“When I first became a GP in England well over 30 years ago, the early diagnosis of myocardial infarction (heart attack) was a matter of slight importance, since there was no intervention which made any difference to survival.
“You tried to reach patients in their homes quickly to relieve their pain with heroin, but only sent them to hospital if their pain was not controlled, or they were going into shock. Studies at the time indicated that patients with heart attacks survived better at home, where they were less likely to be killed with injections of lidocaine.”
Quite a difference, according to Dr. Richard Lehman, writing this in the British Medical Journal (BMJ) compared to modern cardiac care options like clot-busting thrombolytic drugs or invasive coronary angioplasty procedures that are now routinely available to patients presenting with heart attack symptoms these days. (Unless, of course, you happen to be a woman in your 50s presenting to the E.R in mid-heart attack, in which case, as reported in the New England Journal of Medicine (1), you are seven times more likely to be misdiagnosed and sent home compared to your male counterparts with the same symptoms). But I digress . . . .
We’ve come a long way, baby, since Dr. John Warren wrote the first article in the very first issue of the same New England Journal of Medicine and Surgery back in 1812, in which he described the cardiac chest pain known as angina pectoris. At the time, treatment for this puzzling condition consisted of “bloodletting, a tincture of opium, bed rest, or a combination thereof”.
And even for Dr. Lehman’s own patients who more recently survived a heart attack, about 40% of them would have died within the first year back in the 1980s. But by 2009, this one-year mortality rate had fallen to between 4-8%.
That change in outcomes had me wondering about how the world of cardiology has evolved throughout modern history, and here’s what I found:
1924 Dr. Willem Einthoven of The Netherlands wins the Nobel Prize for Medicine for inventing the electrocardiograph (commonly known as ECG or EKG)
1926 A doctor from the Crown Street Women’s Hospital in Sydney, Australia (who wished to remain anonymous) resuscitates a newborn baby’s heart with electrical stimulation. The doctor wanted to remain anonymous because of the controversy at the time surrounding any research that artificially extended human life.
1929 Dr. Werner Forssmann of Germany makes an incision in one of the antecubital veins in his own left arm and inserts a narrow catheter into his venous system. He then guides the catheter by fluoroscopy into the right atrium of his own beating heart – a precursor to today’s coronary angiography. Dr. Forssmann is later awarded the 1956 Nobel Prize for Medicine.
1930 The active glycosides present in the leaves of the flower known as foxglove (digitalis purpurea) are isolated, and the synthetic agent digoxin is developed as a treatment for chronic heart failure.
1931 Drs. Charles Wolferth and Francis Wood describe the use of exercise to provoke attacks of angina pectoris (from Latin and Greek, meaning “strangling in the chest”). They investigate the EKG changes in normal subjects and those with angina, but dismiss the technique as too dangerous “to induce anginal attacks indiscriminately”. (Archives Internal Medicine 1931;47:339)
1941 Dr. Karl Paul Link at the University of Wisconsin-Madison successfully isolates the anticoagulant factor, which initially finds commercial application as a rodent-killer. It becomes known as warfarin, now one of the most widely prescribed medicines in the world, used in vascular and heart disease patients to prevent stroke and coronary artery blockages.
1947 Dr. Claude Beck, a pioneering cardiovascular surgeon in Cleveland, successfully defibrillates a human heart during cardiac surgery. The patient is a 14-year old boy; six other patients had already failed to respond to this defibrillator.
1948 Researchers with the National Heart Institute, later renamed the National Heart, Lung, and Blood Institute, recruit 5,209 men and women between the ages of 30 and 62 from the town of Framingham, Massachusetts, and begin the first round of studies on cardiovascular disease development that will become known as the Framingham Heart Study. These subjects will continue to return to the study every two years for a detailed medical history, physical examination, and laboratory tests.
1949 Montana physician Dr. Norman Jeff Holter develops a 75-pound backpack that can record the EKG of the wearer and transmit the signal. His system, called the Holter monitor, is later greatly reduced in size, combined with tape/digital recording, and used to record ambulatory EKGs.
1950 John Hopps, a Canadian electrical engineer and researcher for the National Research Council, together with two physicians (Dr. Wilfred Bigelow of the University of Toronto and his trainee, Dr. John C. Callaghan) show that a coordinated heart muscle contraction can be stimulated by an electrical impulse delivered to the sino-atrial node of the heart. The apparatus is the first cardiac pacemaker, which runs on vacuum tubes, and is powered by household electrical current.
