How Dr. Eugene Braunwald changed cardiology, again and again and again

Dr. Eugene Braunwald is often called the father of modern cardiology. He calls that an exaggeration.

"Maybe I've been around longer, but there are a lot of people who have made major contributions to cardiology," the 95-year-old Braunwald said.

Despite risking his disapproval, people around the world who know his work continue to use such terms. Even an abbreviated summary of his career makes clear why. Over the past three-quarters of a century, Braunwald:

­­– showed that fast action could limit damage from heart attacks, paving the way for modern treatments.

– organized and led large, groundbreaking studies that showed the value of, among other things, clot-dissolving drugs and cholesterol-lowering statins that have become standard care.

– wrote and edited influential textbooks in internal medicine and cardiology that remain in use around the globe.

– led the department of medicine at Boston's Brigham and Women's Hospital, mentoring generations of top cardiologists.

Those who know him say Braunwald, whose family made a daring escape from Nazi-controlled Austria, accomplished so much through a mix of sharp observation and hard work. They also describe someone whose insights are coveted on matters personal as well as professional, who is not just a groundbreaking scientist but a passionate opera fan and an affectionate parent.

Dr. Elliott Antman, a professor of medicine at Harvard Medical School and Brigham and Women's Hospital, learned from Braunwald as a cardiology fellow and later collaborated with him on some of those groundbreaking studies. What's breathtaking, Antman said, is not just how much Braunwald accomplished but how varied his accomplishments are.

"You can find somebody who was a fantastic master clinician, but they may not be a profound researcher," Antman said. Someone else might be capable of doing research that alters a whole field, but they couldn't lead a huge medical enterprise.

Braunwald did it all. "A single individual accomplishing all of those things is remarkable," said Antman, a former president of the American Heart Association and currently its clinical science advisor.

Others agree. In 2000, editors of a European Society of Cardiology journal asked living Nobel Prize winners, "Who has contributed the most to the practice of cardiology in recent years?" Every respondent named Braunwald.

How he did it

Braunwald holds the title of the Hersey Distinguished Professor of Theory and Practice of Physic, one of the oldest endowed chairs at Harvard Medical School in Boston. He credits some of his success to simple good luck.

"I was in the right place at the right time, with the right collaborators, the right mentors and mentees," he said.

As a high school student, he'd considered a career in engineering, but his mother nudged him toward medicine. During his final year of medical school in 1951, he reluctantly accepted an elective assignment to work in a cardiac catheterization laboratory for three months. Such labs, where cardiologists perform procedures using a tube inserted into a blood vessel, are ubiquitous today but were rare then. He enjoyed the experience and later became a postdoctoral fellow in the Columbia University laboratory of Dr. André Cournand, who shared a Nobel Prize for developing this important technique.

"So when I say I was in the right place with the right people at the right time, that's an example," Braunwald said.

The connection opened doors, and in 1955, he began work at the National Heart Institute, now the National Heart, Lung, and Blood Institute. He would eventually serve as its chief of cardiology and clinical director. It was at the dawn of an era when the federal government was investing heavily in research.

At each level, success spurred him on. "It's an upward cycle," Braunwald said. "We talk about vicious cycles. This was the opposite. If something worked, it stimulated me to work harder."

Beyond luck

Braunwald's achievements were more than good fortune, said Dr. Thomas H. Lee, a senior physician at Brigham and Women's Hospital who was mentored by Braunwald. He had a gift for making wherever he was the right place and for knowing the right time to act.

"He made his entire life about answering questions that were important to improving the health of people with cardiovascular disease," said Lee, who wrote the 2013 biography "Eugene Braunwald and the Rise of Modern Medicine."

"He realized that was important, and it was interesting. And he organized around doing anything and everything that he could to make a dent in those problems," said Lee, who also is chief medical officer at the health care consulting firm Press Ganey.

Braunwald's efforts shifted with the times.

