Progress in Cardiovascular Care: A Heart-Felt Thanks to Our Forebears

Many new discoveries and developments have been credited to single individuals. The truth is that usually these events result from the interaction and cooperation of many people who have laid the groundwork for creative individuals to bring the ideas and works to final fruition. Unfortunately, space will not allow giving credit to the many that have contributed to each new landmark development. Unfortunately only a few receive credit.

Progress in medicine is a continuum and has no beginning or end except as we define the limits. It exemplifies constant change of our perspectives of disease processes and the best mode of management. My witness of change and its measurement started when I entered medical school in 1957 and continues to this day; however, I must borrow and refer to events before 1957. I feel fortunate to have witnessed and participated in these history-making events.

Post World War II & Early 50s

In the post World War II era and early 1950s our main tools were still our eyes, ears, hands, stethoscope, blood pressure manometers, electrocardiograms, ballistocardiogram, apex cardiograms and X-ray. It was routine to measure circulation time as an indication of cardiac function, this being a precursor of measuring cardiac output by the Fick method. Medicines were limited and heart surgery was in its infancy. Dr. John Gibbons did the first heart surgery using his heart-lung machine in 1953, the same year that Watson and Crick¹ described the structure of DNA.²

Clinical challenges were to understand the disease and then to use the appropriate means to treat hypertension, myocardial infarction, persistent angina and arrhythmias. Our understanding of the factors relating to these problems was limited and sometimes conflicting. It was common knowledge, and accepted, that blood pressure increased with age and was treated only if it became symptomatic. President Dwight Eisenhower had a heart attack in 1955 (See Figure 1) and had experienced hypertension for many years. His physician Paul Dudley White, MD³, the most prominent cardiologist of his time, had taught that it was normal for blood pressure to rise in the elderly and one should be cautious about interfering with a natural event. At that time, the available treatment of hypertension consisted of rice diets and salt restriction. Available drugs consisted of reserpine, hydralazine and ganglionic blocking agents (guanethadine). The side effects of these drugs were poorly tolerated and patient’s compliance poor. The diuretic, chlorothiazide, became available in 1958 and central acting methyldopa in 1960 allowed for more effective treatment. Thiazides became established as the first line of treatment and have continued today as being a first drug of choice. In refractory cases, one resorted to surgical sympathectomy or even radiation of the adrenal glands.

Figure 1.

Popular President Dwight D. Eisenhower’s heart attack in 1955 introduced the American public to the words “myocardial infarction” and raised public awareness of heart problems.

Cardiac arrhythmias were treated with digitalis, quinidine and propylthyouricil. Conduction problems before pacemakers were difficult to treat. Drugs available included isuprel, epinephrine, thyroid extract, corticosteroids and atropine. An Adams-Stoke attack was a dreaded problem. No other effective treatments of arrhythmias were available.

The accepted treatment for acute myocardial infarction included morphine for pain, oxygen for breathing, lidocaine for arrhythmias and epinephrine for blood pressure maintenance.⁴ Persistent angina received nitroglycerine, peritrate, persantine, and heparin. More refractory cases were candidates for sympathectomy, thyoidectomies or radiation to the thoracic rami. Many attempts were made to improve blood circulation supply to the heart muscle. This included implanting the internal mammary artery into the myocardium (Vineberg procedure), installation of talc, asbestos or phenol in the pericardium, coronary endarterectomy, ligation of the coronary sinus and the placing of pectoral muscle or omentum around the heart.

The Framingham Heart Study started in 1948. It took several years to appreciate the roles that blood lipids, smoking, blood pressure, exercise, and family history contributed as factors related to cardiovascular problems. The relationship of cholesterol and vascular disease had not yet been firmly established until the early 1960s. It remained popular and fashionable to smoke, and the tobacco and fast food industries flourished.

With the ability to do heart catheterizations in the 1950s there was an explosion in understanding the structure and function of the heart. We could now see the heart functioning in real time and enabled us to measure pressures and flows at every site. This was a descriptive era. Every parameter of cardiac structure and function including flow rates, pressures at all sites, were measured and related to clinical problems. We needed new tools to do these measurements. ‘Need’ being the mother of ‘creativity’ opened the door for innovations of all kinds. The transistor became commercially available in 1958 placing us into the digital and computer age. This revolutionized our diagnostic tools to new levels.

