Book Review

Recent Advances in Cardiology

Cardiovascular Disease in the Elderly Patient

N Engl J Med 1994; 331:1386-1387November 17, 1994

Article

Cardiovascular Disease in the Elderly Patient
Edited by Donald D. Tresch and Wilbert S. Aronow. 662 pp., illustrated. New York, Marcel Dekker, 1993. $125. ISBN: 0-8247-8864-8

Clinicians have focused their attention on cardiovascular problems in the elderly since 1937, when Sir Thomas Lewis devoted a section of his Diseases of the Heart, Described for Practitioners and Student (London: Macmillan) to special problems in elderly patients. He recognized the syndrome of dyspnea, normal systolic function, and absence of histologic myocardial abnormalities at autopsy. The recent interest in the health care of elderly patients has stimulated the publication of at least four textbooks devoted to geriatric cardiology.

Practical clinical issues are driving this interest. Clinicians caring for the elderly are trying to apply existing therapeutic options rationally to elderly patients. There is persistent uncertainty with regard to applying the results of multicenter trials (which may exclude the elderly or may not analyze data with respect to age) or the reports of series of cases (possibly highly selected) from single centers. Textbooks devoted to geriatric cardiology can fill the perceived need to evaluate available data in order to apply current therapy specifically to elderly patients.

Tresch and Aronow have assembled a 26-chapter textbook (with 7 chapters by the editors) with help from their colleagues (12 of 36 are from Montefiore Medical Center or Albert Einstein College of Medicine). The book covers much of the field of geriatric cardiovascular disease and targets all physicians who care for the elderly. In general, the editors have succeeded in covering many topics, with each chapter focused on data about the elderly, and they have avoided duplicating the information found in cardiology textbooks. As with many multiauthored books, the style and content (especially the use of figures and the depth of the background discussion) vary considerably among chapters.

Each chapter first cites epidemiologic data, usually from the Framingham Study or from Aronow's interesting surveys of very elderly nursing home residents. After framing the problem, the authors discuss unique clinical presentations and diagnoses in the elderly. Extensive background discussions and reviews of pathophysiology are usually avoided. Happily, the chapters that deviate from this formula -- those on epidemiology by Vokonas and Kannell, on anticoagulation by Sebastian and Tresch, and on heart failure by LeJemtel and Sonnenblick -- provide excellently organized, detailed background information that greatly improves the usefulness of the book to nonspecialists.

The generalist and physician in training will be emboldened to pursue aggressive workups and management in the elderly by the well-documented discussions of cerebrovascular disease, hypertension, myocardial infarction, vasovagal syncope, angioplasty, and coronary bypass surgery. The chapters on mitral-valve disease (including a comparison of balloon valvuloplasty with surgery), supraventricular tachycardia, and cardiopulmonary resuscitation are also well done.

The omission of discussions of disease of the conducting system in the elderly, the natural history of the sick sinus syndrome, Doppler echocardiographic evaluation of diastolic function, and echocardiography with dobutamine for the diagnosis of coronary disease and of focused discussions of cardiomyopathies, peripheral angioplasty, and endocarditis in the elderly are disappointing but understandable, because the techniques are new or not widely available, or because few specific data have been reported for the elderly on these topics.

Overall, I found the book well organized and informative. It will be very useful to physicians who care for the elderly, both as background reading and as a reference for specific questions.

Charles R. McKay, M.D.
University of Iowa, Iowa City, IA 52242