Heart of the Matter: The History of Cardiovascular Medicine
“Angioplasties are a little like potato chips. You can’t have just one.” –William Castelli, M.D.
The need for multiple angioplasties is inarguably a misfortune. The availability of this life-saving procedure to repair blocked arteries in the heart, however, is most certainly a blessing.
Indeed, the world has made monumental strides in cardiovascular medicine and surgery in the last century. We’ll explore the history of cardiovascular medicine, uncovering some of the greatest minds in the field, and we’ll look at some of the breakthrough discoveries in cardiology in the nineteenth and twentieth centuries.
From Ancient Egypt, to Renaissance Europe, to Contemporary America
People have understood for millennia the life sustaining importance of the heart. Although the ancient Egyptians had a fairly basic understanding of the cardiovascular system, it was nonetheless advanced for the time. They understood that the body had a pulse that was associated with the function of the heart, as long ago as 2,500-5,000 years.1
The Greek philosopher Aristotle (fourth century B.C.) believed that the heart was the most important organ in the body, and that it was the seat of intelligence and motion. While many of his ideas have been disproved—including his belief that the heart had only three chambers—he also described the heart as the center of vitality in the body, which cannot be argued.2
The Chinese Emperor Huang Ti Na-Ching Su Wen (2,600 BCE) wrote “The blood current flows continuously in a circle and never stops,” indicating his awareness of the heart and its role in the circulation of blood around the body.3
In the second century A.D., Greek physician and surgeon Aelius Galenus, or Galen, described the heart as the source of the body’s “innate heat” in his treatise On the Usefulness of the Parts of the Body. He noted the strength and fibrousness of the heart, and argued that the expansion and contraction of the heart muscle had to do with its role as an “intelligence” organ.
Galen also believed that the veins connected the liver to the heart and circulated vital “sprits” throughout the body via the arteries. These ideas may sound utterly silly, today, yet it would be well over a thousand years before we came to more fully understand the functioning of the heart. Galen’s ideas generally prevailed until the mid-1600s.
By the Renaissance period, advancements in anatomy brought general agreement among physicians that the heart had four parts (chambers), two ventricles, and two auricles (today auricles are known as the left and right atrial appendages).
By the mid-1500s several physicians began to question traditional assumptions about the heart and its anatomical structure, but it wasn’t until an English physician called William Harvey wrote On the Circulation of the Blood in 1628 that the experts in the field began to accept an alternative to Galenic physiology, which had prevailed for 1,400 years.
Harvey didn’t challenge the idea of the heart as a spiritual center and the seat of all emotions (which spawned a slew of popular imagery of the heart as the body’s “sun”). He did, however, propose an alternative view of the mechanisms of the heart, suggesting that when the heart contracted, it expelled blood, and when it was at rest, it filled with blood. He wrote that the heart’s role was in the transmission of blood, and that arteries propelled blood to the body’s extremities.
The French philosopher Rene Descartes expanded on Harvey’s ideas, suggesting that the heart was like a pump or combustion engine.
In 1628, English physicist and mathematician Isaac Newton published his pivotal book, De motu cardis, in which he described the circulation of the heart. By this time, progress in understanding the heart and treating its ailments was solidly on the horizon.
Interest in heart disease grew in the eighteenth and early nineteenth centuries, and the introduction of the stethoscope in 1819 by French Professor René Laennec helped physicians diagnose valvular heart disease. Despite this, little progress was made in terms of effective cardiovascular therapies for another century, until the introduction of three breakthrough instruments.
X-Rays, and Sphygmomanometers, and ECGs, Oh My!
The technological revolution of the late nineteenth/early twentieth centuries and three major breakthroughs transformed the way diseases of the heart were diagnosed and treated.
- The first of these was the use of diagnostic x-rays, discovered by German physicist William Roentgen, who won the first Nobel Prize in physics for his accomplishment. The first radiographs enabled physicians to see the silhouette of the heart; later, fluoroscopy allowed physicians to assess cardiac motion.
- The second breakthrough was the mercury-sphygmomanometer (blood pressure cuff) introduced by Italian internist and pediatrician Riva Rocci in Turin, Italy, during 1896. This simple, non-invasive device, coupled with the auscultatory measurement of blood pressure, a technique discovered by Russian surgeon Nikolai Korotkoff, allowed physicians and surgeons to identify problems of the heart.
- The third discovery was the string galvanometer, invented around 1901 by Dutch physician William Einthoven. The device detected and recorded the electric currents generated by the human heart. It was the first instrument that could reliably produce electrocardiograms. Einthoven was awarded the Nobel Prize in Physiology or Medicine for his discovery in 1924. ECG machines are still an essential tool for cardiologists around the world today.
