- Email: [email protected]
An American Dream: To Develop Coronary Artery Disease
~
illll.
crillcal Issues In clinical care An American Dream: To Develop Coronary Artery Disease Mark D. Altschule, M.D. *
Clinical cardiology has been transformed in the past two decades from a transaction between a physician and a patient, based on history-taking, physical diagnosis and a few simple laboratory procedures, to one based almost entirely on highly sophisticated laboratory procedures. The physician does not have to spend much, if any time with the patient, but considers himself required to study the results of laboratory tests whose bases are far from valid and whose interpretation is usually ambiguous. Diagnosis and treatment are both far from acceptable, although the physician may be unaware of the irrelevancies and artefactuality of what is today considered the most modern clinical cardiology In the case of coronary atherosclerosis, the expenditure of millions of dollars and thousands of man hours has failed to establish etiology However, in order to offer some comfort to those who are troubled by this fact, medical writers offer the words risk factors, which imply etiology and yet do not signify etiology These words may be more significant for stripteasers: the words promise much but reveal little. However, they do permit uncritical physicians to convince themselves that such factors should be the basis of diagnosis and treatment. On the other hand, the gadgetry that has transformed clinical cardiology has persuaded some physicians that they need not communicate directly with the patient, but only with his record. The occurrence, progression and regression of coronary atherosclerosis has no relation to risk factors. 1,2 Attempts to control the risk factors apparently lower the incidence of severity of myocardial infarction in some countries, but increase them in Sweden. 3 The increasing evidence of the inadequacy of current views on the causation of coronary atherosclerosis has encouraged consideration of other factors. Actually when, a hundred years ago, coronary artery ligation came to be studied systematically in animals in Porters
*Francis A. Countway Library of Medicine, Harvard Medical School, Boston. Reprint requests: Dr. Altschule, Francis Countway Medical Library, 10 Shattuck Street, Boston 02115
laboratory at Harvard, a most consistent finding was the inconstancy of the findings produced so that from the very first there was skepticism about the etiology of myocardial infarction. 4,5 One concept that has recurred for centuries is that emotional or psychosocial factors have an etiologic role in all diseases. That concept implies a fundamental distrust of the human mind, which is perhaps justified, but in any case, the possible role of such factors in the etiology and progression of coronary disease cannot be ignored, no matter how puerile the evidence bearing on the subject may seem in some of the writings. 'Ioday in America, the use of surveys is held to justify firm psychosocial concepts. For example, the notion that with respect to coronary atherosclerosis, there are two types of men: those who have it, and those who do not. For want of anything better, these two personality types have been designated type A and type B (these designations have led in some quarters to designate the concept the anus ofthe bee). To some workers in the field, it has become an accepted, though poorly understood, approach to the problem of atherogenesis. The general imprecision of survey types of psychosocial data gathering was shown recently when a survey of coronary patients revealed that their healthy wives had a large number of firstdegree male relatives with coronary artery disease. 6 Drawing valid conclusions from these data is currently impossible. To make things even more complicated, Bruhn and WolF published a book a decade ago (it did not receive appropriate attention at the time) that showed convincingly that family life-style in immigrants was a main factor in coronary atherogenesis. In the community studied, the persistence of an ancient, noncompetitive, nonacquisitive lifestyle seemed to be protective, whereas the acceptance of American competitive ways, with ostentatious, acquisitive lifestyles, brought the clinical manifestations of coronary disease up to levels that obtained in nearby Americanized communities. Is the development of coronary atherosclerosis part of an American dream? CHEST / 94 / 1 / JUL~
1988
191
REFERENCES 1 Kramer JH, Kitayume H, Proudfit WL, Matsuda Y, Williams GW Progression and regression of coronary atherosclerosis: relation to risk factors. Am Heart J 1983; 105:134-44 2 Hamsten A, Walldius G, Szamosi A, Dahlen G, de Faire ~ Relationship of angrographically defined coronary artery disease to serum lipoproteins and apolipoproteins in young survivors of myocardial infarction. Circulation 1986;78:1097-110 3 Alfredsson L, Ahlborn A. Increasing incidence and mortality from myocardial infarction in Stockholm county Br Moo J 1983;
192
286:1931-33 4 Porter WI: On the results of ligation of coronary arteries. J Physiol 1894; 15:121-28 5 Baumgarten WI: On the results of ligation of coronary arteries. J Physiol 1894; 15:121-28 6 von Kate L£ Bowman H, Daiger S~ Motulsky AG. Increased frequency of coronary heart disease in relatives of wives of myocardial infarct survivors: assortive mating for life-style and risk factors. Am J Cardioll984; 53:399-403 7 Bruhn JG, WolfS. The Roseto story Anatomy of health. Norman: University of Oklahoma Press, 1979
Syrnpoeium
illll.
