The Causes of Heart Trouble

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GUESTS: Dr. A. Wilbur Duryee, Dr. Edwin P. Maynard, Jr., Dr. Simon Dack
VTR: 01/20/1957

ANNOUNCER: The Open Mind, free to examine, to question, to disagree. Our subject today, “The Causes of Heart Trouble.” Your host on The Open Mind is Richard D. Heffner, Author and Historian.

MR. HEFFNER: This is the first time that The Open Mind is being telecast at 12:30 on Sunday afternoon and this will be our regular time from now on. The Open Mind is also rebroadcast on WRCA-Radio every Sunday night at 11:45.

Now our subject today, “The Causes of Heart Trouble,” is of course a vitally important one for all of us for I think that we all realize that heart disease has become by far the greatest killer of our times. Our program today is timely, too, for the month ahead of us is Heart Month, and such organizations as the New York Heart Association will ask us all to help combat the killer disease.

Now I suspect that most laymen are as puzzled as I am when it comes to the question of what causes heart trouble. And reports in our newspapers do not serve particularly well to unravel this mystery. For instance on February 23 of last year Dr. Paul Dudley White, President , Eisenhower’s physician, the heart specialist, said something about work has been wrongly blamed as a cause of heart disease. He advocates work, not the undoing of it.

At the same time there are those people who say that tensions of our times, particularly tensions in cities, can cause heart trouble; but Dr. White and Dr. Duryee, President of the New York Heart Association, were quoted on April 16 as saying that although there is thought to be some connection between the tensions of everyday life and certain illnesses, including high blood pressure, they said that there is no evidence that heart disease is more prevalent in the metropolitan areas with which tensions are associated.

And then May 8, 1956 the New York Times headlined the story, “Fat in diet linked to heart disease.” And this past week, January 16, 1957, the New York Times listed a headline, “Experts disagree on diet versus heart.”

So that we want to try to unravel this mystery and ask our three specialists what are the causes of heart trouble; and our experts today, three outstanding specialists in the field of heart disease are first, Dr. Simon Dack, President of the American College of Cardiology; next Dr. A. Wilbur Duryee, President of the New York Heart Association; and Dr. Edwin P. Maynard, Jr. past-President of the New York Heart Association.

Well gentlemen, suppose l begin our program today by asking first — let me ask you, Dr. Duryee, whether heart trouble, heart disease, is increasing in our own times?

DOCTOR DURYEE: There has been a great deal of confusion, Mr. Heffner, about that question. The statisticians have given us figures but there is no question whatsoever that the number of people in the United States today and in our big city are suffering from heart disease in one of its forms to a far greater degree percentage-wise, number of people who are living in this city, than they were twenty-five years ago. So that whether it is actually increasing among individuals more frequently or whether more people are living into the age when the greatest form of heart disease predominates is one of the questions that time alone will solve, but it is our biggest problem today and it has become so,so at the present time heart disease kills three times more people than all other diseases put together.

MR. HEFFNER: Is there any particular kind of heart disease that is a killer or that is increasing?

DOCTOR MAYNARD: I think we should elucidate that a little bit. We really shouldn’t use the term heart disease at all, it is a misnomer. There are many diseases of the heart just as there are many diseases of the lung. There is coronary heart disease, of which Dr. Duryee was speaking; there is rheumatic heart disease caused by rheumatic fever; syphilitic heart disease caused by syphilis; thyroid heart disease, hypertension heart disease, caused by high blood pressure; and that is a very hopeful point of view because each one of these has different methods of prevention and different treatment.

MR. HEFFNER: Well, which one is on the increase in our times? Is it coronary?

DOCTOR DURYEE: Yes, that disease which is called coronary disease because it is a disease of the blood vessels in the heart. They are the coronary vessels, and the deposits of fat are laid down in these vessels which tend to narrow them, which means that the heart muscle does not get as much blood as it should, and in the early stages there may be no symptoms, no disability, and the disease can go on for many many years and the patient can live a very healthy and happy life without even knowing he has the disease.

On the other hand it may be a rapidly advancing disease and strike a man down suddenly because what happens in those cases the blood supply is markedly reduced at a certain point and the man knows he has heart disease and that is the disease we are talking about today.

