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developing collateral circulation help bring him through. He loses only a few
1. Suffering and fear of death at least for a time.
5. A financial burden that, despite health plan measures subscribed for and maintained and used, may mean he must give up plans for an adequate
home for the family. For the family :
1. Worry over their father's condition, and adjusting to it.
2. The threat that the source of support may be lost through death or disability.
3. Giving up, perhaps, some of the necessities of a wholesome family life. For the community :
1. Loss of productivity by his company.
4. The necessity for possible future expenditures in caring for him in a hospital or in other ways if he becomes a charge upon the community. Thus, and in many other ways, every case of heart disease, from the less severe types to those of complete disability and death, affects the individual, his family, and the whole community.
In summing up the First National Conference on Cardiovascular Diseases, jointly sponsored by the American Heart Association and the National Heart Institute in 1950, Dr. Abel Wolman of Johns Hopkins University expressed the significance of heart disease in terms of its positive meaning for the community and for cooperative action :
“What does this all mean? * * * First, it means that we cannot avoid coming to grips with this most dramatic group of diseases, most dramatic statistically or by any other measure; secondly, that we can develop a program for diagnosis, prevention, care, and cure, by the raising of the level of sights of every medical practitioner; by laboratory and other diagnostic techniques; by research; and by well-organized and active health departments and heart associations responsible for maintaining effective control and contact between the patient, the doctor, the nurse, the social worker, and all of the other contributors to social management; in general, in a community service that is intended to do only one thingto convert the managed patient into an educated person. It is to make possible the return of a very significant number of people to normal activity in our society * * * to substitute a philosophy of hope among a large mass of people in this world for a philosophy of despair.”
A summary description of the present status of the major types of heart disease follows:
RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE
Rheumatic heart disease, the major heart disease arising in childhood, is caused by rheumatic fever. The cause of rheumatic fever is unknown, but an attack apparently follows an infection by a certain type of streptococcal germ (group A beta hemolytic streptococci). Rheumatic fever may inflame connective tissues widely throughout the body, but the heart is usually the only organ permanently affected. The disease has been called one that licks the joints and bites the heart. It is characteristic of rheumatic fever that one attack increases susceptibility to further attacks. Repeated attacks of rheumatic fever greatly increase the chances of serious heart damage. This damage is to the heart muscle itself or to one or more of the heart valves.
Rheumatic fever almost always occurs between the ages of 5 and 15, and rarely do first attacks occur in those over 25. From 3 to 10 percent of cases of group A strep infection develop rheumatic fever. According to the Commission on Chronic Illness, more than 30,000 new cases of rehumatic fever arise each year, and approximately 750,000 Americans under the age of 50 have damaged hearts because of rheumatic fever. Nearly half (210,000) of the rejections for military service in World War II because of heart and blood vessel abnormalities were due to rheumatic heart disease. In 1952, more than 21,000 persons died from rheumatic fever and rheumatic heart disease.
Statistics show that there is considerable variation in different parts of the country in the amount of rheumatic fever. The Middle Atlantic States and the Mountain States have the highest mortality rates, the East, North Central, and New England States are high, the Pacific States are lowest, and the South is generally low. There also seem to be family and hereditary factors involved, and a relationship to poor living conditions.
The outlook for the future is encouraging. Mortality from rheumatic fever and rheumatic heart disease is steadily going down. In 1935, the death rate per 100,000 population was nearly 16. In 1940, it was 13; in 1945 it was reduced to 11; and by 1950 it had dropped to below 7.
PREVENTION AND TREATMENT
Prevention.-Rheumatic heart disease can be prevented by preventing rheumatic fever. Rheumatic fever can be prevented by controlling the streptococcal illness which almost always precedes an attack. Streptococcal illness can be controlled by treatment with penicillin or sulfonamides.
Adequate and early treatment of strep infections with penicillin will prevent most first attacks of rheumatic fever. Individuals who have had an attack of rheumatic fever, and who are therefore particularly vulnerable to recurrences, can escape further attacks by taking penicillin or sulfadiazine regularly.
