President Trump’s recent heart health tests have generated a lot of discussion in the media. Some experts opined that he was at serious risk for a heart attack even though his own doctor said the President’s cardiac health is excellent. I wanted to get another opinion, so I invited Andrew Waxler, MD, a triple-boarded practicing cardiologist affiliated with Berks Cardiologists in Wyomissing, Pennsylvania to join my Podcast to talk about diagnostics in heart health. Here’s the transcript (condensed and modified for readability).
Pat: Andy, in general, what kind of advice you have for older Americans who are concerned about their own or their loved ones’ heart health? What do you recommend that they do? Should they have an annual physical? Should they get heart tests like the ones that President Trump had during his physical? Or should they go straight to a cardiologist like you?
Andy: We always want people to start with the basics. First of all, eat a good diet with fruits and vegetables, lean meats, whole grains, nuts, that kind of thing. Try to exercise 30 minutes a day even if you just walk around the block. Try to maintain a reasonable weight and don’t smoke.
Next, everybody—young or old—should see a doctor on a regular basis because there are a lot of things that will harm us in later years that develop slowly over time without symptoms. High blood pressure is known as the silent killer, but diabetes and high cholesterol can also be silent. These three conditions can lead to hardening of the arteries (atherosclerosis), which can cause heart attacks and strokes. So, the main reason to see a doctor on a regular basis is to be screened and tested for simple things that you may not know you have.
The other reason to see a doctor on a regular basis is that you may not be aware that certain symptoms you are experiencing could be serious. My wife is a nurse practitioner. One of her patients once told her, “I’ve been getting indigestion.” She asked him, “When do you get indigestion?” The patient answered, “Every time I walk on the treadmill.” What the patient perceived to be indigestion actually was a symptom of heart disease!
Pat: I totally agree about starting with the basics, but we know from reading President Trump’s recent physical exam that he had more than the simple tests you mentioned. He had a stress test and a calcium test. I think he also had an echocardiogram. When should people expect to get these more sophisticated tests? And, what is their significance?
Andy: Every President gets extra treatment and extra diagnostic studies. That’s just the way it’s been.
Pat: More than the average guy, more than you or me. Right?
Andy: That’s right! I don’t know whether that’s fair or correct, but given the importance of the office, it is probably a good practice. So, yes, President Trump got a whole battery of tests. First and foremost, he had what’s called a coronary calcium score. Anybody out there can get a coronary calcium score; you do need to get a doctor’s prescription in most states. But even if a prescription is necessary, any doctor is going to say okay.
A coronary calcium score is basically a very quick CT scan of your chest. It takes about 30 seconds or a minute, maybe even less. It is a radiation test but there is only a small amount of radiation and no x-ray dye is used. It costs somewhere between $100 and $150, but usually not covered by insurance. So, it is available to most of our listeners out there and it’s reasonably priced, but it is not free.
Here’s the concept behind the calcium score. Some smart person, literally about a hundred years ago, around World War I—when they first started having primitive x-rays—figured out that on an x-ray, you cannot see the hardening of the arteries, but you can see specks of calcium where arteries are. This is because the body doesn’t like it when you develop hardening of the arteries. So, it tries to cover it up—you know the old expression sweep things under the rug. Your body tries to cover up hardening of the arteries with the layer of calcium. So we know if we see calcium where we know there are arteries, that’s a clue that the body is reacting to the hardening of the arteries. The calcium is not the problem, the calcium is the smoke that tells us that there’s fire.
About 1995 or 2000, some smart people put together some CT scan programs that can actually measure the amount of calcium in your coronary arteries. There’s a formula to calculate a number; the higher the number, the more calcium is in your heart arteries. The higher the calcium score, the more likely you are to have a significant blockage.
President Trump has a moderate calcium score. It was not very high, but it was not normal either. Some of the people who commented on his results kind of overreacted and said, oh my gosh, the president has coronary artery blockage. The truth is he is right in the middle of the predicted value for his age which is another way of saying that as we get older most people will develop some hardening of the arteries. So, if you get a calcium score on a bunch of people in their early 70s, very few of them are going to be zero. Most are going to be around where Donald Trump is.