crillcal Issues In clinical care An American Dream: To Develop Coronary Artery Disease Mark D. Altschule, M.D. *
Clinical cardiology has been transformed in the past two decades from a transaction between a physician and a patient, based on history-taking, physical diagnosis and a few simple laboratory procedures, to one based almost entirely on highly sophisticated laboratory procedures. The physician does not have to spend much, if any time with the patient, but considers himself required to study the results of laboratory tests whose bases are far from valid and whose interpretation is usually ambiguous. Diagnosis and treatment are both far from acceptable, although the physician may be unaware of the irrelevancies and artefactuality of what is today considered the most modern clinical cardiology In the case of coronary atherosclerosis, the expenditure of millions of dollars and thousands of man hours has failed to establish etiology However, in order to offer some comfort to those who are troubled by this fact, medical writers offer the words risk factors, which imply etiology and yet do not signify etiology These words may be more significant for stripteasers: the words promise much but reveal little. However, they do permit uncritical physicians to convince themselves that such factors should be the basis of diagnosis and treatment. On the other hand, the gadgetry that has transformed clinical cardiology has persuaded some physicians that they need not communicate directly with the patient, but only with his record. The occurrence, progression and regression of coronary atherosclerosis has no relation to risk factors. 1,2 Attempts to control the risk factors apparently lower the incidence of severity of myocardial infarction in some countries, but increase them in Sweden. 3 The increasing evidence of the inadequacy of current views on the causation of coronary atherosclerosis has encouraged consideration of other factors. Actually when, a hundred years ago, coronary artery ligation came to be studied systematically in animals in Porters
*Francis A. Countway Library of Medicine, Harvard Medical School, Boston. Reprint requests: Dr. Altschule, Francis Countway Medical Library, 10 Shattuck Street, Boston 02115
laboratory at Harvard, a most consistent finding was the inconstancy of the findings produced so that from the very first there was skepticism about the etiology of myocardial infarction. 4,5 One concept that has recurred for centuries is that emotional or psychosocial factors have an etiologic role in all diseases. That concept implies a fundamental distrust of the human mind, which is perhaps justified, but in any case, the possible role of such factors in the etiology and progression of coronary disease cannot be ignored, no matter how puerile the evidence bearing on the subject may seem in some of the writings. 'Ioday in America, the use of surveys is held to justify firm psychosocial concepts. For example, the notion that with respect to coronary atherosclerosis, there are two types of men: those who have it, and those who do not. For want of anything better, these two personality types have been designated type A and type B (these designations have led in some quarters to designate the concept the anus ofthe bee). To some workers in the field, it has become an accepted, though poorly understood, approach to the problem of atherogenesis. The general imprecision of survey types of psychosocial data gathering was shown recently when a survey of coronary patients revealed that their healthy wives had a large number of firstdegree male relatives with coronary artery disease. 6 Drawing valid conclusions from these data is currently impossible. To make things even more complicated, Bruhn and WolF published a book a decade ago (it did not receive appropriate attention at the time) that showed convincingly that family life-style in immigrants was a main factor in coronary atherogenesis. In the community studied, the persistence of an ancient, noncompetitive, nonacquisitive lifestyle seemed to be protective, whereas the acceptance of American competitive ways, with ostentatious, acquisitive lifestyles, brought the clinical manifestations of coronary disease up to levels that obtained in nearby Americanized communities. Is the development of coronary atherosclerosis part of an American dream? CHEST / 94 / 1 / JUL~
1988
191
REFERENCES 1 Kramer JH, Kitayume H, Proudfit WL, Matsuda Y, Williams GW Progression and regression of coronary atherosclerosis: relation to risk factors. Am Heart J 1983; 105:134-44 2 Hamsten A, Walldius G, Szamosi A, Dahlen G, de Faire ~ Relationship of angrographically defined coronary artery disease to serum lipoproteins and apolipoproteins in young survivors of myocardial infarction. Circulation 1986;78:1097-110 3 Alfredsson L, Ahlborn A. Increasing incidence and mortality from myocardial infarction in Stockholm county Br Moo J 1983;
192
286:1931-33 4 Porter WI: On the results of ligation of coronary arteries. J Physiol 1894; 15:121-28 5 Baumgarten WI: On the results of ligation of coronary arteries. J Physiol 1894; 15:121-28 6 von Kate L£ Bowman H, Daiger S~ Motulsky AG. Increased frequency of coronary heart disease in relatives of wives of myocardial infarct survivors: assortive mating for life-style and risk factors. Am J Cardioll984; 53:399-403 7 Bruhn JG, WolfS. The Roseto story Anatomy of health. Norman: University of Oklahoma Press, 1979
Syrnpoeium