One of his early accomplishments grew out of what, at first, appeared to be a career-threatening mistake. He'd taken readings that indicated a young man had a congenital obstruction in his heart and would be a good candidate for surgery.

It was risky. "Open-heart surgery, which is routine now, was a very, very big deal in 1958," Braunwald said.

Dr. Andrew Glenn Morrow, the chief of heart surgery at the Institute, performed the operation – but found no obstruction. Mid-surgery, he summoned Braunwald to see the man's heart for himself. "And Morrow says, 'Gene, you've messed up.'"

Braunwald retreated from the operating room and called his mother to tell her, "I'm going to be fired."

Morrow and Braunwald later went over the readings, decided it was some kind of fluke and agreed to move on. But two months later, another young man came in, and the story repeated itself.

He and Morrow published their observations in Circulation in 1959 and later wrote about dozens of similar cases. They showed that severe thickening of the heart's walls caused the obstruction in the beating heart. The condition now known as hypertrophic cardiomyopathy is relatively common, and the treatments that Braunwald and Morrow identified are still widely used.

Rethinking heart attacks

What Braunwald has called his major achievement was accomplished in a lab while he was simultaneously helping create the department of medicine at the University of California, San Diego.

In the 1960s, it was thought that during a heart attack, heart muscle dies instantly, like throwing a light switch. Braunwald and his colleagues showed it was more like a dimmer switch – creating the possibility that early intervention could prevent damage.

The finding, a radical notion then, was published in Circulation in 1971. At the time, it wasn't possible to open a blood vessel to restore blood flow. Soon, that changed.

"His insight that doctors could intervene in the process to reduce injury to the heart opened the door to the entire field of modern heart-attack treatment, from clot-busting drugs to balloons that inflate inside blood vessels," the Boston Globe reported in 2002.

In 1972, Braunwald left San Diego for Harvard Medical School and to become physician-in-chief at what was then the Peter Bent Brigham Hospital, now Brigham and Women's. He would serve as chair of the department of medicine for 24 years. He's credited with transforming the culture, reshaping training and building the program into one of the nation's best. A 16-story tower at the hospital was named in his honor in 2019.

In 1984, he founded the Thrombolysis In Myocardial Infarction, or TIMI, Study Group. He and his TIMI colleagues helped show the power of the clot-busting drug tPA for treating heart attacks and strokes. Other TIMI clinical trials demonstrated the value of lowering LDL cholesterol.

Separately, he helped show the value of ACE inhibitors in treating people after a heart attack. After one large clinical trial, published in 1992, showed that an ACE inhibitor could lower mortality by 19%, they became a routine part of treatment.

Braunwald said that while the hands-on experiments of his early career contrasted with the huge clinical trials of his later years, he didn't have a preference for one type of science over the other.

"I see the whole process as a chain," he said. Coming up with an idea, experimentation, validation and publication are all different links in that chain. And "quite frankly, I'm interested in all of them."

Driven to learn

His drive to find answers was evident early on.

As a high school, college and medical student, he would use an electric clock to track his study time, he told Lee. Every time he took a break, he'd stop the clock. On Saturdays, he'd start after breakfast and wouldn't quit studying until he'd hit 13 hours.

As a professional, Braunwald could be similarly focused, Lee said. He didn't waste time with light banter. "I had meetings with him where I realized it was over when he would pick up the phone to make a call to someone else."

But Braunwald had great instincts about what was important, Lee said, whether it was a personal issue or a project. "And when he says it's important, you think, 'Oh, he's right.'"

He could tell jokes but was never the type of leader who could be found schmoozing on a golf course, Lee said. He zeroed in on "answering questions, moving the needle on what we can do for people with disease, and training great young people."

Antman said that in addition to being excellent as a clinical cardiologist, Braunwald could be "wonderful as a mentor for whatever the situation," whether it was related to a small departmental issue or a big problem at a national organization.