A recommended schedule of treatment to prevent rheumatic fever has been widely published in medical journals as part of a national prevention campaign started in January 1953, in which the American Heart Association and the National Heart Institute are cooperating. In this campaign, the objective is to prevent the disease by promoting (1) proper treatment of strep infections in all individuals and (2) prevention of strep infections in those individuals under the age of 18 who have had rheumatic fever or St. Vitus' dance and all those over 18 who have had an attack within 5 years. The program advocates that children who have had rheumatic fever continue daily prophylactic treatment at least until they reach 18, and that anyone over 18 continue treatment for at least 5 years from their last attack. If these treatment recommendations were widely followed, it is probable that in a very few years the number of new cases of rheumatic fever would be extremely low. Thus, the knowledge which could mean the virtual elimination of rheumatic heart disease in the future is at hand today.
Treatment. There is no drug which will cure rheumatic fever. Complete bed rest is the prime treatment for active rheumatic fever, and this must be maintained until activity subsides. Adequate nutrition is very important. Salicylates such as aspirin, or the hormonal drugs, ACTH and cortisone, are effective in treating the usually short acute phase of the disease. Penicillin routine is begun at the end of the second week of the rheumatic fever attack to prevent new strep infections. Where the heart is seriously affected by the disease, resulting in cardiac insufficiency or failure, the giving of oxygen, the use of diuretics, and sometimes the administration of digitalis, may prove beneficial. Remedial surgery may later afford relief for many persons who develop rheumatic heart disease characterized by a defective mitral valve. A recent study has shown that there is only a 15 percent operative risk for persons properly selected for the mitral stenosis operation.
Because of the long duration of rheumatic fever, schooling and occupational therapy should be provided as soon as severe signs of the disease are over. Rehabilitation services, including guidance and training for sedentary occupations, are important for rheumatic heart disease patients who have suffered moderate to severe heart damage and whose cardiac reserve is low.
The basic cause of rheumatic fever is unknown, the diagnosis difficult, the mechanisms of the disease are unclear, and there are no drugs which cure. The research approach, which has brought about the means of prevention, is concentrating on finding answers to many questions which may aid in solving these problems.
Among studies under way are investigations on the relationship of group A hemolytic streptococci to rheumatic fever, on the way the disease develops, on the conditions under which it develops, on the chemistry of connective tissue, on the role of enzymes and enzyme inhibitors, on hereditary susceptibility, on hormone balance, on metabolism and nutrition, on development of compounds and drugs, on surgical techniques for correction of valve damage, and on the epidemiology of the disease. Recent research findings have shown that a treatment which combines cortisone or ACTH with a special diet and standard therapeutic measures can prevent permanent heart damage in a high percentage of children who have suffered a single attack of carditis, and that the extension of injury can be reduced in those whose hearts have already been damaged. In surgical research, an operation has been originated (and successfully used on human patients) whereby a plastic valve can be inserted in the main artery to prevent backflow of blood into the heart caused by an impaired aortic valve.
The facts known today place the matter of rheumatic fever in a position somewhat similar to that of the matter of nuclear fission several years ago when basic facts were known and it was a question of the need for concentrating great developmental resources upon the problem of producing an atom bomb. At the initiation of that endeavor it could not be predicted exactly how long a period would be required for physical research engineering to do the job. Nor can it be predicted today how long it will take for medical research engineering to do the job against rheumatic fever. We can be certain, given the resources to proceed, of the attainability of the goal, the conquest of rheumatic fever and rheumatic heart disease.
HIGH BLOOD PRESSURE AND HYPERTENSIVE HEART DISEASE
High blood pressure, or hypertension, is a disease possibly systemic-directly affecting the blood vessels, from which the heart may ultimately suffer.
Each arteriole and artery of the body is made up of an inner lining, an elastic layer, a series of muscle layers, and an outside covering tissue. With sustained high blood pressure, a gradual thickening of the muscle layers occurs, followed by breaking up of the elastic layer. As the process continues, the passage becomes narrower. To keep the blood flowing at a normal rate against this increased resistance, the heart must perform extra work, as a result of whichlike any muscle-it enlarges. This increased resistance may cause the heart to wear out prematurely or may cause kidney failure. Cerebral strokes or heart failure are frequently the end result of long-unabated pressure.
