Book Review

Atrial Fibrillation: Mechanisms and Management

Contemporary Management of Ventricular Arrhythmias

Cardiac Electrophysiology and Arrhythmias

N Engl J Med 1993; 328:291-292January 28, 1993

Article

Atrial Fibrillation: Mechanisms and Management
Edited by Rodney H. Falk and Philip J. Podrid. 428 pp., illustrated. New York, Raven Press, 1992. $95. ISBN: 0-88167-831-7

Contemporary Management of Ventricular Arrhythmias
(Cardiovascular Clinics [22/1].) Edited by Arnold J. Greenspon and Harvey L. Waxman. 368 pp., illustrated. Philadelphia, F.A. Davis, 1992. $75. ISBN: 0-8036-4343-8

Cardiac Electrophysiology and Arrhythmias
(Current Topics in Cardiology.) Edited by Charles Fisch and Borys Surawicz. 488 pp., illustrated. New York, Elsevier, 1991. $84. ISBN: 0-444-01601-5

The diagnosis and treatment of cardiac arrhythmias have evolved into a full-fledged subdiscipline of cardiovascular medicine; in recognition, the American Board of Internal Medicine has administered the first subspecialty certifying examination in clinical cardiac electrophysiology. The vigor of this subdiscipline is reflected by the publication of these three books, which represent attempts to coalesce into single-source references recent advances in our understanding of cardiac arrhythmias. Although the books are directed toward the cardiovascular specialist and subspecialist in electrophysiology, they contain state-of-the-art information that will be of use to the general internist as well as to trainees in medicine and cardiovascular medicine. It is appropriate to emphasize that internists and other providers of primary care are usually the first to encounter patients with arrhythmias; proper initial evaluation and treatment of these patients are critical to both their short-term and their long-term care.

Atrial fibrillation is probably the most common sustained arrhythmia encountered by internists and cardiologists, as pointed out by Falk and Podrid in the preface to Atrial Fibrillation. Perhaps because familiarity breeds contempt, this arrhythmia has not (until recently) been the subject of much study. This collection of articles surveys our current understanding of this common clinical problem.

After several interesting articles on pathophysiology, the medical and nonmedical management of atrial fibrillation is addressed. The reader will find a helpful summary comparing recently published trials of anticoagulation in atrial fibrillation, written by one of the investigators of the Copenhagen AFASAK (Atrial Fibrillation, Aspirin, Anticoagulation) study. Because this is currently an area of intense investigation, the article will probably require updating in the very near future.

“How can one control the ventricular rate during atrial fibrillation?” once was answered with one word: “Digitalis.” This reflex response has been challenged with the advent of alternative treatments such as intravenous calcium-channel and β-adrenergic antagonists and an improved understanding of the pharmacodynamic activity of digitalis compounds. Although the editors allude to the controversy about digitalis treatment in their preface, Falk underemphasizes this issue in his chapter on controlling the ventricular rate in atrial fibrillation. This is of interest since he and Leavitt outlined the controversy nicely elsewhere (Annals of Internal Medicine 1991;114:573-5). In general, however, this book is a useful source of current information on the pathophysiology and management of atrial fibrillation. Of the three books reviewed here, this one is likely to have the widest appeal, since the management of atrial fibrillation is a virtually unavoidable problem in treating adults.

Contemporary Management of Ventricular Arrhythmias is a volume in the Cardiovascular Clinics series. This collection of articles, each written by recognized authorities, focuses on a vexing clinical problem in cardiovascular disease. Although the book includes some material on the mechanisms of ventricular arrhythmias, its general thrust is clinical. It is therefore likely to be of interest to practitioners and trainees in medicine and cardiovascular medicine.

As noted by the editors in the preface, since the publication of the results of the Cardiac Arrhythmia Suppression Trial (CAST) (New England Journal of Medicine 1989;321:406-12), many of the old clinical saws regarding the treatment of ventricular arrhythmias have been discarded. Much of this book represents post-CAST thinking about the treatment of ventricular arrhythmias -- i.e., not only how to diagnose and treat these arrhythmias, but also how to determine which patients should not be treated and how to avoid exacerbating rhythm disturbances.

Noteworthy among the contributions to this book is a chapter on the classification of antiarrhythmic agents, by Coromilas. Many readers will be familiar with the Vaughan Williams classification of antiarrhythmic drugs found in standard textbooks. Coromilas discusses this classification in the context of a very intelligible and clinically applicable presentation of the modulated-receptor hypothesis of antiarrhythmic drug action. A chapter on ventricular arrhythmias occurring soon after myocardial infarction, by Brugada and Andries, presents a very thoughtful discussion of the literature on this subject as well as the authors' own clinical data.

As in any medical textbook, especially one focusing on a topic of current investigation, some of the data are or will soon be in need of revision. Thus, the discussions of the CAST results do not mention the recent cessation of moricizine treatment in that study. In addition, the results of the Electrophysiologic Study Versus Electrocardiographic Monitoring study, currently available only in preliminary form, will undoubtedly dictate further revision of our thinking (and writing) about the treatment of ventricular arrhythmias.

Cardiac Electrophysiology and Arrhythmias is a volume in the Current Topics in Cardiology series. As the title indicates, it is directed largely toward the subspecialist in cardiovascular and arrhythmic disorders. However, two excellent chapters focus on the differential diagnosis of wide and narrow complex arrhythmias by electrocardiography. These will be useful to medical students, trainees, and practicing internists.

A third of the book is devoted to a discussion of arrhythmic mechanisms and experimental arrhythmias. Although the book is a monograph, its basic-science content is on a par with that found in standard textbooks of cardiology and electrophysiology. The remainder of the book focuses on the diagnosis and management of clinical arrhythmias. The discussions of clinical issues, however, are presented in the context of arrhythmic mechanisms, making this much more than a cookbook for managing arrhythmias.

Several chapters are devoted to the rapidly evolving field of nonpharmacologic management of arrhythmias. Pacing therapy for bradyarrhythmias and tachyarrhythmias, cardioverter-defibrillators, and surgical and nonsurgical ablative treatment of ventricular arrhythmias are discussed in detail by recognized investigators in these fields. Notably lacking in this section, however, is a discussion of catheter ablation of supraventricular arrhythmias, an area of intense interest and recent investigation. In general, however, this book is a very useful source of state-of-the-art information about the mechanisms and management of arrhythmias. The editors and authors are to be commended for their efforts in combining up-to-date basic-science and clinical-science material in one book.

Robert F. Rea, M.D.
University of Iowa College of Medicine, Iowa City, IA 52242