1
Those of you who lived through the 1960s may be asking, “What coronary pandemic? Did I miss something?” The 1960s were known for the Beatles, Vietnam, the civil rights movement, hippies, Woodstock, and the moon landing—not a pandemic. Certainly, there was nothing like the current novel coronavirus pandemic, which threatens to rival the fierce and grisly 1918–19 influenza pandemic that killed 675,000 Americans and 40–50 million people worldwide in two years.1 But not all pandemics are infectious, and not all pandemics are explosive and grisly. The 20th-century cardiovascular disease pandemic that peaked in the 1960s was an instance of a slow-moving non-infectious pandemic, which killed millions, but far more slowly and almost gently.
How is it possible to experience a pandemic without even realizing it? Let me begin with the story of A.L., a prosperous 53-year-old businessman I encountered as a medical student, who checked into a Chicago hospital in the early 1970s after experiencing crushing chest pain one spring night. His pain, which radiated down his left arm, and his electrocardiogram (ECG) were typical of an acute myocardial infarction (MI)—a “heart attack” in common parlance—which occurs when a fatty deposit (atherosclerotic plaque, in medical jargon) in the wall of one of the major coronary arteries, ruptures and forms a clot that suddenly and catastrophically obstructs the flow of oxygen-carrying blood to a portion of the heart muscle (myocardium). Confirmatory blood tests showed typically high levels of cardiac enzymes, normally found only inside cells, which had spilled into the bloodstream from oxygen-starved heart muscle cells.
Nothing about A.L.’s prior medical history was out of the ordinary. His blood pressure (BP)—160/90 mmHg—and cholesterol level—270 mg/dL—were elevated by today’s standards but were then considered to be in the upper range of normal. He smoked a pack of cigarettes per day. He had a modest middle-aged paunch, but he was not obese and did not have diabetes. His father and an older brother had died of heart attacks in their late 50s, but three other siblings (a brother and two sisters) were fine and eventually lived past the age of 75. In some ways, A.L., who never lost consciousness, was fortunate in that many victims of a fatal heart attack simply collapsed and died on the spot or their bodies were discovered in their beds or chairs after being fine when last seen.2 So A.L. was treated in the usual prescribed manner, spending 36 hours in intensive coronary care, where he was monitored closely and given oxygen, intravenous lidocaine (a chemical relative of cocaine and Novocain) to control his heart rhythm and suppress extra beats, and morphine (an opiate) as needed for sedation and pain control. No coronary angiogram was done (as it would be today) since no invasive procedures were contemplated. Coronary artery bypass surgery was still in its infancy at that time, and coronary angioplasty and stents were not yet in use. When his vital signs and heart rhythm were stable, A.L. was moved to a quiet private room to rest and recuperate. A few days later, during morning rounds, he was found dead on the floor of his private hospital room, having collapsed while shaving.
A.L. was not an unusual case. Indeed, he was one of approximately 2.15 million middle-aged American men, aged 45–64, who died of heart attacks during the peak of the pandemic in the U.S. in 1955 through 1974.3 The pandemic did not spare women; almost 700,000 45- to 64-year-old women died of heart attacks during this period. Heart attacks also killed millions of older Americans, including 2.0 million men and 1.2 million women between the ages of 65 and 74 during these 20 years. Altogether, heart attacks accounted for 414–483 deaths per 100,000 Americans each year in 1955 through 1974.4 In addition, the same pathological process (atherosclerosis) in the cerebral arteries, which supply oxygen-carrying blood to the brain, is a major contributing cause of stroke, which accounted for 136–183 deaths per 100,000 each year during this period.5 Although perhaps one-third of strokes are due to bleeding rather than atherosclerosis, it is reasonable to assume that another 1.2 million Americans between ages 45 and 74 died of atherosclerotic strokes during these two decades. In 1968, the peak year of the pandemic in the U.S., 956,000 Americans died of heart disease or stroke—nearly half of the 1.93 million deaths recorded in the U.S. that year and about three times the death toll from cancer.6 Atherosclerosis of the arteries of the heart and brain was likely the underlying cause for more than half a million of these deaths. Although this book will focus on trends in the United States, this surge in mortality was a worldwide phenomenon. Atherosclerotic heart disease was a true pandemic, similarly affecting industrialized countries throughout the world.
It had not always been this way. Let us flash back for a moment to 1900. The U.S. had only 45 states; Utah had just entered the union that year, and Oklahoma, New Mexico, Arizona, Alaska, and Hawaii had yet to be added. The U.S. population was roughly 76 million, of whom 30 million (39%) lived on farms.7 The three leading causes of death—pneumonia and influenza, tuberculosis, and diarrheal and other gastrointestinal diseases—were all infectious.8 Many of these deaths occurred in very young children, 10% of whom did not live to see their first birthday.9 Thus, the average life expectancy was only 46.3 years for men and 48.3 years for women.10 Heart disease was the fourth leading cause of death, but the age-adjusted heart disease mortality rate was only half of what it would become in 1968.11 In other words, an American of any given age was twice as likely to die of heart disease in 1968 as in 1900.
