Book Review

Atrial Arrhythmias: State of the art

N Engl J Med 1995; 333:742September 14, 1995

Article

Atrial Arrhythmias: State of the art
(American Heart Association Monograph Series.) Edited by John P. DiMarco and Eric N. Prystowsky. 432 pp. Armonk, N.Y., Futura, 1995. $70. ISBN: 0-87993-604-5

Was it only a few years ago that card-carrying electrophysiologists were turning up their noses at the mere mention of a patient with atrial fibrillation? Their thoughts were directed elsewhere, to arrhythmias that could be managed with blade, heat, or appliance. But the worm has indeed turned. Atrial arrhythmias, especially fibrillation and flutter, now command extraordinary attention from the electrophysiology community. The sheer number of patients with these arrhythmias is one reason, but more important is the incredible recent growth in treatment options, drug and nondrug. With this increased interest among all physicians has come a need to understand atrial arrhythmias and their mechanisms, pathophysiology, and natural history more clearly. To help accomplish this, the American Heart Association convened a distinguished group of scientists and clinicians in October 1993 to review the topic; this monograph is a summary of those proceedings.

The book was edited by two renowned electrophysiologists who attempt to include basic science, epidemiology, and treatment in the broad reach of the topic. The title is misleading. It suggests a wide-ranging discussion of atrial arrhythmias, but as the editors themselves point out, most of the material in the monograph deals specifically with atrial fibrillation. What was clearly not intended was any discussion of atrioventricular reciprocating or atrioventricular tachycardias, although a few chapters do contain some information on those arrhythmias. The narrow focus is unfortunate, since a wealth of new information has revolutionized the therapy of atrial flutter and other atrial tachycardias.

A limitation of this and similar monographs is that the information is not optimally organized; some clinical topics that assume basic knowledge are covered in the earlier chapters, whereas some of the basic-science chapters appear later. A few topics seem out of place, such as the highly technical chapter by Spach on nonuniform anisotropic cellular coupling. This is a problem for anyone who expects a systematic clinical review. In addition, there is the problem of overlap. For example, the same illustration involving the “maze” procedure is used by Lowe and by Josephson et al. in separate chapters. One interesting aspect of the book is the provision of editorial comments by experts in the field after some (but, curiously, not all) the chapters. Some of these are quite useful, while others merely restate what was said before.

As so often happens in a rapidly changing field, much of what is written is outdated by the time the book is published. For example, the authors of the chapters on nonpharmacologic control of the rate response to atrial fibrillation could not have anticipated the current interest in modification of the atrioventricular node as an alternative to producing complete atrioventricular block. Likewise, they could not have surmised that newer antiarrhythmic drugs, such as propafenone, sotalol, and flecainide, would supplant quinidine as rapidly as they have. Trials of anticoagulant agents have led to ever-evolving recommendations about the role of warfarin, aspirin, and other antithrombotic drugs in preventing thromboembolic events, especially stroke. Much of what we learn becomes clinical dogma faster than the presses can print.

Despite these limitations, the book makes for interesting reading. Its 432 pages contain a wealth of information presented by leaders in the field who provide unique perspectives. The price tag may deter the casual reader; one could argue that a monograph on a single subject should be more comprehensive and better organized for the price. However, for those with a strong interest in atrial fibrillation, especially those faced with the daunting task of caring for patients with this troubling arrhythmia, this book should be regarded as an important supplement to an up-to-date cardiology library.

Peter R. Kowey, M.D.
Jefferson Medical College, Philadelphia, PA 19107