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Primary Prevention of Pulmonary Heart Disease

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Primary Prevention of Pulmonary Heart Disease Heart disease resources Primary prevention of pulmonary vented or diagnosed, and adequately treated, heart disease it must be recognized as a specific form of both acute and chronic heart disease. Such PULMONARY HEART DISEASE STUDY GROUP: recognition can be facilitated by the accep- Chairman: ROY H. BEHNKE, M.D. tance of a single definition of the disease Members: S. GILBERT BLOUNT, M.D.; entity. Pulmonary heart disease, cor pulmo- J. DAVID BRISTOW, M.D.; VIRGINIA CARRIERI, R.N.; JOHN A. PIERCE, M.D.; nale, is here defined as: Alteration in structure ARTHUR SASAHARA, M.D.; or function of the right ventricle resulting ALFRED SOFFER, M.D. from disease affecting the structure or func- Consultant: RICHARD GREENSPAN, M.D. tion of the lung or its vasculature, except when Introduction this alteration results from disease of the left Pulmonary heart disease, cor pulmonale, is side of the heart or congenital heart disease. a major form of heart disease yet there is reasonable evidence that it can be prevented. Incidence and prevalence Support for this contention rests in the fact Effective programs of prevention are facili- that the causative or precedent pulmonary tated by an accurate assessment of the scope diseases are in large part preventable. Primary and magnitude of the health problem. Chronic prevention of the related pulmonary diseases obstructive lung disease (bronchitis and/or is thus the initial and basic step in the pre- emphysema) is by far the most important of vention of cor pulmonale. Such an under- the respiratory diseases associated with pul- taking is a major task. It can only be achieved monary heart disease. Definitive data on the by the global application of existing knowl- prevalence of the respiratory diseases and cor edge to the environment and the population at pulmonale are not available, largely because large. The force which is most apt to activate uniform diagnostic criteria and reporting are broad programs of primary prevention of not employed by all physicians. This is true pulmonary diseases is an enlightened public not only in certifying the cause of death but demand that these diseases in fact be much more importantly in reporting patient eliminated. morbidity in office visits and hospital admis- In individuals who develop pulmonary sions. disease, the prevention of cor pulmonale The increasing toll of death and disability becomes the joint responsibility of the patient caused by chronic obstructive lung disease has and his physician. Early diagnosis and treat- become a matter of grave concern to federal ment of the pulmonary disorder is essential if officials, the public, and to voluntary and the anatomic and physiologic alterations private health organizations. According to the which produce cor pulmonale are to be National Center for Chronic Disease Control avoided. Thus, secondary prevention and and the Social Security Administration, em- specific treatment of pulmonary disease is physema is now second only to coronary primary prevention of pulmonary heart dis- disease in disabling the nations workers. Each ease. year some 15,000 middle aged and older American workers become unable to work Definition because of emphysema and/or chronic bron- If pulmonary heart disease is to be pre- chitis. The Social Security Administration, 1139/88 currently paying out $90 million annually to or emphysema had risen to 25,000. Studies in support people totally disabled by chronic two hospitals, Colorado General Hospital and lung disease, has reported that respiratory Denver Veterans Administration Hospital, disease was the primary diagnosis in 38,263 show that the death certificate understates workers who were retired prematurely be- emphysema and/or chronic bronchitis as a cause of disability in 1965. This number cause of death in men over 40 by almost 30% represents 14.3% of all workers who first and the presence of disabling emphysema received benefits under the disability program and/or chronic bronchitis at the time of death that year. A considerably higher portion of by 50% or more. Another study indicates that men than women had a respiratory disability, the prevalence at death of chronic respiratory particularly emphysema. This disease was the disease is found to be nine times greater than leading cause of respiratory disability with its underlying cause death rate. 16,879 workers receiving benefits for pulmo- Chronic obstructive lung disease is often nary disease. complicated by the development of cor It is estimated that more than three million pulmonale and congestive heart failure. The Americans over the age of 45 have demonstra- exact morbidity and mortality due to cor ble emphysema or significant chronic bronchi- pulmonale