Christopher P. Cannon, ed
659 pp. Totowa, NJ: Humana Press; 1999. $125.00. ISBN: 0-89603-552-2
The management of acute coronary syndromes is of great current interest because it represents a considerable burden for public health and it is one of the fields of cardiology in which we have seen the most overwhelming advances in our understanding of its pathophysiology and treatment.
The organization of this book breaks from the traditional separation of acute coronary syndromes (ACS) into unstable angina and Q-wave and non-Q-wave myocardial infarction (MI), and it takes into account the new paradigm, which considers 2 main entities: ACS with or without ST-segment elevation. These entities differ in both their pathophysiological and therapeutic aspects.
The editor has organized the contributions of the 47 authors into 5 sections. The first section, which is on pathophysiology, describes the multifactorial nature of the process and demonstrates the link between plaque rupture, humoral changes, and clinical presentation. Then, the still-debated issue of the triggers of plaque destabilization, is addressed. Finally, a comprehensive review of the angiographic results from the TIMI trials enables us to follow the shift of the target of reperfusion from the epicardial coronary artery to the myocardium.
The second section addresses the challenging issue of the diagnosis of ACS, in particular, in the setting of the emergency room, where ruling out MI is crucial. All the available means are presented in detail, and their respective roles in diagnosis and risk stratification are critically reviewed. Finally, strategies for triage are suggested to optimize the initiation of early and tailored management.
The third section, which is devoted to the management of patients with ST-segment elevation MI, pays most attention to reperfusion strategies. It begins with a review of the different steps in the evaluation of fibrinolytic therapy, a demonstration of efficacy and risks, and the search for better agents. Mechanical reperfusion is then addressed by showing the comparative trials between primary angioplasty and fibrinolysis and beginning a discussion of the somewhat conflicting results between these trials and the “real life” registries. Then, guidelines are proposed for achieving tailored reperfusion. The usefulness of the other antithrombotic therapies, both in combination with fibrinolysis and percutaneous intervention, is also demonstrated, as is that of other adjunctive treatments, ie, β-blockers or ACE inhibitors. Finally, risk stratification after the acute phase is discussed.
The fourth section concerns the treatment of non-ST-segement elevation MI and follows the same organization as the previous one. Antithrombotic treatment is here represented by antithrombins and antiplatelet agents, because fibrinolytics are ineffective. The authors recall the efficacy of keystone agents, which are aspirin and standard heparin, stress the emerging role of low-molecular-weight heparins and intravenous glycoprotein IIb/IIIa blockers, and end with the hopes in the newer agents. The second part of the section considers the means and results of revascularization and discusses the respective indications of conservative versus early invasive strategies.
The final section reviews several aspects of particular clinical interest, including women, young patients, cardiogenic shock, secondary prevention, and cost-effectiveness. The book finishes with a thoughtful discussion of critical pathways for the management of ACS and makes practical proposals for the management of the 3 main clinical situations: (1) ST-segment elevation and (2) non-ST-segment elevation MI and (3) ruling out MI, using the current practice in their institution as an illustration.
In all, the book offers a thorough, wide-ranging review of the current knowledge on ACS in the light of the authors’ personal experience from the TIMI studies or large registries they have conducted. Its other strengths include clarity and a continuous search for practicality by including clinical implications and recommendations for patient management.
The chapters are well written, and the references are cogent. The text is supplemented by tables, photographs, and explanatory diagrams for decision-making, which make the book very readable.
The only regret is that this book, which was published in 1999, could not include some recent developments, such as the new definitions of MI; new scores for risk stratification; results of clinical trials showing the clinical potential of bolus fibrinolytics; the better efficacy of intravenous glycoprotein IIb/IIIa blockers during intervention than in the medical strategies; and the advantage of an invasive approach over a conservative strategy in non-ST-segment elevation ACS. These limitations are inherent to the nature of “the book,” which does not allow for “catch-up” against the instant presentations of the most recent findings through the Internet. However, in my opinion, these limitations do not fundamentally alter the considerable interest of the book. For example, the recommendations made in this book are consistent with the most recent US and European guidelines because of the authors’ excellent knowledge and vision for the future.
Cannon and his colleagues should be commended for their efforts in producing a book that is a valuable resource for cardiologists and emergency physicians and that will also serve residents, fellows, internists, and practicing physicians, who will discover much to learn and to enjoy within this book.