"If you really got to know him very well, and he could tell something was bothering you, he might actually have his administrative assistant, out of the blue, call to make an appointment for you to see him, because he sensed that there was a need to talk," Antman said.

When presented with a problem, Braunwald would listen carefully, digest the information and then give concrete, actionable advice, Antman said. "He has a unique capacity to see through all the clouds of confusion and issues and actually say, 'This is the path you want to take, so in order to achieve that goal, to get on that path, the most important things that you need to do are the following: 1, 2, 3.'"

Antman would tell trainees he knew two secrets to succeeding with Braunwald. "You must never, ever lie to him about having done something when you didn't do it. And you have to work very hard at what you're trying to do. You don't always have to be successful and get it right. You just have to have really tried and explain precisely what you did."

Braunwald's eye for detail would spot the tiniest flaws, Antman said. He recalled a chapter he wrote for the textbook "Braunwald's Heart Disease."

"There were many, many figures and tables," Antman said. "And I worked very hard to find just the right figures to illustrate the point I was trying to make and assemble the tables, and I was confident in every table and every element in every table – except for one element in one table where I wasn't completely sure."

He submitted it to Braunwald. "He called me into his office, and he said, 'Terrific job. Love everything you've got here. I just have a couple of questions.' And the first question was, 'Where did you get this?'" He pointed to the one element Antman was unsure of.

"I was able to say where I got it, and he understood," Antman said. But Braunwald said, "Let's find something better."

"He could find that one thing," Antman said, still astonished. "Now, that's incredible."

Escaping the Nazis

Antman and Lee both speculated that Braunwald's harrowing experiences as a refugee might have been part of what drove him.

Braunwald was born in Vienna, Austria, in 1929. "Life was very good when I was a child," he said. "I remember very positive things until the age of 9, when the country was taken over by the Nazis."

Braunwald's father ran a wholesale clothing business. But the family was Jewish, and the Nazis forced him to sell everything. An SS officer was assigned to oversee the sale and reap the profits.

In 1938, Braunwald's father was arrested in the middle of the night and loaded on a train with other Jewish men, presumably to be sent to a work camp. Braunwald's mother convinced the SS officer that the arrest would cost him money, given how much her husband knew about the business. The officer made a call and had Braunwald's father pulled off the train.

The family soon fled Austria for Switzerland. "It was like 'The Sound of Music' – except that there was no music," Braunwald told the Journal of Clinical Investigation in 2013. "We ended up in London two days later, literally with just the shirts on our back." The next year, with help from a relative, the family arrived in New York.

Braunwald started college at 16 and earned straight A's at New York University. But because of quotas at the time that limited the number of Jewish medical students, he was narrowly admitted to NYU's medical school in 1948. He would graduate at the top of his class.

His daughter Jill Braunwald Porter, a health care attorney who lives near him in the Boston area, said it is "just incomprehensible to hear him talk about the day the Nazis arrived in Vienna and the speed his world turned upside down." But she does not think he's been motivated by bitterness or anger. "I see it more as an intense internal drive to focus and tackle issues, to contribute, and to share knowledge while you have the ability to do so."

It's true that he works exceptionally hard, she said. "There is no one that I've ever met in my life that works half as hard as he does to this day."

Braunwald himself emphasizes that having "a very supportive family" was a cornerstone of his success. And that's a story of superlatives as well.

Family life

He met Nina Starr while they were both pre-med students at NYU and later became classmates at NYU Medical School. The couple married in 1952 after medical school graduation, and Dr. Nina Starr Braunwald would become a medical pioneer in her own right as the first woman to be a cardiac surgeon.

"I think it says a lot about him that he married someone who was such an intellectual equal and challenged him intellectually as well," Porter said.

Although he recognized the immense challenges Nina would face pursuing a career in which there were no other women, Porter said her father "was really unusual in supporting her decision to be a cardiothoracic surgeon 110%. He never, ever pressured or wanted her to be anything other than what she wanted to be, and certainly not a traditional housewife."

