Book Review

Lipoproteins in Health and Disease

N Engl J Med 2000; 342:297January 27, 2000

Article

Lipoproteins in Health and Disease
Edited by D.J. Betteridge, D.R. Illingworth, and J. Shepherd. 1302 pp., illustrated. London, Arnold, 1999. $225. ISBN: 0-340-55269-7

Death from cardiovascular disease in middle age is much less common now than it was 40 years ago. This change did not come about spontaneously. Concerted efforts to understand, treat, and prevent cardiovascular disease started in about 1950, when infectious diseases seemed to be on their way out and scientists turned their attention to other diseases of the middle-aged and elderly. As far as cardiovascular disease is concerned, this enterprise has been remarkably successful. The effort involved not only biology and medicine, but also disciplines as diverse as physics, which provided devices and imaging techniques, and economics, which was used to study the cost effectiveness of drugs and procedures. The very success of the prevention and treatment of cardiovascular disease has created new problems about where such efforts should stop; is it not better to allow a patient to die at the age of 81 from ventricular fibrillation than at 82 from cancer or from the congestive heart failure that may follow a successfully treated myocardial infarction?

Despite such misgivings, the fact remains that many men — and some women — who would have died in middle age in the 1950s and 1960s now live to see their grandchildren. Numerous studies on cholesterol and lipoproteins have made an essential contribution to this outcome: over the past 20 years, about 500 papers on cholesterol or lipoproteins have been published every month.

Lipoproteins in Health and Disease thus fills a need. It consists of 73 review chapters, almost all written by acknowledged experts. The book covers the structure and metabolism of lipoproteins, laboratory techniques, atherosclerosis and its consequences, dyslipidemias, and treatment. Topics range from the theoretical, such as mathematical modeling of lipid metabolism, to the practical, such as the performance of desktop blood analyzers. The question about the extent of efforts to prevent and treat cardiovascular disease falls outside the scope of this book, but a chapter on cost effectiveness provides challenging data on the topic. For example, dietary management of hypercholesterolemia in middle-aged English adults would cost only $100 per quality-adjusted life-year, but when drugs are added the cost rises to $2,600. Even at this price, cholesterol-lowering drugs still yield more quality-adjusted life-years per dollar than heart surgery or cervical-screening programs.

To get 116 authors to produce 73 chapters in a uniform style takes years, and as a result, discoveries made during the past two to four years are treated scantily. Nevertheless, the chapter on Tangier disease is an excellent basis for understanding the recent discovery of defects of ATP-binding cassette transporter 1 in familial high-density lipoprotein deficiency, and the chapter on 3-hydroxy-3-methylglutaryl–coenzyme A reductase inhibitors is essential reading, even though it does not discuss the newest statins.

A whole chapter is dedicated to obesity and eating disorders. The subject is important, because the oncoming epidemic of obesity threatens to undo much of the preventive and therapeutic benefits in cardiovascular disease over the past few decades. Also discussed are the paradoxical hypercholesterolemia sometimes seen in patients with anorexia nervosa and the changes in lipoproteins during and after weight loss.

A short chapter on sitosterolemia, enhanced with graphs, tables, and photographs, will help internists who suspect this rare disease and researchers in the field of plant sterols. There are also separate chapters on the major drugs. I was interested to read that probucol was originally developed as an antioxidant gasoline additive that breaks the radical chain reactions responsible for engine knocking. The cholesterol-lowering action of probucol was discovered during toxicity tests in animals, and its antioxidant properties in humans became of interest much later, when oxidation of low-density lipoproteins became a focus of research.

The book does have drawbacks. It weighs 3.7 kg (8.2 lb) and is too heavy to be read in the standing position; the reader has to lay it down on a desk. Also, not all topics can be located quickly, because the index has only 2200 entries, or fewer than 2 per page of text. (By comparison, the index of my copy of Harrison's Principles of Internal Medicine has almost 30,000 entries.) As a result, there is a listing for “acquired immunodeficiency syndrome” but none for “AIDS,” and those in a hurry will therefore miss the overview of lipid metabolism in patients with AIDS. Similarly, there is no specific entry for fish oil, apolipoprotein A-IV, or side effects of statins, even though each topic is treated competently in several places. A section in each chapter listing the contents, with page numbers, would have been helpful, as would summaries of the chapters. Also, some chapters run on for pages without illustrations or tables. Most chapters, however, do provide lively reviews with plenty of tables and illustrations.

This book is an excellent investment for general libraries and for laboratories working on lipoproteins. It does not have all the answers, but checking what the experts have to say on a topic before plunging into a Medline search may save a lot of time.

Martijn B. Katan, Ph.D.
Wageningen University, 6703 HD Wageningen, the Netherlands