1950 Using a newly invented centrifuge, University of California medical scientist Dr. John Gofman discovers several fat-like substances circulating in the blood, including LDL (low density lipoprotein) and VLDL (very low density lipoprotein). At this time, he reports that total cholesterol is a “dangerously poor predictor” of heart disease.
1951 Dr. Charles Hufnagel, an American surgeon, develops a plastic valve to repair an aortic heart valve.
1952 Dr. F. John Lewis, an American surgeon, performs the first successful open heart surgery.
1953 Dr. John H. Gibbon, also an American surgeon, first uses a mechanical heart and blood purifier, the heart-lung machine that’s now used during open heart surgeries.
1952 Cardiologist Dr. Paul Zoll, Chief of the Cardiac Clinic at Boston’s Beth Israel Hospital, is credited with successfully using electrical stimuli applied externally to the chest of a 65-year-old patient with end-stage coronary disease; the patient is revived and survives for six more months. According to the Harvard University Gazette, although Dr. Zoll’s clinical experiments are published by the prestigious New England Journal of Medicine, they are not well received by some of his colleagues, who consider this work “against the will of God.” Around the same time, Dr. Zoll and his collaborators invent a machine to display the electrical activity of the heart on an oscilloscopic screen that also registers each heartbeat with an audible signal, and also sounds an alarm upon the onset of cardiac arrest. We now call this invention a cardiac monitor, a mainstay in all Emergency Departments and Cardiac Intensive Care units. Four years later, Dr. Zoll will develop a safe electrical countershock technique to resuscitate hearts during cardiac arrest. Until now, emergency thoracotomy and manual compression of the heart have been the only life-saving approaches available.
1953 Swedish physician Dr. Inge Edler and his physicist friend Dr. Hellmuth Hertz develop a diagnostic non-invasive technique called echocardiography, using ultrasound waves to visualize the human heart.
1957 Margarine consumption increases to about 9 pounds per year in North America – surpassing butter for the first time ever. Editorial note: yuck!
1958 Professor Ake Senning of Sweden places the first implantable cardiac pacemaker (designed by Rune Elmqvist) into a 43-year-old patient with complete heart block.
1960 Jack La Lanne is North America’s premier fitness guru. Obesity is not a public health issue. Annual revenue in the health club industry: $200 million.
1960 Cigarette smoking is found to increase the risk of heart disease.
1961 American cardiologist Dr. J. R. Jude leads a team performing the first external cardiac massage to restart a heart.
1961 The first coronary care unit is opened at Bethany Medical Center in Kansas City, Kansas by Dr. Hugh Day. Until then, patients like me recovering from acute myocardial infarction are placed in beds located throughout the hospital and far enough away from nurses’ stations that their rest will not be disturbed. Patients are commonly found dead in their beds. Bethany is also where the first crash carts are later developed.
1961 The Framingham Heart Study reports that men under 50 with elevated cholesterol are at greater risk of heart disease. However, this group of vulnerable middle-aged men are also more likely to smoke, be overweight, and not exercise. These make up the famous Framingham risk factors, but elevated LDL cholesterol is the risk factor most talked about.
1964 The World Medical Association issues its Declaration of Helsinki, which set standards for clinical research; pharmaceutical companies are now required to prove efficacy in their clinical drug trials before marketing their drugs.
1964 Dr. Charles Dotter advances the procedure called angiography (the process of making blood vessels viewable by X-ray). He inserts a guide wire and coaxial Teflon catheter into the femoral (upper thigh) artery of an 82-year-old woman with gangrene who has refused leg amputation. The circulation returns to her leg, and her newly-dilated artery stays nicely open until her death from pneumonia two and a half years later. Dr. Dotter is later dubbed “The Father of Interventional Radiology”, and 14 years later is nominated for the Nobel Prize for Medicine.
1965 American surgeons Drs. Michael DeBakey and Adrian Kantrowitz implant mechanical devices to help a diseased heart.
1967 Dr. Christiaan Barnard, a South African surgeon, performs the world’s first heart transplant from one person to another.
1967 The first coronary bypass surgery is performed at the Cleveland Clinic. Dr. Rene Favaloro pioneered the open-heart technique, which allows a physician to remove a blood vessel from another part of a patient’s body and use it to connect the arteries in the heart, creating a grafted bypass around blocked coronary arteries.
1970 Women’s experience and tolerance of cardiac surgery begins to appear in medical literature for the first time.
1971 The Framingham Heart Study enrolls a second generation – 5,124 of the original participants’ adult children and their spouses, known as the Framingham Offspring Cohort – to participate in the same longterm health examinations as their parents.