Nina died in 1992. Braunwald later married Elaine Smith, a former chief operating officer at Brigham and Women's, who Porter said has become "a fantastic part of the family."

Porter, the youngest of his three daughters, recalls many details that don't show up on his list of career achievements. To them, he's not a giant of cardiology. He's Dad.

"Around the house he's always wearing khakis with ink-stained pockets because he always has a pen on him," she said. He carries 3 by 5 index cards in his shirt pockets for jotting down ideas.

When she was young, after dinner with the family he would go into his den or study and crank up opera music as he worked for several more hours into the evening. His passion for the music genre is well-known.

"He absolutely loves opera," said Antman, who lived near Braunwald for many years and used to see him walk his dog after work. "He'd have headphones on, listening to a CD of some opera. And everybody learned to drive carefully because he couldn't hear the cars because he had the headphones on."

When pressed, Braunwald names Verdi as his favorite composer. "I think everybody who's interested in opera says that Verdi was the king of opera," he said.

His love for the music runs deep. "My parents met at the opera, and so I think that opera is in my DNA," he said. They started taking him to the opera in Vienna when he was 6, and it thrilled him. As a college student in New York City, he became an extra at the Metropolitan Opera, not singing but appearing in crowd scenes. "It was an extraordinary experience to be with these great artists."

Porter said one of her mother's passions was horses and her father loved the thrill of horseback riding. Showing what she called his adventurous streak, he "would go galloping off across fields on a retired racehorse, the faster the better. We would cringe, and he would have a big grin on his face."

His work has allowed him to travel around the world, another way he satisfies his curiosity to learn. While the typical passenger in a taxi stares out the window, "he'll start up a conversation with the driver and ask probing questions to better understand their perspective of what's going on in their region," Porter said.

She also knows him as an affectionate father.

"He's an excellent hugger," she said. When Porter was a girl, he would take breaks from work, lie down next to her on the carpet and watch "The Muppet Show" with her. He still holds her hand on walks.

Her father's gift for offering valuable advice applies outside of cardiology and across generations. One of her sisters became an endocrinologist; the other is a clinical psychologist. His grandchildren include a macro-economist and a materials scientist engineer whose expertise is too technical for Porter to attempt describe.

"He can have conversations with each of them," she said, and everyone seeks his professional advice.

When he's in a conversation, he gives the same intense level of focus and attention whether he's talking to the president of Harvard or his 3-year-old great-grandson, Porter said.

His ongoing work

Braunwald's first peer-reviewed study appeared in the AHA journal Circulation Research in 1954, and his name has appeared on more than 1,600 scientific papers since then – three times in October, and a detailed review on hypertrophic cardiomyopathy will soon be published.

Porter said that whatever topic her father's tackling, he reads methodically. Even at 95, he might spot something in a footnote, which "leads him to something else, and then his mind is turning, and he makes some connection." She's come across his handwritten drafts and suspects he goes through at least 10 versions of whatever he's writing. "He's just always looking to improve."

He is involved with the next edition of "Braunwald's Heart Disease," which he said people from around the world still scrutinize with each update and correspond with him about it.

That's motivating, he said. It makes him think, "I've got to stay with this. We've got to get this 13th edition out, and we've got to make certain changes because it can be improved."

Braunwald keeps on going, he said, "because I'm curious about cardiology and very excited by the new techniques that have been developed." He notes that cardiovascular disease, "even though we've had tremendous advances, is still the most common cause of death globally. So there's still a lot of work to be done."

Asked what motivated him to keep working, Braunwald said his curiosity has never abated. "The questions change," he said. "They've become bigger questions." He was intrigued by advances in genetics and the idea of primordial prevention – stopping risk factors before they start. He's also fascinated by neuroscience and neurology. "The next big advances are going to come in the central nervous system," he said.

For all he's accomplished, Braunwald said, he's still looking forward. "I think this is a very exciting time in cardiology," he said, "and I wish I could keep going, because it's so interesting."