American
Heart
June, 1975, Volume 89, Number
Journal
6
Editorial What do the heart disease tell us? George M. Wheatley,
M.D.,
mortality
statistics
M.P.H.
New York, N. Y.
Cardiovascular diseases are responsible for half of all deaths in Northwestern Europe and North America. Heart disease is, by all odds, the dominant cause of death in men under 65. Heart disease is also the leading cause of death among women under 65, even though in this broad age range female mortality rates from heart disease are only about a third of the male rates. No other single factor is as significant as sex in heart disease mortality. These facts are well known, even to the public because of education and fundraising campaigns over the last several decades. Since the 1950’s, billions of dollars have been spent by governmental and private agencies seeking control over this vast and complex public health problem. What trends or clues of progress are suggested by the mortality data available from population studies and insurance statistics? Essential to any consideration of this subject is the recognition that the term “heart disease” represents many diseases of the cardiovascular system. While every clinician and medical scientist knows this, because of the publicity given to heart attacks, the man in the street generally equates heart disease with coronary artery disease. Even this condition may need to be seen From the Metropolitan Life Insurance N. Y. Received for publication March 12, 1974. Reprint requests to: Dr. George M. Wheatley, Medical Director (now retired), Metropolitan Madison Ave., New York, N. Y. 10010.
Company,
New
York,
Vice President and Chief Life Insurance Co., One
June, 1975, Vol. 89, No. 6, pp. 683-685
as a more complex phenomenon. Deaths from heart disease due to congenital defects, rheumatic fever, and hypertension have decreased quite dramatically in the 1960’s, reflecting advances in surgical and medical management. According to detailed studies performed by the Metropolitan Life Insurance company by Lew and Entmacher’ for the white male population, the mortality rate for rheumatic heart diiase decreased 34 per cent. However, this form of heart disease accounts for less than 2 per cent of the total mortality. Congenital heart disease dropped 22 per cent in the 1960’s, but is responsible for only 1 per cent of total heart mortality. Hypertensive heart disease declined 29 per cent, but represents only 4 per cent of all heart mortality.* On the other hand, during this same period, mortality from arteriosclerotic heart disease, which includes coronary disease, increased by 2 per cent among white males, and 1 per cent among white females of all ages. Since this form of heart disease accounts for five-sixths of the total mortality from heart disease among white males, and three-fourths among white females, these losses more than offset the gains in the other forms of heart disease. Thus, in the 1960’s, for the United States population, the balance sheet for heart disease mortality showed virtually no gain. *Between 1960 and 1967, the codes for the cardiovascular causes of death remained unchanged 89 that a valid comparison can be made between the death rates from these diseases reported in these years.
American
Heart
Journal
683
Wheatley
This is disappointing in light of the vast resources thrown into this battle in the last decade. On the other hand, the problem of arteriosclerotic heart disease is extremely complex. Warren’ suggests that coronary artery disease be thought of as a group of major syndromes. Each is a manifestation of the underlying arteriosclerotic process and each responds differently, perhaps, to risk factors. Modifying lifestyles and risk factors-if these be etiologic factors-is a formidable task, In spite of some enthusiastic claims, assessment of the outcome may require a decade or more. Management of acute heart attacks, while vastly improved, needs further expansion, especially to include health education of the public so that an acute attack is recognized earlier and emergency measures can be administered by trained laymen even before the arrival of the ambulance. In seeking evidence of the value of programs of primary and secondary prevention which have been applied during the past decade, mortality studies by socio-economic class provide clues. There is a growing body of facts which shows a close relationship between higher economic and education attainment and lower mortality from cardiovascular disease. In a country as large and heterogenous as the United States, the mortality rates of the total population can mask evidence of mortality trends. Comparisons among states and countries with significantly different standards of living reveal contrasts in cardiovascular mortality. Analysis of data by education and social class because of the influence on lifestyles also reveals important differences. For example, the mortality studies of Guralnick,” in 1950, among men 20 to 64 years of age in nine major occupational groups showed generally lower heart disease death rates for occupations in the higher socio-economic classes. Kitagawa and Hauser, in 1960, showed that higher education was significantly related to lower mortality from heart disease as well as for all causes. The Metropolitan Insurance Company recently conducted a variety of studies on its insured populations and on prominent and successful professional and businessmen which sheds further light on these factors.+? For example, persons insured with the Metropolitan Life Insurance Company under standard ordinary policies had a substantially lower mortality rate from heart diseases than did those persons
