruction). It is precisely these types of plaques -- non-calcified -- that are missed by coronary calcium scanning. Also, even minimal amounts of coronary disease may enable spasm of the artery, with all the consequences of obstructed blood flow. The most sobering statistic is that sudden death is the first symptom of coronary artery disease in 20% of patients. That said, many people do well in the long term with coronary disease. But all in all, it is better not to have it!

Risk Factors & Preventive Therapy

Arterial disease can be prevented by manipulating risk factors. Trump's risk factors have been measured many times, with known results tabulated here: MORE. Summarized qualitatively:

• Age            = [worse every year] But not amenable to treatment!
• Tobacco usage  = [good] Lifelong non-user
• Diabetes       = [good] Does not have diabetes mellitus
• Blood pressure = [good] Lifelong healthy pressure (apparently)
• Family history = [good] No heart attacks or strokes in close blood kin
• "Cholesterol"  = [bad→good] Blood lipids are under treatment
• Obesity        = [bad] Unsuccessful treatment
• Exercise       = [bad] Unsuccessful treatment

Comment: Trump's risk-factor profile would be quite reassuring had physicians disclosed values from past years. Good numbers now generally don't erase the damage from decades of bad numbers.

Trump takes a cholesterol-lowering "statin" medication and reported in September 2016: "And actually I've experimented with three statins. And one seems, for me, to work the best. And it's really brought my cholesterol down into a good range." Asked how long he's been on it: "Couple of years, I would say. Couple of years" 12. Doctors quadrupled the dose of Trump's statin during his second year in office after a marked rise in his cholesterol levels. The dose of his statin (rosuvastatin / Crestor) is now at the maximum normally allowed... assuming the patient has been compliant in taking the pills.

Blood pressure is more important than cholesterol in determining arterial disease. Trump's blood pressure is suprisingly low, assuming the reported numbers are accurate. MORE Trump echoes this: "I actually have very low blood pressure, which is shocking to people" 13, also noting "I've always been lucky with blood pressure. I've always had very good blood pressure." 12

Prevention is always more important when coronary disease is already established.