Elsevier

The Lancet

Volume 383, Issue 9921, 15–21 March 2014, Pages 999-1008
The Lancet

Review
The Framingham Heart Study and the epidemiology of cardiovascular disease: a historical perspective

https://doi.org/10.1016/S0140-6736(13)61752-3Get rights and content

Summary

On Sept 29, 2013, the Framingham Heart Study will celebrate 65 years since the examination of the first volunteer in 1948. During this period, the study has provided substantial insight into the epidemiology and risk factors of cardiovascular disease. The origins of the study are closely linked to the cardiovascular health of President Franklin D Roosevelt and his premature death from hypertensive heart disease and stroke in 1945. In this Review we describe the events leading to the foundation of the Framingham Heart Study, and provide a brief historical overview of selected contributions from the study.

Introduction

Cardiovascular disease is the most common cause of mortality in high-income countries.1, 2 Globally, the number of deaths from cardiovascular and circulatory disease has risen by a third between 1990 and 2010; by 2015, one in three deaths will be due to cardiovascular disease.3 Epidemiological studies have played an important part in the elucidation of predisposing factors for cardiovascular disease and opportunities for prevention. On Sept 29, 1948—65 years ago—the first volunteer of the Framingham Heart Study was examined. In this Review we describe the events leading to the foundation of the Framingham Heart Study, and review some important contributions that the study has made to understanding of cardiovascular disease and risk factors.

Section snippets

Origins of the Framingham Heart Study

By the 1940s, cardiovascular disease was the main cause of death for Americans, accounting for half of deaths.4 Prevention and treatment were so poorly understood that most Americans accepted early death from heart disease as unavoidable. Franklin D Roosevelt, the wartime President of the USA from 1933 to 1945, was in no way exempt from the epidemic, with heart failure due to undiagnosed and later untreated risk factors.5 In this Review we describe how medical care provided to the President

Location of the study

In 1947, as legislators were drafting the National Heart Act, the US Public Health Service delegated a young officer and physician, Gilcin Meadors, to compile a proposal for the future epidemiological study (figure 1). Although the study initially focused on ischaemic heart disease, Meadors set the tone for the next 65 years with a proposal “to study the expression of coronary artery disease in a ‘normal’ or unselected population and to determine the factors predisposing to the development of

Early days of the Framingham Heart Study

The Framingham Heart Study was the first long-term study of its kind, with the exception of Sir James Mackenzie's aborted attempt to longitudinally follow the health status of residents in the town of St Andrews, Scotland.21 As Framingham investigators were setting up their research in the late 1940s, Ancel Keys22 in Minnesota was also in the process of establishing a three-decade-long study (the Twin Cities Business and Professional Men's Study23), as were researchers at University of

Fight for survival

In 1966, as the initial 20 year funding commitment neared an end, the National Heart Institute established a committee to assess the Framingham Heart Study. Sensing the possible loss of the needed $336 000 in annual funding, Dawber moved to Boston University to raise private funds to continue the study.36 In his place, Kannel took over as the third director of the Framingham Heart Study.

Dawber's concern was well founded. On May 27, 1969, the National Institute of Health issued a directive

Epidemiological activism

Dawber, the second study director, noted that medical practice in the mid-20th century was directed towards care for those who were already ill rather than the prevention of disease.37 Dawber had had little success in altering the way physicians practised medicine, despite early findings from the Framingham study, and concluded that “attitudinal changes on the parts of physicians, although difficult, is essential [for] advances”, and that “medical education and training was basically

Framingham risk scores

The Framingham Heart Study and other epidemiological cohorts contributed to a shift in focus in the second half of the 20th century, from treatment of those with established cardiovascular disease to the prevention of disease in those at risk. A key element of this strategy was the ability to identify those most likely to have a future cardiovascular event, to enable targeting of preventive interventions. Studies from this period helped to elucidate cardiovascular risk factors, such as

Framingham and epidemiology of heart failure

Roosevelt's failing health from heart failure underscores the poor understanding of the clinical syndrome at the time the Framingham Heart Study was initiated. Until the late 1960s, research into heart failure was made difficult by the absence of consistent diagnostic criteria. For instance, investigators of a 1965 observational study53 to assess the prevalence of heart failure in two rural US communities explained that “no attempt was made to define congestive heart failure to the assessing

Metabolic risk factors for heart disease

Framingham investigators also joined worldwide efforts to understand the links between metabolic risk factors and cardiovascular disease. In the first half of the 20th century, findings of autopsy and hospital-based studies showed an association between diabetes mellitus and cardiovascular disease.64, 65 By the mid-20th century, clinical data had shown a link between diabetes and vascular disease,66, 67, 68 an association also reported by the Framingham investigators.69 In the Framingham study,

Epidemiology of stroke and atrial fibrillation

By the 1960s, stroke was still the third-biggest cause of death for Americans.29 In the preimaging era, Framingham investigators diagnosed stroke through clinical history, neurological examination, and sometimes lumbar puncture. Each suspected new case of stroke was confirmed by a second examiner and neurological consultation. In addition to establishment of the link between systolic blood pressure and stroke,29 Framingham investigators showed that the risk of stroke from hypertension was even