Furthermore, many of these heart disease deaths were almost certainly unrelated to atherosclerosis, although it is impossible to say how many since separate mortality statistics were not recorded for heart attacks and other heart disease (rheumatic heart disease, congenital heart disease, cardiomyopathy, etc.) until 1950. However, Dr. William Osler, the preeminent turn-of-the-century Canadian American physician and medical scholar, observed that angina pectoris and its allied states (i.e., myocardial infarction) were relatively uncommon afflictions of men of high “station” over age 45. “It (angina) is an attendant rather of ease and luxury than of temperance and labor; on which account, though occurring among the poor, it is more frequently met with among the rich, or in persons of easy circumstances. It is remarkable how many prominent individuals have succumbed to the disease. We may say of it as Sydenham did of the gout, that more wise men than fools are its victims.”12 Putting aside Osler’s conflation of wealth and wisdom in the last sentence and his conflation of lack of wealth with temperance and labor a few sentences earlier, Osler was quite correct in pointing to the remarkable frequency of prominent men (versus ordinary citizens) dying of heart attacks. According to their Wikipedia biographies, five of the nine presidents who served between 1876 and 1928 and escaped assassination (Hays, Cleveland, Taft, Harding, and Coolidge) died at ages 57–72 under circumstances suggesting coronary heart disease, and two others (Arthur and Wilson) died of strokes.13 However, by mid-century, coronary heart disease flourished as Americans (and citizens of other industrialized countries) became plump and comfortable. Also, while angina pectoris may have been relatively uncommon in Osler’s time, that is because many persons with coronary blockages died suddenly or in their sleep before ever seeing a doctor.
I have plotted the arc of the pandemic in Figure 1.1 for annual mortality from heart attack, all heart disease, stroke, and all cardiovascular disease in the U.S., expressed as deaths per 100,000 people and adjusted to the age distribution of the U.S. in 2000, covering more than a century from 1900 to 2017.14 (Note also that reporting requirements were not uniform in all states and territories before 1932.) The “all cardiovascular disease classification” includes all heart disease, strokes, and other vascular diseases (like aortic aneurysms, venous thromboembolic disease, and peripheral artery disease).
U.S. trends in age-adjusted mortality rates for Heart Attack (CHD), All Heart Disease, All Cardiovascular Disease, and Stroke, 1900–2017. Data were obtained from CDC Vital Statistics compilations.
It is clear in Figure 1.1 that heart diseases are the predominant component of cardiovascular death and that (at least after 1950) heart attacks are the predominant component of heart disease death. One sees that heart disease mortality more than doubled over the first half of the 20th century from only 265.4 per 100,000 in 1900 to 588.8 per 100,000 in 1950. Clearly, a significant pandemic had hit America. Total cardiovascular mortality increased less steeply because of the partially offsetting decline in stroke mortality during this period. While total cardiovascular and heart disease mortality leveled off in the 1950s, heart attack mortality continued to climb, peaking at 482.6 deaths per 100,000 in 1968. Since 1968, there have been sharp declines in all four of these categories over the ensuing five decades—81% in heart attack mortality, 69% in heart disease mortality, 77% in stroke mortality, and 71% in cardiovascular mortality. Translating these percentages into American lives, if conditions in 1968 had remained unchanged in 2017, an additional 1.13 million Americans (out of a population of 325 million) would have died of heart attacks and an additional 406,00 would have died of strokes.15
So why hasn’t this pandemic been obvious all along? Outbreaks of infectious diseases have plagued mankind throughout history, going back to Biblical times and including the bubonic plague outbreaks of the middle ages and the introduction of smallpox and syphilis to the New World by European settlers. Indeed, the Book of Revelations names Plague as one of the four Horsemen of the Apocalypse. Even in the early 20th century, local outbreaks of cholera and yellow fever killed thousands, and millions died in the 1918–19 influenza pandemic, which attained global scope thanks to World War I. But the 20th-century heart disease pandemic was quite different. First, it was not contagious. Since most of its victims died quickly, quietly, and without much fuss, it did not incite panic or xenophobia. Second, unlike most infectious disease outbreaks, which thrive among poor people living in close quarters and with limited access to clean food and water, coronary heart disease epidemic began as a disease of affluence, promulgated by plentiful rich food and relative freedom from hard manual labor. Furthermore, the coronary heart disease pandemic happened over decades rather than months. By 1960, people suddenly collapsing and dying of heart attacks in their 50s and 60s became—not exactly normal—but part of the natural way of things. When then 25-year-old Paul McCartney and the Beatles poked gentle fun at the elderly in their 1967 song “When I’m 64,” there is no doubt that people of that age were considered near the end of life, and that a quick and relatively painless cardiac collapse was sad but hardly shocking.16 President Eisenhower, for example, was 64 years old when he had his first heart attack in 1955.17 It is safe to say that Americans of that period would have been far more shocked at the idea that two men in their middle to late 70s would run for president in 2020 than by Eisenhower’s condition in 1955.
