The National Cooperative Trial on Multifactorial Prevention of First Heart Attacks and Coronary Mortality in Free-Living, High-Risk, Middle-Aged American Men, Also Known as JUMBO: A Short Story

The concept of a multiple risk-factor intervention trial (MRFIT) originated in mid-20th century efforts to determine whether modifying the "risk factors" established by cardiovascular disease epidemiology would prevent heart attacks. The term "MRFIT" probably first appeared in the 1968 report to the National Heart Institute from investigators of the National Diet-Heart Feasibility Study. Based on their pilot experience, they recommended a trial of diet alone. Aware, however, that authorities might agree with the rationale but not the implementation of such a massive and risky undertaking, they also proposed an alternative: whether coronary heart disease was preventable at all by simultaneous intervention on several risk factors; that is, a multiple risk-factor intervention trial. After some years agonizing by serial expert committees, the National Heart Institute opted against an explanatory diet trial and for a pragmatic multiple risk-factor intervention, one designed by Institute staff and operated under contract. Meanwhile, an impatient community of investigators met together in the Makarska Conference, outlined a broad cardiovascular disease prevention policy, and submitted their idealized version of a multiple risk-factor trial, called JUMBO. But the National Heart Institute, because of the plan for its own trial, had no funds left for an investigator-initiated proposal. Hence, this background and story of the MRFIT that wasn't.

Living history of medicine: vascular scaffolding, from dream to reality

Following the launch of balloon angioplasty in 1977, its deficiencies-abrupt occlusion requiring emergency bypass surgery in one in twenty attempts and recurrence in one in three cases-became soon apparent. The attempts to eliminate the element of chance from this otherwise highly attractive technique resulted in the concept of intra-vascular scaffolding. Following the inception of self-expanding mesh stents made from stainless steel and extensive bench testing and animal experiments, the first clinical data were obtained in Switzerland almost 30 years ago in 1986 with promising, albeit not undisputed results. Technical improvements including potent platelet inhibitors have made the technique a cornerstone of catheter-treatment of vascular disease. This paper gives an account of the sometimes difficult beginnings of coronary and non-coronary stenting at the University of Lausanne in Switzerland.

The. Thoma Ionescu - Victor Gomoiu Procedure: Cervicothoracic Sympathectomy for Angina Pectoris. The First Surgical Attempt to Treat the Coronary Heart Disease

Cervicothoracic Sympathectomy is a common indication in the treatment of Raynaud Syndrome, Palmer Hyperhidrosis or Acute Ischemia of the superior limb. Nonetheless, almost a century ago it represented one of the first innovative attempts in curing coronary heart disease. Nowadays, this indication is no more than a footnote in a volume on the History of Medicine, and a trivia fact for medical history enthusiasts. The operation's history is rather conflicting. A young Romaninan surgeon, Victor Gomoiu seems to have come up with the idea, in the early 20th century. However, his contribution remains unknown, after his successful collaboration with the famous surgeon and anatomist, Thoma Ionescu unfortunately turns into a dispute. This procedure was once thought cutting-edge. Furthermore it is the starting point for cardiovascular surgery. Whoever sparked the idea, gains an important place in the hall of fame of international surgery, that is why it is important to know its creator.

The decline and rise of coronary heart disease: understanding public health catastrophism

The decline of coronary heart disease mortality in the United States and Western Europe is one of the great accomplishments of modern public health and medicine. Cardiologists and cardiovascular epidemiologists have devoted significant effort to disease surveillance and epidemiological modeling to understand its causes. One unanticipated outcome of these efforts has been the detection of early warnings that the decline had slowed, plateaued, or even reversed. These subtle signs have been interpreted as evidence of an impending public health catastrophe. This article traces the history of research on coronary heart disease decline and resurgence and situates it in broader narratives of public health catastrophism. Juxtaposing the coronary heart disease literature alongside the narratives of emerging and reemerging infectious disease helps to identify patterns in how public health researchers create data and craft them into powerful narratives of progress or pessimism. These narratives, in turn, shape public health policy.

