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Research Letters |

Computed Tomographic Assessment of Atherosclerosis in Ancient Egyptian Mummies FREE

Adel H. Allam, MD; Randall C. Thompson, MD; L. Samuel Wann, MD; Michael I. Miyamoto, MD, MS; Gregory S. Thomas, MD, MPH
JAMA. 2009;302(19):2091-2094. doi:10.1001/jama.2009.1641.
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To the Editor: The current epidemic of atherosclerosis is commonly ascribed to risk factors associated with the modern human lifestyle. Computed x-ray tomographic (CT) imaging can visualize calcium hydroxyapatite in vessel walls and is widely regarded as pathognomonic of atherosclerosis.1

To evaluate the presence of atherosclerosis in ancient humans, we performed whole-body, 6-slice CT using a Siemens Emotion 6 (Florsheim, Germany) on 22 mummies housed in the Egyptian National Museum of Antiquities in Cairo, Egypt, specifically searching for cardiac and vascular calcification. Mummies were selected for scanning based on a good state of preservation and were not randomly selected. Two mummies had been scanned previously and were included in this study because cardiovascular tissue was known to be present. The remaining 20 mummies underwent CT scanning in February 2009. Images were interpreted by consensus of 5 experienced cardiovascular imaging physicians (the authors).

Calcification in the wall of a clearly identifiable artery was considered diagnostic of atherosclerosis, and calcification along an artery's expected course was considered probable atherosclerosis. Age and sex were determined by biological anthropologic assessment and demographics assessed by a team of Egyptologists and preservationists. Identity or social position could be determined for 16 mummies; all were members of the pharaoh's court or priests or priestesses. Contrast-enhanced CT images obtained from a contemporary patient (who had provided written informed consent) were available for comparison.

The imaged mummies lived between 1981 BCE and 334 CE. Computed tomographic images demonstrated identifiable aortic or peripheral vascular tissue in 15. The heart, but not the coronary arteries, could be identified in 4, 3 of whom also had identifiable aortic or peripheral vascular tissue. Thus, 16 of 22 mummies (73%) had identifiable cardiovascular tissue (Table).

Table Graphic Jump LocationTable. Ancient Egyptian Mummy Demographics and Evidence of Vascular Calcification

Definite atherosclerosis was present in 5 of 16 mummies (31%) and probable atherosclerosis in an additional 4 of 16 (25%). Among those who died when 45 years or older, calcification was present in 7 of 8 (87%) compared with 2 of 8 (25%) who died when younger than 45 years. Calcification was present in 4 of 7 women (57%) and 5 of 9 men (56%). The most ancient mummy with findings diagnostic of atherosclerosis was Lady Rai, nursemaid to Queen Amrose Nefertari, who died in approximately 1530 BCE at an estimated age of 30 to 40 years.

Representative CT examples of atherosclerosis in the thoracic aorta, abdominal aorta, and superficial femoral artery are shown in Figure A, B, and C, respectively. An analogous image of vascular calcification in a contemporary human with lumen enhancement by CT contrast is also shown.

Place holder to copy figure label and caption
Figure. Computed Tomographic Examples of Atherosclerosis in Ancient Egyptian Mummies and a Contemporary Human
Graphic Jump Location

A, Axial computed tomographic (CT) image demonstrating calcification in the wall of the thoracic aorta (arrowhead) at the level of the aortic arch in the mummy of Lady Rai, who lived during the early 18th Egyptian dynasty (mummy No. 8). B, Calcification in the wall of the abdominal aorta (arrowhead) in the mummy of Tjanefer, a man who lived during the third intermediate period (mummy No. 5). C, Longitudinal CT view of the leg demonstrating the superficial femoral artery with a calcified plaque (arrowhead) in the mummy of a woman who lived during the 18th dynasty (mummy No. 14). The density at this location measured 1530 Hounsfield units. The view of a CT angiogram of the living individual demonstrates a calcified plaque in a similiar location with a comparable density measurement to mummy No. 14.

Evidence of atherosclerosis has been reported based on pathologic examinations performed on several mummies in the early 1900s.2,3 Our findings that atherosclerosis was not infrequent among middle-aged and older ancient Egyptians of high social status challenges the view that it is a disease of modern humans. Regarding risk factors, although ancient Egyptians did not smoke tobacco or eat processed food or presumably lead sedentary lives, they were not hunter-gatherers. Agriculture was well established in ancient Egypt and meat consumption appears to have been common among those of high social status.4 The prevalence of diabetes and hypertension during this time is unknown.

Study limitations include lack of direct pathologic evidence of atherosclerosis in these mummies to correlate with CT findings. However, vascular calcification observed on CT scanning of contemporary humans is documented to be diagnostic of atherosclerosis.1,5 While the presence of calcification does not demonstrate that atherosclerosis was a common cause of clinically manifest disease or death, it does provide evidence that humans in ancient times had the genetic predisposition and environment to promote the development of atherosclerosis.

Author Contributions: Dr Thomas had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Allam, Thompson, Wann, Miyamoto, Thomas.

Acquisition of data: Allam, Thompson, Wann, Miyamoto, Thomas.

Analysis and interpretation of data: Allam, Thompson, Wann, Miyamoto, Thomas.

Drafting of the manuscript: Allam, Thompson, Wann, Miyamoto, Thomas.

Critical revision of the manuscript for important intellectual content: Allam, Thompson, Wann, Miyamoto, Thomas.

Obtained funding: Allam, Thompson, Wann, Thomas.

