Winning the 100-year war against heart disease | Dr. Daniel Levy | TEDxBoston

What's the leading cause of death in the United States today? Okay, that's right. It's heart disease. It's the leading cause of death in men and in women. In fact, it's been the leading cause of death in our country for 100 consecutive years. Show of hands, who has a parent or a grandparent who's been affected by a heart attack or a stroke? Wow, many of you. And who, like me, is taking medication to lower cholesterol or blood pressure? Again, quite a few people. Well, I'd like to have you join me on a journey to the town of Framingham, Massachusetts, a town of ordinary people that have played an extraordinary role in our fight and winning the battle against heart disease and stroke. Let's go back to the beginning of the 20th century. The leading cause of death in our country were infectious diseases. Pneumonia, influenza, tuberculosis, and diarrhea. And the average life expectancy of a baby born in our country was about 50 years. Fast forward to today, the leading causes of death in our country are all non-infectious. Heart disease is number one. Stroke is number four on that list. And the life expectancy of a baby born in our country is 75 to 80 years. In the course of just about 100 years, we've seen life expectancy in our country increase by 50%. That's a remarkable achievement. Heart disease, number one cause of death in men and women. When did the wake-up call occur? April 12, 1945. What happened on that day? Yeah, I heard someone say it. That was the day the American people learned that President Roosevelt had died. Here's a quote from the press secretary who expressed concern here because the president had been pronounced healthy and his death occurred as a bolt out of the blue. Imagine hiding the president's wellness from the public. Well, the truth is we know that a normal blood pressure is a value of less than 120 over 80. When we go back and look at Roosevelt's blood pressures, we can see that in 1931 when he was a young man and governor of New York running for the White House for the first of four times, his blood pressure was already hypertensive at 140 over 100. And over the course of the next 14 years, you can see the acceleration of his blood pressure to the point where in November of 1944, his blood pressure is 210 over 112. Quite dangerous levels of blood pressure. And shortly after that, after the fighting in Europe stopped, he would travel to the Crimean Peninsula to Yalta in the company of Churchill and Stalin to carve up the map of Europe, making big decisions. He was not a very healthy-looking man at that time. You can see smoking and looking gaunt. His blood pressure at that time in Yalta was 260 over 150. I can assure you that these are levels of blood pressure that are life-threatening and levels that many young trainees in medicine have never seen. But it's a level of blood pressure that anyone should be treated for, and in the United States today, everyone is. Well, just two months later, he would go back to the United States and in Warm Springs, Georgia, while posing for a portrait in the company of his mistress, Lucy Rosa Rutherford, would complain of a terrible headache, grab the back of his head, and collapse. He would die moments later from uncontrolled hypertension, leading to a massive cerebral hemorrhage. Roosevelt would be succeeded by Harry Truman, and the post-World War II years would result in a period of prosperity. Truman, in 1948, would sign the National Heart Act that would establish the National Heart Institute, and there was a call for investment in research. One of the programs of research that he invested in was the Framingham Heart Study in 1948. It would enroll its first participants, 5,209 men and women from Framingham who were put through extensive evaluations, medical history, physical exam, laboratory tests, and much more, and they would be brought back every two years since that time for further evaluations and for waiting for them to develop heart disease. And over the course of time, the study would enroll the children and grandchildren of the original participants, as well as two generations of minority participants from the community. It would be through the development of cardiovascular disease in this initially healthy population that some of the earliest clues to the causes of heart disease would emerge. But I get ahead of myself for a moment. The early tools for computing did not exist. These are the tools that my predecessors at the Framingham Heart Study used. An IBM card sorting machine and a Remington Rand four-function adding machine were used to do the simple calculations to analyze the data coming back on the study participants. But the clues would come out. Two of my early career mentors, Bill Cannell and Joe Stokes, would be involved in a paper called Factors of Risk in the Development of Coronary Heart Disease, remembered by many as one of the single most influential medical publications of the entire 20th century. And in that paper, Bill Cannell and that team would write about high blood pressure and high cholesterol being two of those factors of risk. The word factors of risk would get turned around to become risk factors part of common medical parlance. And in addition to identifying those factors of risk, they would ask the question about whether intervention to lower blood pressure or lower cholesterol was a means by which we can reduce the risk of heart disease in the population. They went on to recommend clinical trials. One of the people who read that monumental paper was Ed Freese. He was the head of the hypertension program at the Veterans Authority. And he put together a clinical trial of blood pressure lowering in men with moderate to severe hypertension. They were treated with three active drugs or placebo. The treatment dramatically lowered levels of blood pressure compared with placebo. And the