History of Coronary Heart Disease

Summary

Coronary heart disease, in the mid-twentieth century has become the most frequently occurring lethal disease.

Coronary vessels, that is, coronary arteries tend to develop atherosclerotic plaques already at an early stage. The onset and course of this development has often been a mute one, without pain, rendering thereby the recognition of coronary artery disease difficult – far into the twentieth century.

The many experiments and investigations performed during the “Renaissance” brought no results.

An exact description and depiction of damaged coronary vessels as primary cause of occluded coronary arteries became possible towards the beginning of the twentieth century only.

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The onset of knowledge on coronary heart disease cannot be precisely dated. Among the first to describe and work on coronary arteries were Leonardo da Vinci (1452–1519) as well as Andreas Vesal (1514–1564). Leonardo reports, the course of coronary arteries, leaving, however, many questions unanswered: all the more “as the coronary arteries are embedded in greasy material”. Vesal even thought that the coronary arteries would not be depict-able due to that very reason.

Of utmost importance was,  the discovery made one hundred years later of the closed circulation of blood by William Harvey (1628) (Exercitatio anatomica de motu cordis et sanguinis in animalibus). Harvey showed that the blood moves within a closed circuit from the right ventricle through the lung into the aorta, the peripheral vessels and back into the lung. 

William Harvey's publication, which helped tremendously in the discovery of  coronary heart disease

The anatomist Giovanni Battista Morgagni (1628–1771) can be given credit for his publication “The seats and causes of diseases investigated by anatomy” (Padua 1761). His work also included a description of anginal syndromes. Almost concomitantly, Friedrich Hoffmann (1660–1742), chief professor in cardiology of the newly founded University of Halle wrote “that the origins of coronary heart disease lie in the reduced passage of blood within the coronary arteries”.

Laennec's stethoscope

The French physician Nicolas Corvisart (1755– 1821), chief in cardiology at the Charité, Paris, worked, on the one hand, with organic lesions of the heart and the vessels. The invention of the stethoscope by R. T. H. Laennec (1781–1826), based on the direct auscultation performed for the first time by the latter, represented enormous progress and enabled further technical improvements in the 17th and 18th centuries.

The solution of diagnosis and treating angina pectoris concerned the minds of a number of physicians in the 18th and 19th centuries. The cardiologist William Heberden (1710–1801) was the first to exactly recognize and describe the disease in his publication “Some account of a disorder in the breast”; it appeared in the College of Physicians on July 20, 1768. He was, of course, unaware of many technical details, yet he perfectly knew that his work dealt with one of the most important diseases of the century.

Laennec also worked with angina pectoris; however, he thought that the course of the disease was altogether a harmless one. Many English, German, and Italian physicians, however, believed that angina pectoris was a disease of organic order caused by an impediment of the circulation within the coronary arteries.

The second half of the 19th as well as the beginning of the 20th century was marked by the appearance and life of the cardiologist William Osler (1849–1919). He worked extensively with angina pectoris as reflected in the paper “Lectures on angina pectoris and allied states”. He did not think angina pectoris to be a disease, but rather a syndrome. He gives credit to Morgagni for having described angina pectoris first. Osler himself depicted the coronary vessels at great length, as well as coronary sclerosis, embolies, thrombi and cardiac sudden death – his famous saying was “it begins where other diseases end – in death.”

The American cardiologist James B. Herrick (1861–1954) made an important contribution to the analysis of coronary sclerosis in the paper “Clinical features of certain obstructions of the coronary arteries”. He concluded in 1912 that “a slow, gradual narrowing of coronary vessels is a possible cause, permitting the heart to adapt to the new conditions, and that a severe obstruction of a vessel must not necessarily lead to death”. He brought this theory to Europe in 1918, propagating it widely; he also created the term “ heart attack”. Herrick described in 1918 the electrocardiographic changes after ligation of the coronary vessels. Historians disagree as to how long the term “coronary heart disease” had already existed. According to the English cardiologist MacMichael (1966), a relevant reference had not been made before the 18th century.

