Kannel W B
Department of Medicine, Boston (Mass) University School of Medicine/Framingham Heart Study 02118, USA.
Circulation. 1995 Dec 1;92(11):3350-60. doi: 10.1161/01.cir.92.11.3350.
The epidemiological approach to investigation of cardiovascular disease was innovated in 1948 by Ancel Keys' Seven Countries Study and T.R. Dawber's Framingham Heart Study. Conducted in representative samples of the general population, these investigations provided an undistorted perception of the clinical spectrum of cardiovascular disease, its incidence and prognosis, the lifestyles and personal attributes that predispose to cardiovascular disease, and clues to pathogenesis. The many insights gained corrected numerous widely held misconceptions derived from clinical studies. It was learned, for example, that the adverse consequences of hypertension do not derive chiefly from the diastolic pressure, left ventricular hypertrophy was not an incidental compensatory phenomenon, and small amounts of proteinuria were more than orthostatic trivia. Exercise was considered dangerous for cardiovascular disease candidates; smoking, cholesterol, and a fatty diet were regarded as questionable promoters of atherosclerosis. The entities of sudden death and unrecognized myocardial infarction were not widely appreciated as prominent features of coronary disease, and the disabling and lethal nature of cardiac failure and atrial fibrillation was underestimated. It took epidemiological research to coin the term "risk factor" and dispel the notion that cardiovascular disease must have a single origin. Epidemiological investigation provided health professionals with multifactorial risk profiles to more efficiently target candidates for cardiovascular disease for preventive measures. Clinicians now look to epidemiological research to provide definitive information about possible predisposing factors for cardiovascular disease and preventive measures that are justified. As a result, clinicians are less inclined to regard usual or average values as acceptable and are more inclined to regard optimal values as "normal." Cardiovascular events are coming to be regarded as a medical failure rather than the first indication of treatment.
1948年，安塞尔·基斯的七国研究和T.R. 道伯的弗雷明汉心脏研究开创了心血管疾病的流行病学研究方法。这些研究以普通人群的代表性样本为对象，对心血管疾病的临床谱、发病率和预后、易患心血管疾病的生活方式和个人特征以及发病机制线索提供了真实的认识。由此获得的诸多见解纠正了许多源于临床研究的广泛存在的误解。例如，人们了解到高血压的不良后果并非主要源于舒张压，左心室肥厚并非偶然的代偿现象，少量蛋白尿也并非仅仅是体位性的琐事。运动曾被认为对心血管疾病患者有危险；吸烟、胆固醇和高脂饮食曾被视为动脉粥样硬化的可疑促发因素。猝死和未被认识的心肌梗死这两种情况并未被广泛视为冠心病的突出特征，心力衰竭和心房颤动的致残和致死性质也被低估。正是流行病学研究创造了“危险因素”这个术语，并消除了心血管疾病必有单一病因的观念。流行病学调查为卫生专业人员提供了多因素风险概况，以便更有效地针对心血管疾病患者采取预防措施。临床医生现在期望流行病学研究能提供有关心血管疾病可能的易感因素和合理预防措施的确切信息。因此，临床医生不太倾向于将通常值或平均值视为可接受的，而更倾向于将最佳值视为“正常”。心血管事件正逐渐被视为医疗失败而非治疗的首要指征。
