Book Review

Coronary Heart Disease Prevention

N Engl J Med 1993; 328:1284-1285April 29, 1993

Article

Coronary Heart Disease Prevention
Edited by Frank G. Yanowitz. 470 pp., illustrated. New York, Marcel Dekker, 1992. $69.75. ISBN: 0-8247-8713-7

The first and last chapters of Coronary Heart Disease Prevention, by the book's editor, use a systems model to emphasize the importance of nonmedical influences on coronary heart disease. These chapters serve as lonely bookends for the middle chapters, which take the traditional approach of screening and aggressive treatment for coronary heart disease risk factors. Each of these chapters winds up having to stand on its own, with varying success. The interesting topics that might link the ends with the middle -- such as the harmful effects of labeling or the benefits of being in control of one's risk factors -- are not discussed.

Primary care physicians are more likely to engage in preventive care if they understand its purpose and know how to do it. Only a few of the chapters in this book meet those goals. The chapter on genetics is clear and concise. It is also unabashedly controversial, with a plea for additional funds to control familial hypercholesterolemia, which the author points out is as lethal and as common as AIDS. Aimed at practicing clinicians and those soon to have that role, the chapter provides just the right amount of technical detail about the genetic hyperlipidemias as well as the hows and whys of obtaining a family history. The chapter on promoting physical activity includes several practical lists, such as the energy expenditures for selected activities. (After discovering that writing was the lowest listed activity, at 1.7 metabolic equivalents, I ran to the hospital for attending rounds.) By contrast, the chapter on the preventive health examination is too broad in scope and does not explain or justify its recommendations. The chapter on high blood pressure overemphasizes epidemiology and has almost no practical suggestions, such as how far to lower blood pressure or how to use nonpharmacologic therapies. It could also benefit from some updating; the only specific treatment discussed for diastolic hypertension is the stepped-care approach from the Hypertension Detection and Follow-up Program that includes reserpine, methyldopa, and guanethidine.

Surprisingly, much is missing. An interesting chapter on stress assigns it an important role in the causation of coronary heart disease, but neglects the details of its measurement and vaguely recommends a “flexible approach” to treatment. Aspirin merits only a brief discussion. Women get short shrift: the controversy over the treatment of mild hypertension is not mentioned, nor is postmenopausal hormone-replacement therapy. Except for rehabilitation exercise programs after myocardial infarction, there is no distinct emphasis on secondary prevention, such as the use of beta-blockers. Perhaps as a result of the book's origin in Utah, alcohol is not discussed.

The references are up to date, but the editing needs to be tightened. The lipid hypothesis is discussed repetitively. The questionnaire on current exercise is located in the appendix to the diet chapter. Management algorithms would be more useful than figures showing anecdotal responses to cholesterol-lowering medications or photographs of patients doing push-ups. A specific example of the factors that influenced a particular patient's response to his or her disease might be more accessible to readers than a theoretical diagram of the model for health behavior change that contains a dozen boxes and 27 arrows.

Those seeking the big picture can peruse Coronary Heart Disease Prevention while riding a stationary bicycle. Clinicians seeking an off-the-shelf resource to answer specific questions as they arise in practice will have to look elsewhere.

Warren S. Browner, M.D., M.P.H.
Veterans Affairs Medical Center, San Francisco, CA 94121