So, let me translate what his calcium score means, he most likely does have some early hardening of the arteries of his heart, but most likely it’s not significant. We can’t say that with 100% certainty, but that’s what the calcium score would suggest. It’s a good news/bad news result. The bad news is there is some early hardening of the arteries; the good news is it’s probably early. This interpretation is supported by the fact that he also had a stress test which only picks up significant blockages. He passed his stress test. So, the fact that he had a low to moderate calcium score and he passed his stress test would suggest he probably has early, mild blockage but nothing bad. The take-home message is most of our listeners in their 70’s probably have that right now.
So, if you want to spend $150 and get a calcium score, you can, but I would just say if you feel fine, I would just talk with your family doctor and decide if you need a stress test or not. I don’t think the average seventy-year-old out there who feels fine needs a calcium score because it’s going to be mildly elevated and it’s just going to get them upset. You could argue that if it’s really super-elevated, it might be helpful. But we don’t usually routinely recommend getting one.
Pat: Let’s close by having you explain to our listeners, some of whom they have the perception that the way you get a heart attack is that the artery gets narrower and narrower and narrower and then gets blocked. But in actual fact, isn’t the mechanism that the areas of hardening of the arteries, called plaque, rupture, triggering a clot that causes the heart attack?
Andy: Atherosclerosis or hardening of the arteries is a slow process. It actually starts, believe it or not, in your teens or your 20’s. And it takes decades to build up. People can present with hardening of the arteries in one of two ways. Either they’re older and they often show up with bad blockages and need bypass surgery because they’ve had 60 years of building up hardening of the arteries.
What happens to other people, and we don’t completely understand why, is that other people, often younger or middle-age, can actually have what’s called a vulnerable plaque. A vulnerable plaque means some hardening of the arteries that is not completely stable. Something happens that triggers the plaque to rupture or tear. The artery itself doesn’t tear but the plaque does. But the body actually thinks there is a tear and it rushes platelets and other blood clotting factors to the site. So, you end up with a blood clot in your heart artery and that causes a heart attack. So, there are two different ways that coronary artery disease can behave. It can grow very slowly over time narrowing the artery. Or it can suddenly tear and cause this cascade of blood clotting factors then leads to a heart attack. And, it’s really unclear why it does that. We are not really sure.
Pat: I want to thank you for joining us today and helping us to better understand heart health and heart disease. I hope you will come back and talk to us again.
Patricia Salber, MD, MBA
Patricia Salber, MD, MBA is the Founder. CEO, and Editor-in-Chief of The Doctor Weighs In (TDWI). Founded in 2005 as a single-author blog, it has evolved into a multi-authored, multi-media health information site with a global audience. She has worked hard to ensure that TDWI is a trusted resource for health information on a wide variety of health topics. Moreover, Dr. Salber is widely acknowledged as an important contributor to the health information space, including having been honored by LinkedIn as one of ten Top Voices in Healthcare in both 2017 and 2018.
Dr. Salber has a long list of peer-reviewed publications as well as publications in trade and popular press. She has published two books, the latest being “Connected Health: Improving Care, Safety, and Efficiency with Wearables and IoT solutions. She has hosted podcasts and video interviews with many well-known healthcare experts and innovators. Spreading the word about health and healthcare innovation is her passion.
She attended the University of California Berkeley for her undergraduate and graduate studies and UC San Francisco for medical school, internal medicine residency, and endocrine fellowship. She also completed a Pew Fellowship in Health Policy at the affiliated Institute for Health Policy Studies. She earned an MBA with a health focus at the University of California Irvine.
She joined Kaiser Permanente (KP)where she practiced emergency medicine as a board-certified internist and emergency physician before moving into administration. She served as the first Physician Director for National Accounts at the Permanente Federation. And, also served as the lead on a dedicated Kaiser Permanente-General Motors team to help GM with its managed care strategy. GM was the largest private purchaser of healthcare in the world at that time. After leaving KP, she worked as a physician executive in a number of health plans, including serving as EVP and Chief Medical Officer at Universal American.
She consults and/or advises a wide variety of organizations including digital start-ups such as CliniOps, My Safety Nest, and Doctor Base (acquired). She currently consults with Duty First Consulting as well as Faegre, Drinker, Biddle, and Reath, LLP.
Pat serves on the Board of Trustees of MedShare, a global humanitarian organization. She chairs the organization’s Development Committee and she also chairs MedShare's Western Regional Council.
Dr. Salber is married and lives with her husband and dog in beautiful Marin County in California. She has three grown children and two granddaughters with whom she loves to travel.