and right heart failure is very tis and the number of United States citizens difficult to determine. In some instances death partially or totally disabled by emphysema is attributed to heart disease with congestive and/or chronic bronchitis is estimated at from failure while in others the lung disease is listed five to ten million. Furthermore, the number as the primary cause. Stuart-Harris found 30 of persons with respiratory disease increases to 40% of patients with congestive heart fail- sharply with advancing age-89% of those ure in Sheffield, England had cor pulmonale to granted disability benefits because of emphy- some degree. In the United States it is sema were 50 years of age or over. estimated that 10 to 30% of congestive heart A report by The Task Force on Chronic failure admissions to medical centers have cor Bronchitis and Emphysema sponsored by the pulmonale as a predisposing condition. More National Tuberculosis and Respiratory Dis- definitive data on the frequency of cor ease Association and the Public Health Service pulmonale and its relationship to other forms reveals that the number of deaths attributed of cardiopulmonary disease are needed. It is to emphysema and bronchitis is doubling estimated that if pneumonia and conges- every five years. While emphysema has in all tive heart failure deaths in which emphysema probability always existed, there is no ques- and/or chronic bronchitis played the major or tion that its reported incidence is growing a substantial contributory role were included, sharply. This is probably due to an actual the true number of deaths from chronic increase in incidence combined with a height- obstructive lung disease would approximate ened interest and diagnostic acuity on the part 75,000 per year. of the medical profession. Thus, in 1955 As previously stated, vital statistics on emphysema was reported as a cause of death these diseases lack precision. Nevertheless, it in 3,639 persons in the United States while in is clear that incidence is increasing. Limited 1959 the number was up to 7,728. By 1967 surveys suggest that as high as 25% of the reported deaths from chronic bronchitis and/ population over 40 years of age have abnor- Journal AOA/vol. 69, July 1970 1140/80 Heart disease resources mal lung function. This leads to an estimate of monary disease than their counterparts who up to 14 million persons in the United States do not smoke. with some degree of chronic obstructive Studies of pulmonary function supply data pulmonary disease. There is no accurate base on alterations in respiratory physiology which upon which to estimate what per cent of these correlate well with clinical symptomatology will develop cor pulmonale and right heart and physical findings. There is a diminution in failure, but there is every reason from present many parameters of function: timed vital clinical experience to believe that the number capacity, peak expiratory flow, and diffusing will be large. capacity in individuals who smoke. These same individuals have increased airway resis- Prevention of the causative pulmonary diseases tance and a larger than normal oxygen debt There is need for more information on with exercise. Like the clinical symptoms of pathogenic mechanisms leading to chronic respiratory disease these functional abnormali- respiratory disease. Nevertheless much is ties improve with the cessation of the cigarette known about prevention. The basic risk habit. Pathological studies on lungs and the factors are cigarette smoking, infection, and tracheobronchial tree of smokers vs. nonsmok- air pollution. ers demonstrate the deleterious effects of smoking. A grading of emphysema (panlobu- Smoking lar, centrilobular, or mixed type) with lung It is well established that smoking is macrosections is similarly discriminating, re- injurious to health in many ways. Cigarette vealing a greater incidence and degree of em- smoking is the major cause of pulmonary physema in the lungs of smokers. The relation- heart disease in that it is the most important ship between smoking, bronchitis-emphysema cause of the chronic non-neoplastic broncho- and pulmonary heart disease is such that there pulmonary diseases in the United States. is little doubt that a radical reduction or Epidemiological and laboratory evidence elimination of the cigarette habit would result strongly supports the view that cigarette in a greatly lowered incidence of the chronic smoking can contribute to the development of respiratory diseases and cor pulmonale. pulmonary emphysema in man. If these advantages are to be realized there Prospective studies indicate that morbidity must be increased education of the public, and mortality from bronchitis and emphysema with particular emphasis upon programs are much higher among smokers than among which discourage the young from smoking.
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