1977 Dr. Andreas Gruentzig performs the first coronary balloon angioplasty at a hospital in Switzerland. According to The Society for Cardiovascular Angiography and Interventions:
“During the procedure, Dr. Gruentzig inserts a catheter into a coronary artery that is largely blocked and inflates a tiny balloon (made at his kitchen table), compressing the buildup of plaque against the walls of the coronary artery.”
1980 Increased focus begins in medical journals on various health issues concerning women (abuse, breast cancer, menopause and cardiovascular disease).
1982 Dr. Willem DeVries, an American surgeon, implants a permanent artificial heart (designed by Robert Jarvik) into a patient.
1983 Dr. Dean Ornish publishes his landmark book, Stress, Diet and Your Heart: A Lifetime Program for Healing Your Heart Without Drugs or Surgery, claiming that his extreme dietary restrictions and lifestyle changes can reverse heart disease.
1984 Dr. Antonio Gotto*, president of the American Heart Association, writes:
“If everyone went ahead with cholesterol-lowering, we will conquer atherosclerosis by the year 2000.”
* Dr. Gotto’s admitted financial conflicts of interest: he was co-author on “Intensive lipid lowering with atorvastatin in patients with stable coronary disease”, a study sponsored by Pfizer (the drug company that makes atorvastatin, better known as the name brand cholesterol drug, Lipitor); he has also received consulting fees from drug companies such as AstraZeneca, Bristol-Myers Squibb, Merck, Schering-Plough, Pfizer, Novartis and Reliant; he was also paid to give lectures on behalf of Pfizer, Merck, Schering-Plough, AstraZeneca, and Reliant; and he also testified before the Food and Drug Administration on behalf of Johnson & Johnson-Merck. (N Engl J Med. 2005;352).
1986 In Switzerland, the first intracoronary metal stents are successfully implanted in coronary arteries, acting as tiny scaffolds to help keep previously blocked arteries open.
1988 After 20 years researching carbohydrate metabolism, Dr. Gerald Reavan of California announces his discovery of Syndrome X, now referred to as Metabolic Syndrome. Syndrome X is a cluster of cardiac risk factors, including high blood sugar, high insulin levels, elevated triglycerides, and low levels of protective HDL cholesterol.
1987 Mevacor, the first cholesterol-lowering statin drug, is approved for sale.
1995 For the first time ever, a chapter on cardiovascular disease in women is written for the Heart and Stroke Foundation of Canada.
1997 Over one million angioplasties are performed worldwide, making angioplasty the most common medical intervention in the world.
1997 The American Heart Association presents a scientific statement on cardiovascular disease in women. (Cardiovascular Disease in Women. A Statement for Healthcare Professionals from the American Heart Association. 1997; 96:2468-2482).
1999 WomenHeart:The National Coalition for Women with Heart Disease is founded by three American women who have each survived heart attacks while still in their 40s: Nancy Loving, Jackie Markham, and Judy Mingram. These women, who didn’t know each other at the time of their heart attacks, realize after they are all interviewed for the same magazine article that they share common experiences about the lack of information or services available for women with heart disease. They form their own tiny support network, which gradually grows to include:
- ongoing support groups for women living with heart disease
- a dynamic online support community at Inspire.com
- the annual WomenHeart Science & Leadership Symposium in collaboration with Mayo Clinic in Rochester, Minnesota in order to train survivors to become community educators and group leaders back home
- Advocacy Institute conferences to train women living with heart disease to be public policy advocates and form the basis of a grassroots health policy movement
2000 Annual sugar consumption in North America averages 150 pounds per capita. Butter consumption, meanwhile, is now less than four pounds per capita, down from over 18 pounds per capita back in 1920.
2002 The National Heart Lung and Blood Institute in the U.S. launches The Heart Truth campaign to deliver all women a personal and urgent wake-up call about their risk of heart disease – the #1 killer of women. This campaign also introduces the little Red Dress pin as an iconic symbol to wear in support of women’s heart disease awareness. In Canada, the Heart and Stroke Foundation will launch The Heart Truth campaign here five years later.
2003 A Framingham Heart Study-based report published in the New England Journal of Medicine strongly links obesity with an increased risk of heart failure. This study shows BMI (Body Weight Mass) index to be an independent risk factor. The Framingham Third Generation Study enrolls 3,900 grandchildren of the Framingham Heart Study’s original subjects.
2003 The first drug-eluting stent is approved by the FDA, marking a major advance in the battle to reduce the common problem of restenosis in metal coronary stents.
