Book Review

Coronary Heart Disease in Young Adults: A Multidisciplinary Study

N Engl J Med 1994; 331:207July 21, 1994

Article

Coronary Heart Disease in Young Adults: A Multidisciplinary Study
By Menard M. Gertler and Paul D. White. 218 pp., illustrated. Cambridge, Mass., Harvard University Press, 1954. Out of print.

Although books of historical interest are not often the subject of reviews in the Journal, it is appropriate that this book by Gertler and White be recognized in this way. This book, published 40 years ago, marked a turning point in the history of coronary heart disease, but it has never received the recognition it deserves. It describes an extensive multidisciplinary study of 100 patients who had survived for at least six months after a documented myocardial infarction that occurred when they were 40 years old or younger. The clinical findings in these patients were compared with those in matched and unmatched control groups. Interest in this subject began with a brief report by Earle Glendy, Samuel Levine, and Paul White in 1937 (“Coronary Disease in Youth: Comparison of 100 Patients under 40 with 300 Persons past 80,” Journal of the American Medical Association; 109:1775-81). The authors concentrated on young patients in this study in the hope that the causative factors in coronary heart disease would be more evident than in older people.

In their analysis, genetic predisposition emerged as a particularly important factor, perhaps because a particularly young cohort was selected for study. Thus, 37 percent of the fathers of the patients in the coronary disease group had died of myocardial infarction, as compared with 18.5 percent for the control group. The most striking risk factor was male sex (96 percent of the cases were in men). But other features characteristic of males, including patterns of baldness and levels of 17-ketosteroid excretion, were not significantly different from those in the controls. A decision to exclude patients with diabetes, hypertension, or xanthomatosis doubtless influenced the magnitude of the effect of other identified risk factors. Nevertheless, the mean total cholesterol level was 287 mg per deciliter in the group with coronary disease, as compared with 242 mg per deciliter in the matched controls. At the time of this study, 90 percent of the group with coronary disease and 77 percent of the control group were smokers.

The investigators noted that the patients in the coronary disease group appeared 10 years older than their chronologic age. With the help of Stanley Garn of the Department of Anthropology at Harvard University, the authors lavished great attention on measurements to determine the body build (the somatotype). Patients with coronary disease were found to be predominantly “endomorphic mesomorphs” -- that is, muscular but overweight.

Several features make this a landmark study. First, it entailed a very serious and careful search for clues to the causes of and risk factors for coronary atherosclerosis. Second, 90 percent of the coronary disease group had survived an average of nearly four years after the acute episode, giving cause for optimism. Third, heart disease was recognized as causing half the deaths in the United States and was rising in incidence. Most important, when this study was started in 1946, many physicians regarded atherosclerosis as simply a natural result of the aging process, and hence a phenomenon about which nothing could be done. The publication of Gertler and White's book shook us by documenting myocardial infarction in a substantial number of young patients. In this way, it did much to establish atherosclerosis as a disease rather than an inevitable consequence of aging, and as such, an important area for research.

Paul White maintained his interest in coronary risk factors when he went to Washington, D.C., in 1949 to become the first executive director of the National Advisory Heart Council. This body established the policies of the new National Heart Institute of the National Institutes of Health and helped secure funding for it. While there, he gave strong and continuing impetus to the investigations of the prospective Framingham Heart Study. That project has paid enormous dividends in defining risk factors and pointing a way to prevention. White regarded this as nothing short of an emergency need. It is interesting that Coronary Heart Disease in Young Adults is one of some 758 papers and books found in the list of Paul White's publications, many of which were devoted to the subject of coronary heart disease.

This year, the 40th anniversary of the publication of this book, is a proper time to recognize the debt we owe to Gertler and White, who did so much to open the way for modern cardiovascular medicine.

Allan L. Friedlich, M.D.
Massachusetts General Hospital, Boston, MA 02114

Citing Articles (1)

Citing Articles

1. 1

   B. Holly Smith, A. Roberto Frisancho, Stephen M. Bailey. (2009) Obituary: Stanley Marion Garn (1922-2007). American Journal of Physical Anthropology 138:4, 371-374
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