Why Trump's Heart Report Isn't A Clear-Cut Diagnosis

Which doctor is right? It depends.

Donald Trump is the oldest person to become a U.S. president, which may be why he and his team feel they have to frequently boast about his health. Over the course of his first year in office, his administration has also had to combat questions of potential cognitive decline, following erratic behavior on social media, and calls from doctors to evaluate his mental health.

Trump may have hoped that the release of the results of his first official White House exam would put an end to those questions, but some of his numbers are still raising concerns among voters and members of the press.

For instance, Dr. Ronny Jackson, the White House physician, proclaimed Trump to be in excellent overall health Tuesday, saying that he enjoyed “significant long-term cardiac and overall health benefits” thanks to abstaining from alcohol and tobacco.

But the next day, Dr. Sanjay Gupta, CNN’s chief medical correspondent, said that Trump already has heart disease. Gupta based that on the president’s rising coronary calcium scores over the years. The measurement, which can predict the likelihood of having coronary artery disease, looks at the amount of plaque present.

The dispute left viewers confused and suspicious of both Jackson’s initial assessment and Gupta’s diagnosis based on Trump’s health report, turning cardiac health into a partisan debate. But unlike politics, the science is clear: Experts are siding with Dr. Jackson’s initial assessment of Trump’s heart health. The president’s test results do not reveal heart disease.

A misunderstanding of the coronary calcium test and what its score means lies at the heart of this controversy.

The coronary calcium score is a non-invasive heart scan that allows doctors to identify calcified plaque in the arteries. The more calcified plaque there is, the higher one’s score — and the higher one’s risk of heart attack and stroke. On the CNN segment, Gupta noted that in 2009 Trump scored a 34, which means there was evidence of mild coronary calcification. In 2013, that number rose to 98. Then, by 2018, that number had risen to 133. A score of more than 100 means that there is a moderate amount of plaque in the coronary arteries and that there is a moderate to high risk of having a heart attack.

In contrast, President Barack Obama underwent the scan in 2010 and scored zero — no evidence of coronary artery disease. President George W. Bush also had the scan while in office and scored 24 — what would be characterized as “minimal” or “mild” plaque.

While Trump’s rise may seem alarming, it’s actually pretty typical of what happens when people start statin treatment to lower their cholesterol levels, explained Dr. Richard Chazal, immediate past president of the American College of Cardiology and medical director of the Heart and Vascular Institute at Lee Health in Florida.

While Chazal didn’t want to comment directly on Trump’s numbers, he did point out that after the first coronary calcium scan, doctors generally don’t tend to continue performing the test. This is because as statins start to work, the calcified plaques begin to grow, shrink and then heal in the arteries. This process makes the calcifications seem even larger, thus leading to an elevated coronary calcium score. Trump has been on some kind of statin since at least 2016.

“This is a case where the marker goes up but the risk goes down,” Chazal explained.

After a patient begins statins, heart doctors generally look at other biomarkers, such as cholesterol levels, or the presence of symptoms like chest tightness or shortness of breath to see if heart disease risk is going down.

“There are more complicated tests that could be done to look for progression, but coronary calcification is not a good way to follow the success, or lack thereof, of statin therapy or any preventive care,” he concluded.

No, a high calcium score does not automatically mean heart disease

Besides the fact that Trump’s coronary calcium score may be artificially elevated, there is also the fact that he doesn’t exhibit any symptoms of heart disease.

Heart disease, or cardiovascular disease, is an umbrella term that describes several problems affecting either the heart or its blood vessels. These include coronary artery disease, heart attacks, strokes, heart failure, arrhythmia or heart valve problems.

When it comes to coronary artery disease specifically, which is what the calcium score measures, doctors can disagree about what measures qualify for actual heart disease. To Gupta and other experts HuffPost spoke to, a coronary calcium score over 100 by definition qualifies as coronary artery disease.

But to Dr. Michael Blaha, director of clinical research for the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins, a coronary calcium score of 133, absent any symptoms, doesn’t rise to the diagnosis of heart disease.

“In my view, a clinical diagnosis of coronary heart disease refers to coronary arteries with blockages, or to patients with symptomatic complaints suggesting coronary disease,” Blaha said in an email to HuffPost. “A coronary calcium score of 133 is suggestive of mild to moderate coronary atherosclerosis, which is different than coronary heart disease.”

Atherosclerosis is a term that describes the buildup of plaque in artery walls, and it can lead to heart attack or stroke.

Blaha also pointed out that Trump’s coronary calcium score places him at around the 50th percentile for other men his age, as the condition is extremely common.

“Unfortunately, this is a commentary on American society ― the average male patient of this age has mild to moderate plaque in their arteries.”

Cardiologist Robert Segal, founder and medical director of LabFinder.com, echoed Blaha’s assessment and said that because Trump did well on his physical stress tests, his heart prognosis is good. Segal also said that Trump was in good hands when it came to medical treatment — unlike many Americans who are at risk for heart disease.

“President Trump is getting excellent medical care, and he’s being appropriately screened for heart disease,” Segal said. “The main issue for many Americans is that they aren’t aware that they have heart disease. I would recommend that everyone be aware of their cholesterol numbers and consider screening for heart disease as they approach middle age.”

Heart disease is the leading cause of death for both men and women in the U.S., linked to an estimated one in four deaths every year. About 49 percent of all Americans have at least one of three key risk factors for heart disease, which are hypertension, high LDL cholesterol and a smoking habit. Other risk factors include diabetes, a sedentary lifestyle and a body mass index of over 25.

While Trump doesn’t smoke, he does have several of these risk factors. He has a BMI measurement of 29.9, according to Jackson’s recent assessment, and a total cholesterol level of 223, which is borderline high. He also reportedly believes that exercise is bad for you and loves eating cheeseburgers in bed.

CORRECTION: A previous version of this story incorrectly said that heart disease killed one in four Americans every year. In fact, heart disease is linked to one in four U.S. deaths every year.

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