A change of heart
FDR's death shows how much we've learned about the heart
Today, the prevention of heart disease seems like pure common sense, but it wasn't always so obvious. Sixty years ago, the nation's top cardiologists didn't have a clue about how to save the life of President Franklin D. Roosevelt. His death was one in a growing epidemic of cardiovascular disease that spurred researchers to find answers. In 1948, the Framingham Heart Study was launched, and the lives and deaths of 5,209 volunteers from Framingham, Mass., taught the rest of the world just which behaviors and genetic traits put them at risk.
The study continues into its sixth decade, now enrolling the grandchildren of the first volunteers. With three generations of DNA available to researchers, along with meticulous medical records, it offers a wealth of data to explore the genetic roots of heart disease and its risk factors: high blood pressure, high bad cholesterol, low good cholesterol, smoking, diabetes, and obesity.
Daniel Levy is a cardiologist specializing in prevention, a faculty member at Boston University School of Medicine and Harvard Medical School, and director of the Framingham Heart Study. Susan Brink is a senior writer at U.S. News. Their book, A Change of Heart: How the People of Framingham, Massachusetts, Helped Unravel the Mysteries of Cardiovascular Disease (Knopf, $26.95), begins with an eye-opening reminder of just how far we've come.
It was April 12, 1945, and the country was heart-broken. Franklin D. Roosevelt, the 32nd president of the United States, died suddenly in what had come to be known as the "Little White House," a cottage in the woods of Pine Mountain near Warm Springs, Ga. The public was unprepared for his death, though for many months his doctors knew that he was gravely ill. In keeping with the culture of the times, his personal physicians hid the grim reality of the president's failing health from the press, from the public, from his family--even from FDR himself. A casualty of an as yet unrecognized epidemic, the leader of the free world slipped away.
Roosevelt, his doctors, and the media had colluded to portray him as the picture of health. Long before he was elected president, in the summer of 1921 when he was 39 years old, he had fallen victim to another epidemic. Polio rendered his legs nearly useless. His walk was seldom photographed, nor was the wheelchair on which he often depended.
Strong and steady. Rumors that Roosevelt was in poor health circulated during his first run for president. The country was in the throes of the Great Depression. America was mired in despair, and Roosevelt needed to prove that he was strong and steady. To still the gossip, he released his medical records in 1931. His blood pressure was 140/100--the 140 systolic only marginally hypertensive but the 100 diastolic a bad omen. Even the most brilliant medical minds of the time possessed neither the knowledge to recognize the gravity of his disease nor the tools to treat it. Shortly after assuming the presidency in 1933, Roosevelt selected Adm. Ross McIntire as his personal physician. McIntire was an ear, nose, and throat specialist whose main concern would be the president's head colds and sinus problems.
Roosevelt took the helm of the nation at a time that would have taxed the hardiest of souls. America was then home to between 13 million and 15 million unemployed workers. A couple of million of them created a whole class of homeless migrants. They left behind dust-ravaged farms and boarded-up factories to wander the country in search of work. The plight of a stricken populace surely took its toll on their leader during his first term. "I see millions whose daily lives in city and on farm continue under conditions labeled indecent by a so-called polite society half a century ago. . . . I see one third of a nation ill-housed, ill-clad, ill-nourished," he said in his second inaugural address.
As the strain registered in medically measurable form, McIntire hardly made note of the rise in the president's blood pressure. It was 169/98 in 1937 as Roosevelt began his second term. From then on, it would fluctuate but remain abnormally high. His vital numbers rose to 188/105 in 1941, when the Japanese bombed Pearl Harbor. Still, as is typical, he had no outward symptoms of hypertension. Roosevelt launched a nationwide war effort, committing more than 16 million U.S. troops to the Allied cause in World War II. By the time American soldiers landed in Normandy in June 1944, his blood pressure was 226/118--a life-threatening level. The limited medical technology of the day, electrocardiograms and chest X-rays, showed a damaged, enlarged heart. Still, no one told FDR the bad news, nor did he ask.