The first coronary heart catheterization was performed in 1929 by Werner Forssmann in his famous “self-experiment”. Forssmann worked with a catheter for bladders, Charrière 4, which he introduced approx. 65 cm deep into the right auricle, applying the jugular vein. His achievement was scarcley noticed so that Forssmann abandoned the idea of catheterization.

Coronary cathetherization

The lung specialist André Cournand, however, was fascinated by the procedure: together with the cardio- logic pediatrician Dickinson Richards, he successfully repeated in 1941 the trial of Forssmann. The catheter was pushed into the right auricle; by 1942, they were able to push it further and place it into the right ventricle. The rapid development of angiography in the early 1950s led to the ardent wish for a depiction of coronary arteries by means of intervention. Contrast material was injected into the aorta by the supra-angiographic route, flowing from there into the coronary vessels, resulting, however, quite often in an insufficient filling of contrast material.

Mason Sones, father of coronary angiography

Mason Sones (1918–1985), a cardiologic pediatrician, solved the problem: in performing an angiogram following the well-known technique on a 26 year-old man, the catheter slipped inadvertently from the aorta into the right coronary artery. By this, all contrast material was injected and went into the right coronary artery instead of the aorta. Monitoring of catheterization was not known at that time, yet the mishap of the wrongly performed injection remained without consequences, no damage was observed. Mason Sones immediately grasped the important consequence of the situation: he replaced supraaortic injections by selective coronary angiography, that is, by injecting smaller amounts of contrast medium into the relevant coronary vessel. This was a breakthrough, and the technique became a routine procedure in the Cleveland Clinic in 1959.

The radiologist Melvin Judkins introduced a further simplification in 1967, performing angiography by way of the femoral artery; he thus avoided opening the brachial artery. Of great consequence and importance was the move of Andreas Grüntzig from Heidelberg to the University Clinic of Zurich in 1964. He came as a student, worked as an assistant and after terminating his studies in internal medicine, he became a resident in cardiology at the University Hospital in Zurich. His aim was to repeat the re-opening of occluded peripheral arteries which was first successfully performed by Charles Dotter in 1964. After several years of experimental work, Grüntzig managed to successfully dilate a severe stenosis of the ramus interventricularis anterior in a 38-year-old patient suffering from severe angina pectoris. This was achieved at the University Clinic of Zurich on September 16, 1977. After the intervention, the patient found himself free of pain; the control 4 weeks after dilatation showed no disturbance. Grüntzig’s dilatation was thereafter thought to be a success and became the method of choice to avoid cardiac surgery.

 

In 1978, at the Sessions of the American Heart Association in New York, Grüntzig presented the results of the first 26 dilated patients; by April 1979 the method had been performed in 60 patients: in 41 of them, the graft had remained open. In 1977, balloon dilatation of coronary vessels had undergone great acceptance, especially since the introduction of much more efficient catheter systems.

According to the radiologist Harold Baltaxe, coronary angiography had become a routinely and widely applied method as early as 1971, approx. 10 years after its introduction. Bruce Fye, medical history professor at the University of Wisconsin was of the opinion that coronary angiography had considerably altered the profession in cardiology – a situation similar to that of electrocardiography some 50 years earlier.

As was to be expected, the introduction of coronary angiography as well as of balloon dilatation was markedly delayed in Europe. The first coronary angiography took place in 1965, that is, 6 years after the onset of selective coronary angiography; it was performed at the University Hospital in Zurich by the author of this report. It needed yet a number of years for the method to be generally accepted. The same is true for balloon dilatation of Andreas Grüntzig. Development of this method was slow, and Grüntzig had much more and also much sooner great success in the United States (Atlanta).

References :

http://herzfuehrer-dgk.de/organe/geschichte/75years/KAP7.PDF

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