Progress Against Heart Disease (review)

This book illustrates the close relationship between the history of medicine and the history of disease itself, and also the connection of both with sociological factors and with the prevailing course of technological advancement.

During the past century, the character of cardiac illnesses changed dramatically throughout the developed world. Conditions linked to infections such as rheumatic heart disease became less common, but the overall health benefits were nullified in part by a rising incidence of coronary heart disease (CHD). This triggered a search for causes. Large scale follow-up studies were initiated with results that implicated several risk factors. These included decreasing levels of physical activity, cigarette smoking, and dietary factors, specifically excess intake of calories, sugar, and fats. Collectively, these factors also contributed to a rising incidence of obesity, diabetes, and high blood pressure, all three of which were found to be risk factors themselves. The resulting publicity was followed by initiation of educational programs that encouraged dietary changes, smoking cessation, regular exercise, and, if necessary, appropriate medications. Drugs that could lower blood pressure were introduced mid-century, followed by medications that reduced abnormal blood cholesterol levels. A series of long-term follow-up studies showed that compared to controls, subjects modifying their lifestyles developed CHD significantly less frequently.

Effective medical treatment of established CHD became available mid-century with anticoagulant therapy, followed by drugs that could reduce cardiac work, dilate coronary arteries, and correct rhythm disturbances. Intensive care units, first opened in the 1960s, revolutionized emergency treatment. Closed chest techniques for resuscitation of patients who suffered cardiac arrest saved a minority from otherwise inevitable death. The newly developed heart-lung machine made it possible to stop the heart for the duration of an operation while maintaining normal oxygenated blood flow. Starting in 1968, operations to bypass narrowed coronary arteries were developed. By the late 1970s, it became possible to dilate narrowed coronary arteries by inflating a balloon at the tip of a catheter introduced into a femoral artery and advanced into a coronary. This procedure, percutaneous transluminal coronary angioplasty obviated the need for operation in appropriately selected cases. As indications widened, both procedures were used with growing frequency and efficacy. Subsequent morbidity was reduced.

Adherence to lifestyles that had been proven to lower CHD incidence in the first place also proved effective in reducing the likelihood of recurrences. In the United States, mortality rates from CHD that had earlier increased began a thirty-year decline after 1968. This was shown to be associated with a decline in incidence and a reduction in mortality when the condition did occur.

These developments have been well documented by the authors, the first an academic sociologist and epidemiologist, the second a copy and freelance writer, a partnership recognizable in the style. Their comprehensive coverage of the period is spiced with vignettes quoting past medical writings, from the Bible to the 1929 description of the first cardiac catheterization. Basic cardiac anatomy, physiology, and pathology are outlined, as are the salient symptoms and findings on physical examination of the cardiac patient. A comprehensive chapter is devoted to the expanding role of laboratory tests in diagnosis and assessment, including exercise testing, echocardiography, the most advanced contributions of nuclear medicine, and the delineation of coronary artery anatomy with radiological contrast material. These techniques are examined critically with appropriate comment on their limitations, and, in the case of exercise testing and invasive procedures such as cardiac catheterization, their hazards. Advances in prevention and therapy are documented in detail and critically where appropriate. The clinical course with its variations are outlined and given life by case reports concerning well-known personalities. When necessary, setbacks to progress are acknowledged. For example, adoption of healthy lifestyles in the United States was noted to have come to a virtual halt in the 1990s. There is a justifiable emphasis on the reduction in cardiac mortality, but perhaps at the price of insufficient attention to lessening incidence, particularly with respect to secondary prevention, that is, the prevention of recurrence subsequent...