Facts of Medicine; 1; Heart Disease

The Facts of Medicine presented by the Harvard Medical School and the Lowell Institute with Dr. David D. Rothstein, Professor of Preventive Medicine, Harvard University, and Mr. Parker Wheatley, General Manager of WGBH -TV. The Facts of Medicine is made possible by a grant in aid from the John Hancock Mutual Life Insurance Company and produced in the studios of WGBH -TV, Boston. Dr. Rothstein, just how big is this heart disease problem in the country? Well, we don't know how many cases of heart disease there are in the United States. No one can answer that question at all. We have the least idea of how many cases of heart disease there are. There have been all kinds of estimates made. Most of them aren't very good, but we do have good information on the number of deaths. That are caused by this group of diseases. And right here, I have some information which I think really answers the question. It's the first cause of death in the United States. The last year for which figures are available in 1954, there were

573 ,863 deaths in the United States. That's an awful lot of deaths. They're due to one group of diseases. Now, these deaths don't occur equally in the population, but they occur at different ages. And also, they occur differently according to sex. That is, there are more males dying of this disease in younger ages than there are females in younger ages. You see, there's an age zero to up to 80, and in the middle years, beginning around 40, running up to about 60, there are more males dying of heart disease all along. And this is really a very serious problem. Because we don't really know the answers to that particular question as to why this situation occurs. And it also focuses for us a very important question. And that is, is it important, really, that there are over 570 ,000 deaths from

heart disease? Or is it more important to know at what age people die of heart disease? I think the second question is much more important. We all have to die of something sometime, and people dying of a sudden heart attack at age 85 is, I think, no very great tragedy, but it's people dying of 40 of a sudden heart attack that really worries those of us in preventive medicine, particularly, and really worries all doctors. So that we're more concerned about the age at which people die from heart disease than we are about the fact that there are so many deaths from heart disease. And I've got some figures here, Mr. Wheatley, from other countries for comparison, which I think will be of great interest, because as you'll see in a moment, the death rates in this country from this group of diseases is much higher than it is almost anywhere else in the world. And we really don't know

why. Let's put the United States death rate here. This is for the year of 1952, and it is a rate of 707 .3. These are rates provided to us by the World Health Organization. Dr. Rutzstein, 707 .3 is what of what? Per 100 ,000. I think that's right. Per 100 ,000, yes. In this particular age group of 45 to 64, in that particular age group. Now, if we compare it, let's say, to the British Isles, United Kingdom, and we've corrected these death rates for the differences in population in the age groups and everything else. These are directly comparable figures. You see, it's a little over just half as much in this particular country. You take Canada, and it's a little bit more

than England, but less than the United States. Let's take Australia. We get about the same as Canada. Let's take Sweden. Major difference. Way down to 294 .9. Italy, 258 .2. And other countries lower than ours are Finland, France, Norway, Denmark, and so on. We're about the highest in the world of all these countries of death from heart disease in this particular age group. And we wish we knew why. All kinds of reasons have been given. We have lower infant mortality rates in some of these countries, but not all. You can see, Scandinavian countries have lower infant mortality rates than we have. Some people have thought that maybe Italy up here with higher

infant mortality rate would mean that those who survive are tougher and therefore live longer. It's probably got to do with other things. It's probably got to do with such things perhaps. It's probably something in our environment anyway, whether it's food or diet or the kind of life we lead or the lack of rest that we don't get. That isn't clear exactly what these differences are due to. And this is a very fruitful field for investigation and a lot of people all over the world are now trying to study this particular problem. Because if we could find the reasons for these differences, maybe we could find why coronary disease or other kinds of heart disease are so important as a cause of death in this country, in this particular age group, and particularly among males. These figures here are all males. And as I showed you the chart among the gull, the death rate for males is higher than it is among females. Dr. Rutstein, on that question of males versus females, the death rate among women, however, is not