2003 A 3-6 month dual antiplatelet drug regimen (a combination of aspirin and clopidogrel (Plavix) to reduce incidents of stent restenosis is now recommended when stents are implanted, followed by aspirin indefinitely.
2004 Researchers at the Canadian Institute for Clinical Evaluative Sciences finds that deaths from heart attacks have fallen by 30% in Canada compared to death rates 10 years earlier.
2004 Obesity level in North America now reach 30% of the adult population.
2004 For the first time, the American Heart Association provides recommendations on cardiovascular risk factor management for women.
- 2005 Danish cardiologists report the successful reduction in the time between onset of chest pain and primary angioplasty when the EKG of patients is transmitted wirelessly from ambulance to the cardiologist’s mobile phone. (J Electrocardiol. 2005 Oct;38(4 Suppl):194-8)
2005 Framingham’s Offspring Study report indicates an increase of up to 45% for risk of heart attack, stroke or arterial disease may occur in middle-aged people with a sibling who has already suffered a similar cardiovascular event.
2005 A Canadian Institute for Health Information study shows that women who survive a heart attack are 16% more likely to die within 30 days of hospital admission than their male counterparts.
2006 LVAD (Left Ventricular Assist Device) is improved to create a mechanical circulatory device used to replace the function of a failing heart.
2007 At this year’s meeting of the American College of Cardiology, data from the COURAGE trial is presented, suggesting that the combination of angioplasty/stent implant procedures and intensive medical therapy with cardiac medications did not reduce the incidence of death, heart attacks, or stroke compared to intensive medical therapy alone.
2008 Sugar consumption in North America is now 160 pounds per capita, and most is triglyceride-raising high fructose corn syrup. The Corn Growers Association spends $20 to $30 million on an 18-month TV ad campaign “targeting mothers” with the message that HFCS is healthy for toddlers and other young children.
2008 New CPR guidelines circulated suggest that hands-only CPR may be just as effective as former cardiopulmonary resuscitation “mouth-to-mouth” protocols for cardiac arrest.
2008 The U.S. House Committee on Energy and Commerce begins investigating celebrity endorsements in television ads for brand-name pharmaceutical drugs, sparked by controversy over drug giant Pfizer’s ads for its blockbuster cholesterol medication Lipitor. These Direct-To-Consumer (“Ask Your Doctor”) drug ads feature Dr. Robert Jarvik, a pioneer in the development of the artificial heart (see 1982). Viewers are not told that Jarvik is not a cardiologist, nor is he licensed to practice medicine.
2009 North American health club revenues now totals $19.5 billion annually, and over 50 million of us are card-carrying gym members at over 30,000 facilities. Yet a Statistics Canada report this year tells us that barely 27% of Canadian adults describe themselves as “active”, which would mean one hour of walking a day.
2010 Pfizer, the world’s biggest drug company, spends a whopping $272 million this year on Direct-To-Consumer (“Ask Your Doctor”) advertising for its cholesterol drug, Lipitor, thus making Lipitor the #1 most-advertised prescription drug in the world. The drug is due to lose its patent protection any minute now, thus opening up the consumer market to low-cost generic alternatives. Good news for patients. Very bad news for Pfizer.
2011 A longterm study from the Ottawa Heart Institute is reported at the 64th Annual Canadian Cardiovascular Congress in Vancouver showing that heart transplant survival rates in Canada average 86% after one year, and 75% after five years.
2012 – Dr. Edward Hannan’s study on elective coronary revascularization procedures is published in the Journal of the American College of Cardiology; his research finds that the justifications for implanting over two-thirds of coronary stents implanted in almost 34,000 patients investigated were either “uncertain” or “inappropriate.” (Appropriateness of Coronary Revascularization for Patients Without Acute Coronary Syndromes. JACC, 2012; 59:1870-1876)
2016 – After 92 years in existence, the American Heart Association issues its first ever Scientific Statement on Acute Myocardial Infarction in Women.
2016 This site, Heart Sisters, attracted over 7.4 million views from 190 countries worldwide since I launched it in 2009. UPDATE: currently at over 17.6 million.
(1) Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342:1163-1170.
NOTE FROM CAROLYN: I wrote much more about cardiac care in women in my book, “A Woman’s Guide to Living with Heart Disease”. You can ask for it at your local library or favourite bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use their code HTWN to save 20% off the list price).
The New England Journal of Medicine‘s 200th Anniversary article called A Tale of Coronary Artery Disease and Myocardial Infarction
Q: What is the most significant advancement so far in cardiac care?