MR. HEFFNER: This is arteriosclerosis?

DOCTOR DURYEE: That is correct.

MR. HEFFNER: I see. Well let me turn to Dr. Dack and ask him to start us off on this question of causes because I think as I said before as a lay person I am confused, the experts seem to disagree; what are the causes of arteriosclerosis?

DOCTOR DACK: Well, that is a very important problem, Mr. Heffner. Probably the most research which has been done in the field of heart disease in the past decade or two has been in this special field of arteriosclerosis and we have all been interested in trying to determine whether there are any known
precipitating or predisposing causes to this type of heart disease which we call coronary disease.
I believe that a lot of the research which has been done will help to dispel some of the hopelessness which was associated with this type of heart disease in the past.

Now there are various factors which are under investigation now. Probably the most important and the one which is obtaining the most headlines is probably the matter of diet and fats, and relation of fat to arteriosclerosis. But there are other causes which we should talk abbut, namely, is there any difference in men versus women? Is there any effect of age itself on arteriosclerosis? Is there any effect of an active physical work or active life versus a sedentary life? Is there any effect of smoking? Is there any effedt of such diseases as diabetes, for example? So I think that if possible we should try to touch
briefly on these various causes.

MR. HEFFNER: Well, I was going to say you are asking the questions and suppose I ask them now, and what are some of the answers you experts have come up with? First, diet. I gather this is certainly from the newspaper headlines this seems to be number one in consideration.

DOCTOR DURYEE: Last week, or the first part of this past week, that question was bantered back and forth by some of the experts from all over the United States. And there was certainly a large amount of this agreement as to the exact cause of large amounts of fat in the diet. There seemed to be though a certain overall feeling that excesses in fat that produced changes in the fat in the blood which you can measure in the laboratory, as a rule were found much more commonly, that is the increase in fat was found much more commonly in people who were suffering from heart disease; so there is some correl-ati6n-between fat which we eat and the changes that we find in these blood vessels.

Unfortunately some people seem to be able to get away, in the slang of it, with eating large amounts of fat and never develop heart disease; and then there are those individuals who do not eat too much fat and do get heart disease, so it is not a constant finding.

There are certainly other factors, but I think all of the medical profession is beginning to believe this question of the intake of fat, the kind of fat we eat, how frequently we eat excess fat, is a very important one.

MR. HEFFNER: I wonder if 1 could ask this question? I have seen a good many reports about fat in some of the conflict and T wondered whether the doctors are motivated to consider fat largely or possibly considerably because of the fact that is something we control, we can control. We can control the intake of fat. If it is something beyond our control we are a little more pessimistic about it. Do you think this is a factor or are there scientific studies?

DOCTOR EAYNARD 1 would like to say something about that because the scientific studies have been fascinating, particularly the work of Dr. Ancil Keyes of Minnesota and Dr. Paul White. They have done studies throughout the world comparing the instance of coronary heart disease with the habit, the national habit as to fat intake.

In the United States I am sorry to say it has the highest incidence of coronary disease of any country in the world, and our ingestion of fat is also the highest. Then at the other end of the scale countries that eat very little fat such as Japan, the Okinawans, have very little coronary disease.

We have found in intermediate countries -Portugal– where the economic conditions are such that there are large numbers of poor people unable to get fat, thee instance of coronary disease is low. But because of the poverty they die of tuberculosis; but nevertheless their coronary disease is low. So that the circumstantial evidence is very strong from the study of the habits of peoples.

Another interesting feature was the effect of two world wars. Now when Norway was blockaded by the Germans in World War II the instance of coronary disease in Norway dropped tremendously. The same way with Germany.

MR. HEFFNER: You mean because–

DOCTOR MAYNARD: Because they couldn’t get fat any more. The same way with Germany. After the war when they had such deprivation in Germany after this last war the incidence of coronary disease went down.

DOCTOR DURYEE: But isn’t it, Dr. Maynard, a little dangerous to draw a conclusion like that? Because in the country that is deprived of fat in their diet during the war there are many other factors that are also altered so that even though we assume it was the alteration in the fat it is possible that there were some other factors.

