Book Review

Clinical Cardiology in the Elderly

N Engl J Med 1999; 341:926September 16, 1999

Article

Clinical Cardiology in the Elderly
Second edition. Edited by Elliot Chesler. 837 pp. Armonk, N.Y., Futura, 1999. $165. ISBN: 0-87993-421-2

In his book of essays, In the Country of Hearts: Journeys in the Art of Medicine (New York: Delacorte Press, 1990), John Stone writes, “[The heart] provides three billion heartbeats for the average person in a lifetime — and even that huge number, as we live longer, continues to spiral upward in a kind of benevolent cardiac inflation.” This benevolent cardiac inflation has two faces: the longevity of our population is increasing, yet the heart of the elderly person is subject to the changes of “normal” aging, the ravages of cardiovascular disease, and the effects of coexisting illnesses. The characteristics unique to the hearts of this growing population are the focus of Clinical Cardiology in the Elderly. Authors with a variety of backgrounds lend their expertise to such issues as the physiology of natural aging, the factors complicating diagnosis, the natural history and management of various diseases, the goals of care unique to the elderly, and medical ethics.

Two chapters in the first section of the book carefully describe the effects of aging on the structure and physiology of the heart, changes that impair the ability of the heart to adapt to large shifts in intravascular volume. The authors urge the reader not to lump various pathologic changes in the elderly with the effects of normal aging; many changes once thought to be due to aging are now recognized as abnormal. Rather, the physician must keep in mind these abnormal changes while evaluating and treating the elderly patient.

The subsequent sections of the book describe diseases common among elderly patients with cardiac disease and discuss various approaches to the diagnosis and management of these conditions. With each disease, the authors encourage the reader to carefully define and assess the goals of care for elderly patients, shifting the focus from increasing the length of life to increasing the quality of life. Careful attention is given to the change in the risk–benefit ratio of treatment as patients age, a change inherent in the process of natural aging, the result of coexisting conditions common among the aging population, or both. As Stone writes in his book, “An allied part of the cardiologist's job, though, is to know when to stop trying. It is this part of the job . . . that requires the greatest skill, in a sense. For once one has learned what to do and how to do it, the main question is whether to do it.”

Yet this careful attention to the goals of care of older patients is not nihilistic. On the contrary, the authors are careful to remind the reader to consider a patient's physiologic age when assessing the risks and benefits of various cardiac procedures rather than to limit treatment options on the sole basis of chronologic age. In addition, the chapter on the management of lipid disorders — a new chapter in this edition — points out that modification of risk factors improves outcomes in the elderly. The book does not discourage aggressive care of elderly patients, but rather instructs the reader to keep the goal of treatment carefully in mind when choosing a therapeutic approach.

In the final section of the book, several authors reflect on aspects of medical ethics in the care of elderly patients with cardiac disease. As in earlier sections of the book, the writers focus on optimizing the quality of life while addressing such issues as the autonomy of patients, the responsibility of physicians to their patients and to society as a whole, and the cost of care at the end of life. They remind the reader that this therapeutic goal — improvement in the quality of life — must be kept in mind when making ethical decisions about the costs and benefits of care for the elderly.

Throughout this book, the authors address important issues unique to elderly patients: the changes that occur as a result of natural aging, common coexisting conditions, and the shifts in the risk–benefit ratios of treatment and the therapeutic goals of treatment decisions. In each of these areas, they illuminate key aspects that can aid general internists or cardiologists in the optimal care of their elderly patients with cardiac disease — to know when to do, and whether to do, what we know how to do.

Anne Pemberton, M.D.
Harvard Medical School, Boston, MA 02115