Tale of Coronary Artery Disease and Myocardial Infarction.

Tale of Coronary Artery Disease and Myocardial Infarction.

The remarkable facts, that the paroxysm, or indeed the disease itself, is excited more especially upon walking up hill, and after a meal; that thus excited, it is accompanied with a sensation, which threatens instant death if the motion is persisted in; and, that on stopping, the distress immediately abates, or altogether subsides; have . . . formed a constituent part of the character of Angina Pectoris “Remarks on Angina Pectoris” by John Warren, M.D., appeared in 1812 in the time medical section.

Warren’s description of angina pectoris (derived from the Latin angina, “infection of the throat”; from the Greek α´´γχο_νη, “strangling”; and from the Latin pectus, “chest”) is equally apt for physicians and medical students today. At the time, the pathogenesis was unknown, and treatment consisted of bloodletting, a tincture of opium, bed rest, or a combination thereof. In 1799, Caleb H. Parry speculated that Syncope Anginosa was related to coronary-artery ossification (i.e., calcification), occurring predominantly in men at about 50 years of age and rarely in women or children.

Medical knowledge in the 18th and 19th centuries was grounded in clinical observation and anatomical dissection. Cardiovascular science emerged in the physiological era of the late 19th and early 20th centuries, first in Europe and subsequently in North America. Our essay focuses on the themes of coronary artery disease and myocardial infarction to highlight the interplay between science and medicine, emphasizing how the remarkable advances in our understanding of the pathogenesis of heart disease have produced life-saving and life-extending therapies.

The Emergence of Coronary Artery Disease After Heberden’s clinical description of angina in 1772, it took almost a century for pathologists to focus their attention on the coronary arteries and describe thrombotic occlusions in addition to “ossification.” However, for decades thereafter, these observations were not related to the symptoms of myocardial ischemia, which had become well known to physicians. Near the end of the 19th century, cardiovascular physiologists noted that occlusion of a coronary artery in the dog caused “quivering” of the ventricles and was rapidly fatal.4,5 These three great branches of medical knowledge — clinical medicine, pathology, and physiology — advanced in separate yet parallel universes.

In 1879, the pathologist Ludvig Hektoen concluded that my ocardial infarction is caused by coronary thrombosis “secondary to sclerotic changes in the coronaries.”6 In 1910, two Russian clinicians who were trained in pathology described five patients with the clinical picture of acute myocardial infarction, which was confirmed at postmortem examination.7 Two years later, n engl j med 366;1 nejm.org january 5, 2012 55 James B. Herrick emphasized total bed rest as the treatment for this condition8 and by 1919 had used electrocardiography to diagnose it.  These approaches were the standard of care for patients with myocardial infarction until the mid-20^th century.

Coronary Risk Factors Two seminal developments in the 1960s radically changed our understanding and management of acute myocardial infarction, which struck down and killed or greatly impaired apparently healthy men in their 40s or 50s, during their most productive years. One of the first acts of the National Heart Institute, later renamed the National Heart, Lung, and Blood Institute (NHLBI), was to establish the Framingham Heart Study in 1948, which involved the close collaboration of professionals from three disciplines: clinical cardiology, biostatistics, and epidemiology. Their goal was to understand how heart disease developed by studying the lifestyles of the residents of Framingham, Massachusetts.

The first description of their findings, “Factors of Risk in the Development of Coronary Heart Disease,” indicated that elevations in blood pressure and cholesterol levels were associated with an increased incidence of ischemic heart disease and acute myocardial infarction. The study also showed a high frequency of myocardial infarction among women, which often occurred later in life than it did in men. The identification of elevated blood pressure and cholesterol levels as risk factors and the institution by the NHLBI of national programs to educate clinicians and the public about the importance of controlling these risk factors have contributed to dramatic improvements in age-adjusted cardiac death rates.

With the identification of these coronary risk factors and others that followed, the veil that masked the underlying mechanisms in angina and myocardial infarction was lifted, and the concept that coronary heart disease and its complications could be prevented was introduced.

ML & Dr. Georgious Andreas.