684
insured under industrial policies. The two categories may be considered to represent broadly different socio-economic strata. Standard ordinary policyholders are drawn chiefly from urban middle and well-to-do classes, while industrial policyholders are mainly members of urbanwage-earning families in the lower income brackets. Our statisticians have also conducted studies of mortality experience of Metropolitan Life Insurance employees and employees of several other large employers. Altogether, these represent several hundred thousand persons and from five to fifteen years’ observation. In all cases, executive and administrative personnel representing the highest salary groups had the lowest mortality from heart disease. Even among those in the highest corporate levels, where coronary disease and mortality is lowest, there were appreciably lower rates among college graduates than among noncollege men. In Great Britain,8 where mortality studies have been related to social class for several generations, the most recent report indicates that the highest classes have the lowest mortality rate from heart disease. The experience for married women follows the pattern of their husbands. A comprehensive review of the follow-up studies of men who survived a first myocardial infarction indicates that persons in the higher socio-economic segments of the population have a distinctly better record of survival after a year or two have elapsed following the acute episode.” A similar long-term study of Hrubec and Zukel’” relating to the survival of well-authenticated cases of myocardial infarction suffered while in the Armed Forces of the United States during World War II, shows clearly that physicians and professional men with a college education have had a better survival record than men in other occupations or with lesser education attainments. Is this lower mortality due to better health practices and easier access to first-rate medical care for the better educated and the more affluent? Are there other factors which account for these differences? Are the mortality differentials associated with different manifestations of coronary artery disease? What is the relative importance of socio-economic factors vs. hypertension, smoking, elevated cholesterol, and obesity in primary and secondary prevention programs? June,
1975, Vol. 89, NO. 6
Heart disease mortality
While socio-economic factors appear to have a distinct influence on the mortality from coronary artery disease, epidemiologic studies point up the importance of hypertension, smoking, elevated cholesterol, and obesity. These factors cut across socio-economic classes and thus complicate the study of their relative importance in programs of primary and secondary prevention. For example, there is evidence that moderation in living habits, as exemplified by a state such as Utah with its relatively homogenous population, predisposes to low mortality. Stressful living, often manifested by excessive cigarette smoking, by overeating, and by hypertension, may be the catalyst that precipitates acute myocardial infarction. The differences between individuals in responding to various stresses lend support to the concept of the coronary-prone personality. Much speculation and an increasing amount of research have been devoted to evaluating the importance of psychological factors in cardiovascular disease. Brenner” suggests that a significant proportion of the population is subject to major stresses that originate in threats to their economic status. His studies show clearly that economic downturns are associated with increased mortality from heart disease and, conversely, that heart disease tends to decrease during economic upturns. In countries where the social motivation to achieve material success is very strong, economic depressions obviously constitute highly stressful situations for large segments of the population. The present international energy crisis and its attendant economic crunch provides an opportunity to test this thesis. The etiology of coronary artery disease undoubtedly involves numerous fe.ctors, and we need more objective studies to determine their relative importance in primary and secondary prevention. As medicine moves toward more
American Heart Journal
stat&b
involvement with Health Maintenance Organizations and other approaches which seek to apply risk concepts to prospective medicine and health knowledge to the prevention, minimizing of disability, and life-saving, the acquisition of reliable data on the life history of heart diseases must have the highest priority. In the future, such research is essential for proper evaluation of society’s enormous financial commitment in the struggle against cardiovascular disease. REFERENCES 1.