Administrative, technical, or material support: Allam, Thompson, Wann, Miyamoto, Thomas.

Study supervision: Allam, Thompson, Wann, Miyamoto, Thomas.

Financial Disclosures: Dr Thompson reported receiving lecture honoraria from Pfizer, Merck, and AstraZeneca. Dr Thomas reported receiving lecture honoraria from Abbott and Merck, consulting fees from General Electric, and research support from ISIS and Hoffman-La Roche. No other disclosures were reported.

Funding/Support: This investigator-initiated study was supported by the National Bank of Egypt, Cairo; Siemens Healthcare, Florsheim, Germany; and St Luke's Hospital Foundation, Kansas City, Missouri.

Role of the Sponsors: The funding sources had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.

Previous Presentation: Presented in part at the Annual Scientific Sessions of the Society of Cardiovascular Computed Tomography; July 19, 2009; Orlando, Florida; and to be presented at the Annual Scientific Sessions of the American Heart Association, November 17, 2009; Orlando, Florida.

Additional Contributions: The Egyptology and preservationist group was an integral part of the research team, guiding selection and determination of the demographics and historical relevance of the mummies, and it received financial support. They were led by Abd el-Halim Nur el-Din, PhD (Cairo University, Giza, Egypt), with Gomaa Abd el-Maksoud, PhD (Cairo University), and Ibrahem Badr, PhD (Institute of Restoration, Alexandria, Egypt). Nasry Iskander, PhD (Center of Research, Supreme Council of Antiquities, Cairo, Egypt), also added significant contributions and received financial support. Hany Abd el-Amer, PhD (National Research Center, Dokki, Giza), was instrumental in the CT scanning and received financial support. The authors are grateful to Zahi Hawass, PhD (Secretary General of the Supreme Council of Antiquities, Egyptian Ministry of Culture), for allowing us to scan these mummies; to Muhammad Al-Tohamy Soliman, PhD (National Research Centre, Cairo), for performing the anthropological measurements to estimate the age and sex of the mummies; and to Jennifer J. Thomas, PhD (Massachusetts General Hospital, Boston), for her data analysis and critical review of the letter; these individuals did not receive financial compensation for their contributions.

Budoff MJ, Achenbach S, Blumenthal RS,  et al; American Heart Association Committee on Cardiovascular Imaging and Intervention; American Heart Association Council on Cardiovascular Radiology and Intervention; American Heart Association Committee on Cardiac Imaging, Council on Clinical Cardiology.  Assessment of coronary artery disease by cardiac computed tomography: a scientific statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology.  Circulation. 2006;114(16):1761-1791
PubMed   |  Link to Article
Ruffer MA. On arterial lesions found in Egyptian mummies (1580 BC–535 AD).  J Pathol Bacteriol. 1911;16(4):453-462
Link to Article
Long AR. Cardiovascular renal disease: report of a case three thousand years ago.  Arch Pathol (Chic). 1931;12:92-94
Darby WJ, Ghallounghul P, Grivatti L. Food: the Gift of Osiris. Vol 1. London, England: Academic Press; 1977
Agatston AS, Janowitz WR, Hildner FJ, Zusmer NR, Viamonte M Jr, Detrano R. Quantification of coronary artery calcium using ultrafast computed tomography.  J Am Coll Cardiol. 1990;15(4):827-832
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure. Computed Tomographic Examples of Atherosclerosis in Ancient Egyptian Mummies and a Contemporary Human
Graphic Jump Location

A, Axial computed tomographic (CT) image demonstrating calcification in the wall of the thoracic aorta (arrowhead) at the level of the aortic arch in the mummy of Lady Rai, who lived during the early 18th Egyptian dynasty (mummy No. 8). B, Calcification in the wall of the abdominal aorta (arrowhead) in the mummy of Tjanefer, a man who lived during the third intermediate period (mummy No. 5). C, Longitudinal CT view of the leg demonstrating the superficial femoral artery with a calcified plaque (arrowhead) in the mummy of a woman who lived during the 18th dynasty (mummy No. 14). The density at this location measured 1530 Hounsfield units. The view of a CT angiogram of the living individual demonstrates a calcified plaque in a similiar location with a comparable density measurement to mummy No. 14.

Tables

Table Graphic Jump LocationTable. Ancient Egyptian Mummy Demographics and Evidence of Vascular Calcification

References

Budoff MJ, Achenbach S, Blumenthal RS,  et al; American Heart Association Committee on Cardiovascular Imaging and Intervention; American Heart Association Council on Cardiovascular Radiology and Intervention; American Heart Association Committee on Cardiac Imaging, Council on Clinical Cardiology.  Assessment of coronary artery disease by cardiac computed tomography: a scientific statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology.  Circulation. 2006;114(16):1761-1791
PubMed   |  Link to Article
Ruffer MA. On arterial lesions found in Egyptian mummies (1580 BC–535 AD).  J Pathol Bacteriol. 1911;16(4):453-462
Link to Article
Long AR. Cardiovascular renal disease: report of a case three thousand years ago.  Arch Pathol (Chic). 1931;12:92-94
Darby WJ, Ghallounghul P, Grivatti L. Food: the Gift of Osiris. Vol 1. London, England: Academic Press; 1977
Agatston AS, Janowitz WR, Hildner FJ, Zusmer NR, Viamonte M Jr, Detrano R. Quantification of coronary artery calcium using ultrafast computed tomography.  J Am Coll Cardiol. 1990;15(4):827-832
PubMed   |  Link to Article
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