Decline in Cardiovascular Mortality

The first 60 years of the 20th century saw a remarkable transformation in health and longevity in the United States and other industrialized countries. In 1900, life expectancy in the United States was only 47.3 years (46.3 for men and 48.3 for women and only 33 for blacks). Infectious diseases such as pneumonia, influenza, tuberculosis, and gastroenteritis were the leading causes of death and collectively accounted for more than twice as many deaths as heart disease and stroke, the next 2 leading causes of death. By 1960, improvements in sanitation and the development of vaccines and antibiotics had brought about dramatic declines in infectious disease mortality and concomitant increases in life expectancy to 69.7 years (ranging from 61 for black men to 74 for black women). Heart disease, cancer, and stroke replaced infectious diseases as the leading causes of death. The increasing preeminence of heart disease among causes of death in the first half of the 20th century in part reflects the decline of infectious diseases and the resulting increase in life expectancy, with many more Americans living to an age when they are likely to have the sequelae of chronic atherosclerosis. Indeed, many physicians of that era viewed atherosclerosis as a natural and somewhat inevitable feature of aging and regarded only premature cardiovascular disease (CVD; before the age of 60 years) as a legitimate target for preventive medicine. However, even in the 1960s, it was evident from time trends in age-adjusted heart disease rates since 1940 that heart attack rates were on the rise and were not merely a spurious manifestation of an aging population. Then, in the early 1970s, epidemiologists in the United States and Australia published an unexpected observation that coronary heart disease (CHD) mortality rates, after peaking in 1968, had apparently begun to decline. This observation was met with skepticism in many quarters. For example, a 1975 editorial in the British Medical Journal questioned Review