In an opinion piece titled, “I Was Dick Cheney’s Cardiologist. Trump Has Not Looked Well, and We Should Know Why” published in The New York Times last week, Dr Jonathan Reiner questioned the state of Donald Trump’s health.
“Despite reassurances from the White House to the contrary, at times over the past year, the president has not looked well,” wrote Reiner before adding: “He’s had large bruises on both hands, swelling in his legs and episodes when it appears that he is struggling to stay awake.”
Though Reiner stressed that he was not Trump’s doctor and was not attempting to diagnose him, a cardiologist raising concerns based on physical appearance asks what are the visible signs of a heart issue.
Cardiovascular disease (CVD) encompasses diseases of the blood vessels and heart, such as coronary heart disease and stroke. It is one of Australia’s biggest health problems and accounts for one in four of all deaths in Australia.
Symptoms of CVD include pain or discomfort in the chest, arms, the left shoulder, elbows, jaw or back; difficulty in breathing or shortness of breath; nausea or vomiting; light-headedness or faintness; a cold sweat, dizziness or numbness down the side of the body.
Of the patients Professor Jason Kovacic sees in clinic, up to one third have visible physical signs of CVD.
Swollen legs
“The most visibly obvious [symptom] is swelling in the legs, ankles and feet,” says Kovacic, the director and chief executive of the Victor Chang Cardiac Research Institute in Sydney.
Why? The heart is a pump, so it is basic plumbing.
“If you have reduced pumping function, you’re going to get back pressure, and that goes down through our venous system and also puts pressure on our lymphatics,” explains Clinical Associate Professor Kegan Moneghetti, a senior research fellow at the Baker Heart and Diabetes Institute in Melbourne.
Fluid is then pushed down into the body’s tissues, pooling in the legs. It often goes hand in hand with veins in the neck becoming distended and engorged.
While it may be a sign of CVD, there are other causes, including chronic venous insufficiency, which Trump is said to have. It occurs when the valves in the leg veins weaken or fail, impairing blood flow back up to the heart.
A blue hue or clammy skin
There is not one cause of blue or grey discolouration of the lips, fingers or toes, but it can signal severe heart failure or congenital heart disease.
In a normal heart, the deoxygenated blood flows from the right ventricle into the lungs, where it gets oxygenated. The oxygenated blood then flows through the left chambers and is pumped out to the rest of the body, where the oxygen is utilised before the cycle begins again.
When the heart pump is not working properly, oxygen delivery to the tissues is reduced which can cause discolouration.
Some types of congenital heart disease or holes in the heart can also cause mixing of the blood, making it less oxygenated
Cool clammy skin may be another sign of advanced heart failure, adds Kovacic, signalling that the heart is unable to pump enough warm oxygenated blood around the body.
Lumps and bumps
Fatty, raised bumps around the eyes or in leg tendons can signal very high cholesterol, and means a person is at high risk of coronary artery disease.
Normal total cholesterol is between about four and six mmol/L, Moneghetti says.
More than two in five (42 per cent) Australian adults, however, have high cholesterol. When total cholesterol is above 12 mmol/L, so much of it is floating around the bloodstream that it starts to permeate through softer, thinner parts of the skin, including around the eyes.
Baldness, wrinkles and grey hair
A series of studies in the last decade have made associations between baldness, depth of forehead wrinkles and greying hair and CVD.
“There was discussion that it might point to poor metabolic health, or other life stresses,” says Moneghetti.
More likely is that they are simply signs of ageing.
“The number one risk factor in all these models and all this research is always age,” he says.
An 80-year-old is twice as likely as a 40-year-old to develop cardiovascular disease.
Kovacic adds that baldness, for instance, is related to changing levels of testosterone, which is not generally linked to cardiovascular disease.
“In fact, there are some studies to suggest that testosterone replacement in older men that are testosterone deficient is probably fine for heart health,” he says.
“So generally, yes, older people are more likely to get cardiovascular disease. And older people are more likely to have wrinkled skin and be bald.”
You can’t see the most dangerous symptoms
Trump may have swollen legs and other visible symptoms, but visible signs alone rarely tell the whole story, Kovacic says.
“It’s possible that someone with leg swelling, easy bruising and falling asleep could have cardiovascular disease, but it’s impossible to determine whether he has cardiovascular disease based on those public observations alone.”
The most dangerous signs of CVD are invisible, Moneghetti adds.
For instance, those with coronary artery disease, who have a build up of plaque in their arteries, can be completely asymptomatic for a long time.
“Until that plaque is causing a narrowing of upwards of 70 or 80 per cent, patients will not experience angina, chest pain, breathlessness,” he explains.
It is vital then to “know your numbers”, says Moneghetti. “Your cholesterol, and your blood pressure are not things that we can see visually, but they are incredible, powerful prognosticators when it comes to cardiovascular disease.”
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Sarah Berry is a lifestyle and health writer at The Sydney Morning Herald and The Age.Connect via X or email.
