NEW YQWK HEART ASSOCIATION, Inc. NEW YORK ACADEMY OF MEDICINE BUILDING 2 East 103rd Street, New York 29, N. Y. Telephone ATwater 9,7400 EDWIN P. MAYNARD, JR., M.D. ROBERT L. LEVY, M.D. HAROLD E. B. PARDEE, M.D. J. HAMILTON CRAWFORD, M.D. ROBERT H. CRAFT MARGARET MATHESON Actiiig Exec. Director Treasurer President 1st Vice-President 2nd Vice-President Secrctary April 17, 1947 Mrso Mary Woodard Lasker, Secretary Albert and Mary Lasker Foundation, Inc. Chrysler Building New York 17, New York Dear Mrs. Lasker: One of the major activities in relation to the advancement of howledge project on the natural history of the heart of about 25 years by a committee of experts especially trained for that work. of the Jkw Pork Heart Association in the heart diseases is its diseases, pursued during a period and agoup of statistical clerks It is for the pursuit of this project for the next three years that the New Pork Heart Association seeks agmt-in-aidfrom the Albert and Mary Lasker Foundation. Already the achievements of the study have been most satis- Thereresulted the discot-ery that the term heart disease was a mis- factory. nomer, that heart disease was not a single disease but a wide variety of diseases differingfrom each other with respect to their cause, theirde- velopment, their outlook, and their control. Physicians used to attach great importance to a heart mullllur, enlargement ofthe heart, or a dis- turbance of rh@m, and progress in this field was practically at a stand- still until they too begar- to realize that what was of vital importance was the etiology, namsly, the fact that the patient had rheumatic heart disease, or arteriosclerotic! heart disease, hypertensive heart disease, or syphilitic heart disease, or one of the otherso tions transformed the face of medical thinking inrespect to the heart dis- eases o The publications of these hvestiga- The course of these long-range investigations on natural history was attended by numerous developments of much significance, cians had not agreed on a cmon language, but in order to integrate the work of some 50 or more cardiac clinics, it became necessary to devise a common terminology. study of natural history. nNomenclature widely employed throughout the world as a means for the uniform description of eases with heart disease. Physi- This was predominantlythe work of the committee on the TheEsults have been incorporated in a volume called and Criteria for Diagnosis of Diseases of the Heart", now In the first 25 years, this Committee confined itself chiefly to the description of the natural course of rheumatic fever through the study of many thousa.nds of cases from the beginning of the disease until the end. We now know what kind of people have this disease, at what age it BOARD OF DIRECTORS ERNST P. BOAS M.D. FRANCIS T. CH~ISTY ALFRED E. COHN M.D. ROBERT H. CRAF; J. HAMILTON CRAWFORD, M.D. ARTHUR C. DE GRAFF, M.D. CLARENCE E. DE LA CHAPELLE, M.D. ALFRED C. HOWELL CURRIER McEwsh-, M.D. HOMER F. SWIFT, M.D. ALFRED G. LANGMANN, RI 1). ROBERT L. LEVY, M.D. BERNARD S. OPPENHEIMER. M.D. HAROLD E. B. PARDEE, M.D. H. E. UNGERLEIDER, M D. IRVING S. WRIGHT, M.D. A. WILBUR DURYEE, M.D. HARRY GOLD, M.D. WILLIAM GOLDRING, M.1). ALEXANDER T. MARSIN, M.U. ARTEUR M. MASTER, M.D. EDWIN P. &fAYN.ARD, JR., a1.D. CHARLES A. POINDEXTER, M.D. IRVING R. ROTA, M.D. DAVID D. RUTSTEIN, M.1). begins, how the disease progresses, how the patient's life and work are affected by it, fundamental, sf treatment, and points the direction which future researches need to take in order to provide the necessary cures. and what factors influence it, This type of knowledge is It serves as the basis for determining thevalue of any form As the population has grown older, the degenerative diseases have presented increasingly pressing problems, In 1925, 50% of the clinic load was rheumatic heart disease and only 20%, arteriosclerotir and hyper- tensive, 'he ratio has shifted in recent years; the degeneratiw ham in- creased more than three-fold and now constitute approximately 65% of the clinic population. The Committee for the study of the natural history of the heart diseases now proposes to turn its attention to the degenerative diseases, and hopes to be able to describe the natural history of these in much the same way, "he vroblemis much more difficult, New techniques are needed and have to be devised, in order to insure that the physicians Functioning in the numerous cooperating clinics will again be using a common language for describing their experiences, New criteria for diagnosis and a new terminology need to be established The heart alone does not seem to be thehe center of the problem of degenerative diseases, but rather thewxular system as a whole. The study offhe degenerative diseases has not heretofore been approachedfYom the standpoint of the whole vascular system, judging from thefact that these patients are at the present time, so to speak, dismembered, and clinics are set up for the study of the individual parts: a clinic on peripheral vascular diseases, a neurological clinic, a nephritic clinic, and a cardiac clinjc, is proposed to attempt to pt them together und.er one roof and study these patients, regardless of what part of the vascular tree appears to bear the brunt of the disease, tients with degenerative diseases of the vessels, to learn when they begin, how fast they progress, when disability appesrs, how long it takes from be- ginning to end, and what factors appear to influence them. It A plan has been worked out to chart the co-mse of pa- During the past 25 years, the Committee dealing with research on the natural history of diseases, has already accumulRted the records of some 20,000 cases of the degenerative dis..ases, art2riosclerosis and hyper- tension, A preliminary examination of some of these records is beginning to show that a wealth of vital information is to be found in