With accumulation of knowledge, a physician could no longer be competent in all areas of medicine and increase specialization developed. The internist was the specialist in adult medicine and continues to be so, but with the increase of knowledge, specialties developed in cardiology, oncology, hematology, nephrology neurology, gastroenterology, etc. This was also true with surgery. Each of these developed their training programs and credentialing processes. Each specialty subsequently developed their subspecialties such as invasive and interventional cardiology, echocardiology, and nuclear medicine, electrophysiology, etc.

The National Institutes of Health (NIH) advanced medicine by liberally funding research and clinical training programs. Medical school teaching and research programs flourished. States supported their medical schools very well. In the mid-1960s, the NIH developed Regional Medical Programs. These federally-funded programs accelerated the development of intensive care units for heart, strokes, and vascular diseases. Institutions were rather liberal in letting physicians try new procedures and treatment which ultimately resulted in opening the door for creativity. Regulations today would not allow such liberties.

The catheterization laboratory became an important part of a hospital. We could now document cardiovascular physiology and accurately diagnose congenital and valvular heart problems. This was an era of collecting data. With this information explosion, critical rethinking of cardiovascular problems occurred. The cath lab answered many of our previous unanswered questions and allowed us treat more appropriately. Initially cath lab equipment consisted of x-ray without cine or image intensifiers. One had to adapt their eyes with red glasses before attempting a right heart cath. Pressure recordings were done on photographic film and had to be developed. Pressure transducers had to be balanced. Dye dilution curves and hydrogen curves were used for shunt detection in addition to oxygen step-up measurements. Echocardiograms and NMI have made these procedures historical events.

The Modern Era of Cardiology

Charles Dotter, MD, did the first coronary angiogram in 1958 by occlusive aortography, injecting a bolus of dye into the aortic root. Dr. Mason Sones did the first “selective angiogram” in 1958 when he accidentally entered the right coronary artery and injected 35 cc of dye in a patient with aortic valve disease.⁵ After resuscitation from asystole, with a thump to the chest, he had the first selective coronary angiogram. Heart catheterizations became a common procedure. Since Sones did the first angiograms, refinement of the procedure produced many new tools. Melvin Judkins, MD, in 1967 simplified the procedure with a femoral approach using the Seldinger technique with preformed left and right coronary catheters, negating the need for brachial artery cut-downs.⁶

Claude Beck, MD, in 1947 did the first direct cardiac defibrillation. Zoll did the first closed chest defibrillation using alternating current in 1956. Bernard Lown, MD, did the first direct current defibrillation in 1959, opening a new era for resuscitation. No longer were “grand openings” of the chest and manual massage of the heart necessary. A horrific event! The article in this edition by Drs. Flaker and Coats gives the details of defibrillator history.

Wilson Greatbach, MD, constructed the first implantable pacemaker in 1960.⁷ It consisted of two transistors, powered by mercury batteries. Prior to this, there wasn’t any effective treatment for Adams-Stokes attacks. Electrophysiology as a specialty was born. With the development of monitoring and defibrillation, the treatment of heart attacks had changed forever. Coronary care units were developed in most hospitals for the critical heart cases and postoperative care. The first cardiovascular care unit was established in Springfield, Missouri, through the efforts of Glenn Turner, MD, in 1960.

We held our professors in high esteem for their ability to use Sir William Osler’s technique in arriving at diagnoses and their ability to care for heart patient. What they lacked in technology and our present knowledge, they excelled in their concern and caring for their patient. Patients had confidence and trust in the medical profession. For many generations, the course of a heart problem was in God’s hands. Now there were things that could be done including defibrillation the heart, treating congestive heart failure, and pacing the heart. An evolving change in doctor-patient relationship, cost of medical care, insurance companies involvement, government involvement and all the legal consequences associated with delivery of care have made health care a very complicated industry. These all blend into our fabric of health care. Each factor influences others in a complex way.

