Cardiovascular Epidemiology and Prevention in Spain: Balaguer-Vintro, Sans, and Menendez

The first meeting of the Spanish Society of Cardiology took place in Madrid in November 1944 (1), and included a lecture on “Reumatismo cardiaco, desde el punto de vista profiláctico y social” (Rheumatic Heart Disease from prophylactic and social aspects) given by Prof. F Rodríguez Fornos from Valencia. Rheumatic heart disease was in those years the most prevalent cardiac disease in Spain. The identification of children with group A streptococcal infections and the discovery of valvular cardiac disease in school children from Madrid were the objectives of the team of the Escuela Nacional del Tórax with the leadership of Joaquin Márquez Blasco and José Calderón Montero (2).

The first issue of the journal, Revista Española de Cardiología, was published in January 1947, and included an article (3) by Manuel Vela (1886-1950), a cardiologist from Sevilla, “El infarto cardiaco en la juventud” (Cardiac Infarction in young people). He reported 12 men and a woman below the age of 40 years with a suggestive crisis of chest pain and changes in the electrocardiographic limb leads and in some cases in a precordial bipolar lead. Eleven of the men were smokers and the woman was a diabetic. Vela suggested that the number of infarctions in women would increase if they adopt the smoking habit.

Ancel and Margaret Keys carried out a survey in Madrid in May 1952, helped by Francisco Grande Covian, who was selected as their assistant by Prof. Carlos Jiménez Díaz. Following the survey, Francisco Grande joined the Keys team in Minneapolis for many years (4). The Madrid survey showed a great contrast in the level of serum cholesterol and in dietary habits between men of different income levels, similar to findings previously observed in Naples (5). Unfortunately, when Ancel Keys prepared the list of countries to be included in the Seven Countries Study in 1956, “Spain was eliminated because pf the lack of funds and interested local personnel” as he wrote some years later (6).

Between April and June of 1958 a Nutrition Survey of the Armed Forces of Spain was conducted for the US. Interdepartmental Commitee on Nutrition for National Defense (7). The survey included serum cholesterol determinations in a significamt sample of annual draft recruits. Mean serum cholesterol was 150±35mg/dl. In the same year in the US, the mean serum cholesterol for a similar age group was around 200 mg/dl.

The first WHO Expert Committee Report on cardiovascular prevention and epidemiology was reproduced in 1963 in the Revista Española de Cardiología (8).During the annual meeting of the Spanish Society of Cardiology in Barcelona, November 1966, cardiologists interested in the identification of patients with clinical atherosclerosis wrote a document to facilitate the comparison of data (9). This group was the origin of the Sección de Cardiología Preventiva of the Sociedad Española de Cardiologia created in 1971. Ignacio Balaguer-Vintro was the first chairman of this Section.

Lluís Tomàs-Abadal was in 1968 a young man undergoing training as cardiologist in the Escuela de Cardioangiología de la Universidad de Barcelona. He was born and lived in the town of Manresa, 60 km North of Barcelona, in the center of Catalonia. He was working as an occupational physician in the Pirelli factory of his town and discussed the potential to carry out a study of this population with Ignacio Balaguer-Vintró, who was one of his teachers in the Escuela de Cardiologia and interested in coronary heart disease and knowledgable about longitudinal studies on coronary risk factors conducted in the U.S. They decided to start a longitudinal study of the staff and workers of the Pirelli factory of Manresa where the first survey began in April 1968. Baseline data of the coronary risk factors and the five-year incidence of coronary heart disease was published in 1976 (10). The cohort of the Manresa Study was followed up for 28 years and 20-year follow-up data were published in 1994 (11), with updated data under preparation.

Tomàs-Abadal and Balaguer-Vintró were invited to present the Manresa Study data at the International Congres of Hygiene and Preventive and Social Medicine held in Madrid in October 1971. Hugh Tunstall-Pedoe also attended this meeting and proposed Lluis Tomàs-Abadal as participant in the Ten-Day Seminar of ISC to be held in Singapore in the following spring. He also informed Ancel Keys about the Manresa Study and Keys contacted the Spanish team. In September 24, 1971, the WHO CVD Officer Zbynek Pisa met Ignacio Balaguer-Vintró in Barcelona during an official trip and invited him to attend the meeting on ischaemic heart disease prevention in Innsbruck, March 1973. There he met Geoffrey Rose, chairman of the meeting. The Barcelona team was invited by Geoffrey Rose after his visit to Barcelona in November 1973, to take part in the WHO Multifactorial Primary Prevention Trial on IHD. The inclusion of the Barcelona team was approved in Ghent in June 1977. Ignacio Balaguer-Vintró, Lluís Tomàs Abadal and Susana Sans were charged to run the Barcelona Center of this project (12). The two last meetings of this group were held in Barcelona in 1988 and 1992. In addition to general publications, changes in coronary risk factors due to intervention in workers of the five participating countries were published in the Revista Española de Cardiologia (13).

