Reviews

The Problem of Preventing Diseases of the Circulatory Organs from a Hygienic Perspective

A Review of the Literature

Professor I. I. Belyaev

From the Gorky Medical Institute

At the present stage in the development of hygiene and sanitary practice, the need for hygienists to participate actively in preventing diseases of the blood vessels and heart is becoming increasingly pressing. The urgency of this task is determined by the widespread prevalence of diseases of the circulatory organs. According to incomplete data, more than 3.5 million people in the USSR suffer from cardiovascular diseases (M. D. Kovrigina).¹ Diseases of the cardiovascular system rank first in our country among the causes of initial disability, accounting for 23.3% (S. V. Kurashov).

Diseases of the circulatory organs are the leading cause of overall mortality in the population. Diseases in this group were responsible for 26.6% of all deaths and 32% of deaths among those over 15 years of age. In other countries, cardiovascular disease accounts for an even greater proportion of deaths: 52.7% in the United States [Mangun], 40% in the GDR [Wollenberger], and 32.4% in France [Candiotti and Moine]. Similar figures have been reported by Pozzi for Italy, Lancaster for Austria, and others.

The importance of combating diseases of the blood vessels and heart was emphasized at the Twentieth Congress of the CPSU. It is therefore no coincidence that medical science is devoting enormous attention to this question.

The international literature on cardiac disease is truly vast. Prevention, however, receives relatively little attention and, in most major works on cardiology, is confined to a few general statements. Although the broad outlines of a comprehensive hygienic approach to preventing cardiovascular disease have long been known, the means of putting it into practice remain imprecisely and incompletely defined.

Only in recent years have works by L. K. Khotsyanov, Ya. I. Rodov, Z. E. Bykhovsky, I. I. Belyaev, and others appeared in the hygiene literature addressing the prevention of cardiovascular diseases. Yet these works are far from exhaustive, since prevention in cardiac disease encompasses an extraordinarily wide range of issues owing to the multiple causes of these diseases.

Unfortunately, the practical implementation of preventive measures already known is far from commensurate with the importance of the problem. This was emphasized in the resolutions of the Thirteenth All-Union Congress

¹ Meditsinsky Rabotnik, 1956, October 9.

hygienists as early as five years ago. However, to determine the specific components of a comprehensive hygiene program correctly, one must begin with a precise understanding of the etiology of cardiovascular diseases.

In studying the etiology of diseases of the blood vessels and heart, it is possible, with some qualification, to identify the leading factors and accordingly divide all cardiovascular diseases, as N. S. Molchanov recommends, into three main groups: diseases in which the principal role is played by adverse effects of the external (social) environment on the central nervous system (hypertension and angina pectoris); diseases associated with infectious agents and intoxication (carditis); and diseases caused principally by an inadequate diet (atherosclerosis).

The specific measures for combating diseases of the circulatory organs should be considered separately for each of these groups, although the etiology and prevention of these diseases have a number of issues in common, and the diseases themselves often coexist and occur in combination.

The diseases of the first group—the term “first” is, of course, arbitrary—hypertension and angina pectoris, are the most prevalent. According to A. L. Myasnikov, the age-standardized prevalence of hypertension in the USSR is 5.3% among men and 5.29% among women. Authors who have studied the prevalence of hypertension in the population (N. E. Kavetsky, E. P. Krasnyuk, I. M. Rybakov, and others) report figures ranging from 1.6% to 13%. Among cardiovascular diseases, according to data from the city of Gorky (E. I. Sheinova), hypertensive disease accounts for 53.1% and angina pectoris for 13% of initial consultations.

Neurogenic influences play a decisive role in the development of hypertensive disease. In light of Pavlovian nervism and the work of M. K. Petrova, the major role played by impaired function of the cerebral cortex in the development of a wide variety of pathological conditions, and cardiovascular diseases in particular, has become clear. At the laboratory of higher nervous activity of the Sukhumi Medical and Biological Station of the USSR Academy of Medical Sciences, directed by D. I. Miminoshvili, experiments on monkeys showed that creating conditions that overstress nervous functions leads in some animals to a sustained rise in blood pressure and in others to coronary vasospasms accompanied by typical attacks of angina pectoris.

It is therefore no coincidence that hypertension, in the words of F. A. Andreev, strikes precisely those people who lead very full, stressful, and emotional lives. Nor is it coincidental that hypertension and angina pectoris most often affect people in “nervous” occupations. According to numerous observations by Morris, Pozzi, Morrison, S. S. Barots, S. S. Ilyina and coauthors, A. M. Dadashyan, N. M. Anastasyev, and others, these diseases are most prevalent among administrative personnel, bank employees, cashiers, telephone operators, and locomotive drivers.

