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650 I am Dr. Henry I. Russek, a practising specialist in the field of cardiovascular disease. I received my medical degree from the Royal College of Physicians & Surgeons in Edinburgh, Scotland. Formerly, I was Director of Cardiovascular Research at the U.S. Public Health Service Hospital, Staten Island, and Research and Clinical Professor in Cardiovascular Disease at New York Medical College. In addition, I served as consultant in cardiology at several other New York area hospitals. I am a Fellow of the American College of Physicians, the American College of Cardiology, the Council on Clinical Cardiology of the American Heart Association, the American College of Chest Physicians and the International College of Angiology. I am certified by the American Board of Internal Medicine and . hold certification in the subspecialty of cardiovascular disease. I have published over one hundred and fifty scientific articles and have edited seven books concerned with diseases of the heart. Since 1968, 1 have been Program Chairman for the Annual Cardiovascular Graduate Symposium for the American College of Cardiology. I have been asked to comment on proposed legislation in the current Congress (H.R. 4957 and S. 1929) which contains several statements describing cigarette smoking as a"cause" of heart disease. would like to direct my comments to those conclusions. For more than 30 years I have had a sustained interest in identifying the factors responsible for the high incidence of coronary heart disease among persons living in the United States. My early investigations conducted in young coronary patients and healthy controls ~ clearly indicated that e: important statistically t cigarette smoking in re Those early occurrence of coronary were significant differet employment. In a quest 25,000 persons in 20 oc found between the preju< prevalence of coronary observation that the frec different professional g2 stressfulness of the occ could not say whether at or whether it is simply stress. My studies c me to question the widel blood pressure and ciga the etiology of coronary risk factors are often at clinical practice. More preventive measures dir been successful. In this physicians over a twent} significant change either ~ w 0 00 ~ ~ ~ 95-077 0-82-42

-actising specialist in the my medical degree from in Edinburgh, Scotland. .r Research at the U. S. Public Research and Clinical w York Medical College. In gy at several other New York College of Physicians, the :i1 on Clinical Cardiology of ican College of Chest Physicians Board of Internal Medicine and -diovascular disease. I have ific articles and have edited heart. Since 1968, I have rdiovascular Graduate Symposium on proposed legislation in the which contains several s a"cause" of heart disease. I conclusions. had a sustained interest in high incidence of coronary United States. My early . patients and healthy controls 651 clearly indicated that emotional stress of occupational origin was far more important statistically than high fat diet, obesity, lack of exercise or cigarette smoking in relation to prevalence of the disease. Those early observations led to our investigation of the occurrence of coronary heart disease in professional groups in which there were significant differences in the demands and responsibilities of routine employment. In a questionnaire survey which we conducted among 25, 000 persons in 20 occupational categories, a striking correlation was found between the prejudged stressfulness of occupation and the reported prevalence of coronary heart disease. Of further interest was the observation that the frequency and intensity of the smoking habit in different professional groups was directly correlated with the relative stressfulness of the occupational alctivity. Due to such confounding, we could not say whether smoking is independently associated with heart disease or whether it is simply related to what may be the real culprit, emotional stress. My studies of emotional stress and clinical experience have led me to question the widely accepted view that high cholesterol, elevated blood pressure and cigarette smoking are the most important factors in the etiology of coronary heart disease. The fact is that these traditional risk factors are often absent in new cases of heart disease encountered in clinical practice. Moreover, I believe one can question seriously whether preventive measures directed against these "etiologic" influences have been successful. In this regard, our analysis of data on American physicians over a twenty-year period showed that there had been no significant change either in overall longevity or in average age at death 95-077 0-82-42 2.

652 from coronary heart disease. This observation made it evident to us that other risk factors must be involved because U.S. physicians are reported to smoke very little and no segment of our society is more aware of the potential dangers of hypercholesterolernia and hypertension. F urther insight into the etiology of heart disease was obtained during our analysis of data from large population surveys. We observed that persons who had stop~ed smoking of their own free will actually had a lower prevalence of coronary heart disease than persons who had never smoked. The original Framingham studies showed similar findings but no attempt was made to interpret this anomaly. Our explanation is that persons who discontinue smoking for reasons unrelated to medical necessity, fear or coercion, may possess an unusual capacity for adaptation to stress and thus a diminished vulnerability to atherogenic influences. My clinical observations and research have led me to conclude that while smoking of cigarettes is harmful to the cardiac patient, many of the conclusions and findings about heart disease etiology need to be reexam- ined in a broader framework. Consistent and persuasive findings are being reported linking coronary heart disease to prolonged emotional stress, coronary-prone behavior patterns, sociocultural mobility, and stressful life events. Obviously, if cigarette smoking is involved in the pathogenesis of coronary artery disease, the relationship is far from clear and further research is needed in this complex area. ~ 3. nry1l. Russek, M.D. Statement of Bernice ; After gradu. :Iedical School "with ship and post-graduat and Medical Center, a: Psychiatric Research . Since that time, I ha- T.edicine in a pre-pai comprehensive medical environs. The Cooper eligible physicians w it owns and operates It is one of the firs Maintenance Organizat I am Presid Medicine, Trustee of to the Drug Abuse and Cooperative's Cancer and Research Foundati Hypnosis, and Chairma I am past Chief of T1 (1970-72, 1976-78), F Women's Association, American Psychiatric