Some of our most dramatic changes have occurred in our diagnostic ability in evaluating and understanding the diseases we treat. The development of the transistor and computers has revolutionized our diagnostic equipment. Any physical signal generated can now be detected, digitalized, and be handled by computers. This has resulted in the development of computerized tomography in 1972⁸, echocardiography in 1970s⁹, fiber optics in the 1970s, nuclear magnetic imaging in 1977, nuclear perfusion studies in the 1970s, and positron emission tomography in 1976. Evaluation of coronary artery disease using the Bruce Protocol for treadmill testing in 1963, replaced the Masters two-step exercise test.¹⁰ The gamma camera developed in 1957 by H. Anger, and years later made possible the addition of perfusion studies to be coupled with exercise, making risk stratification of coronary artery disease more accurate. New imaging agents became available. Thallium 201 became available 1964 and technetium-99-sestimiba in the 1980s.¹¹ New chemical markers for cardiac damage and function have added to our diagnostic armamentarium such as troponinin in 1996, C-reactive protein, atrial naturetic peptide 1985.^12,13 Coronary angiograms remains the gold standard for comparison, however rapid CT scanning and MRI studies are evolving and will establish their appropriate place.

With the information from heart catheterizations demonstrating congenital and valvular problems, the surgeons were eager to correct the holes in hearts and open stenotic valves. Charles Bailey, MD, at Heinemann College did the first successful mitral commissurotomy on his fifth try in 1948.¹⁴ The first four patients had died on the table. Closed mitral commissurotomy later became an accepted procedure.¹⁵ At the University of Minnesota, Walton Lillehei, MD, “father of heart surgery,” led the way for getting inside the heart to directly repair defects.¹⁶ He used several means for oxygenation and championed cross circulation between a compatible donor and patient as his early choice. He assisted F. John Lewis, MD, using hypothermia, on the first successful open heart atrial septal defect repair in 1952.¹⁷ He followed this with the first ventricular septal defect repair in 1954 (with cross circulation between father and patient) and the first Tetrology of Fallot in 1954 using a dog’s lung for oxygenation. Gibbons and his associates in 1953 developed the first heart-lung bypass machine that allowed one to operate in a blood-free field.² Aggressive surgeons, not controlled by institutional review and ethics committees nor constantly sued by attorneys, made history in cardiac surgery. This was a time of experimentation. The mortality was extremely high but there was no other treatment available in these terminal cases. The real heroes of this time were the parents, who out of desperation, allowed their children to be surgical candidates to pave the way for heart surgery. This kind of surgery would never be allowed today. Did the means justify the end?

The caseload of congenital and valvular heart disease, that previously could not be treated, was enormous. Work began on artificial valves. The Hufnagel caged valve developed in 1952 and the Starr Edwards silastic valve in 1960 led the way for development of disc and tissue valves that improved performance and lessened the chances of embolic problems. Valve repair rather than replacement followed and now work on percutaneous valve repair continues evolving. What next?

Our medical pharmacopoeia expanded rapidly allowing us to effectively treat conditions previously difficult. The initial medicines available to treat heart problems included nitroglycerin, digitalis, quinidine, procainamide, epinephrine, reserpine (1952) and a new diuretic, clorothiazide (1958). A plethora of new medicines have occurred since 1960. The development of loop diuretics in 1966 changed the treatment of congestive heart failure. The beta-blockers (propranalol), in 1965 changed the way we treat arrhythmias and angina. The angiotensin converting enzyme inhibitors in 1977 made blood pressure management more controllable. The family of calcium channel blockers in the mid-1970s gave us a new group of medicines to control blood pressure, angina and arrhythmias. Our ability to control cholesterol and reduce cardiac risk came with the statins (1976) and became a landmark in preventive medicines. The angiotensin receptor blockers (1995) gave us an alternative for those who could not tolerate ACE inhibitors.

The advent of interventional cardiology necessitated the need to control blood clotting. Clopidogrel, ticlopidine and glycoprotein inhibitors joined aspirin and persantine as platelet inhibitors.¹⁸ The ability of the thrombolytic agents streptokinase, urokinase and TPA changed our treatment of acute coronary occlusion and strokes.^19,20 An understanding of the chemistry and interactions of these many drugs have given us a new understanding of the biological processes that underlie health and illness and open new avenues for research. Many second-generation drugs continue to be developed. We are not sure of the long-term results of many of these drugs with their many combinations. There are many ongoing trials to answer these questions. A list of these trials is like alphabet soup.

