Book Review

Heart Failure in Clinical Practice

N Engl J Med 1997; 336:1396-1397May 8, 1997

Article

Heart Failure in Clinical Practice
Edited by John J.V. McMurray and John G.F. Cleland. 318 pp. St. Louis, Mosby, 1996. $75. ISBN: 1-85317-225-1

The historical perspective with which this book begins informs us that the ancient Greeks considered the heart to be the seat of the human spirit and that the ancient Egyptians used bleeding to improve breathlessness. In modern times heart failure has become an important public health problem, partly because we can now treat myocardial infarction more effectively and also because we physicians are dealing with an aging population. Rather than write a comprehensive review, the editors of this predominantly British book, with contributions from the United States, Sweden, and New Zealand, have chosen key topics of clinical and research interest for the authors to tackle.

The initial chapters discuss the epidemiology, treatment, and diagnosis of heart failure. Their message is that the diagnosis can be elusive; in some patients a wrong diagnosis leads to overtreatment with diuretics or to undertreatment, especially the failure to use angiotensin-converting–enzyme (ACE) inhibitors. The latter not only robs the patient of the chance for a longer life but may also raise health care costs by increasing the frequency of hospital admissions. A chapter on heart failure in the elderly fails to persuade the reader that older patients should be looked at in a different light, but it usefully discusses the controversial problem of diastolic heart failure.

The central section deals with specialized topics and includes a chapter on the human immunodeficiency virus and heart failure. Discussions of natriuretic peptides, endothelin, and aldosterone give glimpses into therapeutic possibilities that may open up as the molecular mechanisms of heart failure are further understood and the interacting web of peptides disentangled. This continuing interest in the peripheral actions of various mediators should come as no surprise: the endothelium has an estimated surface area of 400 to 700 m². Aldosterone levels, we are reminded, decrease little in response to ACE inhibition, and if that hormone has deleterious clinical effects, it would be predicted that blocking them with spironolactone might add to the benefits of the inhibitors. Trials of this hypothesis are being completed.

The section on therapy gives one cause to reflect that treating the failing heart with inotropic stimulation provides short-term symptomatic benefit but often has an adverse effect on longevity. Two of the authors suggest that inotropic drugs should not be discarded automatically — some patients may be willing to swap longer lives for lives of improved quality. The comprehensive review of digoxin has been clarified by landmark papers that appeared since the book was written. The final chapter looks ahead to new ways of improving prognosis and delaying the progression of heart failure. It is not yet clear whether angiotensin-receptor antagonists improve prognosis in patients with heart failure more than ACE inhibitors. These additional approaches to treating heart failure will add increasing complexity and refinement to what has been a reasonably straightforward process. The book lacks a chapter on the role of surgery in heart failure, with some discussion of whether hibernating myocardium can be brought back into action if blood flow through stenosed coronary arteries is restored.

Half of patients with mild heart failure die suddenly, but this proportion falls to about 30 percent among patients with New York Heart Association class IV heart failure. Physicians have had their fingers burned when they have attempted to reduce the risk of sudden death in patients with ischemic heart disease, and the authors of the chapter on this subject make it clear that the best management of arrhythmias in heart failure is still being clarified. Implantable cardioverter–defibrillators are being evaluated, but many health care systems will find their cost prohibitive.

Although this book offers a valuable summation of topical issues in heart failure, it is best dipped into rather than read through. Further editing would have helped remove some duplication of comments about definitions, epidemiology, and the role of digoxin. The book will appeal to an audience with a special interest in heart failure, rather than to generalists.

Peter Wilkinson, M.D.
Ashford Hospital, Ashford TW15 3AA, United Kingdom