greatly lower, is it? Well, it didn't look so in that chart, but it really is strikingly different. you actually look at the figures, there is a major difference. And that chart had a large scale on it, so it was hard to tell, but there really is a major difference in the death rate. Now, of course, if you remember at the top of that chart, let's look at it again. You'll see that they both came together up above again. They finally catch up. But in this area here, see this goes from 100 to 1 ,000 here and that little space there. How about 30? This is 75. 100 to 1 ,000, you see. So this is a major difference. The scale is a big scale in this particular chart. Thank you. I'm glad I have it straight. Now, what's happening? People want to know, is this increasing in this country? And we don't have any good evidence as far as the whole group is concerned that it's increasing. Now, here are some figures from 1900 to 1940. We use this big long -term cardiovascular renal. Now, that's right, Dr. Wait a minute. The whole group, the whole group of what? People or heart diseases? These are deaths

classified as cardiovascular renal. Yes. Well, you said we didn't have any figures on the whole group. I didn't know what you meant by the whole group. I said we have figures going from 1900 to 1940. But we have figures only on this combination, namely diseases of the heart, the blood vessels, and the kidneys related to the heart and blood vessels. That doesn't include all the heart diseases. It includes all the heart diseases plus a few others. More. More. That's right. It includes more than the heart diseases. Oh. it's remained about the same over this period, you say. This is the only way we can calculate it because going back to 1900, that's the way they classify those figures. But now if we look at these same figures by the two sexes, we'll see that there has been a difference. One's been going down, the other's been going up, and they're canceling themselves out. Here, the female rates have been dropping, and here, the male rates have been going up. And this is a rate that we're worried about, you say. This rate keeps climbing all the time, and we don't know why it's climbing. This is the same age group, 45 to 64, that we talked about up on the board

a moment ago. But this doesn't seem a very big climb to look at that chart. but it's dead. It's dead. And it's gone up from around below 700 here to almost 1000, you say. But that includes more than heart diseases. Yes, it does. with the disease of the kidney, including in here, are diseases primarily of the blood vessels in the kidney. And this terminology ties all of those together. So that we have a big problem. We have a problem increasing in males and apparently decreasing in females. And we're concerned about the fact that there are many kinds of diseases here. This is not one disease. This is a series of many diseases that cause death as a result of affecting our heart or blood vessels. And here I have a list of all those diseases to give you some idea of how important they may be. And we ought to spend a moment on this because this is the crux, I think, of the whole situation. Now all heart diseases,

we pointed out, over 570 ,000. Now congenital heart disease, this is the heart disease that occurs in babies at the time that is present in babies at the time of birth that develops as they're developing. means abnormality in the development of the heart around 9 ,000 a year. This is a disease of small children. And we have a rheumatic heart disease, a disease of school children, about almost 20 ,000 deaths a year. We have hypertensive heart disease, which is a high blood pressure kind of heart disease of middle age and older people, 75 ,000 a year. And here we have this great big one, coronary disease, over 375 ,000 a year. Really the big one, middle age and older. And then other, about 90 ,000, and there are many, many different kinds in there other. There are two of them particularly I'd like to mention. One is the heart disease that's produced by dystheria. A great many of the deaths in dystheria are due to heart disease. And this is a disease that we've practically wiped out because of

immunization of protecting our children by immunizing them against dystheria. So this disease has become very rare. And the other one is heart disease caused by syphilis. And that is a disease of early middle age and middle age. And this also is being wiped out rapidly because of early treatment of syphilis with penicillin. So these are kinds of heart diseases that we've done something about. Now let us go back and start over with these various kinds of heart disease one at a time and summarize for you quickly just what things you should know about these heart diseases. So you'll know what to do about them if someone in your family has these diseases or might get them. First let's start off with a kind of heart disease that occurs before a child is born, namely congenital heart disease. This is a disease which occurs in less than one percent of the population, really a group of diseases in itself because there are many kinds of congenital heart disease.

