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
, 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.
- 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.
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)
A different, unnamed model has been reported to yield a 17% risk
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%.
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).
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.
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
. 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
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"
. 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
Trump echoes this: "I actually have very low blood pressure, which is shocking to people"
, 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.