ESC Textbook of Cardiovascular Medicine
John Camm, Thomas F. Lüscher, Patrick W. Serruys, eds
1136 pages. Oxford, UK: Blackwell Publishing; 2006. $295. ISBN 1-4051-2695-7
Editor’s Note: In our effort to provide an insightful, balanced, and constructively critical review of the new first edition of theESC Textbook of Cardiovascular Medicineedited by Drs A. John Camm, Thomas F. Luscher, and Patrick W. Serruys that was published under the auspices of the European Society of Cardiology by Blackwell Publishing Ltd (2006), we have obtained the opinions of 3 distinguished senior cardiologists, Drs Gottlieb Friesinger, Desmond Julian, and Elliot Rapaport, to serve as a Select Panel for Review. To ensure the book was read in its entirety, the text was divided into thirds and apportioned equally to each reviewer; all 3 reviewers were assigned 4 chapters in common to read as well.
This summary review by 3 individuals, each of whom is internationally recognized for expertise in the broad field of general cardiology, is offered in the spirit of helping the ESC achieve its stated objective of providing a textbook that is successful in covering the knowledge that should be required of all general cardiologists.
This textbook is primarily targeted at the specific audience of those wishing to be accredited with the European Board for Accreditation in Cardiology (EBAC). It is not intended to be a work of reference, but, as stated in the foreword, of producing “a clinically focused resource for general cardiologists and trainees.” It presents 36 chapters within 1092 pages, each authored by anywhere from 2 to 6 multinational collaborating members of the European Society of Cardiology. One of its remarkable achievements in addition to the high standard of writing is its superb illustrations, figures, and tables that appear on virtually every page. They are well placed within the text and contribute in making the book easy and interesting to read. A refreshing new touch to this book is the incorporation in each chapter not only of a succinct summary at the beginning but also a brief personal perspective of the future direction of the field by the authors at the chapter’s end.
With so many authors, the resultant product, as might be predicted, is somewhat uneven. Many chapters are written by distinguished leaders in their fields who have collaborated to write highly authoritative and informative chapters. In other cases, the chapters are rather poorly balanced, emphasizing particular areas of authors’ interest rather than serving as an overall and balanced text. There is great variation in the detail into which various authors delve. The chapter on acute coronary syndromes (ACS), for example, has an outstanding section on pathophysiology, whereas the topic is hardly touched on in that on chronic coronary heart disease. In the latter case there is extremely informative detail provided regarding the physiology of the coronary circulation, but it seems excessive. Overall, most chapters are completed within 30 pages, but the management of ACS is dispensed in 16 pages, that of atrial fibrillation within 32 pages, and myocardial disease takes up 53 pages.
The overall approach to the subject matter concentrates on a combination of evidence-based medicine, imaging, and interventional cardiology. Important areas of cardiovascular medicine that represent more recent advances in our understanding of the field, such as chapters on the Genetics of Cardiovascular Disease and Clinical Pharmacology of Cardiovascular Drugs, add importance to this book; there is a striking emphasis on the role of diagnostic technological procedures. It begins with a chapter on the morphology of the ECG, which is succeeded by chapters on cardiac ultrasound, cardiac magnetic resonance, cardiac computerized tomography, nuclear cardiology, and invasive imaging and hemodynamics.
Little attention is directed at some of the basic tenets of cardiology. Most notable omissions concern any discussion of the value of a thorough cardiac history and physical examination. Significantly, in the printed version, such familiar terms as systole, diastolic gallop, and palpation, among others, cannot be located in the index. The emphasis on technological procedures is an apparent index of our time.
Chapters 1 to 11
The first 6 chapters comprise the expanded body of imaging techniques that in a bygone era was known as graphic methods and have already been singled out for their remarkably clear illustrations and precise language. However, the chapter Invasive Imaging and Hemodynamics would appear to fall short in covering its designated subject. For example, a cardiac trainee would have difficulty trying to calculate bidirectional shunt flows in a case of congenital heart disease just from reading the brief section on “Blood Oxygen Measurements and Flow and Shunt Calculations.” Chapter 8, on Clinical Pharmacology of Cardiovascular Drugs, is highly informative, with a particularly lucid discussion of Clinical Trials and the assessment of evidence. Although it is excellently written and clarifies many biostatistical terms as well as misconceptions, there are a multitude of terms and concepts mentioned throughout the text, such as sensitivity, specificity, or the Bayesian concept of prior probability that are never explicitly defined. This situation compels the reader to search the index for this missing information, but to no avail; here a glossary of definitions would be most helpful for the reader. Similarly, an example of unevenness among chapters is seen in Table 8.1 and the column labeled “Indications.” The use of clopidogrel under “Secondary Prevention of Vascular Events” lists only its use in patients intolerant to aspirin, with no mention of its role in preventing major cardiac events in patients with peripheral arterial disease or who have had a prior stroke or transient ischemic attack. It seems evident that the full measure of the success of this textbook will rely on its ability to update and revise chapters frequently. Chapters 10 and 11 cover the major perils of hypertension and diabetes quite thoroughly, and both are concise and elegantly illustrated.