Finally, although the heart attack rate at any given age has declined by more than 80% since 1968, this decline has served to put off coronary heart disease deaths to a later age, rather than prevent them entirely. Thus, if A.L. had been born 40 years later, he might still have died of a heart attack, but perhaps at age 73 instead of age 53, or perhaps he might have died of something else before his heart condition overtook him. So despite the steep fall in age-adjusted mortality rates over the past 50 years, heart disease has remained our leading cause of death, killing 655,000 Americans in 2017 and accounting for nearly one of every four deaths.18 More than half of those deaths (365,914) were due to coronary heart disease.
Let us pause for a moment to consider the trajectory of the decline in heart attack mortality since it peaked in 1968. The decline is not linear. It can’t be; otherwise the 50% decline in heart attack deaths per 100,000 over 23 years from 482.6 in 1968 to 240.6 in 1991 would have had to be followed by another 242 line deaths per 100,000 decline in the 23 years between 1991 and 2014, which would now leave us with a heart attack death rate below zero—an impossibility. So, when I tell you that heart attack mortality declined by 25% between 1990 and 2000, I mean that the heart attack mortality rate in 2000 had declined in the preceding decade by 25% of its 1990 rate—not by 25% of its 1968 rate. The percent decline per 10 years is plotted from 1978 to 2017 in Figure 1.2.
U.S. trend in rate of decline in heart attack mortality, 1978–2017. Each data point represents the 10-year decline in heart attack mortality rate over the preceding 10 years as a percent of the heart attack mortality rate 10 years earlier. Data were obtained from CDC Vital Statistics compilations.
The percent decline per 10 years held steady between 23 and 28% before 2000. Mathematically, this is called a log-linear decline; that is, the logarithm of the death rate—not the death rate itself—declines linearly with the passage of time. The pace of decline then accelerated in the first decade of the new millennium, climbing to nearly 40% per 10 years in 2009–12, before falling back to 28% in 2017. I will return to this figure repeatedly in the coming chapters as I try to dissect the factors contributing to this pattern of decline.
The decline in heart disease rates since 1968 is clearly manifested in a gradual increase in life expectancy (Figure 1.3).19
U.S. trend in life expectancy at birth, 1900–2017. Data were obtained from Berkeley and Macrotrends websites.
As stated earlier, the average American born in 1900 could expect to live fewer than 50 years, largely due to the ravages of infectious respiratory and gastrointestinal diseases, which had a high death toll in children as well as adults. Heart disease (137 deaths per 100,000) ranked only fourth, while cerebrovascular disease (107) and cancer (64) were fifth and eighth, respectively.20 Thanks to the profound decline in deaths from infectious diseases due to improved sanitation and the development of vaccines and antibiotics, life expectancy increased by 20 years (to 68.1 years in 1950) over the next five decades, despite the rise in vascular diseases and cancer, which displaced infectious diseases as the leading causes of death. (The transient 12-year life expectancy drop in 1918 reflects the profound impact of the 1918–19 influenza pandemic.) The rate of improvement slowed slightly in 1950–68, but then accelerated dramatically from 70.4 years 1968 to 78.9 years in 2013, until the recent rise of opioid deaths flattened the curve. The current coronavirus pandemic another—hopefully transient—1.5 year dip in 2020 (https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/202107.htm). In the coming chapters, we will explore how this much overlooked 8.5-year gain in life expectancy over the past 50 years, largely reflecting the 81% declines in age-adjusted heart attack and 77% decline in stroke rates during this period, came about. It is a story of the success of scientists, physicians, health professionals, and public officials working tirelessly and collaboratively to understand atherosclerosis and to develop ways to prevent or treat its dire consequences on an individual and population level.
1. JM Barry. The Great Influenza: The Story of the Deadliest Pandemic in History. New York: Penguin Random House, 2004, 2005, 2009, 2018.