With the objective to promote cardiovascular prevention in Spain, the Fundación General Mediterránea led by Leopoldo Martínez Osorio, organized a Seminar on Epidemiology and Prevention of Cardiovascular Disease, in the monastery of El Paular near Madrid in October 7-11, 1974. The Seminar was co-chaired by Ancel Keys and Ignacio Balaguer-Vintró. The Faculty included Frederick Epstein, Thomas Strasser, Robert Ringler, James Dalen, Mario García Palmieri, William Zukel and Francisco Grande Cobian. As a consequence of the Seminar, the Siete Ciudades Study that included Barcelona team and other groups in Madrid, Sevilla, Pamplona, Salamanca, Tenerife and Baleares was launched, but had to be closed after two years due to difficulties to raise funds for each survey included in the study.

To support their activities and to interest other people, the Barcelona team promoted and organized three successive meetings. In the first meeting, November 25-26, 1976, Professor Geoffrey Rose gave the inaugural annual lecture of the Societat Catalana de Cardiologia on: “Coronary heart disease. Can we prevent it?” and was elected Honorary member of Acadèmia de Ciències Mèdiques de Catalunya i Balears. In the second meeting (May 15-16, 1980) Kalevi Pyörálä and Pekka Puska joined the WHO Multifactorial Prevention Project of the IHD teams that attended a previous meeting in Sitges (May 12-14 1980). The second meeting of the Working Group on Epidemiology and Prevention of the European Society of Cardiology was held in Barcelona, September 15-16, 1982 with Ignacio Balaguer-Vintró and Susana Sans acting as Chair and Secretary of the Local Organizing Committee. At that meeting, the final results of the MRFIT trial were presented by S. Hulley 24 hours after their public disclosure at NHLBI in Washington. During that meeting, the possibility to join the WHO-MONICA Project was discussed for the first time with Zbynek Pisa. In the following year Jeremiah Stamler, Rose Stamler and Francisco Grande took part in a meeting with the Barcelona team.

The Catalan Regional Health Administration launched in 1981 a community program for the control and prevention of chronic diseases (CRONICAT Programme) including cardiovascular diseases in three counties of Catalunya with the cooperation of the WHO, (14, 15). Ignacio Balaguer-Vintró was nominated as Director of the Program and Susana Sans took the responsibility of its development. Control of arterial hypertension at primary care centres was one of the first activities of the CRONICAT Programme (16), followed by the development of other proposals to control risk in occupational settings selected by the community, measures for the control of smoking habits and diet, a programme of continuous education for health workers and other community services to improve the treatment of acute coronary patients (17), and an enquiry into facilities for the regular practice of physical activity in the community.

In 1983 the MONICA Protocol was included in the CRONICAT Programme and the center MONICA-Catalonia was included in the WHO MONICA Project, following site visits by Martti Karvonen from WHO and Ruth Hegeli from the NHLBI. (18) The MONICA Project was carried out with a team that worked for more than ten years realizing three population surveys between 1986 and 1996, a register of acute coronary events during thirteen years, and the organization and support of the meeting of the Principal Investigators in Barcelona in August 1992. Susana Sans was a member and Chair of the Steering Committee during the crucial mid-term years of the WHO MONICA Project.

Following the attendance of Susana Sans to the First ISFC Ten-Day Advanced Seminar, which developed the INTERSALT Study protocol on blood pressure and electrolyte excretion, Sans was invited to join the Steering Group of the Study. Barcelona was one of the two Spanish study centres, together with Torrejón de Ardoz in Madrid, contributing to the study a sample of 100 subjects in 1985 (19, 20).

Founded by the Spanish Minister of Health and the Joint Hispanoamerican Committee for Scientific and Technological Cooperation, a Ten-day Seminar was held in El Paular, September 1-12, 1985, to offer an opportunity to Spanish physicians interested in this field. The Seminar was a joint venture between the Department of Community Health and Preventive Medicine of Northwestern University Medical School of Chicago and the Cardiovascular Epidemiology Section of the Autonomous University of Barcelona Hospital Sant Pau. The Seminar was co-chaired by Jeremiah Stamler and Ignacio Balaguer-Vintró and the scientific coordinator was Susana Sans. Other academic faculty were Geoffrey Rose, Kalevi Pyörälä and Darwin Labarthe. As a consequence of the interest raised during this Seminar, many new groups and activities in prevention have been developed in different geographical areas of Spain during the last fifteen years. (Ignacio Balaguer-Vintro, Susana Sans Menéndez, Lluís Tomàs-Abadal)