Since normal blood pressure readings are extremely variable, a diagnosis of high blood pressure requires not one but repeated examinations to assure the exclusion of temporary outside influences. The disease may be present for years without symptoms, but patients usually complain of fatigue, nervousness, dizziness, palpitation, insomnia, weakness, and headaches at some stage all of which may be signs of this or other disorders. Blood pressure which is only moderately elevated is often a relative benign condition-especially in women-and may be tolerated well for decades.
High blood pressure usually progresses slowly. The course of the disease begins with moderate elevation, increases to a high stable elevation, and is accompanied by changes in the vessels of certain of the vital organs, usually the brain, eyes, and kidneys. Sometimes it is rapidly progressive-so-called malignant hypertension. In these instances the elevated pressure is a clearly demonstrated secondary factor caused by another disease condition, such as coarctation of the aorta, certain kinds of kidney disease, or a tumor or the suprarenal glands. This is secondary hypertension, due to a specific, determined cause. In the vast majority of cases, however, there is no determined cause to explain the increased pressure. This is called primary, or essential hypertension.
Thirteen percent of the deaths from cardiovascular disease in the United States are definitely due to high blood pressure. Many more which cannot be strictly classified are attributable to hypertensive causes. An additional 30 percent of heart-disease deaths cannot be accurately classified as to whether they are due to arteriosclerosis or hypertension, but they are due to 1 of the 2, or both.
Of the estimated 10 million persons with some form of cardiovascular disease, fully 4,600,000 have high blood pressure. Of the young men examined by Selective Service during the years 1940–44, 165,000 were rejected because of high blood pressure.
Hypertension is far more common in females than in males, by a ratio of about 2 to 1. On the other hand, hypertension is less frequently fatal for women.
High blood pressure causes a progressively increasing amount of disability after middle life. Less than 1 percent experience disability at the age of 45, while at the age of 85 the incidence approaches 10 percent.
PREVENTION AND TREATMENT
There is no specific prevention or cure for essential hypertension as yet. Research may in the future bring knowledge of causes. Ultimately, there may be cures and preventive measures. But even today treatment from various directions is better than a decade ago and is improving as time goes on. Surgery, drugs, psychotherapy, and special diets have all been used with frequently, but not uniformly, encouraging results.
A wide variety of drugs have been used in hypertension, but many have been discarded as experience taught they had no particular lasting effect, or produced accompanying toxic effects. Drug treatment, however, continues to be regarded as one of the most important forms of therapy available at present. There are a number of drugs employed today for certain types of cases which give beneficial results, and these therapeutic agents are being continually improved as more knowledge of the body's chemistry, the action of the drugs, and other factors are learned from research.
Diet currently is considered under headings including: (1) Low salt, (2) low protein, and (3) low cholesterol diet, (4) low caloric diet, (5) rice diet. There is much evidence in favor of the usefulness of some of these and, though the final answers here have not as yet been found, there is much promising work under way in basic and clinical fields that is yielding information of value.
Contemporary surgical treatment consists of removal of a diseased kidney suspected of being the cause of hypertension, removal of an endocrine tumor, correction of coarctation of the aorta, or sympathectomy. Sympathectomies, nerve operations designed to reduce blood presure, are of two types: The total sympathectomy which aims to remove as many sympathetic ganglia as feasible (those nerves alongside the spinal column which are linked to the blood vessels of the large abdominal area), or partial sympathectomy which restricts the surgery to specific nerve areas. Each denervation differs in procedure, area, and response. The problem of the extent of these operations is far from settled, however, and no one knows for sure which areas to denervate or why differing responses occur.
There are many real ties between hypertension and emotional disturbances, and psychotherapy sometimes brings results as good as those obtained from any other form of treatment. In meeting this problem, the physician seeks to establish a mood of composure, self-possession, and reassurance. As a general rule he prescribes the good moderate life, individually adjusted to the patient's inner and outer needs—taking particular care to avoid unnecessary invalidism.
Research has been active on a broad variety of studies. They are to elucidate physiological and chemical aspects including the renal (kidney), endocrine, and nervous control of blood pressure and their effects on the blood pressure. The problem of arteriosclerosis is indissolubly connected with hypertension and an interrelated multidiscipline approach is called for in their study.
