Book Reviews

Cardiac Emergency Care, ed 4

John M Howell, MD, FACEP

Modern Management of Acute

Myocardial Infarction in the

Community Hospital

Keith Wrenn, MD

Cardiac Emergency Care, ed 4 EK Chung

1991, Lea and Febiger, 428 pages

This is the fourth edition of a 428- page, paper-bound textbook on the emergency treatment of patients with cardiovascular disorders. Subjects covered range from CPR and dysrhythmias to pediatric disorders and digitalis intoxication. Generally, the authors are cardiolo- gists, cardiothoracic surgeons, and internists.

Cardiac Emergency Care seems to be written primarily for resident and attending physicians working in coronary and intensive care units. The chapter on direct current shock starts out discussing a semielective approach including the importance of keeping patients NPO; the use of countershock as a life-saving tech- nique is mentioned later, and the use of etomidate is not included. Further, synchronous and asynchro- nous cardioversion modes are not described. The chapter on percuta- neous transluminal coronary angio- plasty discusses, in addition to indications and contraindications, premedication, the percutaneous transluminal coronary angioplasty procedure itself, and post-procedure care.

Chapters include an historical introduction followed by an outline approach to the general information in each section. These outlines are a strong point and make it easy to cull pertinent information rapidly. There

are many ECGs in the dysrhythmia sections, and pathophysiology and physical diagnosis are discussed at length. Another strong point is the conclusion section of each chapter, which serves as an abbreviated "pearls and pitfalls."

Initial management and resuscita- tion are downplayed, although there is a short chapter on acute coronary care that expands on the initial approach to sick ICU patients. The countershock chapter described above is an example of this difficulty. Under cardiogenic shock, IV access is mentioned before oxygen therapy, and intubation is listed in step 6 of the outline.

Some concepts are missing from various chapters. There is no men- tion of adenosine in one section on arrhythmias, and the alveolar-arteri- al oxygen gradient is nowhere to be found under pulmonary embolus. When discussing complete atrioven- tricular block, the authors leave out transcutaneous pacemakers and fail to mention the deleterious (hypoten- sive) B 2 effects of isoproterenol. The physical diagnosis of various chest pain syndromes is touched on in appropriate chapters, but there is no one section that deals solely with the differential diagnosis of acute chest discomfort.

Citations are not referenced, but there are lists Df suggested read- ings. The index is about five pages long, perhaps a bit short considering the breadth of this topic. Also, there are a few copyediting errors; for example, the outline format is incon-

sistent regarding the WoN- Parkinson-White syndrome.

The chapter on pediatric cardiac emergencies is an overview of com- mon, acute presentations. It is fortu- nate that this topic is included because many emergency medicine texts omit pediatric cardiology. Digoxin intoxication is covered in an organized, accurate, and appropriate manner.

In summary, Cardiac Emergency Care is an accessory, quick reference on the pathophysiology of cardiac disorders, pediatric cardiology, and digoxin intoxication. However, I de not recommend this book to emer- gency physicians as a primary refer- ence on cardiac emergencies. It is more appropriate for housestaff physicians rotating through the CCU.

John M Howell, MD, FACEP Department of Emergency Medicine Georgetown University Hospital Washington, DC

Modern Management of Acute Myocardial Infarction in the Community Hospital JL Anderson (ed)

1991, Marcel Dekker, Inc, 560 pages, $89.75

This easily read text on the manage- ment of acute myocardial infarction fills a niche for physicians who come

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BOOK REVIEWS

in contact with this common prob- lem. However, I believe Modem Management of Acute Myocardial Infarction in the Community Hospital is mistitled. It is more a detailed reference work dealing predominantly with the rationale for thrombolytic therapy and less a text for the com- munity hospital-based physician to refer te during the actual manage- ment of an acute myocardial infarc- tien. There is much useful informa- tion about the relative merits of the various thrombolytic agents and very detailed and useful discussion of the many trials of these drugs, all of which seem to have colorful, if con- fusing, acronyms. Unfortunately, the reader cannot readily lay hands on a quick guide to which agent to use when and in what dose.

This text should be read more for its background information by physi- cians with an interest in the man- agement of myocardial infarction. The ins and outs, ups and downs, and good and bad points about the many thrombolytic trials are laid out clearly and comprehensively for the reader. The next step, however, of a useful algorithmic approach to the management of acute myocardial infarction would be useful but is not realized.

The interesting and readable chapters "Dietary and Lifestyle Interventions," "New Device Therapy," and "Laser Therapy" have little application to the actual practice of emergency medicine at the community hospital level.

It is sometimes redundant and frequently confusing to present detailed information about each thrombolytic agent separately by different authors. After each chap- ter, I was left feeling that indeed this was the agent that I should use only to have the next chapter sup- plant this impression. Although informative, the extensive data pre- sented about the use of each of these agents in pulmonary embolism and peripheral vascular disease (with different doses and schedules) are also confusing and do not fit with the title.

Unlike the ten chapters on throm- belysis, there is but a single chapter

on the use of nitrates, &-blockers, calcium channel blockers, aspirin, anticoagulants, and angiotensin converting enzyme inhibitors. Although this chapter is well writ- ten, it seems unbalanced to spend so much time on the thrombolytic agents at the expense of these other useful drugs when only 25% of patients are eligible for thrombolytic therapy.

One chapter with great potential for emergency physicians is entitled "The Diagnosis and General Management Principles." It presents the standard internal medicine party line about historical and physical data that need to be collected: "The importance of a goal-oriented medi- cal history cannot be overempha- sized in the initial evaluation of patients suspected of AMI." The "goal," however, is not specified. My goal in evaluating the patient with chest pain is to have a very high sensitivity for detecting patients with acute ischemic chest pain. As written, I'm not sure this chapter would fulfill my goals. I don't so much object to the material presented in this chapter as to the way in which it is presented. For example: "No medical history is complete without a detailed [car- diac] risk factor analysis." I think these questions should be asked eventually in all patients, but in the patient with unequivocal acute ischemic heart disease, they add little to the initial ED evaluation and may waste time before thrombolytic therapy is given. The risk factors that are important up front are the risk factors for bleeding if thrombolytic therapy is given. Likewise, "an astute clinician may occasionally observe external manifestations of hyperlipidemia including tendinous or tuberous xanthomas, and xanthe- lasma," implies that those of us who don't search for these findings are not "astute." I generally do not spend a lot of time in evaluating patients in the ED for these findings.

The chapter "Current and Future Cardiac Imaging Techniques" is very useful for the emergency physician. It contains a very good table that compares the various techniques

and when they provide useful infor- mation.

In summary, this book would seem te be a useful addition te the library of an academic emergency medicine residency. Physicians interested in acute myocardial infarction also will be rewarded with muchuseful back- ground information about thromboly- sis in particular. The format, howev- er, leads to confusion, and the reader is cautioned that this book will not have much use outside the ED during the actual management of a patient with acute myocardial infarction.

Keith Wrenn, MD Division of Emergency Medicine Vanderbilt University Nashville, Tennessee

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