A history of cardiology: the night that changed medicine

Less than a century ago, a diagnosis of acute myocardial infarction was effectively a death sentence or, at best, a sentence of permanent disability. Cardiology as an independent, high-technology science did not exist in the form we know. All of this changed dramatically in the middle of the twentieth century, set in motion by a turning point in world history — the heart attack of an American president.

The night that changed medicine

On 23 September 1955, the 34th President of the United States, Dwight Eisenhower, was on holiday in Denver, Colorado. The following morning, at around two o’clock, he woke with severe pain and tightness in the chest.

His personal physician, Dr Howard Snyder, was called urgently. In that era, understanding of heart attacks was so limited that the doctor mistook acute cardiac ischaemia for indigestion following the president’s late supper of hamburgers and onions.

Through the night and into the early morning, Dr Snyder treated the head of state with morphine for the pain, antacids and stomach medicines, and bed rest — while the president was in fact in cardiogenic shock and cold sweat.

Only at around midday — more than ten hours after the symptoms began — was a cardiology consultant called, with a portable electrocardiograph. The recording confirmed a severe acute anterolateral myocardial infarction.

Eisenhower was taken urgently to Fitzsimons Army Hospital. There the doctors were virtually powerless: there was no resuscitation, no defibrillator, no clot-dissolving medicine and no possibility of catheterisation.

Treatment consisted solely of an oxygen tent, absolute bed rest for six weeks — which we now know further increases the risk of pulmonary embolism — and morphine with the anticoagulant heparin or coumadin.

The treating cardiologist, the legendary Dr Paul Dudley White of Boston, called a press conference and told a frightened nation the truth. The event shocked the world: the most powerful man on the planet had been brought down by a disease against which doctors had almost no weapons.

Building the modern scientific base

The shock of Eisenhower’s heart attack pushed the American government and the National Institutes of Health into radical measures. A dedicated funding and research mechanism directed millions of dollars towards cardiovascular research.

This gave powerful momentum to a study that had begun a little earlier, in 1948, in Framingham. The scientific community realised that to stop heart attacks it first had to understand what caused them in the general population.

Researchers followed thousands of residents of the small town of Framingham, Massachusetts, for decades. It was this study that produced the concepts we use today. The term risk factor was introduced for the first time, and a direct link was established between high blood pressure, high cholesterol, smoking, diabetes and obesity and the development of heart attack and stroke. Thanks to Framingham, medicine understood why prevention matters as much as treatment.

The revolution in cardiac surgery

While cardiologists searched for causes, surgeons began looking for ways to operate on failing and damaged hearts.

Michael DeBakey became one of the greatest pioneers of modern surgery. During the 1950s he developed the first artificial vascular grafts, using Dacron fabric sewn on his own household sewing machine. DeBakey introduced the concept of operating on aortic aneurysms and built the first pumps for mechanical support of the left ventricle.

In 1967, at the Cleveland Clinic, the Argentine surgeon Dr René Favaloro performed the first planned coronary artery bypass operation, using a vein from the patient’s leg to bypass a blocked coronary artery. This saved millions of lives from otherwise certain death.

The first heart transplant

Only a few months after the first bypass, on 3 December 1967 in Cape Town, South Africa, Dr Christiaan Barnard performed the first successful human heart transplant in history. He transplanted the heart of a 25-year-old woman killed in a road accident into 53-year-old Louis Washkansky. Although the patient survived only 18 days and died of pneumonia because of the weak immunosuppressive drugs of the time, the event proved that heart transplantation was entirely possible.

The birth of invasive cardiology

Alongside surgery came the idea of bloodless treatment from within the vessels — what we now call interventional cardiology.

In 1953 the Swedish radiologist Sven-Ivar Seldinger devised the revolutionary method of puncturing a vessel with a needle, passing a guidewire and introducing a catheter. Every invasive procedure performed today rests on this technique.

In 1958 Mason Sones accidentally injected contrast into a coronary artery during a study of the aorta, and the first coronary angiogram was born.

Andreas Grüntzig, a brilliant German doctor working in Zurich, performed the world’s first percutaneous transluminal coronary angioplasty on a conscious patient on 16 September 1977. Grüntzig widened a narrowed coronary artery using a hand-made balloon catheter, changing medicine for good.

The evolution of medicines

As invasive methods developed, pharmacology took giant strides. The 1960s brought the beta blockers — described as the brakes of the heart, and for which Sir James Black received a Nobel Prize — as well as the diuretics.

The 1970s and 1980s saw the arrival of angiotensin-converting enzyme inhibitors, the first of which, captopril, was derived from the venom of a Brazilian snake, and of the calcium channel blockers.

The 1980s brought the era of the statins: the discovery of these cholesterol-lowering drugs halted the progression of atherosclerotic plaques. At the same time, thrombolytic treatment with streptokinase and tissue plasminogen activator made it possible to dissolve the clot in a heart attack within the first hours.

From balloons to drug-eluting stents

Grüntzig’s original balloon angioplasty had a major problem: once the balloon was deflated, the vessel often sprang back or narrowed again.

In 1986 Jacques Puel and Ulrich Sigwart placed the first bare metal stents, to hold the vessel open.

To prevent tissue growing inside the metal, stents were coated during the 2000s with a fine polymer layer releasing a drug such as sirolimus or paclitaxel. This reduced re-narrowing to under 5%.

The leading edge today

In the past, replacing a narrowed aortic valve meant opening the chest, stopping the heart and using a heart-lung machine. For elderly and frail patients this was too risky.

In 2002 the French cardiologist Alain Cribier carried out the world’s first transcatheter aortic valve implantation (TAVI). Through a small puncture of the femoral artery at the groin, a new folded biological valve is passed through the vessels to the heart and expanded directly inside the diseased valve — with no chest incision and without stopping the heart. Today this is a routine life-saving procedure for thousands of patients worldwide.