Roosevelt was absent from the White House for nine weeks during the first five months of 1944. In those days, he would go to Warm Springs, an impoverished farm community 80 miles southwest of Atlanta, for an "off the record" absence from duties. In an era when the media grant no mercy in exposing the secrets of public officials, it is difficult to fathom that back then journalists would comply with and help promote such a public deception. McIntire insisted that the president's health was good, that Roosevelt's blood pressure was normal for a man his age. In his treatment notes of April 1944, when the president's blood pressure was 210/120, McIntire wrote, "A moderate degree of arteriosclerosis, although no more than normal for a man of his age."
There is hardly an American today who doesn't know enough to shudder at the president's vital numbers. Careful listeners to his radio fireside chats might have noticed, certainly by 1944, an audible short-windedness that probably reflected some degree of congestive heart failure. And his family was becoming increasingly alarmed. Indeed by early 1944, Eleanor Roosevelt was ready to reject McIntire's diagnosis and ask for a second opinion, and in March the president went to Bethesda Naval Hospital for a thorough examination.
There, a young cardiologist, Howard Bruenn, pronounced the president desperately ill. But McIntire carefully controlled the disclosure of all medical information and believed Bruenn's view of FDR's health would disturb the president and his family.
Dueling memories. Historians speculate that as Roosevelt's cardiac problems became more apparent, McIntire grew more determined to hide the reality that he had overlooked or concealed for so long. Years later, in a 1970 journal article called "Clinical Notes on the Illness and Death of President Franklin D. Roosevelt," Bruenn wrote about the frustration of treating FDR. His account of the examinations and treatments of the president was the first medical data made available apart from McIntire's memoirs. Bruenn's account contrasted sharply with the self-serving recollections of McIntire, and Bruenn concluded by saying, "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." The president's original medical chart vanished immediately after his death, and the most reliable enduring record of his health during his presidency is the notebook that Bruenn kept.
Bruenn persisted in speaking his mind, calling in other experts, and eventually he prevailed over McIntire. But even with focused concern, Bruenn was virtually powerless to control FDR's severe hypertension. Roosevelt began taking digitalis, the only drug available for treatment of heart failure. At the very end of his life, he was prescribed phenobarbital, a sedative, which doctors at the time hoped would lower blood pressure. It proved ineffective. Lifestyle alterations for Roosevelt included a recommendation that he cut back on cigarettes from 20 a day to 10, but Bruenn was frustrated in his attempts to convince the president of the importance of it. Few doctors at the time considered tobacco a risk factor for cardiovascular disease, and Bruenn's concern about FDR's smoking was probably aimed at providing relief from a chronic cough and respiratory problems.
For the next few months, the president rallied publicly. With his country and millions of its troops depending on his strength of command, he felt he could not quit in the middle of war, and he decided to run once again for re-election. In 1944, the year before his death, Roosevelt's blood pressure numbers read like a recipe for disaster: March 27, 186/108; April 1, 200/108; November 18, 210/112; November 27, 260/150. And yet, during those months, he traveled to Hawaii to confer with top brass. He went to the Democratic National Convention in Chicago. He traveled to Alaska and to Washington State. He met with Winston Churchill in Canada.
He may have suffered an attack of angina as he delivered his final inaugural speech on Jan. 20, 1945. He conveyed a message of hope, but the world was at the height of war, and the ceremony was solemn. The expense of a show of festivity would have been inappropriate, and the oath of office was taken quietly on the South Portico of the White House.
The impropriety of public celebration, ironically, served Roosevelt's failing health. The address--about 500 words--was by far his shortest inaugural speech. It was to be the last time the public would see him standing.
As he departed for the Black Sea port of Yalta in early February to determine the destiny of Europe, Roosevelt looked gravely ill. While there, his blood pressure was 260/150, a level we now call malignant hypertension.