Here are a few brief examples of work today:
The rice diet which has a beneficial effect in certain cases of hypertension has developed in recent years. Improvement of patients following this regime bas often been marked and at times dramatic. The diet combines many of the characteristics of the low sodium, low protein, low cholesterol, low caloric diets. Rice, fruit, and sugar are the only foods allowed during the first 6 weeks of treatment. Many patients who are faithful to the diet show a definite reduction in blood pressure, an improvement of eye grounds, electrocardiogram, and heart size. Investigators are now attempting to determine the biological mechanism which brings about the favorable clinical effect in the rice and other diets with the goal of evolving diets that will find greater acceptance among patients.
A recent advance in the problem of sodium retention in the body has been the development of a plastic substance, a cation exchange resin, which when taken by mouth absorbs salt in the body. This substance (though it, too, has disadvantages) will allow patients, presently on low sodium diets, to eat normal foods, since the sodium can be eliminated from the body with the resin.
Other studies are evaluating the varying types of sympathectomy (both total and partial) to determine the degrees of removal of nerves necessary, and methods for predicting in advance those patients who would benefit from the operation. One investigator is studying by anatomical and physiological means, the distribution of the sympathetic nerves commonly removed in sympathectomies.
The significance of hormones and glandular function as factors in high blood pressure are being investigated. One scientist, by removing a part, but not all, of the adrenal cortex (the outer shell of the adrenal glands which are on top of the kidneys) has been able to help a number of hypertensive patients. A marked drop in arterial pressure was noted, with relief from headache and shortness of breath. Findings such as these hold out hope that adrenal-cortex surgery may be an important development for hypertension sufferers—until some therapy based on correcting the as yet unknown cause is discovered.
The development of the new drug, bexamethonium, and its use alone and in combination with others, such as hydrazinophthalazine, give hope of effectiveness in reducing pressure for long periods in patients with hypertension, including critical types. Studies indicate that hexamethonium produces a more complete blockade of sympathetic nerve impulses than any other drug so far studied in humans. Successful management of severe hypertension was reported, including cases of malignant hypertension kept under control for periods ranging from 5 to 11 months.
The study of a number of chemical agents which have the ability to lower blood pressure has determined many of their inherent limitations. In addition to defining the limitation of existing drugs and evaluating their worth to determine the more superior ones, investigators are creating new compounds through synthesis which may have suitable biologic properties, and are seeking still other compounds from natural sources.
Research is under way which indicates that basic biochemical changes in the kidneys and blood stream may have an important bearing on the problem of hypertension. An approach has developed which involves the recognition of counteracting chemical systems that regulate blood elevation. These systems are normally in equilibrium. The present investigations concern those changes in the blood and in the kidneys that are traceable to an upset in this natural balance. Full understanding of this important area of investigation can be expected to yield useful information.
The goal of research in high blood pressure is to find the underlying mechanisms. While this ultimate goal is being sought, the research itself brings data on a wide front-answers and questions that arise from the very nature of progressing research. There are many minute paths to be explored, any one of which may lead to larger paths, perhaps to roads, perhaps to blind endings. Yet each lead must be searched out.
Thus there are many, and there will be increasing numbers of points of departure or embarkation. But the more science learns and knows, the better able its agents are to establish the subjects for investigation, and the hope is strong that before too long the treatment of hypertension will be based on understandable mechanisms.
HARDENING OF THE ARTERIES AND ARTERIOSCLEROTIC HEART DISEASE
Along with high blood pressure—and often coexisting with it—hardening of the arteries is another major form of cardiovascular disease. Arteriosclerosis is the term that has been applied since 1830 to the common chronic arterial diseases of this nature, particularly of the hardening process in the great artery from the heart, the aorta. Today the term is used all inclusively, embracing atherosclerosis and a great variety of arterial changes.
This all inclusive term is used to describe secrious conditions as well as some of little consequence. An artery, for example, has three walls. Hardening of the middle wall is a common phenomenon of the aging process, but does not impede the flow of blood materially and consequently is of less importance.
The arteries themselves are a number of vessels through which the blood passes from the heart to the various parts of the body. They go out from the heart as branches from the trunk of a tree, becoming smaller until they terminate in tiny arterioles. Arteries are the lifeline of the body, since they carry the blood that is a necessary nutrient for the life of every part.