A Tale of Coronary Artery Disease and Myocardial Infarction

Abstract

The remarkable facts, that the paroxysm, or indeed the disease itself, is excited more especially upon walking up hill, and after a meal; that thus excited, it is accompanied with a sensation, which threatens instant death if the motion is persisted in; and, that on stopping, the distress immediately abates, or altogether subsides; have . . .formed a constituent part of the character of Angina Pectoris. 1 " R emarks on Angina Pectoris" by John Warren, M.D., appeared in 1812 as the first article in the first issue of The New England Journal of Medicine and Surgery. 1 Warren's description of angina pectoris (derived from the Latin angina, "infection of the throat"; from the Greek άγχο′νη, "strangling"; and from the Latin pectus, "chest") is equally apt for physicians and medical students today.At the time, the pathogenesis was unknown, and treatment consisted of bloodletting, a tincture of opium, bed rest, or a combination thereof.In 1799, Caleb H. Parry speculated that Syncope Anginosa was related to coronary-artery ossification (i.e., calcification), occurring predominantly in men at about 50 years of age and rarely in women or children. 2 Medical knowledge in the 18th and 19th centuries was grounded in clinical observation and anatomical dissection.Cardiovascular science emerged in the physiological era of the late 19th and early 20th centuries, first in Europe and subsequently in North America.To celebrate the 200th anniversary of the New England Journal of Medicine, our essay focuses on the themes of coronary artery disease and myocardial infarction to highlight the interplay between science and medicine, emphasizing how the remarkable advances in our understanding of the pathogenesis of heart disease have produced life-saving and life-extending therapies. The Emergence of Corona r y A rter y Dise a seAfter Heberden's clinical description of angina 3 in 1772, it took almost a century for pathologists to focus their attention on the coronary arteries and describe thrombotic occlusions in addition to "ossification."However, for decades thereafter, these observations were not related to the symptoms of myocardial ischemia, which had become well known to physicians.Near the end of the 19th century, cardiovascular physiologists noted that occlusion of a coronary artery in the dog caused "quivering" of the ventricles and was rapidly fatal.4,5 These three great branches of medical knowledge -clinical medicine, pathology, and physiology -advanced in separate yet parallel universes.In 1879, the pathologist Ludvig Hektoen concluded that myocardial infarction is caused by coronary thrombosis "secondary to sclerotic changes in the coronaries."6 In 1910, two Russian clinicians who were trained in pathology described five patients with the clinical picture of acute myocardial infarction, which was confirmed at postmortem examination.7 Two years later,