Understanding the Causes of Heart Disease
These three devices, used together with clinical findings, spawned the first heart specialists, known as cardiologists. Now that devices to measure and record heart activity were firmly in place, physicians turned their attention to the causes of heart disease.
Viennese physician Krehl was one of the first to report that coronary occlusion in patients is associated with chest pain and causes myocardial infarction (MI). Obratzov and Strazhenko in Kiev described that heavy exertion and intense emotion often precipitated heart attack. Chicago physician Herrick noted the electrocardiographic changes that occurred in patients under stress.3 Next came the discovery of cholesterol in aortic plaques by Russian scientists Anitschkov and Chalatow, which gave rise to the lipid theory of atherogenesis.
With all of these discoveries, modern cardiology was born, and it quickly spread around the world.
Cardiology developed its own journals and societies—from the Archives des Maladies du Coeur in France to the American Heart Journal, to the British Cardiac Club (founded in 1922), to the American Heart Association (established in 1924).
Milestones in Cardiology
Werner Forssmann, a resident urologic surgeon in Germany, carried out the first cardiac catheterization (on himself!) in 1929. His goal was to develop a method of injecting drugs into the heart.
Fast forward to 1960, and cardiac catheterization was being used in hospitals all over the industrialized world to diagnose cardiac disease. The importance of this procedure cannot be understated—it spawned treatments for arrhythmias, such as pacemakers, and, later, internal cardiac defibrillators and catheter-based replacement of the aortic valve. Stents and other percutaneous coronary interventions came later.
The End of Long-Term Bed Rest
By the middle of the 20th century, it became clear that the prescription of long-term bed rest that had been the cornerstone of therapy after myocardial infarction was misguided. In fact, it was determined that long rest periods could be hazardous, contributing to venous thrombosis and fatal pulmonary embolisms. Eventually, the convalescence period after MI was shortened, and patients were encouraged to walk about.
The Establishment of the Coronary Care Unit (CCU)
Soon after a designated care unit for heart patients was proposed in 1961, such units became the standard of care at hospitals around the world. In the CCU, patients were aggregated into a single area of the hospital and cared for by specially-trained personnel. They were continuously monitored by ECG, and had access to life-saving equipment and drugs.
Balloon Angioplasty and Stents
Another breakthrough in cardiology, angioplasty uses a balloon catheter to widen narrow or obstructed blood vessels. Stents, wire mesh tubes implanted to keep the artery wall expanded, came later. Stents are left in place to keep the artery in its expanded position after the balloon is removed. These two procedures further improved patient outcomes, and are used to this day.
A marvelous array of imaging techniques has been developed in the last 40 to 50 years to assess, diagnose, and monitor heart conditions. They include:
- Computed X-ray tomography (CT)
- Magnetic resonance imaging (MRI)
- Radionuclide imaging
- Positron emission tomography (PET)
Surgery has revolutionized cardiac medicine. The development of open heart surgery using cardiopulmonary bypass in the 1950s enabled surgeons to repair most congenital cardiac disorders. Collaboration between surgeons and engineers in the latter half of the 20th century resulted in the development of prosthetic heart valves, which have transformed countless lives.
Coronary bypass surgery, in which a surgeon takes veins (grafts) from other parts of the body and uses them to reroute (bypass) blood to the heart, has saved millions of lives.
Transmyocardial revascularization (TMR), which uses a laser to drill a series of holes in the outside of the heart into the heart’s pumping chamber, was developed relieve chest pain (angina) in patients who are not candidates for bypass surgery.
Heart surgeries continue to save millions of lives around the world every year.
The introduction of drugs has also been instrumental in managing heart disease. Common drugs include:
- Anticoagulants (blood thinners)
- Antiplatelet Agents
- Angiotensin-Converting Enzyme (ACE) Inhibitors
- Angiotensin II Receptor Blockers (or Inhibitors)
- Angiotensin-Receptor Neprilysin Inhibitors (ARNIs)
- Beta Blockers
- Combined alpha and beta-blockers
- Calcium Channel Blockers
- Cholesterol-lowering medications
- Digitalis Preparations
The Future of Cardiovascular Medicine
After centuries of relentless work to understand the heart muscle, its structure, and its mechanical functioning, today we know that prevention is key. Smoking cessation, weight control, and exercise programs, cholesterol management, family history screening, and other prevention measures are used today to help prevent heart disease. Doctors also routinely use stress test systems to assess the functioning of patients’ hearts.
Unfortunately, heart disease is likely to increase in the coming years due to a variety of factors, including the modern food environment, epidemics of obesity and diabetes, and an aging global population.
The future of cardiovascular medicine will likely include use of stem-cell therapy to prevent and treat heart failure, advances in ventricular assist pumps, gene therapy, and, as scientists learn more about the human microbiome, assessment of patients’ gut flora to predict cardiovascular disease risk and create tailored treatments.
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