2. RJ Myerburg, J Junttila. Sudden cardiac death caused by coronary heart disease. Circulation 2012; 125:1043–1052.
3. Chartbook for the Conference on the Decline in Coronary Heart Disease Mortality. Hyattsville, MD: NCHS, 1978. National Center for Health Statistics, https://www.cdc.gov/nchs/data/misc/corltrtacc.pdf, pp. 12–13, Tables 3A-3B. IHD death rates for 45–54, 55–64, and 65–74 age groups were multiplied by age-specific population data from U.S. Census for 1960–1974 (extrapolated back to 1955) obtained from Centers for Disease Control and Prevention (CDC), National Center of Health Statistics. Population by age groups, race and sex for 1960–97.
4. Centers for Disease Control. Age-adjusted death rates for 69 selected causes by race and sex using year 2000 standard population: United States, 1950–59. https://www.cdc.gov/nchs/data/dvs/hist293_1950_59.pdf, 1960–67. https://www.cdc.gov/nchs/data/mortab/aadr 6067.pdf, 1968–78. https://www.cdc.gov/nchs/data/mortab/aadr6878.pdf.
5. Ibid.
6. Centers for Disease Control (CDC). Leading Causes of Death, 1990–1998. Data provided to NIH by the National Center for Health Statistics.
7. CL Beale. A century of population growth and change. Food Review 2000; 23:16–22. https://wayback.archive-it.org/5923/20110903152144/http://ers.usda.gov/publications/foodreview/jan 2000/frjan2000c.pdf.
8. CDC, Leading Causes of Death.
9. Achievements in Public Health, 1900–1999. Healthier Mothers and Babies. MMWR Weekly 1999; 48:849–858. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4838a2.htm.
10. Life Expectancy in the USA 1900–98, https://u.demog.berkeley.edu/~andrew/1918/figure2.html.
11. Centers for Disease Control and Prevention (CDC), National Center of Health Statistics Mortality Data, HIST293. Age-adjusted death rates for selected causes by race and sex using year 2000 standard population: death registration states, 1900‐32 and United States, 1933‐49, Diseases of the Heart. https://www.cdc.gov/nchs/data/dvs/hist293_1900_49.pdf.
Centers for Disease Control. Age-adjusted death rates for 69 selected causes by race and sex using year 2000 standard population: United States, 1968–78. https://www.cdc.gov/nchs/data/mortab/aadr6878.pdf.
12. W Osler. Lectures on Angina Pectoris and Allied States. New York: D. Appleton and Company, 1897, pp. 22–23.
13. Wikipedia. The free encyclopedia. www.wikipedia.org.
14. CDC Age-adjusted death rates, 1900–49.
Morbidity and Mortality. 2012 Chartbook on Cardiovascular, Lung and Blood Diseases, NIH-NHLBI. Chart 3–24. https://www.nhlbi.nih.gov/files/docs/research/2012_ChartBook_508.pdf.
Centers for Disease Control. Age-adjusted death rates for 69 selected causes by race and sex using year 2000 standard population: United States, 1950–59. https://www.cdc.gov/nchs/data/dvs/hist293_1950_59.pdf, 1960–67. https://www.cdc.gov/nchs/data/mortab/aadr 6067.pdf, 1968–78.
Centers for Disease Control and Prevention (CDC), National Center of Health Statistics. Mortality Data Finder. Table 5: Age-adjusted death rates for selected causes of death by sex, race and Hispanic origin: United States, selected years 1950–2017, https://www.cdc.gov/nchs/hus/contents2018.htm#Table_005 (Excel spreadsheet link).
S Sydney, CP Quesenberry, MG Jaffe, M Sorel, MN Nguyen-Huynh, LH Kushi, AS Go, JS Rana. Recent trends in cardiovascular mortality in the United States and public health goals. JAMA Cardiology 2016; 1:594–599. Doi:10.1001/jamacardio.2016.1326.
15. Centers for Disease Control and Prevention. Heart Disease Facts, https://www.cdc.gov/heartdisease/facts.htm.
16. J Lennon and P McCartney. When I’m Sixty-Four, Sergeant Pepper’s Lonely Heart Club Band, 1967, https://www.songfacts.com/lyrics/the-beatles/when-im-64.
17. Getty Images. B/W 1955 Dwight Eisenhower smiling in wheelchair surrounded by doctors and nurses after heart attack. https://www.gettyimages.com/detail/video/news-footage/2034-252.
18. Mortality and Top 10 Causes of Death, USA, 1900 vs 2010, https://www.ncdemography.org/wp-content/uploads/2014/06/All-Cause-Mortality-and-Top-10_USA-e1402597040445.png.
19. Life Expectancy in the USA 1900–98.
20. Macrotrends, U.S. Life Expectancy 1950–2020, https://www.macrotrends.net/countries/USA/united-states/life-expectancy.