Book Review

Primary Care Management of Heart Disease

N Engl J Med 2000; 342:2004-2005June 29, 2000

Article

Primary Care Management of Heart Disease
Edited by George J. Taylor. 670 pp., illustrated. St. Louis, Mosby, 2000. $69. ISBN: 0-3230-0256-0

The boundary between generalist and specialist is not only changing but also unstable. It shifts, depending on the specific discipline, insurance regulations, the patient's needs, and the physician's training. This book is an example of a new genre of medical textbook that addresses this boundary. These books are usually written by specialists, often with primary care physicians as coauthors, as is the case with many chapters in this book, and they are purported to address the specific educational needs of primary care physicians and other primary care providers. The real test of such books is whether they actually help to define the practice of primary care and speak to the special issues that define it, including primary care epidemiology, early presentation of vague symptoms, care at the initial presentation, and competing demands for the physician's time. So is this book truly innovative, or is it merely an abbreviated version of a standard cardiology textbook, written in a simplified form for the nonspecialist? The best way to answer this question is to look at some common cardiac problems in primary care and to see how the book performs.

A common situation in primary care may be that of a young woman with chest pain who asks for a referral to a cardiologist but who, on more detailed evaluation, clearly has atypical chest pain and panic disorder. In this book, panic disorder is not listed in the differential diagnosis of chest pain, although the presentation of classic mitral-valve prolapse (which is quite rare in primary care) is included, as is hyperventilation associated with anxiety. Panic disorder is discussed in the section on psychological disorders and stress and their relation to heart disease, with some reasonable recommendations for management. However, its incorporation into the differential diagnosis of chest pain is missing, and it is not mentioned in the evaluation of chest pain of uncertain cause, which emphasizes gastrointestinal and musculoskeletal conditions.

Another common problem is the care of the patient, often a man in his 30s or 40s, with an isolated finding of a low high-density lipoprotein level on cholesterol screening. Here the advice is clear and helpful regarding pathophysiologic features, with recommendations for management based on overall risk assessment. Other recommendations regarding the more controversial aspects of managing dyslipidemias are equally helpful. On the other hand, a cost-effective approach to the use of tests for evaluating patients with chest pain is lacking. There are vague recommendations about the use of stress testing, stress echocardiograms, radionuclide imaging, electron-beam computed tomography, and cardiac catheterization, as well as the evaluation of chest pain in chest-pain units within emergency departments. These do not help the primary care physician deal with this common and perplexing problem.

New-onset or intermittent atrial fibrillation, whether associated with risk factors for stroke or not, is a perplexing problem for the primary care physician. Here the book performs relatively well, with a helpful set of recommendations regarding pathophysiologic features, evaluation, management, and decisions about anticoagulation. A statement that cardioversion is not worth trying “when the left atrium is huge” is somewhat difficult to interpret, but the overall approach addresses most of the issues common to primary care practice.

Much of the value of this book comes from its more innovative chapters. A particularly helpful section addresses noncardiac illnesses and special conditions, such as pregnancy, in relation to heart disease and thus speaks to the needs of primary care physicians, who are confronted with a broad range of problems and questions that cross specialty boundaries. Palliative care and end-of-life issues are handled well in a novel chapter for which the editor and the authors of the chapter are to be commended. Preoperative risk assessment and perioperative management are also addressed in a clear and practical fashion, with strong statements about the important role of the primary care physician in handling these matters. A final chapter on cardiac drugs is a helpful resource.

The authors of this book are mainly cardiologists or general internists, with a few family physicians, nurse clinicians, pharmacists, and exercise physiologists. The writing is even and shows the hand of a strong editor. Many chapters have an annotated bibliography in addition to the usual list of references. The graphic and production quality of the book is high, with extensive use of figures and a clean layout.

This book is not quite the innovative primary care textbook it claims to be, but it is also not a “dumbed-down” cardiology book. It generally succeeds in defining the role of the primary care physician in the care of patients with cardiac disease and provides some guidance for this role. Most primary care physicians and trainees will find this book to be of considerable help in dealing with the cardiac problems they commonly face.

Thomas L. Schwenk, M.D.
University of Michigan Health System, Ann Arbor, MI 48109