A Man of His Age

In the photograph taken in the courtyard at Yalta on 9 February 1945, Roosevelt is the one in the middle, sitting in a dark cape with his hands in his lap. He was 63. He had eight weeks to live.

Eleven months earlier a young Navy cardiologist named Howard Bruenn had been sent to examine him and found him in acute congestive heart failure, on top of a blood pressure that had been high for years. Interviewed about it in 1990, Bruenn was asked whether there had been any medication for the high blood pressure. His answer was one word. "No."

What a doctor knew in 1944

There was no treatment because there was barely a diagnosis. Blood pressure that climbed with age was widely taken to be what the body did as arteries stiffened, and possibly what it had to do to keep the brain and kidneys supplied. A rule of thumb held that a systolic reading of a hundred plus your age was acceptable. Roosevelt's own physician, Ross McIntire, an ear nose and throat specialist, took the President's elevated pressure to be no more than normal for a man of his age.

Bruenn's recommendations, when he made them, were considered extreme. McIntire's first response was "You can't do that. This is the President of the United States!" A panel of senior consultants was assembled, looked at the x-rays and the cardiograms, and decided that giving him digitalis was too drastic. They came round the next morning. Within ten days the President's lungs were clear and his heart had come down in size, and Bruenn spent the next year managing a man he could not actually treat.

What Bruenn could do was watch it move. After Roosevelt saw a film about Woodrow Wilson being destroyed over the League of Nations, and said out loud that it was not going to happen to him, his pressure went up sharply that night and came down by morning. After the argument over Poland at Yalta, his heartbeat alternated strong and weak for twelve hours, which is a bad sign.

There was one clear warning. On 12 August 1944, giving a speech on the fantail of a destroyer at the Bremerton navy yard on his way back from meeting his Pacific commanders, Roosevelt kept going to the end and then came below and told Bruenn he had had, in his own words, a hell of a pain. They stripped him down in a cabin and took a cardiogram. It was angina rather than a heart attack, and it passed, and it was the first hard proof that the President had coronary disease as well. On 12 April 1945, sitting for a portrait at Warm Springs, an artery gave way in his brain.

A town

Congress responded to the death of a President from a disease nobody understood by funding an attempt to understand it. The National Heart Act was signed on 16 June 1948. It set up the National Heart Institute and put half a million dollars towards a twenty year epidemiological study of the heart.

The design was unusual, and it is the whole reason the study matters. Nobody would be treated. A large group of ordinary people would simply be measured, thoroughly, every two years, for as long as it took, and then the researchers would look at who got ill.

Framingham, Massachusetts was picked because it was a factory town of about 28,000 that looked like the America of the 1940s, because Harvard's cardiologists were nearby, and because its residents had taken part in a public health study before and could be expected to turn up. 5,209 men and women aged 30 to 62 enrolled. More than half were women, which was not usual in heart research at the time.

The phrase

In July 1961, William Kannel, Thomas Dawber, Abraham Kagan, Norman Revotskie and Joseph Stokes published the six year results in the Annals of Internal Medicine under the title "Factors of risk in the development of coronary heart disease". They reported how particular levels of blood cholesterol, blood pressure and left ventricular enlargement on the cardiogram predicted who would go on to develop coronary disease, and they put numbers on how much each one raised the odds.

The numbers were new. So was the shape of the claim. Medicine had mostly dealt in causes: a thing either gave you a disease or it did not. What the Framingham investigators were describing was a measurement, taken from a healthy person, that changed the probability of an illness years later by a stateable amount. There was no word for that, so the paper's phrase became one. Risk factor.

Everything that followed used it. Cigarettes and cholesterol in the 1960s. High blood pressure and stroke in the 1970s, along with the finding that atrial fibrillation multiplies the chance of a stroke roughly fivefold. HDL cholesterol in the 1980s. An enlarged left ventricle in the 1990s. Prehypertension in the 2000s. The list of things a general practitioner checks on a screen is largely a list of things this study found by measuring the same families over and over.

Who was in the town

The choice that made the study work also limited it. Framingham was selected for being representative of the United States in the 1940s, and it was, which means the original cohort was overwhelmingly of European descent. The country changed and the reference population did not. A first Omni cohort of 507 participants of African American, Hispanic, Asian, Indian, Pacific Islander and Native American descent was enrolled in 1994, forty six years after the study began, and a second followed from 2003.

The study is still running. The Offspring cohort of 5,124 adult children and their spouses came in from 1971. Enrolment of the third generation, the grandchildren of the 1948 volunteers, began in April 2002.

Bruenn was asked in 1990 whether the drugs available by then would have helped his patient. "Unquestionably, it would have had a beneficial effect on his blood pressure, which was, presumably, the initiating factor in his final illness." By then, he said, doctors could bring that pressure down in practically everybody. Almost all of what he had at the end and had not had in 1944 came out of a factory town where five thousand people agreed to be measured every other year.

Sources

• Jan K. Herman, US Navy Bureau of Medicine and Surgery, "Interview With Dr. Howard G. Bruenn, Cardiologist to President Franklin D. Roosevelt, 31 January 1990" (finding the President in acute congestive heart failure in March 1944; the one word answer that there was no medication for hypertension; McIntire's objection that this was the President of the United States; the consultants judging digitalisation too drastic and then agreeing; the effect of the Wilson film and of the argument over Poland at Yalta; the pulsus alternans; and Bruenn's 1990 answer about modern drugs).
• National Heart, Lung, and Blood Institute, "Framingham Heart Study" (the study beginning in 1948 with 5,209 men and women aged 30 to 62; the Offspring cohort of 5,124 in 1971; the Omni cohort of 507 in 1994 and the second from 2003; third generation enrolment from April 2002; and the findings by decade, including atrial fibrillation raising stroke risk fivefold).
• Syed S. Mahmood, Daniel Levy, Ramachandran S. Vasan and Thomas J. Wang, "The Framingham Heart Study and the Epidemiology of Cardiovascular Diseases: A Historical Perspective" (Roosevelt's death prompting the National Heart Act, signed 16 June 1948, with a 500,000 dollar seed grant for a twenty year study; McIntire treating the President's pressure as no more than normal for his age and the rule of a hundred plus your age; Framingham chosen as a factory town of 28,000 near Harvard whose residents had joined a health study before; more than half the cohort being women; and the 1961 paper popularising the term risk factor).
• W. B. Kannel, T. R. Dawber, A. Kagan, N. Revotskie and J. Stokes, "Factors of risk in the development of coronary heart disease, six year follow-up experience. The Framingham Study", Annals of Internal Medicine, July 1961, volume 55, pages 33 to 50 (the paper itself, its authors and its date).
• Framingham Heart Study, "About the Framingham Heart Study" (the study running under the National Heart Institute, now the NHLBI; the cohort figures; and the list of major risk factors identified).
• Boston University and NHLBI, "Framingham Heart Study bibliography, 1960s" (the published output of the study's first decade, including the 1961 paper).