Preventive Cardiology: A Guide for Clinical Practice
Killian C. Robinson. 419 pp. New York: Futura Publishing Co; 1998. $69.00. ISBN 0-87993-692-4.
Cardiovascular diseases and related complications remain the leading cause of morbidity and mortality in most developed countries and will soon achieve similar notoriety worldwide. Despite the increasing availability of sophisticated medical and surgical interventions, many patients succumb to these diseases. Renewed emphasis on prevention is therefore appropriate. Until recently, however, there were few comprehensive textbooks on preventive cardiology. Killian Robinson has succeeded in producing such a book. The 22 authors who contributed to the 14 chapters of Preventive Cardiology include world-renowned clinicians and investigators in the fields of cardiovascular medicine and epidemiology. In general the chapters are lucid, concise, and very informative. With rare exceptions, the 70 figures and 57 tables have refreshing clarity and complement the text well. Although not formally categorized, the book’s 14 chapters fall into four general domains: established risk factors, preventive cardiology in special populations, new targets in preventive cardiology, and a “how-to” section on the establishment of a preventive cardiology clinic.
The epidemiology and clinical importance of hypertension, diabetes mellitus, and the other established risk factors are presented in substantial detail. Recommendations for prevention and treatment are discussed and the role of preclinical disease such as left ventricular hypertrophy and microalbuminuria are highlighted. The merits of nutritional and dietary factors such as fatty acids, fish oils, antioxidant vitamins, flavonoids, fiber, and soy are presented in a balanced fashion. Smoking cessation is appropriately emphasized and practical steps are suggested for physician and healthcare provider intervention.
The special populations discussed include children, adolescents, ethnic minorities, and women. The chapter on children and adolescents is replete with useful tables and algorithms for screening, risk stratification, and management of dyslipidemias in youth. Gender-specific aspects of coronary risk are discussed and appropriate emphasis is placed on the role of smoking, diabetes, and menopause in atherogenesis. The important relations between genetics, culture, environment, and socioeconomic factors and their impact on coronary disease are presented in the chapter on minority groups. Black-white differences in presentation and natural history of coronary disease and the excess coronary mortality in young black men and women are reviewed. The role of hypertension and left ventricular hypertrophy as special problems in African-Americans is emphasized. Access to medical care is discussed as a crucial parameter in preventive cardiology and a key variable in the higher case-fatality rates and coronary mortality in minority groups.
In a book designed for those interested in the preventive aspects of “general cardiac practice,” a chapter on arterial gene transfer may seem out of place. Recent advances in vascular biology, however, suggest that the vessel wall, endothelium, and platelets may be important targets in the prevention of atherosclerosis. The chapter on arterial gene transfer as preventive therapy provides an excellent overview of how genetic manipulation of key events in acute coronary syndromes may play important roles in the prevention of coronary events. New targets such as inhibition of macrophage infiltration of plaques, overexpression of the key moiety in HDL cholesterol, and enhanced endothelial production of native fibrinolytic compounds are discussed. A related chapter emphasizes the fundamental role of platelets and the arterial thrombus in acute coronary syndromes and provides an excellent overview of the available therapies directed against platelets and the coagulation cascade. The final chapter puts it all together by providing a “nuts and bolts” approach in the establishment of a preventive cardiology clinic. It addresses the key concepts, resource needs, and programmatic issues in such an endeavor. Simple measures for quality of preventive care are proposed and the available data on cost-effectiveness of specific interventions are discussed.
This book’s limitations are few, minor, and in large part reflect its publication before availability of new information and guidelines. For example, its recommendations for hypertension treatment do not directly emphasize “compelling indications” for specific comorbidities or the role of “risk groups” as highlighted in the most recent national guidelines. Similarly, newer drugs for smoking cessation, such as bupropion hydrochloride, are not discussed. Reproduction of simple practical charts (such as those published by the American Heart Association or the European Society of Cardiology) for the prediction coronary risk as a guide to individualized intervention would have enhanced the book’s usefulness to practitioners.
Overall, Killian Robinson has succeeded in providing an excellent summary of the essential components of preventive cardiology as it should be practiced today. In addition, Preventive Cardiology reveals a glimpse of future targets from vascular and molecular biology in the prevention of cardiovascular disease. The seasoned clinician and novice alike will find Preventive Cardiology informative and invaluable.
George A. Mensah, MD
Medical College of Georgia and the Veterans Affairs Medical Center
- Copyright © 1999 by American Heart Association