An extraordinary path of progress

From that night in 1955, when President Eisenhower was treated with morphine, rest and helplessness, cardiology has travelled a distance equal to centuries of scientific progress. Today, thanks to the great minds of DeBakey, Barnard, Seldinger, Grüntzig and Cribier, a patient with an acute heart attack can enter a catheter laboratory and, within 30 minutes, have the blocked vessel opened with a stent through a small puncture in the wrist.

Two centuries ago medicine had none of its present understanding of rules, procedures and strict oversight. It was closer to a craft, resting on the personal experience, authority and intuition of the individual doctor. How did an almost chaotic practice become today’s rigorous medical standards, protocols and treatment algorithms?

From dirty aprons to the science of sterilisation

In the early nineteenth century doctors entered the operating theatre in dark, stiffened aprons carrying dried blood from previous patients. The more stained the apron, the more experienced the surgeon appeared. Doctors performed post-mortems on those who had died of infection and, minutes later, delivered babies or dressed open wounds — without even washing their hands.

The great change began in the 1840s with the Hungarian obstetrician Ignaz Semmelweis. Working in Vienna, he noticed something startling: in the maternity ward staffed by medical students, who came straight from the dissection rooms, maternal mortality from puerperal fever was three times higher than in the ward staffed only by midwives. Semmelweis introduced compulsory hand washing with a chlorinated lime solution before every examination. Mortality fell from 18% to under 2%. He was thought mad — the medical profession refused to accept that doctors were carrying death on their own hands.

Only decades later, thanks to Louis Pasteur and the discovery of micro-organisms, did the British surgeon Joseph Lister apply these findings in the operating theatre. During the 1860s he began spraying carbolic acid (phenol) over instruments, wounds and the air of the theatre. For the first time, medicine understood that correct procedure and adherence to a standard — antisepsis and asepsis — were the difference between life and death.

England, the polio crisis and the birth of intensive care

Until the middle of the twentieth century, hospitals were simply collections of general wards. If a patient stopped breathing or went into shock, the nurses had neither the equipment nor the organisation to support their vital functions.

The turning point came in 1952, during the polio epidemic in Copenhagen and, shortly afterwards, in England. Hundreds of children and adults lost the use of their breathing muscles. In response, the anaesthetist Bjørn Ibsen realised that if the most critical patients were gathered in one dedicated room, given a tube into the trachea, and ventilated around the clock by relays of students and nurses squeezing a bag, those patients would survive.

In England during the 1960s this experience became a formal hospital structure. The first intensive care units were built in hospitals such as Kettering (1962) and St Thomas’ in London. Something fundamental was understood: a critically ill patient cannot wait for the duty doctor to come round the wards. They need:

• Continuous observation (monitoring).
• Specially trained staff.
• Standardised equipment for respiratory and cardiac support.

In this way intensive care became a standard without which the modern hospital could not exist.

Turning experience into law: America and Europe

Until the middle of the last century, medical decisions were subjective — every professor treated in his own way. But the growing number of errors, and new technology, made regulation necessary.

• In America: institutions such as the Food and Drug Administration were created, and guidelines were formulated by organisations such as the American Heart Association. United States law ties adherence to medical standards to legal responsibility — the standard of care. If a doctor departs from the rules without scientific justification and the patient is harmed, they are legally liable for negligence.
• In Europe: the European Union and national ministries introduced medical standards and good clinical practice, and European societies were formed for each specialty — for example the European Society of Cardiology. They issue algorithms based on evidence-based medicine.

Cardiology: when every minute has the price of a life. PLEASE READ CAREFULLY.

In no other field do medical standards and speed carry such dramatic weight as in cardiology.

In acute myocardial infarction one of the coronary arteries is completely blocked by a clot. Every minute without blood supply means the irreversible death of thousands of heart cells. Medicine has a rule for this: “time is muscle”.

Modern cardiology standards therefore set clear windows for action — the door-to-balloon time, from entering the hospital door to opening the vessel with a balloon or stent:

• If a patient with a heart attack is delayed and the intervention — angioplasty or stenting — is not carried out within the first 60 to 90 minutes, part of the heart muscle is lost for good.
• This leads to severe heart failure, death or permanent disability.

IMPORTANT. Treatment under modern conditions requires these aggressive, invasive but life-saving methods, because they are the only proven way to preserve the function of the heart. Failure to carry out such an emergency procedure without good reason on the part of the medical team is considered a serious medical error.

Why does the law protect a patient’s refusal?

Here lies the greatest paradox of modern medicine and law:

The emergency procedure is vital, yet the doctor has no right to perform it by force if a conscious and competent patient refuses.

Why do the laws of Europe and America protect the patient’s decision, even when it endangers their own life?

• The principle of personal autonomy. At the heart of modern medical law and bioethics lies a fundamental human right — the right to bodily integrity. Every medical treatment, however life-saving, is an intrusion into a person’s body. Without their consent, any intervention is treated by the law as assault.
• Informed consent. The law requires the doctor to explain in detail the benefits, the risks and the consequences of not having the procedure. The patient has the right to decide about their own body, even if that decision appears irrational or dangerous to the medical team.
• The exception in an emergency. The only exception is where the patient is unconscious, in shock or mentally unable to decide, and no legal representative is present. In such cases the law applies the principle of presumed will — it is assumed that every person would want their life saved, and the doctors are then obliged to carry out all emergency procedures immediately.

Medicine has travelled from complete chaos to a strict system of rules, to guarantee that every patient receives the best and safest care. In modern cardiology those rules save thousands of lives every day. At the same time the law keeps the balance: it obliges doctors to have every modern method of saving life available, while leaving the final choice to the individual.