Book Review

Cardiac Arrhythmia: Mechanisms, diagnosis, and management

N Engl J Med 1995; 333:394-395August 10, 1995

Article

Cardiac Arrhythmia: Mechanisms, diagnosis, and management
Edited by Philip J. Podrid and Peter R. Kowey. 1365 pp., illustrated. Baltimore, Williams & Wilkins, 1995. $159. ISBN: 0-683-06905-5

Drs. Podrid and Kowey invited 168 contributors to write a book on the state of the art in the study of cardiac arrhythmias. Their intention was to produce a useful book for a whole range of physicians: electrophysiologists, cardiologists, internists, and trainees. I found most of the contents well written and informative, but I wonder whether it is possible for a book to appeal equally to all these doctors, with such widely varying knowledge and experience of the arrhythmias. The format of the book is classic. It starts with mechanisms and ends with treatment. In between, many excellent chapters review such topics as antiarrhythmic-drug therapy, sudden death, methods for the stratification of risk of arrhythmias after myocardial infarction, different types of supraventricular and ventricular arrhythmias, and arrhythmias after heart surgery.

When I read the book as an arrhythmologist, I found it most useful. Of course, not everything is (or can be) covered. For example, there is no mention of the importance of reducing radiation hazards for the patient and the operator during radiofrequency ablation by pulsed fluoroscopy and the collimator. Less important was the failure to mention that ventricular tachycardia based on bundle-branch reentry may have a QRS complex with a right bundle-branch–block configuration. The tachycardia circuit can then be confined to the anterior and posterior fascicles of the left bundle branch, and the tachycardia will not be cured by ablating the right bundle branch. Such an example of a complex arrhythmia could serve to remind the cardiologist that in spite of articles suggesting that radiofrequency ablation is a rapid and easy procedure, careful analysis of an arrhythmia is required to prevent unnecessary damage to the heart.

Although as an arrhythmologist I like the book, I wonder whether it has the right format for the practicing clinician. For example, in cases of rapid rhythm, the first question is, What is the type of arrhythmia? To answer it one needs to know the steps that have to be taken to obtain that information from the electrocardiogram. The second question is, what is the significance of the arrhythmia in relation to the presence or absence and the extent of underlying heart disease, and how can that information be obtained in the least expensive manner? The third question is how to treat the arrhythmia after the first two questions have been answered. Such a practical approach calls for a different sequence of chapters from that presented here. The description of the 12-lead electrocardiogram must precede discussions of the different types of arrhythmias and their causes, mechanisms, and treatment. The practicing physician should also know how to obtain a proper history from the patient with an arrhythmia.

Many tachycardias in young people are erroneously diagnosed as neurasthenia, hyperventilation, or hysteria, simply because the doctor does not ask the appropriate questions. In addition, when managing acute myocardial infarction, the physician should know the value of lead V_4R in acute inferior myocardial infarction. It will help the physician recognize in which patient there is a 50 percent chance of high-degree atrioventricular nodal block in the acute phase of infarction. In acute anterior-wall myocardial infarction, the development of right bundle-branch block indicates not only that there is a large infarct and a high chance of pump failure, but also that survival of the acute phase will be followed in one third of the patients by a sustained ventricular tachycardia or ventricular fibrillation in the second or third week after infarction. That knowledge is essential if one is to recognize patients with acute myocardial infarction in whom an attempt to reperfuse that area is mandatory.

Emphasis on practicability is also lacking in some other chapters. In the chapter on long-term electrocardiographic recordings, I would have liked to see illustrations of the initiation of a supraventricular tachycardia by a ventricular premature beat (suggesting the use of an accessory pathway for ventriculoatrial conduction during tachycardia) or the finding of intermittent preexcitation (indicating that the patient will not have a life-threatening high ventricular rate in case of atrial fibrillation).

In summary, this book contains close to 1500 densely filled pages, but it will not completely satisfy all doctors looking after patients with arrhythmias. It will be enjoyed mostly by those who are already knowledgeable about and experienced with cardiac arrhythmias. Paradoxically, they will profit the most.

Hein J.J. Wellens, M.D.
Academic Hospital, 6202 AZ Maastricht, the Netherlands Maastricht