Heart Disease and the Surgical Patient
Heart Disease and the Surgical Patient. S. HowellC. PepperD. R. Spahn (editors). Published by Informa Healthcare USA, New York, USA. Pp. 386 ; indexed; illustrated. Price £115, US$199.95. ISBN 978-0-8493-4091-8.When I left medical school 30 yr ago, the options for diagnosis, investigation, and treatment of coronary artery disease (CAD) were very limited. Although CAD was a leading cause of mortality and unless there were anginal symptoms, the chances of it being diagnosed before myocardial infarction (MI) were slim to naught. Unsurprisingly then, many patients who had undiagnosed CAD underwent anaesthesia and major surgery then suffered perioperative MIs that were frequently fatal. Probably because of the limited options for investigation, diagnosis, and treatment along with a lack of epidemiological data, this outcome was often somewhat fatalistically accepted by anaesthetists and surgeons.
In the intervening 30 yr, the situation for patients presenting for non-cardiac surgery has changed radically as the options for diagnosis, investigation, and treatment of heart disease and, in particular CAD, have burgeoned. Anaesthetists and surgeons are now far more concerned about preventing and treating perioperative MIs than ever before. Along with new methods of diagnosis, investigation and treatment has come a tidal wave of research, sometimes with conflicting results. Some of these treatments also have far reaching effects for patients. For example, drug-eluting stents and the potential need for life-long treatment with anti-platelet agents will create a clinical dilemma every time the patient needs surgery: continuation of anti-platelet drugs may increase the risk of haemorrhage and blood transfusion while discontinuation may result in a perioperative MI. The massive increase in information on the effects of heart disease and its treatment on anaesthetic and surgical outcomes—sometimes conflicting—has made it difficult to know how best to manage our patients with heart disease requiring non-cardiac surgery. For all of you like me that have uncertainties about best management, this book is an excellent distillation of our current understanding of CAD and non-cardiac surgery.
Unfortunately, the title belies the content of the book which largely relates to CAD rather than the wider scope of heart disease. Apart from chapters on arrhythmias, adult congenital heart disease and heart failure, the remaining 15 chapters relate mostly to CAD. Indeed, the introduction even states that the ‘book is aimed at anaesthetists, physicians, surgeons and intensivists who care for patients at risk of perioperative myocardial injury and infarction’. Misleading title aside, there is certainly sufficient merit for such a text given the inexorable increasing numbers of patients with CAD presenting for surgery.
It is a multi-edited and multi-authored book and both were refreshingly Eurocentric in origin. Although their institutional affiliations were provided, the authors' specialities were unfortunately not listed and so it was not always possible to ascertain the background to their clinical insight. Many of the authors are well known in the area and judging by their institutional affiliations, the majority were from an anaesthetic background with a smattering of cardiologists. A lot of the chapters are well illustrated with black and white diagrams and photographs and many also make good use of tables. However, a few chapters could have benefited from illustrations to aid understanding, such as the one on the pathophysiology of CAD. Every chapter is extensively referenced and although the book is indexed, it is weakly cross-referenced. In addition, like any textbook covering a dynamic evidence-base, it got frozen in time when it went to press, although with regard to beta-adrenergic blockers, a useful update was added at proof. My biggest gripe about this book is the amount of unnecessary overlap between some of the chapters. For example, adrenergic blockade is addressed excessively in a number of chapters having been reviewed in depth by a chapter devoted to the subject.
Whatever limitations there are to this book, it contains a wealth of valuable information on heart disease and surgery. Everything from epidemiology and pathophysiology of CAD and myocardial ischaemia through preoperative assessment and diagnosis to prevention and treatment of ischaemia are reviewed in depth. Moreover, anyone unfamiliar with myocardial conditioning or myocardial protection by modulation of the adrenergic systems would benefit from reading the respective chapters in this book. Additionally, there are valuable chapters reviewing heart failure, adult congenital heart disease and concomitant carotid, and CAD.
For anyone who wishes a complete review of CAD and surgery, this is an essential book and without doubt, it should be in every departmental library. Sadly, its price will probably prove far too much for most individuals who are seeking an update on heart disease and surgery.
Edinburgh, UK
E-mail: peter.alston{at}ed.ac.uk
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