And if we take this heart model here and look at it, this heart model sits up in our chest, something like this. You see? And we look at this heart model, we realize that there are all kinds of chambers in the heart here, places that squeeze the blood, and then we have channels through these blood vessels where the blood comes out. Now what happens in congenital heart disease is when this heart is being formed inside the mother's body, it isn't formed properly. And that means that there are holes in places where there shouldn't be holes, for example if we take the heart apart here and we look at this wall in the middle of the heart that separates the right from the left side of the heart, there might be a hole right in that wall. So we let blood leak across, you say? How big a hole? Oh, it might be tiny or it might involve the whole area. might be very tiny or very large. And also, you see this artery coming out here, whether it should be a normal channel, it might be squeezed down tight so the blood can hardly get out. So therefore we have

disturbances in structure of a heart. It's just as if when you build a house you put holes in some of the walls that shouldn't have holes in them, or you put blocks in some of the passageways in the house. And it's very important to know that now we have surgical methods for correcting some of these defects. Some? Some, about five of them, and there are great many. But about five of them can be corrected. And the important thing for you to know about congenital heart disease is that if you suspect congenital heart disease in a member of your family, that individual deserves a complete medical workup. And it's a rather complicated workup. Diagnosis is not easy. Workup, workup. This means a medical workup. means a complete physical examination and a particular laboratory test to determine whether the kind of congenital heart disease that exists can be cured by surgery, whether that particular kind of defect can be cured. And there's also other encouraging news. If

you have congenital heart disease and it's more than five years since your heart disease has been evaluated, have it evaluated again because there have been so many improvements in the last five years that it will be worth trying again because some of the diseases that couldn't have been cured by surgery five years ago can now be cured. Is heart surgery oversold? Yes, I think it's terribly oversold. It's very important in the diseases which it can cure, but it can cure relatively few diseases. We have very good medical treatment for many, many kinds of heart disease, and although the surgical treatment is more dramatic, it's important for you to know that the medical treatment in most instances is much, much more important. Now we go on to this disease of school children, namely rheumatic heart disease. And we see it starts off in childhood, but it causes death throughout life because the permanent heart disease produced by this particular kind of disease carries on and causes difficulty throughout life. This kind of heart disease is usually precipitated. The rheumatic fever is by the hemolytic strepococcus, by strep

infections, which are properly treated early and adequately with penicillin, may actually not result in rheumatic fever as if the strep infections are treated properly and immediately. And also, it's interesting to know that if again we look at our heart muscle and look at our heart model and then look at the left side of the heart and open it up so we can see the valve on the left hand side of the heart. This is the left oracle we call it. This is the chamber where the blood comes back from the lungs to the left side of the heart. It must go through this valve. We call it the micro valve to this chamber, which squeezes the blood out all over the body. And if this valve here becomes narrowed by Michael stenosis, as we call it, or the rheumatic heart disease, the common valve of the disease in rheumatic heart disease, and this can also be relieved by surgery. This is another place where surgery is effective. But in other kinds of rheumatic heart disease, we can by means of drug therapy do

wonderful things and we can prevent recurrent attacks of rheumatic fever by preventing strep infections in people who've had rheumatic fever before by keeping them on penicillin or sulfadiazine for long periods of time. So much can be done about this kind of heart disease. Now we come to the heart disease that follows high blood pressure. And here we have another chart on this kind of heart disease. And you see here that most of difficulty starts in middle life and goes on. And here is one place where in older ages females seem to have a higher death rate than males do. And this is where the females sort of catch up late in life, because there has to be some cause of death in females. And this is where some of the cause of death is. Now I would point out and very important that not everybody who has high blood pressure gets hypertensive heart disease. One can have high blood pressure for many years with no difficulty at all about heart disease. What high blood pressure does is

this. This is the left hand side of the heart here. This is all the left hand side of the heart. And again, if we open up our heart model and take a look inside here, we look at this thickness of this wall here. This is the muscle of the left heart. This is the muscle that squeezes. Now when this has to pump up against high pressure, this wall gets thicker and thicker. And the heart gets, as we say, hypertrophy. It gets much larger than normal. And the blood supply to the heart isn't adequate to carry it. And then the heart really becomes weaker even though it gets bigger and heavier and looks stronger. So that high blood pressure heart disease is the kind where we have damage to the wall by increasing it to thickness. Also some damage to the blood vessels supplying the heart. But the important thing is that this is not inevitable if you have high blood pressure. It's also important to know that there are rare forms of high blood pressure that can be cured by drugs or surgery. That there are drugs to lower blood pressure even when it's high to prevent this load

