Coronary Disease in Women: Evidence-Based Diagnosis and Treatment
http://www.100md.com
《新英格兰医药杂志》
A consensus is growing that cardiovascular disease affects men and women differently in a number of ways. This view is reflected in a recent book in the Contemporary Cardiology series, one that is devoted to coronary disease in women. The book's first chapter quotes from the recommendations of the Institute of Medicine report "Exploring the Biological Contributions to Human Health: Does Sex Matter?" which advocates the study of sex differences "from womb to tomb." The magnitude of that challenge is outlined in the second section of the book, which is devoted to screening and diagnosis. Many women, and even some clinicians, still think that breast cancer is the greatest threat to women's health, even though one in four women dies from heart disease, as compared with one in nine from breast cancer. The risk factors for coronary disease appear to be largely the same for women and men, although the effects of those factors may differ between the sexes. The notable exception is, of course, the putative role of the loss of endogenous estrogen after menopause. The third section of the book discusses aspects of the diagnosis and treatment of coronary disease in women. The book concludes with a discussion of the economics of cardiovascular care for women and the related health policy issues.
There is much to be learned from this book, but it does not give the reader all that it promises. A book that is marketed as "evidence-based medicine" should go further than presenting a bundled set of essays, albeit by a number of experienced investigators and clinicians. According to the Evidence-Based Medicine Working Group, evidence-based medicine stresses the examination of evidence from clinical research as the basis for clinical decision making, rather than relying on unsystematic clinical experience and pathophysiological rationale. The most important limitation of this book is that it is not sufficiently systematic or critical and in several aspects is unbalanced.
To make this information accessible to clinicians and ensure the implementation of the best available evidence in optimal management, a highly structured and concise approach is needed, with an explicit weighing of the level of evidence. The editors have not accomplished this, and as a result each chapter appears to have its own structure and terminology, which results in repetition, inconsistencies, and markedly different handling of the topics in various chapters. The figures and tables differ strikingly in quality (with measurement units sometimes lacking or incomplete). Perhaps more important, the editors do not appear to have judged or classified the information according to the solidity of the evidence. For example, the data on exercise testing in the workup of coronary disease in women is presented in different ways in chapters 10 and 12 through 17. There is ample information about the use of electron-beam tomography in coronary calcium scoring but limited evidence for its application. The discussion of classical risk factors and risk-factor profiling suffers from an overemphasis on novelties (such as measurements of C-reactive protein and homocysteine); consequently, the emphasis is out of proportion relative to established risk factors, such as the lipid profile, blood pressure, and the presence or absence of diabetes. The chapter on clinical risk assessment does not need to devote half a page to postmenopausal hormone therapy, since that topic is covered in its own chapter.
Another limitation of the book is that it was published just before the results of the estrogen-only arm of the Women's Health Initiative study became available. The chapter on hormone-replacement therapy starts with a discussion of the mechanism of cardiac protection by estrogens, explaining that lipid changes account for 25 to 50 percent of the protective effect; it also presents the view that the retardant effect of estrogen on atherosclerosis may relate to its inhibition of the inflammatory response. The uninitiated reader may find it surprising that the chapter ends with evidence from clinical trials showing that postmenopausal hormone therapy may actually increase the risk of coronary disease or, at best, has a neutral effect.
Diederick E. Grobbee, M.D, Ph.D.
Yvonne T. van der Schouw, Ph.D.
University Medical Center Utrecht
Utrecht, the Netherlands
d.e.grobbee@umcutrecht.nl((Contemporary Cardiology.)
There is much to be learned from this book, but it does not give the reader all that it promises. A book that is marketed as "evidence-based medicine" should go further than presenting a bundled set of essays, albeit by a number of experienced investigators and clinicians. According to the Evidence-Based Medicine Working Group, evidence-based medicine stresses the examination of evidence from clinical research as the basis for clinical decision making, rather than relying on unsystematic clinical experience and pathophysiological rationale. The most important limitation of this book is that it is not sufficiently systematic or critical and in several aspects is unbalanced.
To make this information accessible to clinicians and ensure the implementation of the best available evidence in optimal management, a highly structured and concise approach is needed, with an explicit weighing of the level of evidence. The editors have not accomplished this, and as a result each chapter appears to have its own structure and terminology, which results in repetition, inconsistencies, and markedly different handling of the topics in various chapters. The figures and tables differ strikingly in quality (with measurement units sometimes lacking or incomplete). Perhaps more important, the editors do not appear to have judged or classified the information according to the solidity of the evidence. For example, the data on exercise testing in the workup of coronary disease in women is presented in different ways in chapters 10 and 12 through 17. There is ample information about the use of electron-beam tomography in coronary calcium scoring but limited evidence for its application. The discussion of classical risk factors and risk-factor profiling suffers from an overemphasis on novelties (such as measurements of C-reactive protein and homocysteine); consequently, the emphasis is out of proportion relative to established risk factors, such as the lipid profile, blood pressure, and the presence or absence of diabetes. The chapter on clinical risk assessment does not need to devote half a page to postmenopausal hormone therapy, since that topic is covered in its own chapter.
Another limitation of the book is that it was published just before the results of the estrogen-only arm of the Women's Health Initiative study became available. The chapter on hormone-replacement therapy starts with a discussion of the mechanism of cardiac protection by estrogens, explaining that lipid changes account for 25 to 50 percent of the protective effect; it also presents the view that the retardant effect of estrogen on atherosclerosis may relate to its inhibition of the inflammatory response. The uninitiated reader may find it surprising that the chapter ends with evidence from clinical trials showing that postmenopausal hormone therapy may actually increase the risk of coronary disease or, at best, has a neutral effect.
Diederick E. Grobbee, M.D, Ph.D.
Yvonne T. van der Schouw, Ph.D.
University Medical Center Utrecht
Utrecht, the Netherlands
d.e.grobbee@umcutrecht.nl((Contemporary Cardiology.)