Heart Failure: A Comprehensive Guide to Diagnosis and Treatment
http://www.100md.com
《新英格兰医药杂志》
Sir Thomas Lewis opined in 1933 that "the very essence of cardiovascular practice is the early detection of heart failure." Heart failure at that time was a topic of substantial interest to physicians. In the past two decades that interest has been revived, and no longer is cardiology overlooked in favor of surgery, catheter intervention, and the early management of acute coronary syndromes. This change has come about because of the realization that heart failure is a common cardiac problem that is becoming more common, is detectable in the community, is preventable, is treatable, and consumes a considerable proportion of health care resources.
Radiograph Showing Congestive Heart Failure in a 28-Year-Old Woman.
Courtesy of the Centers for Disease Control and Prevention/Dr. Thomas Hooten.
Heart failure is an illness of major public importance, and new treatments, such as the use of inhibitors of the renin–angiotensin and sympathetic systems, have been shown to be efficacious in large, high-quality trials. Indeed, in few branches of medicine has it been shown so clearly how new drugs affect key outcomes — namely, death and the quality of life. The current emphasis is on methods to encourage the implementation of this new medical knowledge. At the same time, many ideas are emerging concerning the prevention of the progression of heart failure or the reversal of the fundamental cause of heart failure — the loss of functioning myocytes. In the immediate future, advances in the fields of engineering and electronics are likely to contribute considerably to cardiac-resynchronization treatment, implantable cardioverter–defibrillators, and left ventricular assist devices. In the longer term, the cure for heart failure must be control of the growth, death, regeneration, and perhaps even cell division of the cardiac myocytes.
This book is a contribution to the ever-growing number of works being published on the topic of heart failure. It is written by a distinguished set of authors, has 25 chapters, is eminently readable, and is of a weight that makes it easy to take off the shelf. It is well referenced, perhaps overly so, and is up to date. There are outstanding chapters on beta-adrenergic signaling, excitation–contraction coupling, heart failure in special populations, angiotensin-receptor blockers, and new treatments such as mechanical support, immunotherapy, gene therapy, and cell treatment. There is useful information on genetic diversity, and it is perhaps a pity that there is no specific chapter on that topic. The review of heart failure in women, the elderly, and ethnic groups is excellent and identifies deficiencies in current knowledge.
The worst feature of the book by far is the quality of the figures, some of which are simply awful. Omitted is a focus on the delivery of health care in the community, the use of health care specialists and nurses for the delivery of that care, and the following of guidelines by members of the community. The problem is that most clinical trials have reported on the use of treatments in men in their 60s, even though the average age of persons with heart failure in Western societies is 75 years and the elderly population is nearly 50 percent female.
The authors adhere rather strictly to the principles of evidenced-based medicine, but not always. For example, there is little evidence that beta-blockers are of benefit in patients who have structural heart disease without symptoms, although it is a reasonable supposition. A long discussion about the use of digoxin is rather unbalanced; the author has a committed belief in the merits of the drug. Perhaps the general point is that when guidelines committees try to assess the outcomes of large trials and the effect on health systems, they should not only identify positive trials but also emphasize neutral or even negative trials.
The recent guidelines of the American Heart Association and the American College of Cardiology have introduced a new classification of heart failure that is based on four stages. Stage A includes patients at high risk with no structural disorders, stage B patients with structural disease and no symptoms, stage C patients with structural disease and symptoms, and stage D patients with severe heart failure or end-stage disease. This system contrasts with the widely used classification from the New York Heart Association, in which grades 1 through 4 are based on the severity of symptoms. The change is a consequence of a better understanding of the biology of heart failure, of the importance of inhibiting the progression of heart failure, and in particular, of the importance of preserving cardiac myocytes and preventing progressive enlargement of the ventricle (i.e., remodeling). This book is a most useful summary of the current state of knowledge in the field of heart failure; many readers will gain from dipping into it.
Philip A. Poole-Wilson, M.D.
National Heart and Lung Institute at Imperial College London
London SW3 6LY, United Kingdom
p.poole-wilson@imperial.ac.uk
Radiograph Showing Congestive Heart Failure in a 28-Year-Old Woman.
Courtesy of the Centers for Disease Control and Prevention/Dr. Thomas Hooten.
Heart failure is an illness of major public importance, and new treatments, such as the use of inhibitors of the renin–angiotensin and sympathetic systems, have been shown to be efficacious in large, high-quality trials. Indeed, in few branches of medicine has it been shown so clearly how new drugs affect key outcomes — namely, death and the quality of life. The current emphasis is on methods to encourage the implementation of this new medical knowledge. At the same time, many ideas are emerging concerning the prevention of the progression of heart failure or the reversal of the fundamental cause of heart failure — the loss of functioning myocytes. In the immediate future, advances in the fields of engineering and electronics are likely to contribute considerably to cardiac-resynchronization treatment, implantable cardioverter–defibrillators, and left ventricular assist devices. In the longer term, the cure for heart failure must be control of the growth, death, regeneration, and perhaps even cell division of the cardiac myocytes.
This book is a contribution to the ever-growing number of works being published on the topic of heart failure. It is written by a distinguished set of authors, has 25 chapters, is eminently readable, and is of a weight that makes it easy to take off the shelf. It is well referenced, perhaps overly so, and is up to date. There are outstanding chapters on beta-adrenergic signaling, excitation–contraction coupling, heart failure in special populations, angiotensin-receptor blockers, and new treatments such as mechanical support, immunotherapy, gene therapy, and cell treatment. There is useful information on genetic diversity, and it is perhaps a pity that there is no specific chapter on that topic. The review of heart failure in women, the elderly, and ethnic groups is excellent and identifies deficiencies in current knowledge.
The worst feature of the book by far is the quality of the figures, some of which are simply awful. Omitted is a focus on the delivery of health care in the community, the use of health care specialists and nurses for the delivery of that care, and the following of guidelines by members of the community. The problem is that most clinical trials have reported on the use of treatments in men in their 60s, even though the average age of persons with heart failure in Western societies is 75 years and the elderly population is nearly 50 percent female.
The authors adhere rather strictly to the principles of evidenced-based medicine, but not always. For example, there is little evidence that beta-blockers are of benefit in patients who have structural heart disease without symptoms, although it is a reasonable supposition. A long discussion about the use of digoxin is rather unbalanced; the author has a committed belief in the merits of the drug. Perhaps the general point is that when guidelines committees try to assess the outcomes of large trials and the effect on health systems, they should not only identify positive trials but also emphasize neutral or even negative trials.
The recent guidelines of the American Heart Association and the American College of Cardiology have introduced a new classification of heart failure that is based on four stages. Stage A includes patients at high risk with no structural disorders, stage B patients with structural disease and no symptoms, stage C patients with structural disease and symptoms, and stage D patients with severe heart failure or end-stage disease. This system contrasts with the widely used classification from the New York Heart Association, in which grades 1 through 4 are based on the severity of symptoms. The change is a consequence of a better understanding of the biology of heart failure, of the importance of inhibiting the progression of heart failure, and in particular, of the importance of preserving cardiac myocytes and preventing progressive enlargement of the ventricle (i.e., remodeling). This book is a most useful summary of the current state of knowledge in the field of heart failure; many readers will gain from dipping into it.
Philip A. Poole-Wilson, M.D.
National Heart and Lung Institute at Imperial College London
London SW3 6LY, United Kingdom
p.poole-wilson@imperial.ac.uk