DOCTOR DACK: In other words, the amount of food may be poor too, the amount of calories ingested may play just as important a role as the individual types of food which are eaten.

DOCTOR DURYEE: Following up your line of thought, in this country today we probably have more economic success than any country in the world, and therefore we have a higher caloric intake, and therefore it may not be the fat alone, as you say, it may be the increased calories.

MR. HEFFNER: We may be overweight in itself. DOCTOR MIME: Well, not only overweight. Maybe some individuals when they eat too much get too fat. That is true, and that certainly has been blamed as one of the contributing causes to coronary disease. But on the other hand even those that don’t get too fat from eating may still — well, it is just like putting too much coal on a fire and getting incomplete combustion because you have got too much coal on there, and that may have some relationship to the development of this disease. So it may not be only fat, it may be eating too much.

MR. HEFFER: Well, in your statistics you talk about a comparison between the United States and other countries that don’t have our standard of living but I know too that don’t have the tensions that beset us. Could we attribute the difference in the rates of coronaries to tension?

DOCTOR MAYNARD: I don’t think there has been any evidence to show that the general idea of tension is the cause of coronary disease. I would like to go back a minute to the fat.

I think that whereas we are not ready yet to say that the public, that the ingestion of fat is the main cause of coronary disease, nevertheless it is the most hopeful avenue of research at the present time and I think that there is a great deal of circumstantial evidence to back this up. It has been pretty well shown it is not just calories and it isn’t just getting overweight.

Now the tensions of life however are a different matter. If you talk about general tensions, working hard, and being anxious, that has nothing to do with it. But emotional stress however at the moment, severe anger, can produce dangerous attacks. Sir John Hunter, a very famous British surgeon, who had coronary disease, once said that his life was in the hands of any rascal that got him mad, and that is a very wise statement.

DOCTOR RACK: In other words, you don’t think that tension itself causes coronary heart disease or arteriosclerosis?

DOCTOR MAYNARD: No.

DOCTOR DACK: But that the man who already has it may get into trouble by severe emotional …

DOCTOR MAYNARD: Not by just worry but by anger.

MR. HEFfNER: But Doctor Dack, I wonder are there heart people who do feel that tension is a cause?

DOCTOR DACK; Oh yes. There are certainly a great deal of difference of opinion on this subject. I think we can battle back and forth all day on the problem of tension. Whether we believe in it or not I think we all agree that if a man already has evidence of heart disease he should be advised to lead as relaxing and tranquil a life as is possible.

DR. DURYEE: Doctor Dack, you have brought out a very important point to this whole discussion, and that is that we can do a great deal for people with known heart disease of the type we are talking about today because we had learned what some of these factors are. Just as Dr. Maynard pointed out you cannot always prevent a fight but at least you can stay away from one once in a while. But there are other things that we can prevent or reduce, regulate, in the program of an individual that will have a great bearing as to how long they live and how successfully they live. I think Dr. Paul White has been one of those individuals who has pointed out the value of proper exercise.

For instance, in years gone by we have been prone to make invalids out of heart people, and now we are quite aware of the fact these people can do a great deal. Many of them do almost as much or as much as they were doing before their heart attack. And some of them perhaps might even be better off doing a little more than they were dOing before their heart attack if it is done with reasonable gain in activity and under a doctor’s direction.

DR. DACK: Well, I think that’s true because modern studies have shown that most patients who have had acute heart attack and recover from the acute stage not only are able to go back to work but should be encouraged to go back to a fruitful and worthwhile existence rather than become invalids.

DR. DURYEE: Well, that’s borne out by the insurance companies. They are all developing their programs of rehabilitation, of trying to take these people who have developed heart attacks while they were working and bringing out the value of going back to work and getting back to a gainful occupation. It not only helps their pocketbooks but it also helps the morale of the population and helps our whole economic status.

MR. HEFNER: Excuse me.. May I just say this? In the reading that you gentlemen gave me when I got through the technical terms I did come up with the thought that there were some other factors that you gentlemen feel are contributing, and I wonder if we could discuss those a minute? For instance, the
hormonal influence. What have you experts decided about that?

