Book Review

Cardiac Intensive Care

N Engl J Med 1998; 339:1169-1170October 15, 1998

Article

Cardiac Intensive Care
Edited by David L. Brown. 836 pp., illustrated. Philadelphia, W.B. Saunders, 1998. $125. ISBN: 0-7216-6006-1

Over the past 20 years the treatment of acute coronary ischemic syndromes has changed remarkably. No longer is the coronary care unit a place where patients are merely monitored or expectant therapy is provided. Rather, the emphasis has changed to early identification of patients with acute ischemic syndromes, risk stratification, and earlier interventional therapies. This approach has reduced mortality from acute myocardial infarction and increased the effectiveness of cardiac care. Cardiac Intensive Care strives to address changes in the care of critically ill patients with coronary and cardiac disorders. Realizing that the term “coronary care unit” no longer sufficiently describes the range of activities in today's cardiac intensive care unit, the editor has attempted to capture the excitement and breadth of activities in today's unit. The book provides a conceptual and practical foundation for actual practice in the cardiac intensive care unit. Implicit in its purpose is that the focus of care moves beyond acute coronary syndromes and involves critically ill patients with other noncoronary but cardiac diseases.

One hundred twenty-one well-known authors joined together to provide 63 chapters, including 17 chapters on the management of acute myocardial infarction, 2 chapters on the management of acute coronary syndromes, 12 chapters on the approach to noncoronary disease in the intensive care unit, 6 chapters on the therapeutics of acute coronary syndromes, and 14 chapters on diagnostic and therapeutic techniques. The result is a comprehensive textbook that redefines the landscape of the modern cardiac intensive care unit. It is written in a very straightforward and direct style.

The majority of these chapters are comprehensive and well referenced. Indeed, the chapters on the pathophysiology of acute ischemic syndromes, thrombolytic therapy, and primary angioplasty in acute myocardial infarction are superb. Topics such as airway management, which really are a part of acute cardiac care as well, are thoughtfully presented and are welcome additions. Also, topics such as continuous arteriovenous hemofiltration, intensive diuretic therapy, and sedation of the critically ill are thoroughly covered.

Although medical ethics and admission criteria are well covered, the book does suffer from the lack of a thorough discussion of ways of organizing cardiac services and resources in the present era. Managers and medical directors of any intensive care unit need to have some perspective on the way in which their units should be integrated with other services in the hospital such as the emergency department and the cardiac operating room. Other textbooks are available to provide some of this organizational insight, but I think discussion of these issues in textbooks such as this is appropriate.

The use of clinical-practice guidelines has received major emphasis from the American College of Cardiology, and yet, the handling of clinical-practice guidelines is somewhat unbalanced in this textbook. Some chapters use accepted guidelines; others, such as that on unstable angina, ignore them completely. Furthermore, the way in which guidelines might be implemented in a more systematic fashion in an intensive care unit is really not considered at all. Finally, a discussion of the use of information services to support quality assurance, quality management, and quality improvement is overlooked, and the reader will clearly need to search for other sources.

With the exception of these limitations, Cardiac Intensive Care does provide general intensivists and cardiologists who are working in the cardiac intensive care unit with valuable, up-to-date information on newer techniques and approaches now available for the treatment of critically ill patients with cardiac disorders.

James E. Calvin, M.D.
Rush Medical College, Chicago, IL 60612