Examining the Heart of Franklin Delano Roosevelt

The skeptical cardiologist has been watching the Ken Burns documentary on the Roosevelts with the SOSC. I find TR fascinating and have always identified with him (bad eyesight, asthma, bullied as a child) but after he dies in the documentary, my interest flagged. The SOSC soldiered on, continuing to watch the series as FDR guided America through the Depression and into WW2.
My ears perked up and I began watching again when I heard that FDR was diagnosed with severe heart disease and that this was kept secret from the public even after his death until 1970.
In early 1944, he developed symptoms that his personal physician, Vice Admiral Ross McIntire, the Surgeon General of the US (an ENT doctor) thought were lingering aftereffects of  the flu. Ultimately, a second opinion was sought and he was examined at the Bethesda Naval Hospital by a young Naval medical officer, Dr. Howard Bruenn. Dr. Bruenn, unusual for the time, specialized in diseases of the heart. The upstart cardiologist  found the President had a markedly elevated blood pressure and  an enlarged heart and diagnosed him as having heart failure. Mcintire refused to accept this diagnosis initially but was overruled by a panel of “honorary consultants” who agreed with Bruenn after listening to the facts.
What fascinated me about this case was the very limited diagnostic and therapeutic modalities available to the cardiologist at that time, even for the most important person in the world. I tend to think of 1945 as in the modern era. After all, this is when the atomic bomb was developed and we had remarkably sophisticated ways of killing other humans. But in medical and cardiology advances, it was still the equivalent of the dark ages.

Cardiac Diagnostic Tools circa 1945

The diagnostic tools available to Dr. Bruenn were as follows:
1. Physical exam. He was able to listen to the lungs and hear “sibilant and sonorous rales” which suggested fluid accumulation. He palpated the point of maximal impulse of the heart (the apex) and felt that it had shifted more laterally, thus suggesting enlargement. He heard a “blowing systolic murmur at the apex.”   A murmur is basically a sound that corresponds to blood flowing across the cardiac valves, and when heard, often corresponds to a valve leakage (regurgitation) or narrowing (stenosis).
The physical exam remains an important tool for cardiologists. It is free of radiation, cost and (usually) discomfort. It does take time and an experienced examiner to do properly. The findings are often not accurate enough to be sure about a diagnosis. For example, the crackling sounds or rales heard in FDR’s lungs could be due to fluid seeping into the small air sacs of the lungs from high pressures in the heart or they could be related to a lung problem (possibly related to his long time cigarette smoking).
The murmur that was heard during systole (the time that the heart muscle is contracting or squeezing) could be due to leakage from the mitral or tricuspid valve, narrowing across the aortic valve or a hole between the left and right ventricles.
2. Vitals signs. Blood pressure and pulse with techniques essentially unchanged from today.
BP was 186/108. Very high and in the range where one could anticipate damage to “end-organs” such as the heart, the kidneys and the brain. His resting pulse was 72 beats per minute.
3. Chest radiograph of x-ray. This test suggested congestion in the lungs and enlargement of the cardiac silhouette. Prior to the advent of more advanced cardiac testing, the only information on heart chamber sizes came from chest x-rays. We still utilize chest x-rays in heart failure patients to look at the lungs for fluid and congestion but their accuracy is limited.
4. EKG. The electrocardiogram had been utilized clinically to record the electrical activity of the heart  since the early 1900s. FDR’s initial ECG is depicted below. He was in the normal rhythm but showed evidence for enlargement of the left ventricle and perhaps a problem with ischemia, our term for lack of blood flow to the heart.
 
 
 
We still use these diagnostic tools to the present day, but recognize that a significant amount of heart failure patients will be misdiagnosed without more sophisticated testing and that the precise cause of the heart failure will remain obscure.

Modern Cardiac Diagnostic Tools

By 1984, when I began my training in cardiology, cardiologists had developed the cardiac catheterization and the two-dimensional echocardiogram which precisely tell us about the complete anatomy and physiology of the heart.  These tools, if present in 1945 would have allowed determination of the pumping function of FDR’s heart, the level of pressure within each chamber of his heart, the function of the valves (and cause of his murmur) and the presence of any blocked arteries supplying blood to the heart. Without them, his cardiologist could only speculate and without an autopsy (forbidden by Mrs. Roosevelt despite the urgent request of the Russian authorities who thought he might have met foul play) we will never know what was causing his symptoms with certainty.
Once the diagnosis was made, FDR’s doctors had very limited treatment modalities available.

Hypertension Treatment Entirely Unsatisfactory

Mark Silverman, has summarized the entirely unsatisfactory approach to hypertension in 1950:

In many cases, no treatment was given on the belief that the symptomatic patient would live for many years without complications. Furthermore, physicians did not want to frighten patients by creating alarm, often informing them of a “tendency” to high blood pressure. Patients were strongly advised to achieve mental and physical tranquility by living at a lower tempo, resting and sleeping long hours and avoiding the strains of work, heavy meals and emotional upset. A mental component was strongly suspected and sedatives such as phenobarbital, chloral hydrate and bromides were used and psychotherapy might be recommended. Alcohol in moderation was permitted and thought to be helpful as a sedative and vasodilator. Salt was stringently restricted,… Drug treatment was limited to thiocyanate and veratrum alkaloids, both highly toxic drugs that were poorly tolerated.

Dr. Bruenn recommended bed rest to which Dr. McIntire replied: “You can’t do that. He’s the President of the United States.”
Despite the recognition that FDR’s BP was dangerously high and the likely cause of his heart failure, there were no medications available to lower his blood pressure.
Over the next year, FDR’s BP remained dramatically high as you can see in this chart taken from Dr. Bruenn’s 1970 paper:

 
 
 
 
 
Bruenn felt that FDR definitely had coronary artery disease, based on one episode of very typical chest pain during a speech.

“He never complained of any chest pain except, if you remember, on one occasion when he gave a speech at Bremerton, WA, on the fantail of a destroyer. 2 He kept on with the speech and came below and said, “I had a helluva pain!” We stripped him down in the cabin of the ship, took a cardiogram, some blood and so forth, and fortunately it was a transient episode, a so-called angina, not a myocardial infarction. But that was really a very disturbing situation. That was the first time under my observation that he had something like this. He had denied any pain before. But this was proof positive that he had coronary disease, no question about it.”

In 1946, one year  after FDR’s death, Dr. McIntire wrote  that FDR’s blood pressure and heart signs had been normal. Dr. McIntire has been accused by historians of destroying FDR’s medical records (they disappeared mysteriously) to hide his misdiagnosis and mismanagement of the President’s case.
It wasn’t until the publication in 1970 by Dr. Bruenn of “Clinical Notes on the Illness and Death of President Franklin D. Roosevelt” in the Annals of Internal Medicine that the record was set straight. I obtained the EKG and BP graph of FDR above from that paper.
Fortunately, in the years since FDR suffered from many of the consequences of untreated hypertension multiple effective and safe antihypertensive drugs have been  developed. It is the rare patient now that we  cannot get the blood pressure down to the current guideline level of 140/90mm Hg (150/90 for >60 years). With this success in BP reduction has come substantial drops in stroke, heart failure and heart attack rates.