What have we learned?
Julian Whitaker, MD
The WHO's MONICA Project found that death rates from cardiovascular disease peaked in the late 1960s and have been dropping ever since.
On September 24, 1955, US President Dwight Eisenhower was playing golf when he had a bout of “indigestion.” That night he awoke with severe chest pain and the next morning was taken to a hospital, where he was diagnosed with a heart attack.
During his six-week hospitalization, Eisenhower was given the only available treatments of his day: an oxygen tent, an anticoagulant drug, and extensive bed rest. A month after his heart attack he was allowed to sit in a chair for several hours a day, and he only began walking shortly before his release from hospital.
Had Eisenhower had a heart attack today, he would have been admitted to a coronary care unit, treated with clot-busting drugs, and had extensive monitoring and testing. His blocked arteries would have been propped open with a metal stent or bypassed with a vein from his leg, and his doctors would have had access to heart-lung machines, robotics, and other tools undreamt of in the 1950s. He would have been discharged from the hospital in a matter of days on an array of pharmaceuticals to regulate his heart rhythm, thin his blood, dilate his arteries, and lower his cholesterol.
We’ve obviously made great strides in the treatment of heart attack over the past 50 years, and during that time, the number of deaths from cardiovascular disease has precipitously declined. The World Health Organization’s Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) project, which looked at statistics from patient populations in 21 countries, found that death rates from cardiovascular disease peaked in the late 1960s and have been dropping ever since. The Public Health Agency reports that Canada’s rate in 1995 was only half of what it was in 1969, and it continues to decline.
The medical community has been quick to take credit, boasting of advances in diagnostics, the introduction of new classes of drugs, and the evolution of
surgical techniques. This sounds reasonable, but is it true?
Prevention, Not Treatment, is the Key
The MONICA project also looked at the reasons behind the remarkable reduction in cardiovascular death rates–and the results may surprise you. In a paper published in The Lancet, MONICA researchers concluded that only a third of this improvement was attributable to medical management. The remaining two-thirds were due to a reduction in coronary events. In other words, fewer people are having heart attacks in the first place.
This is easier to swallow when you realize that more than half of all patients who die of heart disease never even make it to the hospital alive. They succumb to abrupt and unexpected cardiac arrest before they have a chance to benefit from any lifesaving medical advances. Therefore, it stands to reason that the primary force behind the dramatic decline in cardiovascular death rates is prevention.
Fifty years ago, little was known about the underlying causes of heart disease. Eisenhower’s heart attack was attributed to age (he was 64), heredity, his “broad and muscular build,” and his “active, ambitious personality.” Diet and exercise were suspected–some thought golf was a culprit–and alcohol and tobacco use were also considered, although they “appeared to be much less important.”
To ward off future heart problems, Eisenhower was advised to cut some fat out of his diet (the day before his heart attack he had sausage and bacon for breakfast, a hamburger for lunch, and roast lamb for dinner), and he was prescribed a drug to lower his blood pressure, a step that was just beginning to gain popularity. Nothing more was known about prevention.
Today, we have a much greater understanding of heart disease and what can be done to prevent it. Yet, despite the encouraging statistics on death rates, cardiovascular disease remains this country’s leading cause of death, claiming the lives of one in three Canadians. The outlook for the foreseeable future is far from rosy: nearly 80 percent of the population has at least one risk factor for cardiovascular disease, and 10 percent has three or more!
One of the first risk factors to be identified was smoking. Smoking doubles to quadruples the risk of cardiovascular disease, and a large percentage of the drop in death rate may be due to smoking cessation. Nearly half of all Canadian adults smoked in the early 1960s, compared to around 22 percent today.
The link with hypertension is also well established. High blood pressure triples the risk of dying of a heart attack, quadruples the risk of heart failure, and increases the risk of stroke sevenfold. Twenty-two percent of adults in this country have hypertension, and rates have been creeping up over the past decade.
A high cholesterol level is often pointed to as the primary risk factor, a myth perpetuated, in my opinion, by pharmaceutical companies that make the blockbuster cholesterol-lowering drugs. Yes, elevated LDL cholesterol does increase risk, but it isn’t the whole story: half of those who experience heart attacks have cholesterol levels within the normal range. More than 40 percent of Canadian men and women have elevated cholesterol, but lifestyle factors and natural remedies–not drugs–should be first-line therapy.
Diabetes is another growing risk factor. More than three-quarters of people with diabetes die of heart attack, stroke, or other cardiovascular conditions. High glucose and insulin levels, coupled with the nutritional losses endemic in this condition, are a recipe for disaster. Diabetes currently affects two million Canadians, and thanks to the rise of obesity, these numbers will only increase.
It’s Your Choice
For the vast majority of people, these predisposing risk factors are driven by lifestyle choices. That’s the good news and the bad news. The good news is that lifestyle changes such as smoking cessation, regular exercise, a healthful diet, and targeted nutritional supplements can prevent or reverse virtually all of these risk factors. The bad news is lifestyle changes require, well, change, and as we all know, this can be notoriously difficult.
Do not allow the tremendous advancements in the treatment of cardiovascular disease over the past 50 years to blind you to the supreme importance of basic, day-to-day lifestyle interventions such as nutrition and exercise. In the long run, your chances of living a long and healthy life, free of cardiovascular disease–and most other chronic diseases, for that matter–depend much more upon the little things you do every day than all the high-tech paraphernalia and cutting-edge drugs in the world.