Elsevier

The Lancet

Volume 381, Issue 9873, 6–12 April 2013, Pages 1211-1222
The Lancet

Articles
Atherosclerosis across 4000 years of human history: the Horus study of four ancient populations

https://doi.org/10.1016/S0140-6736(13)60598-XGet rights and content

Summary

Background

Atherosclerosis is thought to be a disease of modern human beings and related to contemporary lifestyles. However, its prevalence before the modern era is unknown. We aimed to evaluate preindustrial populations for atherosclerosis.

Methods

We obtained whole body CT scans of 137 mummies from four different geographical regions or populations spanning more than 4000 years. Individuals from ancient Egypt, ancient Peru, the Ancestral Puebloans of southwest America, and the Unangan of the Aleutian Islands were imaged. Atherosclerosis was regarded as definite if a calcified plaque was seen in the wall of an artery and probable if calcifications were seen along the expected course of an artery.

Findings

Probable or definite atherosclerosis was noted in 47 (34%) of 137 mummies and in all four geographical populations: 29 (38%) of 76 ancient Egyptians, 13 (25%) of 51 ancient Peruvians, two (40%) of five Ancestral Puebloans, and three (60%) of five Unangan hunter gatherers (p=NS). Atherosclerosis was present in the aorta in 28 (20%) mummies, iliac or femoral arteries in 25 (18%), popliteal or tibial arteries in 25 (18%), carotid arteries in 17 (12%), and coronary arteries in six (4%). Of the five vascular beds examined, atherosclerosis was present in one to two beds in 34 (25%) mummies, in three to four beds in 11 (8%), and in all five vascular beds in two (1%). Age at time of death was positively correlated with atherosclerosis (mean age at death was 43 [SD 10] years for mummies with atherosclerosis vs 32 [15] years for those without; p<0·0001) and with the number of arterial beds involved (mean age was 32 [SD 15] years for mummies with no atherosclerosis, 42 [10] years for those with atherosclerosis in one or two beds, and 44 [8] years for those with atherosclerosis in three to five beds; p<0·0001).

Interpretation

Atherosclerosis was common in four preindustrial populations including preagricultural hunter-gatherers. Although commonly assumed to be a modern disease, the presence of atherosclerosis in premodern human beings raises the possibility of a more basic predisposition to the disease.

Funding

National Endowment for the Humanities, Paleocardiology Foundation, The National Bank of Egypt, Siemens, and St Luke's Hospital Foundation of Kansas City.

Introduction

When in the course of human history did atherosclerosis appear? Is it a disease of lifestyle? Of ageing? Of another cause? With the doubling of life expectancy across the developed world between 1800 and 2000,1 atherosclerotic vascular disease has replaced infectious disease as the leading cause of death across the developed world.2 A common assumption is that atherosclerosis is predominately lifestyle-related and that if modern human beings could emulate preindustrial or even preagricultural lifestyles, that atherosclerosis, or least its clinical manifestations, would be avoided.3

Human cultures residing in environments that are either very dry, hot, or cold have independently discovered how to mummify their dead. Thus, preindustrial or preagricultural cultures created the opportunity for a natural experiment—to study these ancient human beings with modern CT scanning to assess the extent of vascular calcifications in diverse environments and cultures. A common component of a mature atherosclerotic plaque, vascular calcification in modern day human beings is pathognomonic for atherosclerosis.4 Calcification consistent with atherosclerosis has been identified by CT scanning in the naturally mummified Iceman from present day Italy who lived around 3000 BCE (before common era).5 More than a century ago, Johann Nepomuk Czermak6 and Sir Marc Armand Ruffer7 gave serious evidence for atherosclerosis in several autopsies of Egyptian mummies from around 1000 BCE. Our recent studies confirmed these findings of atherosclerosis in 20 of 44 Egyptian mummies who lived during several dynasties between 1981 BCE and 364 CE (common era).8, 9 However, ancient Egyptian culture and lifestyles might have had unique attributes relative to atherogenesis. Moreover, mummification in Egypt during the bulk of this time was primarily performed on elite Egyptians of high socioeconomic status.

We now ask whether atherosclerosis was common in other ancient societies, including those that had very different diet and genetic makeup to the people of ancient Egypt. The current HORUS study (named for Horus, the ancient Egyptian deity) addressed these and related questions by CT scanning the bodies of mummies from numerous geographically and chronologically disparate cultures.

Section snippets

Study design

137 mummies from populations of four disparate geographic regions were studied by whole body CT scanning: 76 ancient Egyptians (predynastic era, ca 3100 BCE, to the end of the Roman era, 364 CE, 13 excavation sites), 51 early intermediate to late horizon peoples in present day Peru (ca 200–1500 CE, five excavation sites), five Ancestral Puebloan of the Archaic and Basketmaker II cultures living in southwest America (ca 1500 BCE to 1500 CE, five excavation sites), and five Unangan people living

Results

Table 1 shows the demographic and cardiovascular findings of the 137 mummies. The Egyptian mummies generally had better preservation of soft tissues because of embalming techniques. Mummies from the other cultures were naturally mummified without evident evisceration or embalming. Age at death and sex could not be established in four mummies because of poor preservation. In another mummy, age, but not sex could be established, resulting in an age estimate being available for 132 of the mummies.

Discussion

Atherosclerosis was prevalent in mummies from many cultures across four disparate geographical regions over several time epochs. Our findings are consistent with previous autopsy studies of atherosclerosis in several ancient Egyptians,6, 7, 17 autopsies of two Unangan men, one estimated to be age 40–59 years and the other 45–57 years, who were collected from the same cave and time period as the five Unangans in the current sample,18, 19 and of an Inuit woman in her 50s living on St Lawrence

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