Book Review

Congestive Heart Failure

N Engl J Med 2007; 356:2227-2228May 24, 2007

Article

Congestive Heart Failure
Third edition. Edited by Jeffrey D. Hosenpud and Barry H. Greenberg. 869 pp., illustrated. Philadelphia, Lippincott Williams & Wilkins, 2007. $169. ISBN: 978-0-7817-6285-4

Thirteen years have elapsed since the first edition of this book was published. At that time, heart failure was just being recognized as a cardiovascular condition that had major effects on public health, and that recognition was probably the impetus for writing such a book in the first place. Since then, the remarkable pace of change in our understanding of heart failure has been driven by advances in the biologic sciences, engineering, information technology, and the funding of large trials by industry. The evidence base for choices in the treatment of heart failure is probably greater than in any other area of medicine, partly because mortality from heart failure is so high. Clinical trials of new therapies with mortality as a component of the end point are not prohibitively costly or impractical in size. But there is the rub. As many as 40% of patients die in the 6 months after initial presentation, and the attrition rate thereafter is about 10% per year, so that 50% are dead 3 years after initial presentation, despite new treatments. Although advances have been made to improve survival, the outlook for the patient with heart failure remains poor. The problem of cell loss exceeding the slow rate of cell regeneration in the human heart has not been resolved.

This book is an encyclopedia of knowledge related to heart failure, and for that reason it will be valued by specialists. The chapters, written by leading authorities, are quite detailed and well documented — one chapter has 451 references. Nearly all the contributing authors are American, however, and many ignore data from other parts of the world. A great problem for the editors is that heart failure is now so pervasive in cardiology that a book such as this can rapidly expand into one that seems to cover all of cardiovascular medicine. Most chapters include recent references, and the opening paragraphs identify what is new. There is a well-balanced chapter on the use of digoxin. As in many recent guidelines, simple algorithms for treatment and management are not prominent. The recently revised definition of cardiomyopathy is missing, and topics such as the increasing use of alternative medicines and methods for the delivery of care are largely absent. The book would have been improved by the use of color in some otherwise excellent illustrations.

Several controversial topics are avoided in the book. The dichotomization of heart failure into the categories of systolic and diastolic is an error, because the ejection fraction in patients with heart failure follows an almost normal distribution. Patients should not be placed in imaginary categories; instead, an answer should be sought to the question of why the heart enlarges in some patients with heart failure and not in others. Many readers will wish for the early death of the ugly term HFnlEF, used in the book as an abbreviation for heart failure with a normal ejection fraction. The sections on cardiac resynchronization therapy and the implantable cardioverter–defibrillator persist, as do guidelines, in using the entry criteria of major trials, rather than the characteristics of the actual population in the trials, as a means of identifying who should receive these devices. For cases in which the two populations differ greatly, the actual study population is preferred.

More emphasis should have been given to the importance of adherence to treatment and methods for the delivery of health care to the whole population rather than just within special clinics. Several recent trials have shown that when high-quality care is given to patients with heart failure both within and outside special clinics, there is a greater effect on morbidity and mortality than when many pharmacologic and invasive interventions are used. Over the next few years, the greatest benefit to patients will be achieved by the application of what we know rather than by the introduction of new treatments. If a physician wants to know what we know, this book is the place to start.

Philip A. Poole-Wilson, M.D.
Imperial College London, London SW3 6LY, United Kingdom
p.poole-wilson@imperial.ac.uk