The Global Impact of the Framingham Heart Study:

Article Outline

• Copyright

History is different from news. Headlines capture the excitement of the moment and announce the breakthroughs that may or may not influence our lives going forward. The inauguration rather than the fulfillment of what becomes defining events are rarely accorded their due and only in retrospect, in historical review, do we acknowledge their importance and significance.

Nineteen forty-eight was a banner year for news and breakthroughs. Israel was born and Czech democracy was squelched; Gandhi was assassinated and apartheid began; the Polaroid camera appeared on the market and MIGs appeared on Russian runways; The World Health Organization was established and Britain inaugurated its national health service, and the Berlin airlift rescued a city and the Marshall Plan helped rescue a continent.

But also in 1948, the Framingham Heart Study enrolled its first patient. This attracted little attention outside the newly established National Heart Institute, which funded it. During its early years, it slowly collected observational data on the pleasantly cooperative burghers of Framingham, Massachusetts. It made no headlines and created no waves. But like a snowball rolling downhill, it accumulated heft and attracted attention. In the late 1950s and early 1960s, it began to publish its findings and suddenly it blossomed into a transformative observational study that changed forever how society looked at its number one killer, heart disease. The Framingham Heart Study introduced the world to the concept of risk factors for heart disease and that modification of these could forestall or postpone overt disease, it forced the biostatistics world to develop multivariate analyses, it changed the models and targets for epidemiology, and as the cardiovascular epidemic spread to the emerging economies, the Framingham Heart Study has been a dominant force in causing the global health community to confront heart disease specifically and chronic disease generally.

The Framingham Heart Study was powerful in its impact but not unique. There were other attempts at the time to explore the mechanisms of development of cardiovascular diseases (CVDs). However, the Framingham Heart Study was open, and the data from this National Institutes of Health study was available to investigators. Also, the early leaders, particularly William Kannel, understood that the message being brought forth needed the widest possible dissemination. This was an important part of the vision.

What attracted me to the topic of this symposium was that the Framingham Heart Study never had the budget and never really the goal to train the world in CVD prevention. The symposium itself grew out of several lengthy discussions with Peter Wilson, MD, who confirmed the relevance of the topic, helped select the participants, and arranged for us to interview Dr William Kannel, his former colleague and current friend and mentor. As Bill Kannel says in our interview, the Framingham investigators were welcoming, gracious, and sharing with whomever visited. Although hardly the equivalent of training grants, coupled with the commitment to publish, it was enough.

The validity, robustness, and clarity of the Framingham data became a beacon for the world. Certainly, each region and population needed to determine its own specific risk profile, but the template was in place. For sure, populations differ in cultural, dietary, and genetic patterns, but the Framingham model offers an effective pathway to tease out local risk factors and their relative importance.

And prevention works. The final verdict on the efficacy and relevance of the Framingham Heart Study is the outcome. Altering behavioral or cultural or political determinants of risk does reduce the societal burden of CVD. In the United States, though lacking a top-down approach to public health, the dramatic fall in CVD mortality in the early 1960s when little but blood pressure control was available speaks to this. During the ensuing 40 years, about half of the 50% fall in CVD mortality is attributable to prevention and risk factor modification, the legacy of the Framingham Heart Study.

Perhaps the clearest demonstration of the impact of public health on CVD mortality is the North Karelia project. Finland went from the highest European CVD mortality to the low mean of the continent in 30 years by altering behavior that determines CVD risk. Although the founders of the North Karelia project were cognizant of all the studies looking at CVD prevention, the demonstration that the public health model works, and works powerfully and dramatically, is the most effective validation of the Framingham approach to CVD risk reduction.

All the contributors to this symposium played and continue to play important roles in carrying forth the message of Framingham. The authors come from all over the world. The papers collectively tell a story of the globalization and the democratization of scientific dissemination, with reverberations of change reaching everywhere.

We were delighted at the last minute to add a paper from Abu Dhabi. This study, grounded in the concepts of the Framingham Heart Study, began 60 years after Framingham enrolled its first patient and is a testament to the power and validity of the original vision. We are thrilled to embrace the future and confidently anticipate more to come.