Book Review

Cardiovascular Disorders: Pathogenesis and Pathophysiology

N Engl J Med 1993; 329:737-738September 2, 1993

Article

Cardiovascular Disorders: Pathogenesis and Pathophysiology
Edited by Michael B. Gravanis. 576 pp., illustrated. St. Louis, Mosby-Year Book, 1993. $95. ISBN: 0-8016-6336-9

In preparing this book, Gravanis recruited 21 contributors, including 16 from Emory University, to produce 17 chapters, 13 of them coauthored by the editor himself. Each is introduced by a neat outline before proceeding, usually successfully, to cover the material promised in the book's title, with varying emphasis on molecular biology and genetics. The introduction by Willis Hurst emphasizes the suitability of this material for everyone from the student to the specialist, and for once this recommendation amounts to more than a publisher's blurb. Yet, although this book is a major educational achievement, there are imbalances and omissions.

An initial state-of-the-art chapter on atherogenesis is followed by two comprehensive, beautifully illustrated minimonographs coauthored by one of the Renaissance people of cardiology, Harisios Boudoulas: “Ischemic Heart Disease” (50 pages) and “Valvular Heart Disease” (54 pages). These chapters successfully integrate anatomy, pathology, and physiology in the gamut of clinical syndromes. Concise discussions of molecular changes in acute myocardial ischemia and of Boudoulas's pioneering work, ranging from diastolic time (“the forgotten dynamic factor”) to valvular prolapse, are outstanding. In contrast, the paltry 15 pages of chapter 8, “Pericardial Disease,” are well written and necessarily highly condensed, yet one wonders whether there was space rationing. The author, in describing rheumatoid pericarditis, manages to misreference the depressed level of atrial natriuretic factor (ANF) in cardiac tamponade and constriction without mentioning its key manifestation (myocardial stretch) or its striking contrast with the increase in ANF in heart failure at comparable central pressures. Equally incomprehensibly, transmural cardiac pressures are nowhere mentioned in a discussion that otherwise outlines reasonably well the physiology of cardiac tamponade and pulsus paradoxus.

Only parsimony can explain why “The Cardiomyopathies” covers all of them, plus myocardial biopsy, in a mere 43 pages, including references. Restrictive cardiomyopathy receives only 5 pages, 2 1/2 of them on the hypereosinophilic syndrome. In contrast, Wenger's “Tumors of the Heart,” a strong, concise minimonograph, highlights atrial myxomas with excellent illustrations of all imaging methods, and even a good old phonocardiogram of a tumor plop. This chapter's logical, comprehensive, lucid presentation is characteristic of its author.

“Cardiac Hypertrophy and Hypertensive Heart Disease” emphasizes molecular biology and the role of specific genes, such as proto-oncogenes, as well as more familiar aspects of its subjects. “Pulmonary Hypertension and Cor Pulmonale” is an excellent integration of anatomy and physiology, which beautifully condenses the essentials of primary pulmonary hypertension into seven pages. In contrast, “Cardiovascular Manifestations in Systemic Diseases” cuts a wide swath, and one often wishes for more depth; only the discussion of Marfan's syndrome tends to satisfy this wish. “Cardiac Manifestations of Inherited Metabolic and Nutritional Disorders” must receive similiar criticism because of considerable disproportion in its sections. The discussion of muscular dystrophy, for example, crams into 14 lines the Duchenne's and Becker's forms and even myotonic dystrophy, whereas neuronal ceroid lipofuscinosis receives 20 pages. The succeeding chapter on structural congenital heart disease is comprehensive, but only 18 pages are allotted to “Pathogenesis and Pathology of Arrhythmias in Conduction Disease.” Among these, fascicular block is relegated to 10 lines, including the assertion that “the most common causes of left anterior fascicular block are coronary disease and Chagas' disease.”

The foregoing criticisms are individually serious, but the book is a net success and can be modified in forthcoming editions. Its praiseworthy chapters are in the majority, and those coauthored by Boudoulas and Wenger are by themselves worth the price of the book.

David H. Spodick, M.D., D.Sc.
St. Vincent Hospital, Worcester, MA 01604