So, what else has changed since I entered medical school? Most of the above occurred, as did the following. Coronary care units established in 1960, closed chest defibrillation by Bernard Lown in 1959, implantable pacemaker by Chardack and Greatbach in 1960²¹, transvenous pacemaker by Welti and Lageren in 1961, Starr-Edwards valve in 1960 and an implantable defibrillator by Watkins in 1980. With the ability to do coronary angiograms, surgeons were eager to surgically bypass the blockages. Dr. Vasilii Kolesov did the first internal-mammary sutured anastomosis in 1964.²² Rene Favalora, MD, working with Drs. Mason Sones, Donald Effler and William Proudfit at the Cleveland Clinic performed the first coronary bypass in 1967.²³ Building of the work of many, Christian Barnard, MD, did the first heart transplant in 1967 in South Africa.²⁴ Norman Shumway, MD, did the first heart transplant in the United States in 1968 and worked on the rejection problem using cyclosporine, which made heart transplants successful. Denton Cooley, MD, in 1969 replaced a dying man’s heart with a mechanical device as a bridge for a transplant. He worked closely with Michael DeBakey, MD. DeVries in 1982 using the Jarvik-7 model is credited as performing the first artificial heart implant. This was the end product of the unrelenting work of Willem Kolf, MD, the “Father of Artificial Organs.”

Andreas Gruentzig, MD, in 1977 did the first percutaneous balloon angioplasty.²⁵ He gave credit to Dotter and Judkins for their work in 1964 doing angioplasty on peripheral vessels.²⁶ The closure rate after angioplasty led to development of stents. Sigwart used a newly devised, self-expanding wall stent in 1986²⁷ and the Palmaz-Schatz balloon expandable stent was introduced in 1989.²⁸ Restenosis led to the development of drug eluting stents in the 1990s. These developments resulted in dramatic changes in treating coronary problems with percutaneous means rather than surgery. How much more can we do with stents? Studies of electrical pathways led to catheter ablation for arrhythmias in the mid-1980, giving a more definitive treatment for Wolf-Parkinson-White syndrome and atrial arrhythmias.

The National Institutes of Health started the human genome project, headed by Watson in 1990 and completed in May 2006; 53 years after DNA’s structure was defined. We are beginning to unravel the secrets of our genetic make-up that directs our cellular processes, integrating structure and function and the intracellular signaling that controls our life processes. Molecular medicine is the new frontier uncovering the secrets of our disease processes. Preventing atherosclerosis and controlling blood pressure, arrhythmias and congestive heart failure will be our greatest challenges in the future. Funding for research is absolutely necessary for these events to occur.

Not only have changes occurred in our diagnostic tools, medicines, and therapy but also patient’s expectations, doctor-patient’s relationships, insurance issues and legal concerns. We are now in an era of major medical care change. Initially only larger hospital could do heart catheterizations, coronary angiograms, coronary angioplasty and heart surgery including bypass and valve surgery. This is no longer the case. Many of the smaller hospitals are now doing these heart procedures by well-trained physicians. Many are now being done on an out-patient basis owned by physicians. This has a financial bearing on hospitals and how health care is delivered. Minimally invasive surgery, outpatient diagnostic facilities with the entrepreneurship of physicians and private entities have changed the position of hospitals in the fabric of health care. The cost of health care continues to spiral. Attempted solutions will dictate what facilities will deliver cardiovascular care. Initially, people were responsible for the cost of their care, then employers and now more all the time, government is responsible. Medicare and Medicaid in 1965 changed the responsibility of care for the elderly and impoverished to federal and state governments. When DRG reimbursement was enacted, the economics changed. Length of stay in hospitals sharply declined and payments were squeezed to physicians and hospitals.

We are again at a turning point. The question of whether our technological capabilities can be supported by our economic means and how they are used is on the table. I am confident that our dedicated medical people will continue giving excellent care and if allowed will improve the quality of our health care system. What does the next 50 years have in store for us? Use your imagination, it will happen.

Figure 2.

The first heart transplant, done December 3, 1967, by Christian Barnard, MD, in South Africa captured the public’s attention like no other event.

Biography

Lenard L. Politte, MD, is a cardiologist in Columbia and has been a MSMA member since 1977.

Contact: lpolitte@aol.com