The President and Dr. White

The recent debate on whether or not President Eisen-hower should run for re-election following a heart attack would never have arisen in the years prior to 1931. For, between 1912 when J.B. Herrick published the classical description of myocardial infarction and 1931, the condition was thought to be inevitably and rapidly fatal.

In the latter year Dr. Paul Dudley White, already enjoying an international reputation as a cardiologist, reported on 200 coronary patients he had seen in his practice, emphasizing that many were still alive five to ten years following their first attack. In 1941 Dr. White, in conjunction with Dr. E.F. Bland, completed his study of these patients. Because treatment has hardly changed at all since then, these figures are still used in estimating the outlook after the first attack.

Bland and White found that 19 percent of their 200 cases died within the first four weeks, 50 percent within ten years, and 31 percent were still alive after ten years. Of those who did not survive a decade, 30 percent died in the first year, 17 percent the second, 17 percent the third, and ten percent the fourth, with a rapid falling off thereafter.

Important factors for a prediction are hard to determine, but age is one of the most significant. Bland and White found that the average age at the onset of the first attack of those who lived ten years was 51, of those who died within ten years, 57, and of those who died immediately, 61.

Other factors are of course important. The absence of marked persistent electrocariograph changes, irregularities in the heart's rhythm, and pain from temporary closing or spasn of the coronaries, are all reassuring. They indicate that branches of the other coronary have established collateral cirulation to the area once served by the plugged vessel, and that the area of dead heard tissue is not large.

The President apparently has none of these symptoms. He is under constant medical observation. He is receiving anti-coagulant treatment designed to prevent further trouble. He is cutting down on social commitments and detail works.

"Unfortunately in a majority of cases recovery from the acute attack is followed by distressing symptoms, restricted activity, or invalidism," writes C.K. Fishberg of Columbia in his "Disease of the Heart." He notes that two thirds of White's surviving patients pursued fairly inactive lives with definite restrictions. It is an old medical axiom that "the most common complication of myocardial infarction is another myocardial infarction," and Fishberg estimates that such attacks "recur in about 30 percent of the cases, usually within two years of the first attack."

In "Clinical Heart Disease" Samuel A. Levene, Professor of Medicine, writes of coronary thrombosis that "there is no other condition in the practice of medicine in which it is so difficult to prognosticate... The physician should remain hopeful under the darkest circumstances and yet give a guarded prognosis when the progress seems most favorable."

If the prognosis is guarded in a normal convalescence, there is no reason to change it in Mr. Eisenhower's case. No matter how many social duites and petty details are shunted aside, there remains a heavy schedule of conferences, reading, and recommendations. Even if the president is left only the largest and most important decisions to make, he will still be subject to the mental strain and worry that is frequently considered a contributing factor in coronary heart disease.

Despite the risk involved, Dr. White has encouraged the president's second-term plans. In doing this he may not only be voicing his opinion of the president's health, but lending hope for a normal future to cardiac patients all over the world. M.J. HALBERSTAM '53   B.U. MED '57