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Introduction
Cardiovascular disease is the most common cause of
mortality in high-income and developed countries. In
2015, one in three deaths is due to cardiovascular
disease.
On Sept 2, 1!" - #" years ago, $ramingham %eart
Study &as esta'lished. In this presentation &e descri'e
the events leading to the foundation of the study, and
revie& some important contri'utions that the study hasmade to achieve understanding of cardiovascular
disease and its ris( factors.
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Origins of the $ramingham %eart
Study
)y the 1!0s, cardiovascular disease &as the main
cause of death for *mericans.
$ran(lin + oosevelts death due to cardiovasculardisease acted as a catalyst for researching the etiology
of the disease.
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ocation of the study
/he long-term, study &as performed on residents of the to&nof $ramingham, assachusetts.
/he state &as thought ideal 'ecause of the enthusiastic
response of physicians in the area, and $ramingham &as
selected ahead of neigh'oring to&ns 'ecause of its
geographical proimity to the many cardiologists at %arvard
edical School.
oreover, residents of the developing to&n had already
participated $ramingham /u'erculosis +emonstration Study
t&o decades earlier. /herefore it &asthought to 'e representative of S*
in the 1!0s
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3arly days of the Study
On Septem'er 2, 1!", the $ramingham %eart Study
started 'y eamining its o&n staff mem'ers.
On Octo'er 11, 1!", the study officially eamined its first
$ramingham participant. /he 'asic &or( had thus 'een laid
for the longitudinal follo&-up of this group, to identify
individual factors that could 'e related to the futuredevelopment of cardiovascular disease.
Investigators of the study initially decided on an
o'servational study to understand heart disease, rather
than focus on prevention of heart disease.
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*fter that, investigators reali4ed that measurement of the
prevalence of diseases needed random sampling, so they
changed the method from see(ing for volunteers to active
recruitment of a random sample of adults in the to&n, thatall family mem'ers aged 06#0 years &as to 'e recruited.
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/he first ma7or findings from the study &ere reported in
158, almost a decade after the first participant &as
eamined. +efining hypertension as 'lood pressure of
1#095 mm %g or higher, the investigators noted a nearly
four-times increase in incidence of coronary heart disease
per 1000 people for study participants &ith hypertension.
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$ight $or Survival
$ramingham investigators toured the
country to raise private funds. +onors
included a large num'er of life insurance
corporations that recogni4ed theactuarial 'enefits of the study. /he list
also included some surprising
contri'utors, such as the /o'accoesearch Institute and the Oscar ayer
Company, a meat manufacturer.
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/he study 'egan to recruit the children of the
original $ramingham participants into a ne&Off spring cohort, the purpose of this &as to
provide insights into familial clustering of
disease. )ecause the study also needed to include
'iologically unrelated individuals, spouses of
off spring participants &ere invited into the
study, ma(ing up nearly a third of the study
sample.
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3pidemiological activism
In the 180s, physician reference 'oo(s suchas %arrisons :rinciples of Internal edicine
reiterated that diastolic pressure &as a 'etter
measure of 'lood pressure than &as systolic
pressure; conse
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$ramingham investigators analy4ed and
reported increased ris( of coronary heart-disease mor'idity &ith increased 'aseline
'lood pressure. Systolic pressure had a
stronger association &ith coronary-heart-disease events than did diastolic pressure.
$ramingham studies sho&ed that high
systolic 'lood pressure &as a predictor of
cere'rovascular accidents and heart failure,and that diastolic pressure &as not a 'etter
predictor of such events.
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/he $ramingham %eart Study and other
epidemiological cohorts contri'uted to a shift in
focus in the second half of the 20th century, from
treatment of those having cardiovascular disease to
the prevention of disease in those at ris(. =hich
&as a ma7or advancement 'ac( then. Studies from
this period helped to elucidate cardiovascular ris(factors, such as hypertension, hyperlipidemia, and
dia'etes mellitus.
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/he $ramingham investigators proposed
multivaria'le logistic models &ith seven ris(
factors> age, total cholesterol, &eight,electrocardiogram a'normalities, hemoglo'in,
num'er of cigarettes smo(ed, and systolic
'lood pressure. en in the top decile had a 0-
times higher incidence of coronary heartdisease than did men in the 'ottom decile, and
&omen in the top decile had a 80-times higher
incidence than did &omen in the 'ottom decile.Su'se
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oosevelts failing health from heart failure underscores
the poor understanding of the clinical syndrome at the
time the $ramingham %eart Study &as initiated. +ue to
a'sence of consistent results, and standardi4ed criteria it&as al&ays difficult to carry out research and dra&
assumptions.
In 181, ne&ly descri'ed criteria sho&ed that
hypertension &as in fact the leading ris( factor for heartfailure.
/he original 181 pu'lication sho&ed the poor prognosis
for heart failure> only t&o in five men &ere alive 5 years
after diagnosis of heart failure, and only one in fivesurvived to 10 years. )y the 10s, the &idespread use
of mortality-altering drugs such as ? 'loc(ers and
angiotensin-converting-en4yme inhi'itors had altered this
prognosis decreasing mortality.
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ecent guidelines have a nota'le emphasis on the
detection of asymptomatic ventricular dysfunction
@stage-) heart failureA as part of efforts to
understand and prevent overt heart failure. In the first half of the 20th century, findings of
autopsy and hospital-'ased studies sho&ed an
association 'et&een dia'etes mellitus and
cardiovascular disease. )y the early 20th century, cholesterol had 'een
lin(ed to cardiovascular disease through animal and
autopsy studies.
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In 188, an inverse association 'et&een %+
concentrations and incidence of coronary heart
disease &as reported, 'y contrast &ith the positiveassociation 'et&een + concentrations and
incidence of coronary heart disease.
/he population attri'uta'le ris( for heart failure
due to o'esity &as 1!B in &omen, and 11B inmen, higher than that of dia'etes mellitus, valvular
heart disease, or left-ventricular hypertrophy.
$ramingham investigators sho&ed that the ris( ofstro(e from hypertension &as even greater than
that conferred 'y coronary heart disease.
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/o&ards the end of the 20th century, $ramingham
investigators identified a need to epand
(no&ledge a'out genetic and environmental ris(
factors for cardiovascular disease.
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Conclusion
early seven decades have passed since oosevelts
death in 1!5 after a long illness that started &ith
uncontrolled hypertension and progressed to heart failure
and stro(e. Dears later, reflecting on the :residents
premature death, his cardiologist &rote> EI have often&ondered &hat turn the su'se
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