Coronary heart disease and heart attacks, 1912-2010

This paper was originally written for a conference entitled ‘The Future of Medical History. Now it ought to be clear – certainly to historians – that the future of anything is hard to predict; but at least in the short term, any future for medical history seems likely to include the history of disease, and the history of coronary heart disease (CHD) provides an excellent example of what the history of disease has to offer to a wide range of audiences.

Personal reflections on the incidence of ischaemic heart disease in Oslo during the Second World War

The dietary changes in Norway and especially in Oslo during the Second World War, with reduced fat intake and increased consumption of fish and fish products, was paralleled by a reduced incidence of and mortality from IHD. This was probably caused to a high degree by reduced platelet aggregability leading to a reduced tendency to thrombosis. We suggest that the mechanism behind this reduction was a changed balance between pro- and anti-aggregatory prostaglandins towards the anti-aggregatory side, caused by eicosapentaenoic acid from fish lipids. Furthermore, hypocholesterolaemia due to reduced fat intake and increased consumption of polyunsaturated fatty acids certainly contributed to this effect by reducing platelet aggregability.

Diet, lipids and atherosclerosis

During the Second World War there was a temporary reduction in the frequency of myocardial infarction in Finland, Norway and Sweden. This was probably due to the reduced consumption of saturated fat. The total amount of dietary fat and cholesterol presumably played only a minor role. Today it is easier to obtain reliable mortality figures and information about the fat composition of the food in a given country. A compilation of such data has shown that mortality from myocardial infarction is higher in countries with a high consumption of saturated fat. Polyunsaturated fats seem to have an opposite effect. There is no reason to dissuade people from using fat-modified food products with a lower fat content and replacement of part of the saturated fat by polyunsaturated. Refugees from countries where the diet contains very little fat should be warned against using too much of the high-fat food products widely consumed in their new countries.

History of the cholesterol controversy in Britain

The lipid hypothesis, the concept that cholesterol plays a causal role in atherosclerosis and cardiovascular disease, has been the subject of a controversy which started in the 1950s, peaked in the 1970s and 80s and then subsided in the 1990s. It was finally resolved by the positive outcome of the Scandinavian Simvastatin Survival Study, the first of 14 prevention trials using statins which showed that lowering cholesterol reduced both cardiovascular events and total mortality. This commentary focuses primarily on the events and people involved in the cholesterol controversy in Britain. The foremost critics of the lipid hypothesis are now deceased but unfortunately for many of the patients with hypercholesterolaemia and coronary heart disease it took the best part of 50 years to disprove the sceptics. This brief account relates why it took so long.

Acute myocardial infarction and acute coronary syndrome: then and now (1950-2005)

Advances in the prevention, diagnosis, and treatment of acute myocardial infarction (AMI) and acute coronary syndrome (ACS) have been remarkable since the mid-20th century. Even the clinical terminology used to describe some of the various components of ACS have undergone change, while the latter term itself represents a fairly recent addition to the medical lexicon. Although there have been dramatic changes in the diagnostic and therapeutic interventions used and impressive declines in morbidity and mortality, the differential diagnosis and complications of AMI and ACS remain as challenging now as they were a half century ago. This article presents in detail the medical understanding of AMI in the mid-20th century and how physicians of that era managed it and its complications, and contrasts this with current evidence-based knowledge and interventions.

Coronary heart disease (CHD)--one or several diseases? Changes in the prevalence and features of CHD

In retrospect, mortality from coronary heart disease (CHD) in the 20th century followed an epidemic pattern: mortality rates increased dramatically from 1920 until about 1960, remained roughly constant for almost a decade, and have been decreasing since the late 1960s. CHD has traditionally been conceived of as a single disease with multifactorial causality. We suggest instead that CHD cases may comprise at least two distinct populations: those associated with hypercholesterolemia, and those associated with insulin resistance. The epidemic of CHD was due primarily to changes in the incidence of the hypercholesterolemia subgroup. We propose that young adults who survived the 1918 influenza pandemic were rendered vulnerable to lipid-associated CHD and coronary thrombosis upon reinfection with influenza later in life. This vulnerability may be due to autoimmune disruption of low-density lipoprotein-receptor interactions. Historical events may affect the health of populations by affecting the susceptibility of populations to chronic diseases such as CHD. The life experiences of individuals are known to influence their susceptibility to infectious diseases; we suggest that life experiences may also influence individual susceptibility to chronic diseases.