on the heart. And finally, if one is overweight, one is more likely to get high blood pressure and also high hypertensive or high blood pressure heart disease. And it's probably worthwhile to keep your weight within normal limits or if you have high blood pressure to bring your weight down. Dr. Rutzstein, does this enlarged heart muscle have anything to do with what we call athletic heart? Mr. Wheatley, there is no such thing as an athlete's heart. That's a fiction. It used to be believed that athletes when they rode in the crew or ran marathons would get big, thick, heavy hearts. A normal heart doesn't get that way. This is completely not true and you needn't worry about exercising a normal heart. It won't cause any trouble. So that athlete's heart just doesn't exist. There's no such thing. That's a bright part of your discussion about diseases. That's right. What remained? Well, we still have coronary heart disease, which we're going to talk about much more next week, but we thought we just thought of mentioning it this week. And here

you see the differences in death rates between males and females at practically all ages. This is the one disease where the difference in sex is really very striking. Practically all ages beginning at 25, and it's these early deaths among males that we worry about most. And we'll discuss that in some detail. But I think we should point out that these diseases are diseases of the blood vessels which supply the heart. The blood vessels around here, you see the heart itself when the blood goes through it. It doesn't supply its own muscle with blood. There has to be a separate set of arteries to supply the heart muscle. And these become plugged. And when they become plugged, they deprive the heart muscle of the necessary nourishment, which it has to have to do its very difficult job. And the typical kind of disease that's caused by the heart attack, that is the typical result of this disease, is the heart attack.

An angina pecturus, which is this pain that comes on with exertion, which is very typical, starts here, goes down the inside of the left arm. It leaves immediately by rest, or by drugs, such as macroglycerin. This very typical kind of pain is associated with coronary disease. It comes on with exertion. Exertion, you mean if you have a coronary. If you have coronary disease, that is, if there's narrowing of these vessels. And the important thing about this is that the kind of pain that's caused by heart disease is very typical and very clear cut. And in the moment, I'll tell you about lots of pains that don't mean anything at all. That lots of us have pain in our left chest for many reasons, and they are not pain due to angina pecturus. It has to be the typical pain that runs down the left arm, sometimes runs up the vessels of the neck, along the sides of the neck. It's acute enough to be clearly recognized. It's comes on sharp with exertion or emotional excitement. Or

after eating, lasts a short time or leaves immediately by rest or by drugs, as I said. I'd like briefly to say a word about heart failure. There's much discussion about heart failure, and I think it's much misunderstood. All we mean by heart failure is that the heart isn't able to carry the load of blood, which it has to supply to the body, so that the blood backs up behind the heart. The pump just doesn't carry the blood away as fast as it should. And we have very good drugs for heart failure, including digitalis and drugs that make the individual pour out more urine. These are important drugs which get rid of this excess fluid and prevent this backlog from building up in the heart. But heart failure is a very typical kind of disease, and it's not all kinds of simple little symptoms that people imagine associated with heart failure. As a matter of fact, there are a great many symptoms which a lot of people think are due to heart disease, which aren't due to heart disease at all. And this is so important, Mr. Weekly, that I think I'd like to go up to the board and list them right up there so that we

can clearly see what they are. These are symptoms. You say symptoms of heart disease. These are symptoms that are usually thought to be due to heart disease, but for all practical purposes are not. And one of them is, we call palpitation, that is feeling the heartbeat, going to bed at night and feeling your heartbeat up against the pillow. This is usually not heart disease, practically never heart disease, unless it's completely irregular and irregular all the time. An occasional skipped beat doesn't mean anything either. These occur in completely normal hearts and should not be worried about it all and should be no concern. This is the first thing. The second thing is this associated with sort of sighing respirations, sort of taking big deep breaths and sighing along with this palpitation. This also is not a disease of the heart, even though it's a lot of people worry about the fact

