Cardiovascular disease remains the leading cause of death amongst men world-wide. In a commemorative 200th anniversary article of the New England Journal of Medicine, Nabel and Braunwald review the medical discoveries regarding diagnosis and treatment of coronary artery disease (CAD) and myocardial infarction (MI)) over the past two centuries. “Remarks on Angina Pectoris” by John Warren, M.D. appeared as the first article in the first issue of The New England Journal of Medicine and Surgery in 1812. At that time, little was known about the pathogenesis of the disease. Treatment consisted primarily of bloodletting, opium analgesia, and bed rest. It was not until the end of the 19th century that scientists discovered that blockage of coronary arteries caused the clinical sequelae of CAD. Physiologists observed that ligating the coronary artery of a dog quickly resulted in death. In 1929, Werner Forssman performed the first human cardiac catheterization study– on himself. Despite a better understanding of the disease, bed rest remained the standard treatment for patents who presented with acute MI until the mid-20th century.
In response to the alarming number of apparently healthy men who were dying suddenly of MI, the National Heart Institute established the Framingham Heart Study in 1948. Analysis of lifestyles of the enrollees revealed the breakthrough discovery that elevated blood pressure and cholesterol levels were associated with increased incidence of CAD. Large scale educational campaigns which addressed these risk factors soon followed, and resulted in a decline in age-adjusted cardiac death rates. In 1961, the incarnation of the coronary care unit (CCU), which provided continuous cardiac monitoring and external defibrillation, dramatically reduced in-hospital mortality of patients admitted with acute MI. Simultaneously, coronary arteriography emerged as a standard diagnostic tool. Significant advances in the treatment of CAD followed, with the advent of open heart bypass surgery, percutaneous coronary balloon angioplasty, and the insertion of stents. Thereafter, a multitude of large scale randomized, controlled studies demonstrated survival benefits of pharmacologic agents, including beta blockers, platelet inhibitors, angiotensin-converting-enzyme inhibitors, and HMG-CoA reductase inhibitors (statins). Implantable defibrillators, cardiac resynchronization therapy with pacemakers, and left ventricular assist devices have additionally improved survival in patents with heart failure as a result of CAD.
The past two centuries have been host to remarkable and accelerating advances in the diagnosis and treatment of ischemic heart disease. Recent exciting discoveries in genetics, cell-based therapies, and molecular targeting hold promise for the next chapter in the tale for advancing the field of cardiovascular medicine.
Reference: Nabel EG, Braunwald E. A tale of coronary artery disease and myocardial infarction. N Engl J Med 2012;366:54-63