[Coronary angioplasty: view through 30 years]

Andreas Gruentzig executed the first successful percutaneous transluminal coronary angioplasty (PTCA) in 1977. Percutaneous coronary interventions (PCI) have considerably changed since this time. The changes have touched the technical equipment for PCI, the pharmacological and mechanical support of PTCA also. The serious revision was in recommendations for PCI too. New catheter technologies have allowed to perform successful PCI in patients with an acute myocardial infarction, with multivessel coronary disease and in many others. PCI became the most often method of a coronary revascularization for ischemic heart disease in the nineties. Percutaneous interventions pass ahead of coronary artery bypass graft operations in many countries of Europe and America. The coronary angioplasty is carried out more than in 2 million patients in the world annually, and 1 million patients is exposed to the PCI annually in the USA. Coronary stenting became most frequently used technology of PCI from the middle of the nineties. The implantation of drug-eluting stents has been the dominating catheter-based method in world clinical practice during last three years. Nevertheless, both these technologies are not deprived of restrictions and disadvantages. The coronary restenosis has become the main limitation for standard (bare-metal) stents, and late thrombosis has become the most terrible complication for the drug-eluting stents. The big success of a method and huge increase of quantity of coronary interventions would be impossible without sequence of openings, innovations and other important events which are surveyed in this review.

Dietary fat, coronary heart disease, and cancer: a historical review

OBJECTIVES

This report describes the historical development of medical theories and research concerning the relationship between dietary fat intake and breast and colorectal cancer and coronary heart disease (CHD).

METHOD

The historical and medical literature on this topic was analyzed with special reference to the Woman's Health Initiative (WHI) studies.

RESULTS

After 1900, changes in clothing fashions and life insurance mortality studies created strong preferences for slimness and emphasized reduced dietary fat intake as the preferred method of weight control. After midcentury, ecological correlations of countries found that national average dietary fat intake was related to national breast cancer and CHD rates. These relationships were not found in longitudinal studies of the same countries or in studies of dietary fat intake of individuals, including the WHI study. Dietary fat intake was found to affect colorectal cancer in some studies of individuals, although not the WHI. The WHI, like other intervention studies of dietary fat reduction, used unrepresentative samples and costly lifestyle change techniques that are not economically feasible in the community.

CONCLUSION

The WHI concurred with many other studies in finding that dietary fat intake is not a significant risk factor for CHD or breast cancer.

The “Americanisation” of migrants: Evidence for the contribution of ethnicity, social deprivation, lifestyle and life-course processes to the mid-20th century Coronary Heart Disease epidemic in the US

We investigated the contribution of the large-scale immigration of White Europeans into the US between 1850 and 1930 to the timing and extent of the epidemic pattern of heart disease between 1900 and 1980. The analyses are based on data collected through the United States Federal Census from 1850 to the present. The hardcopy historical record confirms that census reports themselves and related monographs were concerned from 1850 with excessive mortality from heart disease of immigrants, particularly of Northern European origin and initially at least, their first-generation native-born children. Our analysis of the electronic database indicates a strong relationship between the percentage of US population foreign born and native born of foreign parentage and age adjusted mortality from heart disease. We identified a lag of 50 years giving the maximum linear correlation coefficient for men (r(2) = 0.92), and for women a shorter lag of 38 years and an earlier decline in Coronary Heart Disease (CHD) rates (r(2) = 0.96). Both the rise and fall of the CHD epidemic over an 80-year period correspond closely to the rise and fall of the foreign population in previous years. For the foreign born only, age adjusted negative binomial general estimated equation (GEE) models calculate the relative risk of dying of heart disease per 10% increase in proportion foreign born. There is an independent influence for men until 1930 and for women throughout the period from 1910 onwards. We conclude there is an impact of immigration on the pattern of the epidemic, mediated through a combination of factors, such as accumulated life-course susceptibility, deprived socio-economic conditions upon arrival, and the enthusiastic uptake of behaviours related to the classic risk factors of smoking, high saturated fat and salt diet. Our analysis provides a more contextualised understanding of the scale and timing of the epidemic of CHD in the US.