Acute Coronary Syndromes
In Chapter 12, the pathological basis of ACS is superb; however, the clinical picture and its natural course are somewhat lacking. The actual prognosis and mortality are not mentioned, although much is said about risk stratification. It is to be noted that the ESC/ACC diagnostic criteria are accepted without question. Cross-referencing should be done in several areas such as including the detailed tables and illustrations from Chapter 1 in the discussion of the ECG, and the section on risk factors should cross-reference Chapter 9. Surprisingly, smoking is not listed as an important modifiable risk factor and receives only scant mention later in this section; considerably more comment is given on low birth rate than smoking.
The information on management of ACS is described in Chapter 13 and is derived largely from a MEDLINE search for “clinical trial,” “meta-analysis,” “review,” and “guidelines.” Accordingly, the description of antiplatelet, antithrombotic, fibrinolytic, and interventional methods is very effectively done, as are the discussions on β-blockers, calcium antagonists, and ACE inhibitors. The reporting of results of clinical trials is exemplary, but one might suggest that the use of the number necessary to treat might be more useful in this chapter than odds ratios with confidence intervals. It would also seem important to mention that there is a large elderly group of patients and others with serious comorbidities who are grossly underrepresented in randomized, controlled trials. Also, the most important causes of death in myocardial infarction are ventricular fibrillation, cardiogenic shock, and acute heart failure. None of these critical outcomes receives significant attention in this chapter.
Chronic Ischemic Heart Disease
Chapter 14 is well written and comprehensive in many aspects. It is surprising that variant angina is listed as one of the 4 manifestations of chronic ischemic heart disease because most would classify this syndrome as an unstable phase of coronary ischemic heart disease. The section on myocardial blood flow is extremely informative but could be better oriented toward the clinicians rather than physiologists, with more attention to issues such as the tight coupling of myocardial blood flow and myocardial oxygen consumption, the recruitment of vessels in increasing coronary blood flow, and particularly, more attention to the importance of endothelial function in atherosclerotic disease as cited in Table 14.1. Here also, cross-referencing to the chapter on invasive imaging would help the reader understand the application of coronary flow reserve in this disease state. When prognosis is discussed, the term “high risk” is used but not defined. Summary statements and flow diagrams would enhance this chapter.
Chapter 15 is a well-written discussion of the treatment of stable angina pectoris. This chapter contains a great deal of pharmacology information, particularly with reference to the statin drugs not found in other portions of the text such as the chapter on risk factor modification or pharmacology. The indications for coronary arteriography in stable angina (Figure 15.4) present the actual guidelines, which is extremely useful to the reader and represents a technique not found in other chapters where guidelines are cited but not provided.
Chapter16, one of the longest chapters, with 62 pages, 286 references, and 8 authors, is comprehensive, well written and, like many multiauthored chapters, has some unevenness in the writing and content. Variables useful in assessing prognoses in the more common forms of cardiomyopathy are well described, but more quantitative, or at least semiquantitative, information could be given to help guide the clinical cardiologist in treating individual patients. Loeffler myocarditis and endocardial fibroelastosis are allotted more space than such rare entities justify, whereas the cardiomyopathies that result from chemotherapeutic agents used in treating oncologic disease are not included.
Chapters 17 to 24
Chapter 17 is appropriately brief and exceptionally well illustrated but calls for cross-referencing with the chapters on imaging. The long-since abandoned Horowitz classification of pericardial effusion is surprisingly emphasized. The comprehensive tables in this chapter do not meet the quality and clarity standard found in the rest of this book. Chapter 18 is well written and is primarily a detailed description of gross anatomy, imaging, and considerable information on histology, but it is questionable if 18 pages should be devoted to this topic.
The chapter on congenital heart disease focuses 52 pages on the newborn infant and child, which seems excessive for the intended readership of general cardiologists. Major clinical problems in adults with congenital heart disease such as arrhythmias and congestive heart failure are not covered in adequate detail. The important role of highly specialized centers is only sparingly mentioned in the text, and guidelines for care of grown-up congenital heart disease (GUCH) deserve considerably more emphasis. The chapter on pregnancy and heart disease is well written, concise, and comprehensive.
Chapter 21, on valvular heart disease, is only partially successful in the near-impossible task of adequately covering the clinical presentation, natural history, and surgical management of this core subject within the allotted pages. A greater emphasis on the physical examination and its correlation with homodynamic findings and echocardiographic estimates would seem important, considering that global migration is sure to persist throughout most of this century, making valvular heart disease a subject with which the general cardiologist must be most familiar. The chapter on infective endocarditis that follows is a very readable and informative contribution to this text, with well-written guidelines that are cited but could be highlighted more.
Chapter 23 covers the epidemiology, pathophysiology, and diagnostic criteria concerned with heart failure. An informative and well-written piece, it is enriched by its many excellent tables and figures. Specific cross-referencing with Chapter 2 on cardiac ultrasound would further enhance the reader’s experience. The chapter that follows regarding management explains very thoroughly the therapies that are available for heart failure today. It outlines the mechanism of action of the various drug groups, although, surprisingly, it includes a number of drugs such as ibopamine and xamoterol that have been abandoned years ago. It details the results of clinical trials but sometimes fails to give absolute as opposed to relative effects. Good practical advice on drug dosages and the choices of treatment is provided.