study was terminated after only one and a half years, terminated early because of the overwhelming evidence of the benefits of blood pressure reduction. Ed Freese, many years later, would tell me that you didn't have to be a statistician to interpret the results of that trial. You can see here the number of events occurring for those randomized to placebo on the left, active therapy on the right. Severe hypertension, 12 events versus none. Stroke, 4 versus 1. Coronary events, heart failure, kidney failure, deaths from any cause, all occurred exclusively in those receiving placebo. Complete prevention in those receiving active therapy. This study would demonstrate conclusively that the lessons learned from Framingham translated into approaches to prevention and that people must be treated for hypertension. Dozens of hypertension trials that would follow over the ensuing years would further refine at what levels we should intervene and what goals of treatment we should shoot for. But they changed our understanding of blood pressure and its necessity for treatment. The same would hold true for cholesterol, although it took longer to develop good drugs to lower cholesterol. We now have quite a few drugs for cholesterol lowering. For example, statins in high dose can lower cholesterol levels by about 60 percent. And new drugs that are available today can reduce cholesterol levels by an additional 60 percent on top of statin therapy. We know from these clinical trials that lower is better. The more you lower cholesterol, the more you prevent heart disease. And that we can effectively lower cholesterol levels in just about anyone. Very important. At the end of the 20th century, the Washington Post put together a list of the 100 most important medical advances of the century. Not surprisingly, at the very top of that list was the development of antibiotics, followed by mass immunizations or vaccines, followed by vitamins and improvements in nutrition. And number four on the list of most important medical advances of the 20th century was the Framingham Heart Study. In June of 2000, President Clinton brought Francis Collins and Craig Venter together to the White House to celebrate the completion of the draft sequence of the human genome. This is a project that took years, and the first sequenced genome would cost $100 million. At that time, Francis Collins predicted that within 10 years, we will identify genes responsible for conditions like high blood pressure, diabetes, heart disease, and others. And that we would be able to put this information together to predict who is at increased risk for developing these diseases. When I first heard this, I thought he was exaggerating. But I had the great honor of being part of the teams that were involved in identifying the first genes responsible for elevated blood pressure. In our first paper, using a genome-wide approach, we identified about 10 genes. Earlier this year, in our most recent publication, the number of genes for blood pressure alone exceeded 2,000. And we can put these genes together to predict who is at increased risk for hypertension. We can predict who will develop hypertension. The National Institutes of Health put together a program called TopMed that combines medical data on thousands of people with sequencing of the human genomes of 200,000 people. This is combined in turn with information about the expression of those genes, information about the proteins encoded for by those genes and the small molecules acted on by those proteins, the ability to combine this information together with analytical approaches such as systems biology in order to advance the cause of precision medicine to identify who's at increased risk, what treatment will be beneficial to identify new forms of therapy, and hopefully many more drugs for years to come to further reduce the population burden of cardiovascular disease and many other conditions. Is this a fishing expedition? The answer is yes, but we're certainly finding a lot of fish with this approach and will continue to find many more. What can I do to lower my risk of developing heart disease? The American Heart Association has developed an approach called Life's Essential Eight, four risk factors, high blood pressure, high cholesterol, diabetes, and overweight, and four lifestyle factors, cigarette smoking, sedentary lifestyle, poor diet, and poor sleep. We can add up these factors to identify who is at optimal risk and who is at poor risk. What you can see is that using this Life's Essential Eight approach, we can identify people at optimal risk who are virtually immune from the risk of developing a fatal heart attack. And even in the subset of the population, at increased genetic risk for the development of a heart attack, an optimal set of Life's Essential Eight factors is overwhelmingly protective. In other words, even if you chose your parents unwisely, there's a lot you can do to control your destiny. Bad genes? Don't worry about it. We can control your risk nevertheless. Over the course of the last 60 years, we've seen death rates from heart disease plummet by 60 to 70% in our country. Analysts who've looked at some of the contributing factors to those declines in mortality from heart disease and stroke have concluded that changes in those risk factors that I talked about, high blood pressure, high cholesterol, and cigarette smoking, the top three, are able to have an enormous impact on our risk. But I believe this is only just the beginning. There are many new treatments and innovations available, and we can be far more aggressive in our ability to treat our entire risk factor profile. I believe that in the near future, we'll be able to reduce our risk of fatal heart disease by 90% or more. The turning point in our journey and our battle against heart disease began in the town of Framingham, a town that will be remembered as having changed America's heart. Thank you.