Lew, E. A., and Entmacher, P. S.: Mortality in cardiovascular disease, pages 67-101, Symposium, September 1921,19’72 - Early phases of coronary heart disease, Skandia International Symposia, edited by W aldenstrom, J ., Larsson, T. and Ljungstedt, N. Sponsored by the Skandia Group. 2. Warren, J. V.: A revolution in coronary artery disease-Editorial, J. Chron. Dis. 26:547, 1973. 3. Guralnick, L.: Mortality in 1950 b> occupation and industry. National Office of Vital Statistics Special Reports, Vol. 53, Nos. l-5. 4. Kitagawa, E. M., and Hauser, P.: Education differentials in mortality by cause of death: U.S. 1960, Demography, Vol. 5. No. 1. 196% Cardiac mortality and socioeconomic status. Statistical Bulletin, Metronolitan Life. June. 1967. Who’s Who Study. Statist&al Bulletin and June 1970, Am. J. Pub. Health, 1968. Fortune 500 Executives. Feb. 1974, Statistical Bulletin. The Registrar General’s Decennial Supplement, England and Wales, 1961, Occupational Mortality Tables. London, 1971, Her Majesty’s Stationery Office. 9. Lew, E. A.: Follow-up studies of myocardial infarction, 10th Int. Congress Life Assurance of Medicine, London, June 8-11, 1970. 10. Hrubec, Z., and Zukel, W. J.: Socioeconomic differentials in prognosis following episodes of coronary heart disease, J. Chron. Dis. 23:881, 1971. 11. Brenner, M. H.: Economic changes and heart disease mortality. Am. J. Pub. Health 61:606. 1971.
‘Much of the data and the discussion of risk factors in this editorial come from a paper prepared by Lew and Entmacher for the Skandia International Symposium, Stockholm, Sweden, 1972 on the mortality in early phases of cardiovascular disease.
685
Heart
June, 1975, Volume 89, Number
Journal
6
Editorial What do the heart disease tell us? George M. Wheatley,
M.D.,
mortality
statistics
M.P.H.
New York, N. Y.
Cardiovascular diseases are responsible for half of all deaths in Northwestern Europe and North America. Heart disease is, by all odds, the dominant cause of death in men under 65. Heart disease is also the leading cause of death among women under 65, even though in this broad age range female mortality rates from heart disease are only about a third of the male rates. No other single factor is as significant as sex in heart disease mortality. These facts are well known, even to the public because of education and fundraising campaigns over the last several decades. Since the 1950’s, billions of dollars have been spent by governmental and private agencies seeking control over this vast and complex public health problem. What trends or clues of progress are suggested by the mortality data available from population studies and insurance statistics? Essential to any consideration of this subject is the recognition that the term “heart disease” represents many diseases of the cardiovascular system. While every clinician and medical scientist knows this, because of the publicity given to heart attacks, the man in the street generally equates heart disease with coronary artery disease. Even this condition may need to be seen From the Metropolitan Life Insurance N. Y. Received for publication March 12, 1974. Reprint requests to: Dr. George M. Wheatley, Medical Director (now retired), Metropolitan Madison Ave., New York, N. Y. 10010.
