The power of Pasteur's quadrant: cardiovascular disease at the turn of the century

During the life span of The FASEB Journal, the decline in cardiovascular mortality was astonishing as the fundamental bases of the complex syndromes of cardiovascular disease were illuminated. In this Silver Anniversary Review, we highlight a few pivotal advances in the field and relate them to research in Pasteur's quadrant, the region of investigation driven by both a desire for fundamental understanding and the consideration of its use. In the second half of the 20th century, we advanced from little pathophysiologic understanding to a near-complete understanding and effective, evidence-based therapeutics for vascular disorders and a similar development of pharmacotherapy to address heart failure, primarily through agents that antagonize the excessive concentration of circulating neurohumoral agents. In the current era, we have witnessed "the rise of the machines," from stents to cardiac resynchronization therapy. The next wave of treatments will build on an increasingly sophisticated understanding of the molecular determinants of cardiovascular disorders. We briefly consider the promise of regenerative medicine and are intrigued by the possibility for the direct reprogramming of resident cardiac fibroblasts into cardiomyocytes. As for the future, genomic profiling should help physicians recommend individualized risk factor modification targeted to prevent specific manifestations of cardiovascular disease. Transcriptional and biomarker analyses will almost surely be used individually to tailor therapy for those at risk of or experiencing cardiovascular disease. Given the ongoing exponential expansion of scientific knowledge, all of human ingenuity will be needed to fully utilize the power of Pasteur's quadrant and to unleash another quarter century in cardiology as scientifically fruitful and effective on human health as the last.

[The world's fist successful closure of the wound of the ascending aorta. Russian priority]

The year of 1896 became the starting point in the development of cardiovascular surgery, since it was just then that Ludwig Rhen was the first in the world to have performed a successful closure of a right-ventricle wound, thus opening up the era of active surgical policy in heart wounds. However, tangible progress in surgical management of intrathoracic vessels was made later on. One of the important stages of this trend was a successful closure of an ascending-aorta wound performed by I.I. Dzhanelidze in 1913. It was not only the world's first successful operation performed in a traumatic lesion of the ascending aorta but also apf intervention giving rise to further development of surgery in this field. The present-day notions concerning surgical policy in traumatic lesions of intrathoracic vessels are based on the experience of prominent and outstanding surgeons of the 20th century. The material for this publication was I.I. Dzhanelidze's article entitled "A case of ascending- aorta wound closure" and published in 1916.

The development of cardiac rehabilitation: a historical critical approach

Cardiac rehabilitation is an interdisciplinary and multidimensional process aimed at preventing and containing cardiovascular mortality, morbidity and disability, and promoting health in subjects with cardiocirculatory pathologies. A body of scientific evidence is today available with regard to the benefits of cardiac rehabilitation in terms of the containment of the progression of atherosclerosis, the increase in physical work ability, the reduction in symptomatology, the improvement in psychological well being and social re-adaptation, and the lowering in hospitalization rates and in recurrent clinical cardiac events. Cardiac rehabilitation derives its origin from the application of physical activity to the therapy of ischemic heart disease, and in this paper the historical evolution of the concept of angina pectoris and myocardial infarction as also the major progress in therapeutic exercise are discussed. Cardiac rehabilitation has become through time a multi-faceted process implemented in hospitals, in outpatient clinics and at home in a variety of models. However, recent data indicate that, in the USA, no more than 20% of eligible patients per year enter cardiac rehabilitation programs, and in Europe no more than 30% participate in them. The historical perception of cardiac rehabilitation provides knowledge of the fact that, through a long and articulated process, this health intervention has achieved relevant medical and social results and it also generates the awareness of the further advantages to be obtained in future cardiovascular patients.

Non-exercise physical activity in agricultural and urban people

With evidence that urbanisation is associated with obesity, diabetes, hypertension and cardiovascular disease, this article compares daily physical activity between rural and urban dwellers. Specifically, it examines habitual daily activity levels, non-exercise activity thermogenesis (NEAT) and energy expenditure in agricultural and urban Jamaicans and urban North Americans. Ambulation was 60 per cent greater in rural Jamaicans than in the urban dwellers (4675 ± 2261 versus 2940 ± 1120 ambulation-attributed arbitrary units (AU)/day; P = 0.001). Levels of ambulation in lean urban Jamaicans were similar to those in lean urban North Americans, whereas obese urban dwellers walked less than their lean urban counterparts (2198 ± 516 versus 2793 ± 774 AU/day; P = 0.01). The data with respect to daily sitting mirrored the walking data; obese Americans sat for almost four hours more each day than rural Jamaicans (562 ± 78 versus 336 ± 68 minutes/day; P < 0.001). Urbanisation is associated with low levels of daily activity and NEAT.