Many authors analyzing the causes of the widespread prevalence of vascular diseases emphasize the importance of neurogenic factors. Noteworthy, for example, is the increased incidence of hypertension among residents of Ashgabat who survived the earthquake (V. M. Solomyanny and S. A. Burmistrov). E. P. Krasnyuk presents interesting data, having identified psychoemotional factors in the etiology of 74.3% of cases of hypertension. A. D. Dakhin notes the major role of neuropsychological factors in the development of angina pectoris.

Stressful social conditions have a particularly adverse effect on the state of the nervous system and, through it, on the functions of the cardiovascular system.

Thus, according to data published in the journal Soviet Health Care, mortality from heart disease in a relatively “quiet” country such as the Netherlands was nearly half that in the United States over the preceding 10 years. The United States, with its intense war psychosis and all the excesses of militant imperialism, exhibits an unusually high prevalence of neurotic symptoms among the population [Rennie].

Extremely intense stimuli have a highly adverse effect on the nervous system as well as on the cardiovascular system. Administrative and technical staff at enterprises and institutions are particularly exposed to such stimuli, especially when carrying out urgent and demanding assignments, often without scheduled rest breaks or adequate sleep. Students are subjected to similarly extreme nervous strain during examinations. Evidence from a number of investigators clearly attests to this. Maisner (Czechoslovakia), for example, found that most schoolchildren aged 14–15 experience a period of intense emotional stress during examinations. This is aggravated by the fact that examinations coincide with puberty. On the basis of physiological examinations of schoolchildren during examinations, E. M. Belostotskaya and D. G. Nusbaum found that nervous tension causes a number of adverse changes in the body’s responses during this period. Evidence of the adverse effects of examinations on university students comes from I. I. Belyaev, who found a prolonged rise in blood pressure and an accelerated pulse in a substantial proportion of examinees, and from V. G. Vogralik and colleagues, who, in studying the blood of students taking examinations, found that the emotional response causes a decrease in phosphorus and a considerable increase in cholesterol in the blood.

Equally pressing is the need to combat rudeness in interpersonal dealings and to address people’s conduct at work and in everyday life, since these factors are widely acknowledged to play a significant role in the development of circulatory disorders.

No less important is the organization of efforts to combat noise, especially in everyday life. R. Koch wrote that the time would come when noise would have to be fought just as plague and cholera are fought. According to Grogger, noise has become a social problem. It is a factor that affects everyone. According to E. Ts. Andreeva-Galanina, G. A. Novozhilov, Koeppen, Jansen, and other authors, diseases of the cardiovascular system are among the consequences of its effects on the body. L. P. Khimenko reported that exposure to noise can produce a model of neurogenic noise-induced hypertension in animals.

In discussing the etiological factors of hypertension and coronary disease, one cannot overlook the harmful effects of certain unhealthy habits. Of these, tobacco smoking and alcohol consumption deserve the most serious attention. According to the American authors Hammond and Horn, who collected statistical data on 187,776 people in 1953–1954, 93.3% of those with coronary sclerosis were smokers and only 6.7% were nonsmokers. Edwards and colleagues, who examined 1,753 people over the age of 60 in England, found a correlation between smoking and the incidence of hypertension. Englisch, Willius, and Berkson, after studying a large number of medical histories, found 54 cases of coronary disease per 1,000 smokers, compared with 38 per 1,000 nonsmokers.

Experimental observations by I. M. Gvindzhiliya and K. K. Maslova demonstrate the hypertensive effect of chronic smoking. The danger of smoking is compounded by its widespread preva—

…prevalence. According to Hegglin, considerably more than half of the world’s men and a quarter of its women smoke. Joules reports that in England 65% of men and 40% of women smoke. In Norway, according to Nilsen, more than half of boys and a considerable proportion of girls begin smoking by the age of 13. Similar figures can be found in the literature from other countries.

Recently, greater attention has been paid to combating alcoholism. I. V. Strelchuk believes that 18–20% of patients with chronic alcoholism have elevated blood pressure that progresses to hypertensive disease. V. A. Kononyachenko found that hypertensive disease occurs 3–4 times more often among patients with alcoholism than in the general population.

Clearly, the prevention of hypertension must include efforts to combat tobacco and alcohol use. To this end, these subjects should be taught in greater depth and with greater focus in medical institutes and schools for feldshers and midwives.

Lectures on the harmful effects of smoking should be given at universities of culture and schools for mothers, and at all courses and seminars for the continuing education of workers in various professions. Our writers, journalists, and radio and television workers should also join the fight against smoking and drunkenness.