that they seem to be, as they say, short of breath. They're actually not short of breath. They actually have sort of sighing respirations and usually they have a lump in the throat to go along with it. They feel as if there's a lump inside the throat. And this is so commonly, people come to doctors and with that they may complain about vague pains in the left side of the chest. Now as I just said, the pain in the left side of the chest associated with heart disease is a typical pain. There are many, many pains in the left chest which are due to pains in the muscles or twists in the muscles or sometimes the ribs being a little bit out of place or sometimes gas in the upper abdomen pressing up against the chest. All these things seem to be associated with little unpleasant feelings in the chest and these have nothing to do with heart disease. Nothing at all to do with heart disease. pain of heart disease, as I is very typical starting here, coming on suddenly with exertion, running down the left side of the arm or running up the side of the neck. This is a typical kind of

pain or a squeezing pain under the chest, tight squeezing pain, which stays then for a while. So with this you may have a very great feeling of weakness. Now these are the things not to worry about, very important not to worry about. If you have a real symptom, it will be much more conspicuous and much more persistent than any of these. Yes. If we had, for example, this matter called palpitation, the spewing of the heartbeat, it is true that in certain diseases of the heart the beat becomes totally irregular and remains irregular. But this is most unusual if a person had a completely irregular beat, they'd know it right away. This doesn't mean going along having a relatively regular beat and then having a quick beat in between. This does not mean heart disease. This is found in normal hearts, particularly in young people. This has nothing to worry about.

And feeling a little short of breath with it, I think, is not very important, particularly if it's a sign kind of respiration that I just talked about. So that it's as important to remember that we're not supposed to worry about these various kinds of things as it is to do something about the kinds of heart disease which are important and where something can be done. Now I'd like to point out then, in summarizing all of this, that there are now a series of many diseases that we call heart diseases. Not one disease, but many diseases. That these diseases occur throughout life. That the diseases that occur early in life, the congenital diseases, heart diseases, and I say diseases, many different kinds of congenital heart disease, occurring before birth can often be handled pretty well by surgery. If not, medical treatment may also be helpful. Rheumatic fever, rheumatic heart disease can be prevented.

And recurrences of rheumatic fever can be prevented. And the end results of rheumatic heart disease can be treated by surgery, like a synosis. So much can be done about that kind of disease in young people. We have also then the diseases due to diphtheria and syphilis, which have been completely controlled, one by immunization in the past, and we continue this immunization in our children, and the other by the treatment of syphilis. Prevent that kind of heart disease. And then we get into this high blood pressure heart disease where it's a bit more complicated. Where overweight is perhaps a factor. And where the kinds of heart disease that occurs involves the heart muscle, as I told you. And then we have coronary heart disease, where we have the disease where the blood vessels applied to the heart is cut down. And then we have all these symptoms that might be heart disease, which aren't heart disease at all. And we have both surgical and medical treatment for a good many of these diseases. And if you have one or another of these diseases or suspect them, then you

must get a complete medical examination and the necessary laboratory tests and constant medical supervision to follow through to get the greatest beneficial effect of the many tools which we now have. And we still are worried about the many deaths that occur, the younger people, and this is a big new field for research that many of us are concerned with. Dr. Rutstein, should we first see our family physician? Yes, I think by all means we should first see our family physician. And if we have a disease that then deserves more careful work by a consultant or in a special laboratory, we would then see that the patient will be referred there. Thank you, Dr. Rutstein. The Facts of Medicine has been presented by the Harvard Medical School and the Lowell Institute with Dr. D. Rutstein, Professor of Preventive Medicine, Harvard University, and Mr. Parker Wheatley, General Manager of WGBH -TV. The Facts of Medicine is made possible by a grant

in aid from a John Hancock Mutual Life Insurance Company, directed by Paul Rader and produced by Dr. Rutstein and Mr. Wheatley in the studios of WGBH -TV, Boston.