Book Review

Emergency Cardiac Care

N Engl J Med 1995; 332:689-690March 9, 1995

Article

Emergency Cardiac Care
Edited by W. Brian Gibler and Tom P. Aufderheide. 758 pp., illustrated. St. Louis, Mosby, 1994. $89.95. ISBN: 0-8016-7056-X

It is interesting that in the past 25 years emergency medicine has become the medical specialty that provides care during the first 60 minutes of an emergency medical encounter regardless of a patient's age, sex, or disease. There are now four journals of emergency medicine that publish results of basic and clinical research in this field. This testimonial to the maturity of the specialty justifies the creation of a standard reference for clinicians dealing with cardiac emergencies. To this end, all the contributors to Emergency Cardiac Care have pooled their resources and expertise as emergency physicians. Despite the many contributors, there is a uniformity of style and organization that makes this textbook easy to read. There are excellent illustrations, charts, and tables, as well as diagnostic and therapeutic algorithms. However, because the editors have not used a sharp pencil, there is tremendous redundancy. Perhaps their attitude is that if it is worth mentioning, it is worth repeating.

Thirteen of the 25 chapters deal with coronary artery disease; half of these include an evaluation and differential diagnosis of chest pain. There is general agreement that history-taking is the most important aspect of the clinical evaluation, but none of the contributors present Heberden's classic description of angina. This is surely the gold standard against which all other descriptions must be compared.

We are told that 5 million people present to emergency rooms annually with chest pain, 1.5 million of whom have coronary artery disease. Emergency rooms release 40,000 patients who are subsequently found to have had acute myocardial infarction. The cost of settling malpractice suits resulting from these erroneous emergency room dismissals average $115,000 per case. However, Emergency Cardiac Care gives no advice to help physicians reduce the number of such dismissals. The best and most sensible approach to emergency room evaluation of chest pain is given in the chapter dealing with medicolegal aspects of emergency room care. This chapter should be mandatory reading for anyone who sees patients with chest pain in the emergency room or office. One of the major factors responsible for erroneous dismissals is improper interpretation of electrocardiographic findings. This is also the most common cause of delays or failures to treat acute myocardial infarction with thrombolysis or angioplasty. Therefore, emergency physicians should strive to enhance their electrocardiographic skills. The use of other tests suggested in this book, such as echocardiography and radionuclide cardiography, would be costly and have a low sensitivity and predictive value.

Detailed discussions of permanent pacing, implantable cardioverter–defibrillators, valvular heart disease, and infection take up a substantial portion of the book. Much of these discussions has little relevance to emergency cardiology. The chapter on valvular heart disease erroneously implies that there are systolic components to the Austin Flint murmur and mistakenly ascribes the opening snap to systolic movement of the anterior leaflet. Old saws that should be modified or eliminated include the listing of “changing murmur” as a characteristic of infectious endocarditis. It should read “a new murmur or increasing murmur of aortic or mitral insufficiency.” In the discussion of hypertension, there is no mention of erroneous blood-pressure readings resulting from excessive arm circumference or inadequate cuff width. The techniques of measuring forearm blood pressure and of measuring blood pressure by palpation are not discussed, although these have clear-cut emergency implications.

Conspicuously absent is a review of syncope. After unstable angina and acute myocardial infarction, syncope is the most common cardiovascular emergency. It is a condition in which the initial history taking and physical examination may be most important in helping to establish a cause.

The portions of the book dealing with coronary artery disease have relevance for those in emergency medicine and are of considerable clinical value. Unfortunately, almost half the book does not deal with cardiovascular emergencies. Therefore, Emergency Cardiac Care is overly long and an average textbook of general cardiology rather than an excellent textbook of emergency cardiac care. Despite these criticisms, noncardiologists who treat emergency cardiovascular problems will find this a valuable addition to a medical library.

Marvin I. Dunn, M.D.
University of Kansas Medical Center, Kansas City, KS 66160-7378