DR. DURYEE: Well, no final decisions but Dr. Katz working in Chicago has done an extensive piece of work following out the idea that women during the childbearing period are not prone to develop this form of heart disease. But after the end of the childbearing period they rapidly catch up to the incidence in the. male. Therefore it must be assumed that maybe there is a possible connection between hormones, and although the work is still in its infancy I think there is a great deal that will come out of that study. I don’t think we are in a position yet where we can advise patients as to hormonal treatment. I think it will
be something of the future.

MR. HEFFER: Have there been attempts made to treat with female hormones?

DR. DACK: As Dr. Duryee says this is still in the investigative stage but there have been research studies based on the attempt to feed men with heart disease female sex hormones in an attempt to reduce the amount of fatty deposits in the arteries, or the fat in the blood. On a research basis there is definite evidence that this will happen, but of course very large doses are necessary; there are a great deal of side effects, and it is still not ready for widespread spplication, but it may in the future lead to fruitful results.

MR. HEFFNER: What about other factors like bodily structure and heredity? How do these come into the consid¬eration of the causes of coronary trouble?

DOCTOR MAYNARD: I would say that bodily structure has a good deal to do with it. It has been shown by work, particularly in Boston, that the football-tackle type of person, the man with the short neck, broad chest the round, powerful forearms, has a very good chance much higher chance of developing coronary disease in the younger age group, So that anthropo¬logical or body build type is important, and one of those things we probably cannot alter.

DOCTOR DACK: Do you think the thin person has less chance of getting heart disease?

DOCTOR MAYNARD: I am sure there is evidence of that yes ..

MR. HEFFNER: When you say thin person do you mean the person who remains thin?

DOCTOR MAYNARD: I mean the body build, not necessarily thin, the body build. That is the broad chest, the short neck and the thick forearms are the ones that have a high percentage chance of getting coronary disease. Now we can’t really alter that very much nor can we alter heredity. Heredity plays a role. We all know there are coronary-diseased families, but that need not be too alarming because the role of heredity is not very powerful, Maybe some day we will be able to affect that, who knows. At the present time we can’t select our progenitors.

MR. HEFFNER: Well, talking about the things we can effect what about smoking?

DOCTOR DURYEE: I would like to say something about tobacco because since 1933 I have been extremely interested in the effects of tobacco on the circulation,. My interest started with the study of the effect of tobacco on the arteries in the arms and legs, not in the heart. The conditions are somewhat similar but not the same, and we do know that every time a person smokes that a large majority of individuals have a reductions temporary reduction in the blood supply in the small arteries. Now in a normal healthy individual that probably does no harm at all and a person can continue to smoke without trouble.

On the other hand, if he does by hard luck develop arteriosclerosis then we know that the tobacco added on top of the disease will further reduce the circulation.

Now as far as the heart is concerned we have a diversified opinion among heart specialists as to whether these individuals should stop stoking completely or not. We can show in some individuals by the electrocardiogram that the same thing apparently’takes place in the heart as takes place in the legs, that the circulation is reduced following the smoking of a cigarette. Whether that is due to the heart having to pump a little-faster or whether there is a spasm of the healthy vessels that are left in the heart,we donit know.

I am expressing this as my personal opinion, not as an agreed opinion among all professional men, that tobacco in people with arteriosclerosis should be eliminated.

MR. HEFFNER: Do you gentlemen agree?

DOCTOR DACK: Do you stop all your patients from smoking?

DOCTOR DURYEE: I do except in the rare instance where it seems to me that the elimination of tobacco produces such a high state of nervous tension that that has to be considered. And I think you,have brought up another important point, that in treating a patient with arteriosclerotic heart disease that you have got to individualize the patient. What we say here does not hold true for every patient. You have got to treat him as a.human being as an individual, and that is the only way you are going to get results.

DOCTOR DACK: most patients claim if you stop them from smoking they are going t gain weight, so we have to weigh the possible dangers of gaining weight versus over-smoking,

DOCTOR DURYEE:—And not only gain:weightjbtt.they will get hungrier and eat more fat so there you are.

DOCTOR MAYNARD: That is just because they don’t want to stop smoking they tell you that.
Now the other interesting point is alcohol. One thing is quite certain, that T think we all would agree, that ingestion of alcohol doesn’t cause coronary heart disease, nor does it cure it.