Recently, greater attention has been paid to occupational factors in the development of hypertensive conditions [L. K. Khotsyanov, Tarnawski, and others]. The literature indicates that certain substances, such as lead, may contribute to the development of hypertension. At the same time, some authors believe that the greatest role in the etiology of this disease is played by poorly organized work and rest schedules, particularly in assembly-line work, with its monotonous, frequently repeated movements performed at an imposed pace and in a strictly fixed body position. Shift work at some enterprises, involving periodic night work and difficulties in obtaining normal sleep during the day, is also relevant to the development of hypertensive disease.

Clinical and hygiene observations at the Stavropol Medical Institute show that the development of hypertension in its initial stages depends to some extent on meteorological factors.

The diseases of the second group—carditis—are caused principally by infection (hemolytic streptococci, viridans streptococci, the diphtheria bacillus, and viruses). Impairment of central nervous system function also plays a certain role in their etiology. These diseases most often develop in people who are insufficiently physically conditioned. Of particular importance in this regard are bouts of tonsillitis, which often lead to rheumatism and subsequently to serious cardiac disorders [V. K. Trutnev and P. P. Sakharov, Krasna and Synkova].

A history of recurrent tonsillitis was found in most children with rheumatism.

Rheumatism is extremely widespread. In England, for example, it accounts for \(1/6\) of all working time lost by the population; in Austria, rheumatic diseases account for \(1/8\) of all social insurance expenditure. Gotsch calls rheumatism a disease of the people. Rheumatism is particularly widespread among schoolchildren: in England and the United States, 3.5–4.4% of pupils suffer from it. At the International Congress on School Hygiene in 1959, Mazziconacci (Italy) reported, on the basis of a survey conducted in 21 countries, that the prevalence of rheumatic heart disease varies…

from 1 per 1,000 to 5 per 100 pupils. He found that up to 30% of schoolchildren in their first year carried streptococci; in the second year, the proportion was up to 50%, and by the end of schooling virtually all pupils became carriers of streptococcal infection. In Soviet schools, rheumatism was found in 1.5–3% of pupils (A. P. Rodina, V. P. Uzdennikova, and others).

Diseases of the mouth and teeth also play a major role in the development of inflammatory heart disease. Dental caries is known to be widespread among substantial sections of the population. Its causes are highly diverse: insufficient fluoride in water, inadequate nutrition, insufficient exposure to ultraviolet radiation, and shortcomings in dental care for the population.

Measures to build the body’s resistance and regular dental care play a leading role in preventing the diseases we have provisionally assigned to the second group. More specifically, the primary concern is to instill lasting health habits relating to physical exercise and hardening from childhood. Some useful recommendations in this regard may be found in the work of P. D. Tambovtsev, L. P. Kondakova-Varlamova, V. N. Kardashenko, and others. A substantial body of experience has been accumulated in promoting and disseminating workplace exercise. To strengthen the fight against dental disease and chronic sepsis, the following are necessary: mandatory preventive dental examinations and follow-up care for the population; artificial fluoridation of water in areas where natural water supplies are deficient in this trace element; wider use of artificial ultraviolet irradiation; and promotion of a sound diet to prevent caries.

The third group of circulatory diseases included atherosclerosis and the accompanying changes in bodily functions. Atherosclerosis is “the most common disease of human beings in the second half of life” (M. S. Vovsi). A distinctive feature of its etiology is impaired nutrition and altered lipid metabolism. According to N. N. Anichkov, A. L. Myasnikov and O. P. Molchanova, B. V. Ilyinsky, O. Kh. Alieva, and others, there is a connection between the prevalence of atherosclerosis and the consumption of foods rich in cholesterol. The mechanism by which atherosclerosis develops, however, is not yet entirely clear. I. V. Davydovsky, for example, believes that application of the cholesterol theory of atherosclerosis has not yet yielded fruitful results. All authors agree, however, on the need to regulate the diets of middle-aged and older people to prevent atherosclerosis. Disturbances in vitamin metabolism also play a role in its development.

Excess dietary fat, which contributes to obesity, adversely affects the health and life expectancy of the population as a whole. An article by A. M. Sigal cites data from Dublin and Lotka, who followed 192,303 people. According to these data, mortality among the obese members of this group at older ages was 1½ times higher. Lack of physical exercise also contributes to the development of atherosclerosis.

These data on the etiology of atherosclerosis also make it possible to determine the appropriate direction of preventive measures.

The principal measure is the provision of a balanced diet. For groups receiving all their meals through public catering services, seasonal menus with specified food quantities should be developed and implemented in accordance with all hygiene requirements. The fortification of individual food products with vitamins also warrants study.

The problem of preventing cardiovascular disease is so broad that it essentially encompasses every aspect of human life. Naturally, even the most detailed review cannot exhaustively cover

…all its aspects fully. The purpose of this report is merely to sketch, in broad outline, the principal approaches to solving this problem.

References

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Received July 9, 1960.