[25 years of organized ambulatory heart sport in Luxembourg. The development of a sustained rehabilitation model]

After Second World War cardiovascular disease (CVD), especially coronary artery disease (CAD), turned out to be an epidemic in the western countries including the Grand-Duchy of Luxembourg, and accounted for nearly half of all deaths. A lot of strategies, among them treatment by physical activity, were developed to fight this challenge and, fortunately, a mortality regression of about 50 % could be achieved. Nowadays, eastern European countries and, more recently, China and India face an increasing CVD mortality. During the seventies ambulatory heart sport clubs, then labeled as, "coronary clubs" became very popular in Europe especially in West-Germany. Around 2000 there were more than 6000 heart sports groups in Germany. In 1984 a first group was founded in Luxembourg City (Centre) a, 1991 a second group started in Esch/Alzette (South) and in 2002 a third regional group in Ettelbruck (North) so that, by now, the 3 main public health districts of the Grand-Duchy of Luxembourg can offer regular ambulatory sports activities to almost all concerned cardiac patients in the country. The ambulatory heart sport groups of Luxembourg cooperate in a federated association allowing an integrated logistic organization. Since the beginning nineties cardiac rehabilitation became a field of interest to the university faculties and later of scientific societies, like the American Heart Association (AHA) and the European Society of Cardiology (ESC). New subgroups were founded and guidelines were published and renewed. The movement of ambulatory heart sport groups was more or less neglected in the prevention and rehabilitation activities of the scientific societies. Recently the ESC proposed a new definition of comprehensive CVD prevention and rehabilitation programmes as "coordinated, multifaceted interventions designed to optimize a cardiac patient's physical, psychological, and social functioning, in addition to stabilizing, slowing, or even reversing the progression of the underlying atherosclerotic processes, thereby reducing morbidity and mortality". The responsible ESC cardiologists agree with the international community that fighting CVD risk factors is at least as important as the whole arsenal of modern heart surgery and interventional cardiology. The core activity of ambulatory heart sport groups remains physical activity, and nowadays 6 different activities can be offered (one activity each day of the week): exercise lesson, swimming, walking, cycling, Nordic Walking and water gymnastics On the other hand comprehensive prevention programs, especially concerning CVD risk factors are also endorsed by the ambulatory heart sport groups of Luxembourg via regular meetings, conferences, brochures and symposia. One advantage of the ambulatory heart sport movement in Luxembourg, in contrast to the German model, is the direct financial allowance of the health ministry, which permits a lifelong activity to all the active members. Another advantage is that all the regional groups are directed by clinical cardiologists knowing the patients very closely. One weak point is that only about 5-10% of all potential candidates adhere to the ambulatory heart sport groups but nearly 50% of the active members are practicing for more than 5 years. These regularly active patients are a positive selection of well committed cardiac patients who, most of the time, control CVD risk factors with scrutiny. The ESC has recommended creating so called "Heart Houses" where all the aspects of comprehensive prevention and rehabilitation can be offered. Their main concern is to develop a sustained strategy which is desperately missing for the moment. A lot of the active members of the heart sport groups of Luxembourg achieve such a sustained activity and, therefore, these heart sport groups can be considered as very cost effective models of sustained rehabilitation. After a 25 years activity the ambulatory heart sport movement of Luxemburg has reached the outstanding goal of being a center of sustained rehabilitation. Although such a goal was not really planned during the first 15 years of activity, the stamina of the active members set the movement into this direction.

History of right heart catheterization: 100 years of experimentation and methodology development

The development of right heart catheterization has provided the clinician the ability to diagnose patients with congenital and acquired right heart disease, and to monitor patients in the intensive care unit with significant cardiovascular illnesses. The development of bedside pulmonary artery catheterization has become a standard of care for the critically ill patient since its introduction into the intensive care unit almost 40 years ago. However, adoption of this procedure into the mainstream of clinical practice occurred without prior evaluation or demonstration of its clinical or cost-effectiveness. Moreover, current randomized, controlled trials provide little evidence in support of the clinical utility of pulmonary artery catheterization in the management of critically ill patients. Nevertheless, the right heart catheter is an important diagnostic tool to assist the clinician in the diagnosis of congenital heart disease and acquired right heart disease, and moreover, when catheter placement is proximal to the right auricle (atria), this catheter provides an important and safe route for administration of fluids, medications, and parenteral nutrition. The purpose of this manuscript is to review the development of right heart catheterization that led to the ability to conduct physiologic studies in cardiovascular dynamics in normal individuals and in patients with cardiovascular diseases, and to review current controversies of the extension of the right heart catheter, the pulmonary artery catheter.

Look but do not fix: the pioneers of interventional cardiovascular radiology

The extension of endovascular radiological procedures to a one-stop combined investigation and treatment of cardiovascular disease has revolutionized clinical practice. The giants in this respect are Charles Dotter, working from Portland, OR; Mason Sones from the Cleveland Clinic; and Andreas Gruentzig from Zurich and latterly Atlanta, GA. Serendipity and lateral thinking were pivotal in developing procedures that are now routine.

[Debating disease: the risk factor concept in political economic and scientific consideration, 1968 to 1986]

The risk factor concept was developed in American epidemiological studies ongoing since the 1940s researching the causes of chronic cardiovascular diseases. By looking at the depiction of this model in a variety of media in Germany between 1968 and 1986 we can put its close interaction with contemporary socio-political debates under scrutiny. Thereby, a strong connection between the various agents' political and economic interests on the one hand and the incorporation of the risk factor concept into their specific agendas will become apparent. The risk factor concept was not fundamentally changed in the process but it was adapted to contemporary conditions and political constellations. Thereby, so it will be argued, the medical uses of the model, especially regarding the prevention of chronic cardiovascular disease, were forced into the background of public debates.

A broken heart — or anguish in top-sport in antiquity

Cardiovascular disease is a major determinant of sudden death. Nevertheless the impact of autonomic dysregulation is grossly underestimated not to say ignored. The limited life expectancy of retired gladiators is a fine example of the interactive influence of an occupational- and socio-cultural hazard at the time. Possibly the fate of retired athletes in antiquity is sealed by autonomic dysregulation, cardiac adaptation and noxious exposure in fatal interaction. Observations like these could be helpful in the understanding of complex pathofysiological mechanisms, and may have implications in medical practice.