The Johns Hopkins Textbook of Dyslipidemia
Management of dyslipidemia has become a mainstay of routine clinical practice for both hospital specialists and those involved in primary care. Although most lipid management is straightforward, a proportion of patients may prove difficult to treat. In addition, lipid metabolism is relatively complex, and so is the pathophysiology of lipid disorders. Textbooks in the area of dyslipidemia tend to be of 2 main types: relatively brief handbooks that focus on clinical management of patients with lipid disorders and provide only a basic grounding in lipid metabolism insofar as this is relevant to patient management, and more comprehensive books that provide detailed background information about lipid disorders but that are generally too complex to attract the casual user.
This textbook sets out to meet both objectives. In the forward, Antonio Giotto suggests that the textbook combines the latest scientific advances with a practical and accessible approach to the management of lipid disorders and that it provides essential information that will prove indispensable to the busy clinician. To what extent does it meet these objectives?
As the title of this book suggests, the majority of the authors are drawn from a single institution, with a minority brought in to address specific topics. There are 24 short chapters in total, averaging ≈10 to 15 pages in length. These are divided into 5 sections. Section 1 covers fundamental aspects of dyslipidemia and atherosclerosis. Section 2 describes the pathophysiology of disorders affecting triglycerides, low-density lipoproteins, and high-density lipoproteins. The third section focuses on dyslipidemia in specific groups of high-risk patients, including those with diabetes mellitus, renal disease, and atherosclerosis, children, the elderly, and women. Section 4 considers nontraditional risk factors and cardiovascular disease. These risk factors include those directly relevant to lipid metabolism, such as the apolipoproteins, but also inflammatory markers and other emerging risk factors for cardiovascular disease not related specifically to dyslipidemia. The final section, Section 5, describes dietary and pharmacological treatments that are available for dyslipidemia and cardiovascular disease, including both lifestyle measures and use of lipid-lowering medications.
Overall, the book is attractively presented but is too large to be carried by a clinician and therefore is best suited to act as an office reference. The font is relatively small, but chapters are well structured and generously illustrated with black and white figures and tables. A small number of colored illustrations are grouped together at the beginning of the book. Some readers will find this mildly irritating because it is undoubtedly more convenient to have figures at the place in the text where they are referenced. Presumably, this approach has been taken to reduce production costs. Chapters have comprehensive referencing that is reasonably up to date and provides a good starting point for further reading. The style is reasonably consistent, and although there is some overlap between sections, it is clear that the editors have done their best to minimize this.
A problem with the book is the relatively small section devoted to a discussion of the drug treatment of dyslipidemia. Chapter 23 is only 11 pages long (including yet another diagram of lipid metabolism!), yet this includes the information that is most likely to help the clinical lipidologist. A good test of the practical utility of a book is to look up the answer to specific questions. Looking up statin intolerance, for instance, directs the reader to a useful section that provides some effective practical suggestions about the appropriate course of clinical action, but it is too brief and should certainly be expanded in future editions. It may be better to conclude the book with this chapter rather than a discussion on obesity and its treatment.
Another area that could be addressed in future editions is the discussion of familial hypercholesterolemia (FH). This appears in 3 chapters (1, 8, and 12), but perhaps it would be better to have a chapter to itself because it is one of the most important conditions in the lipid clinic. Indeed, sitosterolemia is given nearly as much space, despite being far rarer than heterozygous FH, which probably affects ≈600 000 Americans, based on a population of just over 300 million and an incidence of 1 in 500. Although it is mentioned that numerous mutations in the LDLR gene have been identified, in addition to other mutations in the apoB gene and the PCSK9 controller gene, there is no mention of the nature of these gene defects or the benefits to individual families in identifying the defective gene to facilitate cascade screening from identified probands. This is an area of considerable interest, especially because the cost of defining the underlying genetic abnormality has decreased considerably with automated sequencing and with the advent of targeted “chips” containing a selection of known local mutations. In addition, our experience is that tendon xanthomata are becoming increasingly uncommon and are virtually unknown in children and adolescents with heterozygous FH (although they may occur in the much rarer homozygous FH). For this reason, a genetic basis for the diagnosis of FH is likely to become increasingly important.
In summary, this book is a useful and expert summary of where we are now in lipid disorders and their management, but like all good textbooks (and all good gardens), it will need periodic attention and upgrading.
D. Paul Nicholls, MD, DSc, FRCP
Ian S. Young, MD, FRCP, FRCPath
Queen's University of Belfast
Royal Victoria Hospital
Belfast, Northern Ireland, UK
- © 2010 American Heart Association, Inc.