Americans were ready to believe what they wanted to believe: that Roosevelt was healthy. But severe blood pressure elevation such as he was experiencing can cause chest pain, as well as congestive heart failure, kidney failure, deteriorating mental function, and stroke. It represents a medical emergency. In that condition, the president undertook an arduous 14,000-mile round trip and spent a week orchestrating the final strategy for victory in Europe. He returned exhausted from his pivotal meeting with Joseph Stalin and Churchill in Yalta. As the war raged on, the commander in chief involved himself in discussions about a new weapon nearing readiness--the atomic bomb.
He headed to his Georgia sanctuary at the end of March for two weeks of rest. Those who saw him during his last days were shocked at how aged he looked. He was down 15 pounds from his normal range of 184 to 188. Suffering from orthopnea, a telltale sign of congestive heart failure, he had trouble breathing when lying down, and for months had been sleeping with 4-inch blocks of wood propping the head of the bed. The agent at the Warm Springs railroad station, C. A. Pless, accustomed to greeting a smiling, waving man who could never resist the crowd, said later, "The president was the worst-looking man I ever saw who was still alive."
On the morning of April 12, Roosevelt donned a dark-gray suit, matching vest, and red tie to pose for a watercolor portrait by Elizabeth Shoumatoff. As the artist painted, he signed papers. Roosevelt lit a cigarette, raised his left hand to his temple, and then seemed to squeeze his forehead. As he reached for the back of his neck, he said, "I have a terrific headache." Then he lost consciousness. An excruciating headache is a classic symptom of a brain hemorrhage, a catastrophic form of stroke caused by a ruptured blood vessel in the brain. Bruenn was summoned and within minutes took his patient's blood pressure. The numbers, an unsustainable 300/190, went well beyond an indication of danger. They were evidence that the tragedy had already occurred. Two hours later, at 3:45 p.m., the president was dead. Although no autopsy was performed, the cause of death certainly was a massive stroke.
FDR's unexpected demise undoubtedly fed the public belief that cardiovascular disease strikes quickly and without warning. During his four terms as president, he progressed from garden-variety high blood pressure to malignant hypertension--something almost never seen anymore. He suffered from heart failure and died of a brain hemorrhage, without receiving any effective treatment for his hypertension--because none existed.
Roosevelt died in his prime, at 63, within sight of the war victory he helped forge and the peace he had hoped to underwrite.
When Roosevelt died, doctors had little more than folk wisdom at their disposal to control blood pressure. To look at the picture of cardiovascular ignorance just six decades ago is startling. Heart disease, the most common form of cardiovascular disease, was so ubiquitous that it was considered an inevitable consequence of aging.
Life expectancy, which should have soared following the introduction of antibiotics and vaccines, was held back by heart disease and stroke. No one had a clue about the source of the destructive power of these diseases or what to do about them. Roosevelt became a symbol of the vast uncharted territory of cardiovascular medicine. In the postwar years, his death would serve as a wake-up call, shocking Americans and uniting scientists and politicians behind a massive research effort.
Following Roosevelt's death and World War II, the nation's scientists persuaded President Truman to make medical research a national priority. In 1948, Congress created the National Heart Institute. That same year, the Framingham Heart Study began. Since then, deaths from heart disease have declined by 60 percent and from stroke by 70 percent, because of advances in treatment and prevention. Still, about two thirds of people with high blood pressure either don't know it or don't have it under adequate control. The numbers are even worse for cholesterol control. About 1 in 4 American adults still smokes, and obesity is a growing problem. We have come a long way since Roosevelt's death, but we have a long way to go.
From A Change of Heart by Daniel Levy, M.D., and Susan Brink Copyright (c) 2005 by Daniel Levy, M.D. Published by Alfred A. Knopf, a division of Random House Inc. The views expressed in this article are those of the authors and not of the U.S. government.
This story appears in the February 14, 2005 print edition of U.S. News & World Report.