We searched the archives of the Framingham Heart Study at the National Heart, Lung, and Blood Institute in Bethesda, MD, USA. We also searched Harvard University's Widener Library collection of President Franklin D. Roosevelt's Office Files, 1933–1945, in Cambridge, MA, USA. Additional references between January 1947 and March 2013 were obtained from PubMed and Google Scholar by combining the search term “Framingham Heart Study” with the search terms “risk factor”, “hypertension”, “coronary
ReviewThe Framingham Heart Study and the epidemiology of cardiovascular disease: a historical perspective
Introduction
Cardiovascular disease is the most common cause of mortality in high-income countries.1, 2 Globally, the number of deaths from cardiovascular and circulatory disease has risen by a third between 1990 and 2010; by 2015, one in three deaths will be due to cardiovascular disease.3 Epidemiological studies have played an important part in the elucidation of predisposing factors for cardiovascular disease and opportunities for prevention. On Sept 29, 1948—65 years ago—the first volunteer of the Framingham Heart Study was examined. In this Review we describe the events leading to the foundation of the Framingham Heart Study, and review some important contributions that the study has made to understanding of cardiovascular disease and risk factors.
Section snippets
Origins of the Framingham Heart Study
By the 1940s, cardiovascular disease was the main cause of death for Americans, accounting for half of deaths.4 Prevention and treatment were so poorly understood that most Americans accepted early death from heart disease as unavoidable. Franklin D Roosevelt, the wartime President of the USA from 1933 to 1945, was in no way exempt from the epidemic, with heart failure due to undiagnosed and later untreated risk factors.5 In this Review we describe how medical care provided to the President
Location of the study
In 1947, as legislators were drafting the National Heart Act, the US Public Health Service delegated a young officer and physician, Gilcin Meadors, to compile a proposal for the future epidemiological study (figure 1). Although the study initially focused on ischaemic heart disease, Meadors set the tone for the next 65 years with a proposal “to study the expression of coronary artery disease in a ‘normal’ or unselected population and to determine the factors predisposing to the development of
Early days of the Framingham Heart Study
The Framingham Heart Study was the first long-term study of its kind, with the exception of Sir James Mackenzie's aborted attempt to longitudinally follow the health status of residents in the town of St Andrews, Scotland.21 As Framingham investigators were setting up their research in the late 1940s, Ancel Keys22 in Minnesota was also in the process of establishing a three-decade-long study (the Twin Cities Business and Professional Men's Study23), as were researchers at University of
Fight for survival
In 1966, as the initial 20 year funding commitment neared an end, the National Heart Institute established a committee to assess the Framingham Heart Study. Sensing the possible loss of the needed $336 000 in annual funding, Dawber moved to Boston University to raise private funds to continue the study.36 In his place, Kannel took over as the third director of the Framingham Heart Study.
Dawber's concern was well founded. On May 27, 1969, the National Institute of Health issued a directive
Epidemiological activism
Dawber, the second study director, noted that medical practice in the mid-20th century was directed towards care for those who were already ill rather than the prevention of disease.37 Dawber had had little success in altering the way physicians practised medicine, despite early findings from the Framingham study, and concluded that “attitudinal changes on the parts of physicians, although difficult, is essential [for] advances”, and that “medical education and training was basically
Framingham risk scores
The Framingham Heart Study and other epidemiological cohorts contributed to a shift in focus in the second half of the 20th century, from treatment of those with established cardiovascular disease to the prevention of disease in those at risk. A key element of this strategy was the ability to identify those most likely to have a future cardiovascular event, to enable targeting of preventive interventions. Studies from this period helped to elucidate cardiovascular risk factors, such as
Framingham and epidemiology of heart failure
Roosevelt's failing health from heart failure underscores the poor understanding of the clinical syndrome at the time the Framingham Heart Study was initiated. Until the late 1960s, research into heart failure was made difficult by the absence of consistent diagnostic criteria. For instance, investigators of a 1965 observational study53 to assess the prevalence of heart failure in two rural US communities explained that “no attempt was made to define congestive heart failure to the assessing
Metabolic risk factors for heart disease
Framingham investigators also joined worldwide efforts to understand the links between metabolic risk factors and cardiovascular disease. In the first half of the 20th century, findings of autopsy and hospital-based studies showed an association between diabetes mellitus and cardiovascular disease.64, 65 By the mid-20th century, clinical data had shown a link between diabetes and vascular disease,66, 67, 68 an association also reported by the Framingham investigators.69 In the Framingham study,
Epidemiology of stroke and atrial fibrillation
By the 1960s, stroke was still the third-biggest cause of death for Americans.29 In the preimaging era, Framingham investigators diagnosed stroke through clinical history, neurological examination, and sometimes lumbar puncture. Each suspected new case of stroke was confirmed by a second examiner and neurological consultation. In addition to establishment of the link between systolic blood pressure and stroke,29 Framingham investigators showed that the risk of stroke from hypertension was even
New cohorts
Towards the end of the 20th century, Framingham investigators identified a need to expand knowledge about genetic and environmental risk factors for cardiovascular disease.83 Thus, in 2002, they began the recruitment of a new generation of participants, the Third Generation cohort (table), which consisted of children of Offspring cohort participants.83 Recognising the power of the family-based approach, investigators gave priority to 879 large extended families that already had several
Conclusions
Nearly seven decades have passed since Roosevelt's death in 1945 after a long illness that started with uncontrolled hypertension and progressed to heart failure and stroke. Years later, reflecting on the President's premature death, his cardiologist wrote: “I have often wondered what turn the subsequent course of history might have taken if the modern methods for the control of hypertension had been available.”5 The Framingham Heart Study was the product of a bill signed into law by
Search strategy and selection criteria
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