Profiling risk: the emergence of coronary heart disease epidemiology in the United States (1947-70)

This historical study examines the development of coronary heart disease (CHD) research and its role in the evolution of post-1945 chronic disease epidemiology in the United States. To give the examination greater salience, it compares the pathway represented by CHD epidemiology with that of lung cancer. Historians have paid less attention to the differences between the two, which later merged into what we now call 'risk factor epidemiology'. This study assesses why CHD epidemiology in the post-war period almost uniformly began with cohort studies and primarily stressed clinical variables as putative aetiological factors. It describes how CHD epidemiologists sought to justify the creation of a non-infectious chronic disease epidemiology, a position reinforced by the relative swiftness with which they obtained important results. It also follows the emergence of 'risk factor thinking' within CHD epidemiology. CHD epidemiology critically differed from its lung cancer counterpart in that it identified multiple factors of risk, each producing relatively small effects, rather than a single factor producing a strong and evident outcome. Consequently, it was difficult for CHD epidemiologists to demonstrate causality and to confirm scientifically that reducing risk factors would lower CHD rates. This had significant consequences for primary prevention and public health policy.

Thematic review series: The Pathogenesis of Atherosclerosis. An interpretive history of the cholesterol controversy, part IV: The 1984 Coronary Primary Prevention Trial ends it—almost

As of the early 1980s, despite the wealth of evidence from experimental animal models, the extensive epidemiologic evidence, the powerful genetic evidence, and the strongly suggestive clinical intervention trial results, most clinicians still remained unpersuaded regarding the relevance of the lipid hypothesis. What was needed was a well-designed, large-scale, long-term, double-blind study demonstrating a statistically significant impact of treatment on coronary heart disease events. The National Institutes of Health (NIH) had laid the groundwork for such a study as early as 1970, but the study was not completed and the results published until 1984. This study, the Coronary Primary Prevention Trial, showed that treatment with a bile acid binding resin reduced major coronary events in hypercholesterolemic men by 19%, with a P value of 0.05. The NIH followed this up with a national Consensus Development Conference on Lowering Blood Cholesterol to Prevent Heart Disease. For the first time, the NIH now went on record advocating screening for hypercholesterolemia and urging aggressive treatment for those at high risk. The Institute initiated a national cooperative program to that end, the National Cholesterol Education Program. For the first time, preventing coronary heart disease became a national public health goal.

Becoming the Framingham Study 1947-1950

In the epidemiological imagination, the Framingham Heart Study has attained iconic status, both as the prototype of the cohort study and as a result of its scientific success. When the Public Health Service launched the study in 1947, epidemiological knowledge of coronary heart disease was poor, and epidemiology primarily involved the study of infectious disease. In constructing their investigation, Framingham's initiators had to invent new approaches to epidemiological research. These scientific goals were heavily influenced by the contending institutional and personal interests buffeting the study. The study passed through vicissitudes and stages during its earliest years as its organizers grappled to define its relationship to medicine, epidemiology, and the local community.

