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Sixty Years of Preventive Cardiology: A Framingham Perspective

I was pleased to receive the 2011 Joseph Stokes Award for excellence in preventive cardiology from the board of the American Society for Preventive Cardiology. Joseph Stokes and I were close colleagues for most of our careers as faculty at Harvard University, Boston University, and the Framingham Study. We shared a long and abiding interest in preventive medicine in general and preventive cardiology in particular. We were fortunate to have participated in the evolution of preventive cardiology from its inception by identifying correctable predisposing cardiovascular risk factors using population data from the pioneering Framingham Study. It is gratifying to see how this has stimulated cardiovascular drug development, trials to demonstrate their efficacy, and public health measures to alter cardiovascular disease (CVD)-promoting behavior in the population. It is satisfying to reflect on the many important lessons gleaned from our epidemiological investigation over the past 6 decades. Clinical misconceptions were corrected. The impact of overt and subclinical atherosclerotic CVD was revealed. The importance of the principle of multivariable risk factor influences on CVD, with no single essential and sufficient cause, was established. Population-based incidence of nonfatal cardiovascular events was provided to enhance mortality statistics. Useful multivariable cardiovascular risk assessment profiles were developed that minimize possibilities of falsely reassuring or needlessly alarming many potential CVD candidates.1 We provided clues to the pathogenesis of atherosclerotic cardiovascular for further investigation. Familial and genetic influences are being studied in second and third generations of our study participants. We are now able to document the lifetime risks of CVD events and its predisposing risk factors from 6 decades of long-term investigation.2 This provides a more compelling depiction of CVD risk for both patients and physicians than current 10-year risk assessments. Major contributions of observational studies to preventive cardiology also include: proposal and fine-tuning of the multivariable risk factor concept of the etiology of atherosclerotic CVD and its use for risk assessment and gaining pathogenic insights, arousal of interest in preventive cardiology with epidemiology as its fundamental tenet, and redefinition of acceptable levels for predisposing risk factors from usual as normal to optimal for avoiding CVD.3 The complete gamut of cardiovascular events not captured from