Company,
New
York,
Vice President and Chief Life Insurance Co., One
June, 1975, Vol. 89, No. 6, pp. 683-685
as a more complex phenomenon. Deaths from heart disease due to congenital defects, rheumatic fever, and hypertension have decreased quite dramatically in the 1960’s, reflecting advances in surgical and medical management. According to detailed studies performed by the Metropolitan Life Insurance company by Lew and Entmacher’ for the white male population, the mortality rate for rheumatic heart diiase decreased 34 per cent. However, this form of heart disease accounts for less than 2 per cent of the total mortality. Congenital heart disease dropped 22 per cent in the 1960’s, but is responsible for only 1 per cent of total heart mortality. Hypertensive heart disease declined 29 per cent, but represents only 4 per cent of all heart mortality.* On the other hand, during this same period, mortality from arteriosclerotic heart disease, which includes coronary disease, increased by 2 per cent among white males, and 1 per cent among white females of all ages. Since this form of heart disease accounts for five-sixths of the total mortality from heart disease among white males, and three-fourths among white females, these losses more than offset the gains in the other forms of heart disease. Thus, in the 1960’s, for the United States population, the balance sheet for heart disease mortality showed virtually no gain. *Between 1960 and 1967, the codes for the cardiovascular causes of death remained unchanged 89 that a valid comparison can be made between the death rates from these diseases reported in these years.
American
Heart
Journal
683
Wheatley
This is disappointing in light of the vast resources thrown into this battle in the last decade. On the other hand, the problem of arteriosclerotic heart disease is extremely complex. Warren’ suggests that coronary artery disease be thought of as a group of major syndromes. Each is a manifestation of the underlying arteriosclerotic process and each responds differently, perhaps, to risk factors. Modifying lifestyles and risk factors-if these be etiologic factors-is a formidable task, In spite of some enthusiastic claims, assessment of the outcome may require a decade or more. Management of acute heart attacks, while vastly improved, needs further expansion, especially to include health education of the public so that an acute attack is recognized earlier and emergency measures can be administered by trained laymen even before the arrival of the ambulance. In seeking evidence of the value of programs of primary and secondary prevention which have been applied during the past decade, mortality studies by socio-economic class provide clues. There is a growing body of facts which shows a close relationship between higher economic and education attainment and lower mortality from cardiovascular disease. In a country as large and heterogenous as the United States, the mortality rates of the total population can mask evidence of mortality trends. Comparisons among states and countries with significantly different standards of living reveal contrasts in cardiovascular mortality. Analysis of data by education and social class because of the influence on lifestyles also reveals important differences. For example, the mortality studies of Guralnick,” in 1950, among men 20 to 64 years of age in nine major occupational groups showed generally lower heart disease death rates for occupations in the higher socio-economic classes. Kitagawa and Hauser, in 1960, showed that higher education was significantly related to lower mortality from heart disease as well as for all causes. The Metropolitan Insurance Company recently conducted a variety of studies on its insured populations and on prominent and successful professional and businessmen which sheds further light on these factors.+? For example, persons insured with the Metropolitan Life Insurance Company under standard ordinary policies had a substantially lower mortality rate from heart diseases than did those persons
684
insured under industrial policies. The two categories may be considered to represent broadly different socio-economic strata. Standard ordinary policyholders are drawn chiefly from urban middle and well-to-do classes, while industrial policyholders are mainly members of urbanwage-earning families in the lower income brackets. Our statisticians have also conducted studies of mortality experience of Metropolitan Life Insurance employees and employees of several other large employers. Altogether, these represent several hundred thousand persons and from five to fifteen years’ observation. In all cases, executive and administrative personnel representing the highest salary groups had the lowest mortality from heart disease. Even among those in the highest corporate levels, where coronary disease and mortality is lowest, there were appreciably lower rates among college graduates than among noncollege men. In Great Britain,8 where mortality studies have been related to social class for several generations, the most recent report indicates that the highest classes have the lowest mortality rate from heart disease. The experience for married women follows the pattern of