[Coronary risk factors among men and women in Iceland. Results from the Reykjavik Study 1967-1985. 1992]

The Reykjavík Study 1967-1985: Risk factors for coronary heart disease mortality have been investigated in a prospective study of 8001 randomly selected Icelandic men and 8468 women. The men were aged 34-64 and the women 34-76 at the time of their first examination. After followup from 2-17 years 1140 (14.2%) of the men and 537 (6.3%) of the women had died. Coronary heart disease accounted for 43% of the mortality among the men, cancer 27% and cerebrovascular disease 7%. This distribution is in contrast to what was found among the women. Coronary heart disease accounted for 19.4% of the mortality, cancer 42.3% while the relative contribution of cerebrovascular mortality was similar. The effects of various factors were assessed simultaneously with multivariate survival analysis using the Cox's proportional hazard model. Age, serum total cholesterol, triglycerides, smoking and systolic blood pressure were all significant independent risk factors for coronary heart disease mortality in both sexes. Fasting blood sugar was of borderline significance, reaching significance among men, but not among women. However, since the women have much lower risk of dying from coronary heart disease than the men the absolute risk associated with each of the risk factors is much lower in the women.

Switzerland is small in size but big on cardiology

Switzerland is a small country in the heart of Europe and well known worldwide for its Alps, foreign bank accounts, cheese, chocolate and watches. However, it also has made a significant contribution to cardiology, especially interventional cardiology. It was where balloon angioplasty and stenting of obstructed coronary arteries, two of the most stunning advances in cardiology in the last 30 years and the two most frequently performed interventional procedures in cardiology, originated. The author, who recently served as a visiting professor in the University of Geneva, University of Bern and University of Zurich, summarized his personal observations and impressions in this report.

Spanish flu and early 20th-century expansion of a coronary heart disease-prone subpopulation

According to Stephen Jay Gould, "we have a strong preference for seeing trends as entities moving somewhere." However, trends may instead be the product of relative expansions and contractions of different subpopulations constituting the system. Variation in attributes of coronary heart disease cases during the decline in coronary heart disease mortality suggests a change in the primary source-subpopulation of cases over time. It is proposed that an early 20th-century expansion of a coronary heart disease-prone subpopulation, characterized by high serum-cholesterol phenotype and high case-fatality--which contributed to most of the coronary heart disease cases and deaths during the 1960s--may have been a late result of the 1918 influenza pandemic. The same unusual immune response to infection that in 1918 killed preferentially men, whites, and those born from 1880 to 1900 (20-40 years old) may have "primed" survivors of those birth cohorts to late coronary heart disease mortality. Ecologic evidence in favor of a birth cohort and geographic association between both epidemics is presented. Cross-reactive auto-immune response upon reinfection could explain the excess coronary heart disease deaths reported during influenza epidemics from the late 1920s onward. Mimicry between the viral hemagglutinin and the apolipoprotein B or the low-density lipoprotein receptor could be the link between infection and hypercholesterolemia. The extinction of those birth cohorts would result in a relative increase in cases coming from a 2nd subpopulation, which was characterized by insulin resistance and chronic expression of low-grade inflammation markers and was comparatively less vulnerable to die acutely from coronary heart disease.

Advances in the treatment of coronary artery disease

Initial pioneering efforts of direct coronary artery bypass were all performed on a beating heart. Although originally introduced into cardiac surgery for the repair of intracardiac defects, the ability of John Gibbon's heart-lung machine to create a motionless, bloodless operative field catalyzed coronary artery bypass surgery. During the ensuing decades tens of millions of patients benefited from coronary revascularization on cardiopulmonary bypass. As we celebrate the 50th anniversary of the invention of the heart-lung machine the landscape of interventional treatment of coronary artery disease has shifted dramatically. Although instrumental in the genesis of the field of coronary revascularization, the role of the heart-lung machine has now diminished. Two thirds of all coronary revascularization is now performed by percutaneous approaches and one fourth of all coronary artery bypass grafting procedures are performed without the heart-lung machine. However owing to the complexity of patients now requiring revascularization as well as recently introduced incremental improvements to cardiopulmonary bypass including coated, low prime circuits, closed integrated systems, and pharmacologic adjuncts Gibbon's heart-lung machine will continue to play an integral role in this field.