Book Review

Anesthesia and the Patient with Co-Existing Heart Disease

N Engl J Med 1994; 330:946March 31, 1994

Article

Anesthesia and the Patient with Co-Existing Heart Disease
Edited by Joseph I. Simpson. 491 pp., illustrated. Boston, Little, Brown, 1993. $85. ISBN: 0-316-79185-7

The title of this book implies that the anesthesiologist should find it a ready reference pertaining primarily to concerns about anesthesia in patients with “coexisting” heart disease. The editor states in the preface that “this book was written for the noncardiac anesthesiologist, dealing with the anesthetic management of the patient with heart disease who presents for elective and emergent and noncardiac surgery.” I therefore expected to find in-depth discussions of the ways in which cardiac diseases affect patients presenting for noncardiac surgery. I also expected to find an extensive discussion of risk, particularly the added risk that might be posed by the presence of cardiac disease in one form or another on a clinical situation requiring either emergency or elective noncardiac surgery.

Instead, most of this book is about the medical aspects of cardiac disease. Most of the chapters contain extensive discussions of the anatomy, physiology, pathophysiology, diagnosis, and medical treatment of all manner of cardiac disease. These are usually followed by sections about the use of anesthesia and sometimes sections about preoperative evaluation for anesthesia. Most of the chapters do not tackle the difficult problem of the preoperative assessment of risk in depth (or at all). Although often little is known about the actual risks or the risk-benefit ratios associated with specific kinds of noncardiac surgery in patients with specific kinds of uncommon cardiac disease, a great deal is known about risks and risk-benefit ratios in patients presenting for many kinds of noncardiac surgery who have ischemic heart disease. I had hoped to find a detailed discussion of the latter subject, but did not. In most of the chapters many of the early pages are devoted to anatomy, physiology, diagnosis, and pharmacology -- topics that, frankly, would require unflagging attention to wade through to get to the parts about preoperative evaluation, risk assessment, or management. Some chapters even contain detailed discussions of surgical techniques used to treat heart disease.

Many chapters contain whole pages devoted to blurry photos of echocardiographic images. There are curious overemphases and underemphases. In chapter 3, which discusses the hemodynamic effects of intravenous anesthetic agents, for example, only half a page is given to a discussion of the recently introduced and interesting agent propofol, whereas a whole page presents an accurate but useless diagram of the chemical structures of opioids.

Another disturbing problem with this book is the inability of some of its authors to resist making unreferenced statements that, however innocuous they may seem to anesthesiologists, may prove problematic when used against us by lawyers -- for example, “There is no documented difference between the complication rate of radial artery and femoral artery cannulation, but it would be appropriate to avoid the femoral site in obese patients.” Obesity is not defined here; if a physician cannulates the femoral artery of a patient who somebody thinks is obese, and if that patient has a complication, such words are discovered by lawyers with amazing frequency. Another example of this problem: “Since it is difficult to assess how many lives would be lost without the use of the pulmonary-artery catheter, the benefit of the doubt should tilt in favor of using it when indicated.” The author's “indications” are anecdotal and unreferenced in the same paragraph.

Most chapters are heavily referenced and are indeed in-depth discussions, mostly well written and scholarly. My main criticism is that although these chapters are scholarly discussions of pathophysiology, medical diagnosis, and therapy, sometimes even cardiovascular surgical therapy, they include only superficial discussions of risk related to anesthesia in patients with heart disease, risk-benefit ratios, and the preoperative and intraoperative management of anesthesia -- yet the latter subjects are the stated focus of the work. Put another way, in this book cardiology is presented in greater depth than it generally is in major textbooks of anesthesiology and in less depth than it is in major textbooks of cardiology. Perhaps the book should have been titled A Primer of Cardiology for Anesthesiologists. It might be very helpful for anesthesiologists wishing to review cardiology, invasive monitoring, and cardiovascular pharmacology, but it will be less useful as a reference for those faced with patients with coexisting heart disease who present for noncardiac surgery.

John H. Tinker, M.D.
University of Iowa Hospitals and Clinics, Iowa City, IA 52242