New cohorts

Towards the end of the 20th century, Framingham investigators identified a need to expand knowledge about genetic and environmental risk factors for cardiovascular disease.83 Thus, in 2002, they began the recruitment of a new generation of participants, the Third Generation cohort (table), which consisted of children of Offspring cohort participants.83 Recognising the power of the family-based approach, investigators gave priority to 879 large extended families that already had several

Conclusions

Nearly seven decades have passed since Roosevelt's death in 1945 after a long illness that started with uncontrolled hypertension and progressed to heart failure and stroke. Years later, reflecting on the President's premature death, his cardiologist wrote: “I have often wondered what turn the subsequent course of history might have taken if the modern methods for the control of hypertension had been available.”5 The Framingham Heart Study was the product of a bill signed into law by

Search strategy and selection criteria

We searched the archives of the Framingham Heart Study at the National Heart, Lung, and Blood Institute in Bethesda, MD, USA. We also searched Harvard University's Widener Library collection of President Franklin D. Roosevelt's Office Files, 1933–1945, in Cambridge, MA, USA. Additional references between January 1947 and March 2013 were obtained from PubMed and Google Scholar by combining the search term “Framingham Heart Study” with the search terms “risk factor”, “hypertension”, “coronary

References (83)

  • WB Kannel et al.

    A general cardiovascular risk profile: the Framingham study

    Am J Cardiol

    (1976)
  • TC Gibson et al.

    The prevalence of congestive heart failure in two rural communities

    J Chronic Dis

    (1966)
  • RS Vasan et al.

    Congestive heart failure in subjects with normal versus reduced left ventricle ejection fraction: prevalence and mortality in a population-based cohort

    J Am Coll Cardiol

    (1999)
  • IM Liebow et al.

    Cardiac complications of diabetes mellitus

    Am J Med

    (1949)
  • IM Liebow et al.

    Arteriosclerotic heart disease in diabetes mellitus; a clinical study of 383 patients

    Am J Med

    (1955)
  • H Keen et al.

    Blood-sugar and arterial disease

    Lancet

    (1965)
  • WB Kannel et al.

    Role of diabetes in congestive heart failure: the Framingham study

    Am J Cardiol

    (1974)
  • T Gordon et al.

    High density lipoprotein as a protective factor against coronary heart disease. The Framingham study

    Am J Med

    (1977)
  • AS Go et al.

    Heart disease and stroke statistics—2013 update: a report from the American Heart Association

    Circulation

    (2013)
  • The European health report 2012: charting the way to well-being

    (2012)
  • HG Bruenn

    Clinical notes on the illness and death of President Franklin D. Roosevelt

    Ann Intern Med

    (1970)
  • J Bumgarner

    The health of Presidents

    (1994)
  • D Levy et al.

    A change of heart: how the people of Framingham, Massachusetts, helped unravel the mysteries of cardiovascular disease

    (2006)
  • H Goldsmith

    A conspiracy of silence: the health and death of Franklin D. Roosevelt

    (2007)
  • CMW Moran

    Churchill: taken from the diaries of Lord Moran: the struggle for survival, 1940–1965

    (1966)
  • R Klara

    FDR's funeral train

    (2010)
  • BJ Bernstein

    The uneasy alliance: Roosevelt, Churchill, and the atomic bomb, 1940–1945

    West Polit Q

    (1976)
  • 80th US Congress, 2nd Session, Senate Report 2215

    The National Heart Act

    (June 16, 1948)
  • GF Meadors

    Justification for the budget estimate for the sub-project “Epidemiology”

    (July 19, 1947)
  • LC Robbins

    Letter to Gilcin F. Meadors

    (Sept 5, 1947)
  • TR Dawber et al.

    Epidemiological approaches to heart disease: the Framingham study

    Am J Public Health Nations Health

    (1951)
  • T Gordon et al.

    Framingham Study

    (June 1968)
  • Heart disease epidemiology study: manual of operation

    (Nov 1, 1949)
  • Agreement on administrative relationships for fiscal year 1948

    (Dec 1947)
  • GF Meadors

    Memorandum to Dr. Bert R. Boone (Chief Heart Disease Control Section, US Public Health Service)

    (Oct 11, 1948)
  • GF Meadors

    Memorandum to Chief, Heart Disease Control Section, US Public Health Service

    (Nov 1, 1948)
  • D Waterston et al.

    Sir James Mackenzie's heart

    Br Heart J

    (1939)
  • A Keys et al.

    Serum cholesterol and relative body weight of coronary patients in different populations

    Circulation

    (1960)
  • JM Chapman et al.

    IV. Measuring the risk of coronary heart disease in adult population groups. The clinical status of a population group in Los Angeles under observation for two to three years

    Am J Public Health Nations Health

    (1957)
  • A Keys

    Longevity of man: relative weight and fatness in middle age

    Ann Med

    (1989)
  • GM Oppenheimer

    Profiling risk: the emergence of coronary heart disease epidemiology in the United States (1947–70)

    Int J Epidemiol

    (2006)
  • Cited by (0)

    View full text