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Vindication -
                 At Last
A Look at the History of Beta-Blocker Therapy and Professor Y.C. Lee

Details, details, details. For a cardiologist, attention to details is part of the job description. Sometimes the details are obvious, and sometimes they are subtle. But they are always important. The patient’s life depends on the physician’s ability to properly interpret the details, diagnose the problem, and determine the proper course of treatment and rehabilitation. For Yu-Chen (Y.C.) Lee, MD, professor emeritus of medicine at Maryland, attention to details is more than a professional attribute. It is a point of pride and a personality trait. In a medical career spanning half-a-century, including 40 years at Maryland, Dr. Lee has come to personify a physician’s attention to details.

On one recent afternoon, the detail in question was a medical file now more than three decades old. "I know I still have it," said Dr. Lee as he headed down the stairs of his home in Catonsville, Maryland. Moving quickly for a man of 77, he emerged from the basement moments later with the object of his search. The thin folder had yellowed with age, but was still in pristine condition. The typed notes, dictated by Dr. Lee in 1972, seem ancient when compared to the documents churned out by today’s word processors and laser jet printers. But their appearance only adds to the provenance. For in these documents are the details of Dr. Lee’s contribution to a breakthrough in cardiac care.

The file contained a series of reports on the care and treatment of a 72 year-old man who was dying of heart failure. The patient was hospitalized and not responding to conventional treatment. On the patient’s chart, Dr. Lee described his condition: "Patient has a long-standing history of hypertension and developed severe congestive heart failure. Resistant to digitalis, diuretics, and bed rest." Years of high blood pressure had damaged and weakened the man’s heart. Now, in an effort to compensate, his heart was beating too fast, putting more strain on the heart muscle. The prognosis was poor.

Dr. Lee thought a new kind of drug -- a beta-blocker -- might improve his condition. Beta-blockers thwart the effects of stimulating hormones such as adrenaline, or epinephrine. Dr. Lee theorized a beta-blocker, in a small dose, would lower the heart rate and reduce the workload on the heart. But Dr. Lee knew that it would be viewed as a radical treatment. According to conventional medical wisdom, beta-blockers were contraindicated. In fact, doctors were taught in medical school that beta-blockers are bad for heart failure because they slow down the heart and weaken the contractions. Knowing that the patient’s life, and his own professional reputation hung in the balance, Dr. Lee took a daring step. Again, from the medical record: "10 mg of propranolol every six hours were given orally."

According to the record, "His cardiac rate dropped from 115 to 90 and there was a remarkable improvement in the patient’s symptoms." After leaving University Hospital, the patient kept taking the beta-blocker and lived for several more years.

It was a positive outcome for the patient, but for Dr. Lee it was the start of a long battle for vindication and recognition. "Initially, I received a great deal of ridicule," says Dr. Lee. "I was considered crazy for prescribing a medication that was contraindicated." The idea that beta-blockers would only weaken the heart was accepted as gospel by nearly everyone in the medical community. Most doctors simply could not believe that reducing the heart rate could help someone suffering from the debilitating symptoms of heart failure.

Heart failure, also called congestive heart failure or CHF, is a disorder where the heart loses its ability to pump blood efficiently. As a result, the body doesn’t get enough oxygen and nutrients, leading to problems like fatigue and shortness of breath. Everyday activities such as walking, climbing stairs, carrying groceries, and yard work become difficult, if not impossible. Because the heart can’t keep up with the blood returning to its chambers, fluid collects in the lungs and/or other dependant parts of the body, causing swelling. As the body tries to compensate, the heart rate increases, exacerbating the problems.

Nearly 5 million Americans are currently living with heart failure, with 550,000 new cases diagnosed each year. While there are many causes of CHF, the most common are hypertension and coronary artery disease. There is no cure for congestive heart failure, but in many cases it can be managed through medication, and diet and lifestyle changes. In some cases, bypass surgery, a pacemaker, or other heart-assist device may help relieve symptoms. When the damage is severe, a transplant may be the only long-term solution.

In 1972, the conventional treatment included digitalis -- to strengthen the heart muscle and diuretics -- to remove excess fluid and reduce swelling. Dr. Lee knew that if beta-blockers proved to be effective, doctors would have another powerful weapon to treat heart failure. Despite the skepticism expressed by some of his colleagues, Dr. Lee treated seven additional heart failure patients with low doses of propranolol, one of the first beta-blockers approved for use in the United States. In 1978, Dr. Lee reported the results at an international symposium on beta-blockers held in New York. "There was a definite improvement of congestive heart failure in six of seven patients," wrote Dr. Lee.

The article received little attention, but Dr. Lee was not alone in his belief that beta-blockers were an effective treatment for heart failure. In Sweden in 1973, cardiology professor Finn Waagstein had also used beta-blockers to treat congestive heart failure, and was meeting the same skepticism. In 1975, Dr. Waagstein reported on the beneficial effects of beta-blockers for cardiac patients in the British Heart Journal. While the evidence was mounting in favor of beta-blockers, the proof was slow in coming. As late as 1982, an article in the New York Times cautioned, ". . . that patients with congestive heart failure and certain other disorders of the heartbeat should not take beta blockers." Undaunted by the skeptics, Dr. Waagstein continued to investigate beta-blockers in Sweden, while Dr. Lee established himself as a leading cardiologist at Maryland.