Chapters 25 to 36
In Chapter 25, the current knowledge on the genesis, diagnosis, and treatment of pulmonary artery hypertension is very fully reviewed, but only half a page is devoted to chronic lung disease. In some countries, this is an important cause of heart failure. Chapter 26 contains a thorough description of exercise physiology and the methods of exercise testing and prescription. Other aspects of rehabilitation such as lifestyle modification and secondary prevention measures appropriate for patients with cardiac disease are discussed at length. In the following chapter on bradycardia, there is a very thorough description of the indications for pacemaking and of the many different modes of pacing available. The complications of this procedure are well described, although, curiously, the actual technique of implantation is not. The authors of Chapter 28 refer to “the current golden age of cardiac arrhythmology,” and they justify this claim by an exceptionally clear account of the different types of supraventricular tachycardia.
In Chapter 29, the point is made that atrial fibrillation is of great importance because of its frequency and its potential seriousness. It is also of considerable current interest, owing to the recent advances in our knowledge of its mechanisms and of the new and promising forms of treatment. Accordingly, the discussion is divided into 2 quite lengthy chapters, one dealing with epidemiology, pathogenesis, and diagnosis and the other (Chapter 30) with the treatment. The first describes the mechanisms in such detail as would cater to the needs of the specialist arrhythmologist. The second provides a comprehensive review of the many current forms of therapy available but pays particular attention to pulmonary vein ablation—an aspect of the condition that is barely mentioned in the first chapter. One wonders to what extent the authors of the 2 chapters conferred.
Bearing in mind the target audience, Chapter 31, on syncope, is a model of its kind. Lucidly written and practical, it contains enough but not too much information for the aspiring cardiologist. In the chapter that follows on ventricular tachycardia, there is no description of ventricular ectopic beats (premature depolarizations, extrasystoles) and no entries in the index of these terms. This approach differs from those dealing with supraventricular tachycardias that devote almost 2 pages to atrial extrasystoles. There is a good account of the various types of ventricular tachycardia and their treatment, although one might have liked a more detailed description of and better illustration of torsades de pointes. The contribution on the implantable cardioverter-defibrillator is well balanced, but there is considerable overlap with the section on this technique in the following excellent chapter on sudden cardiac death and resuscitation.
Chapter 34 provides a very up-to-date perspective on diseases of the aorta and trauma to the heart and is both well illustrated and well referenced. As the authors point out, there are new endovascular concepts that are likely to affect management.
Chapter 35, on peripheral arterial disease, provides a very informative contribution and, as the authors point out, because of limitations of space, it is regrettable the role of surgery could not be considered. The final chapter on venous thromboembolism emphasizes the importance of clinical evaluation of this common cardiovascular disorder and stresses the increasing place of home-based management rather than hospital-based management.
One of the most valuable features of The ESC Textbook of Cardiovascular Medicine is the electronic version, provided its full potential is appropriately used to enter prompt corrections, timely updates, and facile revisions. To do so will be no easy task, even with the resources of an international society. Fortunately, it appears that the editors have provided a solid foundation on which to build an electronic edifice that will not be outdated. They also seem to have mastered the technological state-of-the art such that the user can navigate through any of the 36 chapters from virtually any sentence in the book in a most friendly fashion. Although the cross-referencing throughout the text is rather parsimonious, it works quite well where it appears.
The electronic images, illustrations, and tables are very impressive, and the search facility built into the full text makes for an individualized index that is not only extremely efficient but also enjoyable to use. Looking for “murmurs” in the printed version was unsuccessful, whereas the electronic version immediately disclosed >100 references to “heart murmurs.” Links from the reference list of every chapter to PubMed are very useful and probably overly tempting. A novel feature introduced by an accrediting body, EBAC, is the provision of high-quality continuing medical education for cardiologists and trainees after specified chapters with multiple choice questions relating to the chapters content, which are scored and displayed with feedback given on the correctly answered questions.
Editor’s Summary Statement: Akin to the multiauthored ESC Textbook, this multiauthored review has several distinct advantages and some obvious but unavoidable disadvantages. Those aside, there are 2 sources of bias in the selection of reviewers for which I offer no apology; one is generational and the other geographical. As for age beyond 3 score and 15 years, only then can one begin to experience true wisdom; as for residing in a West meridian, it matters not at all.
What does matter is that the readership of Circulation be informed of the merits and some apparent limitations of the first printing of the ESC Textbook of Cardiovascular Medicine. The reviewers seem to agree that the future impact of this meritorious first edition will be dependent on the frequency, extent, and caliber of the electronic updating that is promised.
-Thomas J. Ryan, MD
Book Review Editor
Dr Rapaport has served on a speaker’s bureau for Bristol Myers Squibb, Sanofi Aventis, Astra, and Novartis. He has served as co-chair on a Data and Safety Monitoring Board for Bristol Myers Squibb. The other authors report no conflicts.