Book Review

Cardiovascular Evaluation of Athletes: Toward Recognizing Young Athletes at Risk of Sudden Death

N Engl J Med 1994; 330:147-148January 13, 1994

Article

Cardiovascular Evaluation of Athletes: Toward Recognizing Young Athletes at Risk of Sudden Death
Edited by Bruce F. Waller and W. Proctor Harvey. 213 pp., illustrated. Newton, N.J., Laennec, 1993. $75.

Frequently a multiauthored book suffers from inconsistency of writing and lack of continuity. Waller and Harvey, however, have compiled a concise textbook on the cardiovascular evaluation of the athlete and have provided each chapter with clinical pearls and editors' notes -- personal points of view -- commenting in an informal way on whether the editors agree or disagree with the preceding text.

A decade ago a book on the cardiovascular evaluation of the athlete would have been viewed as overly specialized, but the reality is that clinicians now encounter athletes at every level of competitive skill, and physicians frequently face difficult decisions about the nature and importance of symptoms, physical findings, electrocardiographic changes, or dysrhythmia. This change raises one of the main issues in evaluating the athlete: what constitutes “normal” in the context of the elite amateur or world-class performer? Although sudden cardiac death is a rare event among athletes, it is frequently followed by guilt, recrimination, and 20/20 hindsight.

Waller and Harvey's book provides a systematic approach to the problem. It builds on history, physical examination, and noninvasive assessments such as exercise testing, echocardiography, and ambulatory electrocardiographic recordings (Holter monitoring). In the discussion of each procedure, there is an ample review of normal findings, whether that encompasses the echocardiographic characteristics of the athlete's heart as compared with those of patients with obstructive cardiomyopathy or the incidence of ventricular arrhythmia, bradycardia, and atrioventricular block on Holter recordings. It is not surprising, given Dr. Harvey's renown in the area of physical examination, that this aspect of the evaluation is heavily emphasized, with the support of contributors who have had considerable experience with the care of professional athletes.

As a reference book, then, this work offers reassuring statistics on “normal” findings for the clinician. In addition, a series of chapters addresses specific physical activities such as scuba diving, drug testing, and the use of controlled substances. Appendixes and position papers from the American College of Sports Medicine deal with weight loss among wrestlers, alcohol, thermal injuries, blood doping, legal issues, and recommendations and limitations for young patients with heart disease.

This work is concise, well written, and practical and contains ample figures and illustrations. If it has one weakness, it is that there is no definitive section on the care of patients with tachyarrhythmias -- one dealing with electrophysiologic study, antiarrhythmic drugs, radiofrequency ablation, or the use of implantable devices. One could certainly argue, however, that those topics are beyond the scope of this otherwise excellent work.

Thomas B. Graboys, M.D.
Brigham and Women's Hospital, Boston, MA 02115