"Y.C. worked extremely hard, and had an intense, no nonsense approach" says longtime colleague Philip A. Mackowiak, ’70, professor of medicine at Maryland. "He is an excellent physician and teacher and set an outstanding example for our residents. For cardiology, he was the go-to guy." The two still see each other frequently at grand rounds which Dr. Lee attends religiously.

While he retired from the division of cardiology in 1988, Dr. Lee has made several comebacks, working part-time or as a consultant. He recently agreed to return to work once again to assist in the training of fellows in non-invasive cardiology. "It is certainly inspirational," says fellow cardiologist Mary Corretti, MD, associate professor of medicine. "He has a genuine love of medicine, is still enthusiastic about learning, and enjoys imparting his experience and knowledge to young doctors and students."

A friendly and gracious man, Dr. Lee would probably balk at hearing himself described as spry. Perhaps it’s better to say he is in terrific shape for a man who is well into his seventh decade of life. Still fit and trim, he has always tried to practice what he preaches. "I am very grateful that I never wanted to smoke," says Dr. Lee, who has always gotten plenty of exercise. During his years at the hospital, Dr. Lee would make a point of walking from the first floor to the eleventh floor at least once a day. The routine wore out residents and students who often tagged along to ask questions. "He is very good at tennis, and we love to walk, walk, walk," says Gretchen, his wife of 42 years. The couple has lived in Catonsville since 1961.

Y.C. Lee was born and educated in Taiwan. He knew as a young man that he wanted to be a physician, but World War II nearly derailed his aspirations. "My freshman year in medical school was interrupted when all of the students were drafted," he recalls. Luckily the war soon ended there, and Y.C. was able to resume his studies. He practiced medicine in Taiwan and came to the United States in 1954. In 1960, he joined the faculty at Maryland. Since then he has treated thousands of patients, saved countless lives, and influenced a generation of young doctors.
"Physical diagnosis is one of his strengths," says Gary D. Plotnick, ’66, professor of medicine and assistant dean for student affairs. "Residents and fellows could see how excited he was to be around patients. He had fun talking to them while conducting the exam, and the patients loved talking to him," says Dr. Plotnick, who worked with Dr. Lee in the echocardiography lab. "On a professional level, Y.C. didn’t always get the credit he deserved because he was fairly unassuming about his accomplishments."

Perhaps the greatest testament to Dr. Lee’s influence is his daughter, Elizabeth, who inherited her father’s love of science. As a child, Elizabeth was exposed to medicine almost every day—without ever having to leave the house. In addition to the rigorous schedule he kept at the university, Dr. Lee also saw patients in the family’s home. As she got older, Elizabeth would often accompany her father to work, fascinated by what her father did for a living.

It must have made quite an impression. Elizabeth went on to earn her MD from Maryland in 1989, and today, Elizabeth Herrera is associate professor of anesthesiology at the Baylor College of Medicine. Her specialty? Cardiac anesthesiology, of course. "My father has always been very dedicated and enthusiastic about his work, and that definitely had an impact on me," says Dr. Herrera. "He is one of those people who will never really lose interest in what he is doing."

So it’s not surprising that Dr. Lee was paying close attention in 1998, when an international study of more than 4,000 heart failure patients proved that adding a beta-blocker to the standard treatment increases survival by about 35 percent. The results were so positive that the study was stopped three years early; so that all of the volunteers could be offered beta-blocker therapy. The U.S. co-director for the study was cardiologist Stephen Gottlieb, MD professor of medicine at Maryland and director of the heart failure service and cardiac care unit at the medical center. "With this large study, we now know that by adding beta-blocker therapy to our standard treatments for heart failure, we can save many more lives," said Dr. Gottlieb.

The landmark study provided the vindication Dr. Lee had been seeking for more than two decades. "It was extremely gratifying to know that I was right." It was especially sweet because Maryland physicians led the research. Even before that study, Maryland cardiologist Michael Fisher, MD had recognized the benefits of beta-blockers. "Dr. Fisher was instrumental in advancing our understanding of beta-blockers and their effectiveness in treating heart failure," says Dr. Lee. Today, beta-blockers are part of the standard treatment for heart failure. Medical school curriculums have been updated, and the American Heart Association is educating the public about the benefits of beta-blockers in the treatment of heart failure.

While Dr. Lee was among the first to use beta-blockers to treat congestive heart failure, it was Dr. Waagstein who received the credit for making the discovery. When Dr. Waagstein was awarded the King Faisal prize for medicine in 2001, his contribution was hailed as "the greatest recent breakthrough in heart failure therapeutics." Dr. Lee seems to be okay with that, as long as the record is clear about his own contribution. In a lifetime devoted to the science of medicine, it is an important detail that will not be forgotten. 

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