Book Review

Vascular Medicine

N Engl J Med 1993; 329:738-739September 2, 1993

Article

Vascular Medicine
Edited by Joseph Loscalzo, Mark A. Creager, and Victor J. Dzau. 1211 pp,. illustrated. Boston, Little, Brown, 1992. $135. ISBN: 0-316-53317-3

The chief difference between this new book and other textbooks on the subject of vascular medicine is that the first 400 pages are devoted to an in-depth discussion of the biologic features of blood vessels and the pathophysiologic aspects of vascular disease. This material is well organized and well presented, with excellent references. To my knowledge, this is the first time that modern approaches to the cell biology of blood vessels have been comprehensively summarized for clinicians. In fact, the first several chapters should be required reading for any cardiologist performing invasive cardiologic procedures.

Chapter 1, on normal endothelial-cell physiology by Eric Jaffe, is simply outstanding. With more than 800 references, it is a thorough exposition of the topic. The author has emphasized the aspects of endothelial physiology that are rapidly leading to alterations in the therapy and management of disease. Chapter 6, by Jacek Hawiger, on the interaction of platelets with endothelium is also a superb review of this complex and rapidly evolving subject.

In the second section, on the pathophysiologic features of vascular disease, the chapters by Stephen Schwartz and Rodney Dilley on vascular injury and by Michael Mendelsohn and Joseph Loscalzo on endotheliopathies provide material that has not previously been included in textbooks of vascular medicine. Atherosclerosis is covered in two chapters: one on cellular biology by Russell Ross, and one on the role of lipids in the pathogenesis of atherosclerosis by John Guyton and Antonio Gotto. The subject is reviewed in considerably more depth than usual.

Taken together, the first two sections on the basic cell biology, biochemistry, and physiology of vascular disease represent a new contribution to the field. I believe it is a very important one. The third section, on diagnostic methods in vascular disease, begins with the examination of the patient; it covers noninvasive testing, nuclear testing, angiography, computed tomographic scanning, and the use of magnetic resonance imaging (MRI), with separate chapters on each subject. Chapter 15, on the examination of the patient, is relatively short. Curiously, it covers most of the basics but does not address many orthopedic conditions that are frequently confused with intermittent claudication. It also fails to include a detailed explanation of the clinical evaluation of thoracic outlet syndromes. The chapter on MRI provides a detailed discussion of basic principles and reviews the pros and cons of the various techniques used in imaging different areas of the arterial tree. Dr. Schaefer's chapter on the management of hyperlipoproteinemias includes many of the rare forms of hyperlipoproteinemia but discusses the treatment of common disorders only in tabular and abbreviated form, without providing a comprehensive review of the principles of treatment. A chapter on anticoagulant, antiplatelet, and fibrinolytic agents covers many of the basic mechanisms. There is only limited mention, however, of the role of glycoprotein IIb/IIIa inhibitors and of the role of this receptor in platelet aggregation. In my opinion, this subject warrants a more detailed discussion, since these agents will be used extensively in the next few years.

The final section of this book, on specific vascular disorders, unexpectedly includes a chapter on the management of coronary artery disease and one on the diagnosis and management of cerebral vascular disease. Several common forms of peripheral vascular disease are not discussed, however. There is no coverage of the management of ischemic or venous stasis ulcers, except a few brief allusions to the use of an Unna's paste boot for stasis ulcers. Discussion of the care of patients with upper-extremity vasospastic disorders is extremely limited. The chapter on pulmonary thromboembolic disease contains considerable information on the physiology of the disorder, but it does not really address the therapeutic implications of the mechanisms of disease development. The importance of identifying early small emboli as a prelude to the onset of fatal emboli is not emphasized. The chapter on chronic venous disorders also has considerable information on the physiologic aspects of venous flow, but there is little on the treatment of these common diseases. An unusual feature is a separate chapter on neoplastic diseases of blood vessels.

Overall, I believe this book adds substantially to the literature on vascular medicine. Its major strengths are the superb reviews of the physiology, cell biology, and biochemistry of vascular disease. I know of no other textbook of vascular medicine that contains the information in these chapters. The chief weakness is that the book does not include discussion of some common vascular disorders. I would recommend this book as required reading for anyone practicing in the area of peripheral vascular disease and also for those involved in angioplasty and related techniques.

Bruce A. Kottke, M.D., Ph.D.
Mayo Clinic, Rochester, MN 55905