thema ready emerging the observation that so-called essential hypertension may not be a single disease at all, but a grorrp of diseases with different causes and different behaviors, There is, for example, the young person of 35 who presents himself with a blood pressure of 16O/qO, in whom the disease progresses ahst like an acuts disease; within 2 or 3 years the pressure rises to 230/130, and within 4 years after the onset, he dies from a cerebral hemorrhage, or a coronciry thrombosis, or heart failure, kind of patient who presents himself with a blood pressure of 16o/qO at the age of 35 but who may still be up and about at the age of 65 or 70, with a blood pressure not materially higher than it was in the early dags, This There is al- There is at %he other extreme another -3- patient lives out his natural time being seriously hampered These look like two different spm of life and dies at the age of 75, at no in his life's work by his so-called hypertension. diseases. It is now believed, for example, that when a patient's blood pressure shows wide fluctuations, sometimes 150/90, and at other times 200/120, the hypertensive disease is in the early stages, and that as this patient moves along in life, the high blood pressure becomes fixed, and that this patient dies of the disastrous effects of the hypertensive disease. of the thousands ofrecords which have bean collected by the Research Committee of the New York Heart Association are beginning to show that patients with a fixed high blood pressure and those with a widely fluctlrating high blood pressure may in many cases represent different diseases, some vsry benign, and others malignant; in many cases the fluctuating blood pressure never does become fixed, the patient never does develop serious symptoms of high blood pressure disease, and dies of natural causes only after an active life span of 65 or 70 years, or longero Preliminary studies These are examplzs of the kind of vital informstion which emerges from intensive studies of the natural history of the degenerative vascular diseases. One learns from them how to differentiate one disease from another early in their course, how to predict vhat is likely to happen to different types of hypertensives, all of whom are at the present time being thrown into one category under the label hypertension. In the mattsr of judging the value of any particular method of treatment, it is imperative to know how%@ disease behaves withouttreatment, the kind of infornation that comes from a study of the natural history. periencss with the synpathectongr operation for hypertensive disease., %is opera- tion is now bing performed on thousands of patients. There are those who main- tain that it cures as many as 80% of the cases, and others who hold that it provides relief to only 4 or 5 per cent of the C~SBS. Such differences of view arise, in part, from thefact that the natural history of disease and the wide variety of types have not been taken sufficiently into consideration. is the fact that a&pendable account of the natural history of these diseases does not exist, That point has been strongly emphasized by the recentex- One reason Nibblings at this problem by isolated small-group studies of short duration will not provide the basic answers that are needed. requires long-range investigations, planned by experts, and executed with the aid of highly trained statistical clerks of the kind that made possible the mrk of the pst 25 years in the New York Heart Association. It requires the pooling of experience with thousands of patients. The problem No doubt can be entertainedregarding the importance of the facts which thesestudies will supply. To carry them out presents unusual dif- ficulties. hand, provide unusual facilities and opportunities for the pursuit of such studies. lhere is thevast amount of clinical material numbering many thousands of patients in attendance. There are many scientists there with extenst- experience in the conduct of such investigationso The member clinics of the Mew York Heart Association, on the other There are in these clinics already established high standards of performance with respect to history taking, physical examination, equipment, techniques for the recording of facts, and facilities for the training of appropriate medical and social service staffs, the equal of tJhich is hardly to be found anywhere in the United States. It is estimated that the per annum personnel cost of con- ducting the work of the Study of the Natural History of Heart Diseases will amount to $@,5800 The Research staff would be composed as follows: Director of Study $ 6,500 7 Field Workers 21,000 2 Statisticians 6,900 3 Clerical Workers 7.080 TOT_& $@,5a Whereas the Albert and Mary LaskerBundation has generously invited the New Pork Heart Association to present three studies, each requiring sup port not in excess of $5,000 per annum for three years, the Association would prefer to ask in addition to the grant intended for the rrInvestigation Regarding the Mechanism of Thrombosis and the Possibilityof Interrupting Thrombo-E$lbolic Processes in Man", a grant-in-aid for the Study of the Natural History of Heart Diseases in the sum of $10,000 per annum for three years. %is would mean the support of two projects instead of threebut would not change the total mount of money which the Association was en- couraged to ask of you. Additional data in support of this petition can be made available quickly if yv~. desire them and Trofessional members of the Associa- tion who are closely assocrated with this work are prepared to offer any furtherinformation you may reqgire either by correspondence or interviewo The New Pork Heart Association ispteful for the encourage- ment that your Foundation has given to our Officers and Directors and we are greatly pleased with the interest that you arelaking in the Association's pro- gram* n Pre s ident