References

1. De Fuentes, Sagaz M. 1994. Historia de la Sociedad Española de Cardiología. Barcelona: Mosby/Doyma.
2. Márquez, Blasco J., Calderón, Montero J., Vital, Aza, Torrecilla, Martínez I., Criado, J. 1964. Experiencia y conclusiones obtenidas en una primera campaña piloto sobre epidemiología de la fiebre reumática en Madrid. VIII. Resumen y conclusiones críticas generales. Rev Esp Cardiol 17: 649-658.
3. Vela, M. 1947. El infarto de miocardio en la juventud. Rev Esp Cardiol 947. 1: 22-41.
4. Keys, A. 1999. Adventures of a medical scientist. Sixty years of research in thirteen countries. United States Crown Printing Inc.
5. Keys, A., Vivanco, F., Rodríguez, Miñón J.L., Keys, M.H., Castro, Mendoza H. 1954. Studies on diet, body fatness and serum cholesterol in Madrid, Spain. Metabolism 3: 195-212.
6. Keys, A. 1970. Coronary heart disease in seven countries. Circulation 41 suppl 1.
7. Spain Nutrition Survey of Armed Forces. A report of the Interdepartmental Committee on Nutrition for National Defence, November 1958.
8. Hipertensión y cardiopatía Coronaria: clasificación y criterios para los estudios epidemiológicos. Primer Informe del Comité de Expertos en Enfermedades Cardiovasculares e hipertensión. Ginebra 15-18 octubre 1958. Rev Esp Cardiol 1963; 16:194-228.
9. Balaguer Vintró, I., De La Hoz, Fabra J., Tormo, Alfonso V. 1966. Recomendaciones para el estudio de la arterioesclerosis.Rev Esp Cardiol. 19: 399-405.
10. Tomás, Abadal L., Balaguer Vintró, I., Bernades, Bernat E. 1976. Factores de riesgo e incidencia de nuevos casos en el estudio de la cardiopatía isquémica de Manresa. Rev Esp Cardiol 29: 127-133.
11. Tomàs, Abadal L.l., Varas, Lorenzo C., Bernades, Bernat E., Balaguer Vintró, I., 1994. Coronary risk factors and a 20-year incidence of coronary heart disease and mortality in a mediterranean industrial population. The Manresa study, Spain. Eur Heart J 15: 1028-1036 <li.Tomás, Abadal L., Sans, Menéndez S., Caminal, Homar J., Balaguer Vintró, I. 1979. Estudio de Prevención Multifactorial de la Cardiopatía Coronaria. Diseño y metodología. Sant Paul 1: 63 66.
12. Tunstall, Pedoe H., Sans, Menéndez S., Balaguer Vintró, I., 1989. En nombre del Grupo Colaborativo Europeo de la OMS. Cambios en los factores de riesgo coronario durante 6 años de intervencion en el ensayo multifactorial colaborativo de la Organizacion Mundial de la Salud. Rev Esp Cardiol 42, supl 1: 3 16.
13. Sans, S., Balaguer Vintró, I., Fornells, J.M., Borràs, J.M., Méndez, E. 1987. Cronicat programme: review of the three years experience in a community chronic disease prevention programme in Spain. In Preventive Cardiology, Ed Chazov, E.I., Oganov, R.G., Perova, N.V. London: Harwoord Academic Publishers: 481-485.
14. Sans, Menéndez S., Balaguer Vintró, I. 1987. Programa CRONICAT: experiencia en la prevención de enfermedades cardiovasculares. Rev Clin Esp; 180 (1): 35 37.
15. Fornells, Vallès J.M., Balaguer Vintró, I. 1987. En nombre del grupo de control de la hipertensión del Programa CRONICAT. Control de la hipertension en el medio rural: 18 meses de seguimiento (programa CRONICAT). Med Clin (Barna) 89: 450 455.
16. Boada, X., Borràs, J.M., Garcia, J.M., Jodar, I., Mateu, M., Perramon, C., Subirana, J., Balaguer Vintró, I., Corrons, J. 1987. Metodologia y resultados de un programa de formacion continuada sobre el infarto agudo de miocardio. Med Clin (Barna). 89: 54 58.
17. Rodés, A., Sans, S., Balañà, L.l., Paluzie, G., Aguilera, R., Balaguer Vintró, I. 1990. Recruitment methods and differences in early, late and non respondents in the first MONICA CATALONIA population survey. Rev Epidemiol Santé Publique. 38: 447 454.
18. The INTERSALT Co-operative Research Group (among others, S Sans). INTERSALT: An international study of electrolyte excretion and blood pressure.2: Results for 24 hour urinary sodium and potassium. B M J 1988; 297: 319 328.
19. Stamler, R., Shipley, M., Elliot, P., Dyer, A., Sans, S., Stamler, J. 1992. Higher blood pressure in adults with less education: some likely explanatory factors. Findings of the INTERSALT Study. Hypertension 19: 237-241.