their husbands. A comprehensive review of the follow-up studies of men who survived a first myocardial infarction indicates that persons in the higher socio-economic segments of the population have a distinctly better record of survival after a year or two have elapsed following the acute episode.” A similar long-term study of Hrubec and Zukel’” relating to the survival of well-authenticated cases of myocardial infarction suffered while in the Armed Forces of the United States during World War II, shows clearly that physicians and professional men with a college education have had a better survival record than men in other occupations or with lesser education attainments. Is this lower mortality due to better health practices and easier access to first-rate medical care for the better educated and the more affluent? Are there other factors which account for these differences? Are the mortality differentials associated with different manifestations of coronary artery disease? What is the relative importance of socio-economic factors vs. hypertension, smoking, elevated cholesterol, and obesity in primary and secondary prevention programs? June,
1975, Vol. 89, NO. 6
Heart disease mortality
While socio-economic factors appear to have a distinct influence on the mortality from coronary artery disease, epidemiologic studies point up the importance of hypertension, smoking, elevated cholesterol, and obesity. These factors cut across socio-economic classes and thus complicate the study of their relative importance in programs of primary and secondary prevention. For example, there is evidence that moderation in living habits, as exemplified by a state such as Utah with its relatively homogenous population, predisposes to low mortality. Stressful living, often manifested by excessive cigarette smoking, by overeating, and by hypertension, may be the catalyst that precipitates acute myocardial infarction. The differences between individuals in responding to various stresses lend support to the concept of the coronary-prone personality. Much speculation and an increasing amount of research have been devoted to evaluating the importance of psychological factors in cardiovascular disease. Brenner” suggests that a significant proportion of the population is subject to major stresses that originate in threats to their economic status. His studies show clearly that economic downturns are associated with increased mortality from heart disease and, conversely, that heart disease tends to decrease during economic upturns. In countries where the social motivation to achieve material success is very strong, economic depressions obviously constitute highly stressful situations for large segments of the population. The present international energy crisis and its attendant economic crunch provides an opportunity to test this thesis. The etiology of coronary artery disease undoubtedly involves numerous fe.ctors, and we need more objective studies to determine their relative importance in primary and secondary prevention. As medicine moves toward more
American Heart Journal
stat&b
involvement with Health Maintenance Organizations and other approaches which seek to apply risk concepts to prospective medicine and health knowledge to the prevention, minimizing of disability, and life-saving, the acquisition of reliable data on the life history of heart diseases must have the highest priority. In the future, such research is essential for proper evaluation of society’s enormous financial commitment in the struggle against cardiovascular disease. REFERENCES 1.
Lew, E. A., and Entmacher, P. S.: Mortality in cardiovascular disease, pages 67-101, Symposium, September 1921,19’72 - Early phases of coronary heart disease, Skandia International Symposia, edited by W aldenstrom, J ., Larsson, T. and Ljungstedt, N. Sponsored by the Skandia Group. 2. Warren, J. V.: A revolution in coronary artery disease-Editorial, J. Chron. Dis. 26:547, 1973. 3. Guralnick, L.: Mortality in 1950 b> occupation and industry. National Office of Vital Statistics Special Reports, Vol. 53, Nos. l-5. 4. Kitagawa, E. M., and Hauser, P.: Education differentials in mortality by cause of death: U.S. 1960, Demography, Vol. 5. No. 1. 196% Cardiac mortality and socioeconomic status. Statistical Bulletin, Metronolitan Life. June. 1967. Who’s Who Study. Statist&al Bulletin and June 1970, Am. J. Pub. Health, 1968. Fortune 500 Executives. Feb. 1974, Statistical Bulletin. The Registrar General’s Decennial Supplement, England and Wales, 1961, Occupational Mortality Tables. London, 1971, Her Majesty’s Stationery Office. 9. Lew, E. A.: Follow-up studies of myocardial infarction, 10th Int. Congress Life Assurance of Medicine, London, June 8-11, 1970. 10. Hrubec, Z., and Zukel, W. J.: Socioeconomic differentials in prognosis following episodes of coronary heart disease, J. Chron. Dis. 23:881, 1971. 11. Brenner, M. H.: Economic changes and heart disease mortality. Am. J. Pub. Health 61:606. 1971.
‘Much of the data and the discussion of risk factors in this editorial come from a paper prepared by Lew and Entmacher for the Skandia International Symposium, Stockholm, Sweden, 1972 on the mortality in early phases of cardiovascular disease.
685
