David L. Brown. 861 pp. Philadelphia, Pa: W.B. Saunders Company, Ltd; 1998. $125.00. ISBN 0-7216-6006-1.
Coronary care units, initially established in the 1960s as separate units for the early detection and treatment of arrhythmias complicating acute myocardial infarction, currently provide the setting for the monitoring and treatment of a wide variety of critical cardiovascular disease states. The expanded role of the cardiac intensive care unit has evolved in concert with rapid advances in diagnostic and therapeutic strategies in the practice of clinical cardiology. Landmark discoveries bettering our understanding of the pathophysiological mechanisms of acute coronary syndromes, congestive heart failure, and supraventricular and ventricular dysrhythmias have been associated with technological advancements, such as the advent of invasive hemodynamic monitoring, intracoronary interventional procedures and devices, and ventricular assist devices. These changes have resulted in clinical cardiology’s evolution into a more proactive and aggressive interventional field. Subsequently, the breadth and scope of care provided to the acutely ill cardiac patient in the cardiac intensive care unit has markedly expanded.
The textbook, Cardiac Intensive Care, edited by David L. Brown, MD, provides a timely and practical overview of the management of the critical cardiac patient over a broad range of topics. The text, well-written and organized, begins by providing a discussion of the history and evolution of the cardiac intensive care unit, as well as some of the nursing, ethical, and economic issues associated with maintaining such a complex unit.
The second section, “Scientific Foundation of Cardiac Intensive Care,” provides an excellent review of the fundamental concepts of cardiovascular pathophysiology, from the general principles of gas exchange and hemodynamic regulation to the specific arenas of coronary physiology, acute myocardial infarction, and arrhythmogenesis. The detailed descriptions of these basic principles provide a firm pathophysiological foundation for understanding and developing pragmatic approaches to management of various disease states discussed in subsequent sections of the text. For example, the elaborate details provided on gas exchange and pressure-volume relationships in states of both normal and impaired left ventricular function facilitates the correct interpretation of hemodynamic monitoring and the appropriate selection of the various vasoactive and inotropic agents commonly used to treat the abnormal hemodynamics noted in these patients. In addition, current understanding of the pathophysiology involved in acute ischemic syndromes form a firm basis for outlining accepted management strategies in these clinical syndromes.
The next two sections deal specifically with coronary artery disease and acute coronary syndromes. The sections are well-organized, beginning with diagnostic modalities and then incorporating primary and adjunctive therapies, complications, and overall management for patients with acute myocardial infarction and acute ischemic syndromes. The chapters in these sections are concise and replete with evidenced-based management strategies. Recently published literature is thoroughly reviewed and incorporated into the chapters within the text and within the extensive tables and figures. The sections serve as an excellent reference for an up-to-date literature review, especially in the chapters on coronary thrombolysis and primary angioplasty for acute myocardial infarction.
The following section focuses on noncoronary diseases managed in the coronary care unit, addressing the expanded role of the cardiac intensive care unit. Selected for this chapter are the more common disease states: acute pulmonary edema, hypertensive emergencies, and pericardial disease are covered in detail. Each chapter is typically organized in the traditional manner of presentation, diagnosis, and treatment, creating an extremely pragmatic approach to these pathological illnesses. One chapter that deserves special attention is the chapter reviewing hemodynamically unstable presentations of congenital heart disease in the adult. The authors should be commended for including this chapter, as each of us in the field of cardiology will undoubtedly be increasingly involved in the management of this growing and aging patient population.
The sixth section outlines the effects and the role of commonly used pharmacological agents in the cardiac intensive care unit. Individual agents are thoroughly reviewed from a historical and mechanism-of-action perspective, and various clinical scenarios outlining the appropriate selection of these agents are discussed. Specifically, differences in inotropic agents (eg, milrinone and dobutamine) and various antiarrhythmic agents are discussed in practical scenarios guiding the appropriate selection of these agents.
The text ends with a section on the various diagnostic and therapeutic modalities available in guiding the management of patients in the cardiac intensive care setting. These modalities range from noninvasive diagnostic modalities (eg, echocardiography, radionuclide imaging) and invasive diagnostic modalities (eg, right and left heart catheterization, coronary angiography) to various therapeutic modalities (eg, intra-aortic balloon pumping, pericardiocentesis, mechanical support devices, and cardiac transplantation). A full understanding of each of these modalities is crucial to optimally managing complex cardiac intensive care patients.
Cardiac Intensive Care is a well-written text that thoroughly reviews cardiovascular pathophysiology and serves as an excellent reference to aid in the management of a wide variety of patients in the cardiac intensive care unit. Whether serving as a primary educational source or as a means of consolidating one’s knowledge, this practical text represents a much needed, state-of-the-art overview of the various disease states that face the physician caring for the cardiac intensive care patient.
Gene Chang, MD
Evan Loh, MD
Hospital of the University of Pennsylvania
- Copyright © 1999 by American Heart Association