Book Review

Prognosis and Risk Assessment in Cardiovascular Disease

N Engl J Med 1993; 329:1664November 25, 1993

Article

Prognosis and Risk Assessment in Cardiovascular Disease
Edited by Amar S. Kapoor and Bramah N. Singh. 578 pp., illustrated. New York, Churchill Livingstone, 1993. $79.95. ISBN: 0-443-08768-7

In modern cardiovascular practice, the natural history of almost every major disorder has been radically altered by an explosion of medical and surgical forms of therapy. Thus, the accomplished practitioner must be one who, aided by an abundance of diagnostic tools and therapeutic options, is able to choose both when to intervene and what to use.

Kapoor and Singh's textbook Prognosis and Risk Assessment in Cardiovascular Disease is designed to guide clinicians through this often difficult process for most of the common cardiovascular disorders encountered in a practice geared to adults. The book is largely successful in meeting this goal. After several chapters outlining epidemiologic issues in cardiovascular-risk assessment, the book proceeds through a series of very useful chapters covering ischemic heart disease, valvular lesions, cardiomyopathy, common arrhythmias, peripheral vascular disorders, and cardiac surgery. The book best fulfills its goals in the sections on valvular heart disease, in which issues surrounding the timing and risk-benefit ratio associated with valve replacement are thoughtfully elucidated from a clinically relevant perspective. Other excellent chapters include discussions of the prognosis associated with hypertrophic cardiomyopathy, unstable angina, and malignant arrhythmias as well as honest appraisals of data evaluating silent ischemia and premature ventricular beats as markers for future cardiovascular events. Overall, the book is appropriately conservative in tone, with emphasis placed on clinical-trial data and a rational approach, based on “clinical epidemiology,” to decision making and therapy.

As is the case in many multiauthored textbooks (there are 57 contributors), the flow from chapter to chapter is not always even; several chapters are exhaustive and abundantly referenced, whereas others present brief clinical summaries. The two entertaining and insightful chapters by Eugene Robin and Robert McCauley on the difficulties of clinical decision making are different enough in content and tone from other chapters that they almost belong in a different textbook. The book also places a somewhat unusual emphasis on coronary anatomy rather than on the pattern of symptoms; in the section on risk assessment and prognosis in coronary heart disease, there are separate chapters on single-vessel disease and disease of the left main coronary artery, but no chapter on the prognosis of patients with chronic stable angina, the clinical problem that presumably led to catheterization.

Although the book exceeds 500 pages, what is absent is likely to surprise many clinical readers. Specifically, in a textbook that devotes 10 chapters to the prognosis of patients with coronary heart disease, there is virtually no mention of the role of percutaneous coronary angioplasty, a procedure performed more than 300,000 times in the United States in 1992. In their introduction, the authors justify this omission by stating that “no meaningful data are available despite the very widespread use” of this technique. Although there is some truth to this statement, the virtual absence of discussions of angioplasty as even a potential therapeutic approach to coronary artery disease, unstable angina, and acute myocardial infarction detracts from the book and seems unwarranted in a work that provides useful insight into other promising but poorly evaluated therapies, such as interventions for silent ischemia and the use of implantable cardioverter-defibrillator devices.

Despite these deficiencies, Kapoor and Singh have crafted a textbook with clear value to residents and practitioners in internal medicine, as well as cardiologists. By their very nature, textbooks on prognosis and risk assessment require intermittent updating as knowledge concerning new therapies accrues. This book is likely to find a place in many personal medical libraries.

Paul M. Ridker, M.D., M.P.H.
Brigham and Women's Hospital, Boston, MA 02115