DOCTOR DURYEE: Tobacco doesn’t cause it either; I should have said that.

DOCTOR MAYNARD: Nor does alcohol dilate the coronary arteries. However, it is relaxing and where people are tense and tired the moderate use of alcohol is probably beneficial from that standpoint.

MR. HEFFNER: Now you are talking about people who already have shown signs of …

DOCTOR MAYNARD: Already have shown signs. Now have to be very careful about this because every once in a while you will prescribe alcohol to a person as a treatent for coronary disease and then you have the problem of alcoholism, so that tt should be carefully gone into with the patient and taken only on doctor’s prescription, and in moderate amounts as a relaxant, but not with the idea that it is benefitting the coronary disease.

DOCTOR DACK: Of course just the same as with the matter of smoking, excess alcohol does place a definite burden and strain on the heart; it increases the heart rate, increases the work of the heart.

DOCTOR MAYNARD: Correct.

DOCTOR DACK: I think that is true also of excessive smoking, isn’t it?

DOCTOR DURYEE: I agree with you a hundred per cent, and it emphasizes the point that people with arteriosclerotic heart disease get along better if they lead:,a temperate or a moderate life in everything. Marked restrictions are bad and excesses likewise produce real damage.

MR. HEFFNER: Well, I wonder following that up, moderation, I read somewhere in the literature I received that we start from the very beginning as infants developing arteriosclerosis:- — it is very difficult to pronounce for a lay person — and that is this just the nature of life? Are we just experiencing the
general clogging of the arteries or do you project to a time when something very positive can be done by way of prevention?

DOCTOR DURYEE: Well, that is our big job in the Heart Association today, to find out with our monies that are given to us and appropriated for research; if your idea is whether or not we can stop that process or whether it is a natural process, we don’t know the answer. We think and hope and pray that we can stop it. And many of us feel that there must be an answer why this particular process takes place in some individuals excessively and in other individuals very slightly. Therefore I think research will be our only answer to your question.

MR. HEFFNER: I see. Is there much emphasis being put now upon research?

DOCTOR MAYNARD: Tremendous. I should say that in heart diseases that the coronary disease and arterial disease has the greatest attention, and I would like to emphasize one point. You used the word arteriosclerosis.

MR. HEFFNER: I tried to use it.

DOCTOR MAYNARD: The public think that is hardening of the arteries. That is quite an incorrect term. It is a disease entity in which fat is deposited in the arterial wall. If you think about hardening of the arteries that sounds very hopeless. It isn’t just a natural development of life.. It is true that it occurs in young people, but I am one that believes that we will find that we will be able to decrease the amount tremendously.

DOCTOR DACK: Someday we can find some substance or chemical which will prevent the deposition of the fat in the arteries.

DOCTOR NAYNARD: In fact exciting research is going on right now in animals where the fat in the arterial walls put there by scientific experiment can be diminished or prevented.

MR. HEFFNER: Well, I am interested to note that in talking about hope for the future you talk about fat and diet so that you gentlemen do seem to put a tremendous amount of emphasis upon it.

DOCTOR DACK: In general if the general population would be moderate in the amount of food it eats and particularly in the amount of fat, calories it eats, it may be one out of five deaths can be prevented in the next few years.

DOCTOR DURYEE: I think that’s a good statement and I think a very important thing to point out is that there may be a sudden discovery that will solve this. But I don’t think the public should look for a single sudden discovery.

DOCTOR DACK: It is a matter of long time application.

DOCTOR DURYEE: And analysis of what we know and what we are going to learn. Ten million dollars will be spent this year in research, most of it on this problem, in the United States. That is not individual research but that is research money given by the public.

MR. HEFFNER: Well, let me just ask this final question, or make this statement. I gather you agree that there is hope for the future and that if the individual can be treated in terms of what researchers are showing now maybe in the future we will be eliminating you said one out of five deaths due to coronaries?

DOCTOR DURYEE: 1 think we could almost do that right now. l think in the future we could increase that percentage markedly.

DOCTOR DACK: 1 think so, definitely.

MR. HEFFNER: Thank you very much gentlemen, for ending on a hopeful note, Dr. Dack Dr. Duryee, Dr., Maynard.