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Hyperlipidaemia in practice
BOOK REVIEWS John M. Porter, MD, Book Review Section Editor
Vascular surgery: Current questions Aires A. B. Barros D'Sa, Peter R. F. Bell, Simon G. Darke, Peter L. Harris, Stoneham, 1991, Butterworth Heinemann, 257 pages, $115. In his preface the editor writes, "There is a need to explore specific topics which arouse controversy and provoke debate. The purpose is to raise current questions." He also states that the book is aimed at practicing vascular surgeons and higher surgical trainees whose interests are in vascular surgery. We can assume then that the readers will have some considerable knowledge of the subject and will benefit from reading the book, because it highlights what is not known. The chapters in this book are based on presentations made at a meeting of the Joint Vascular Research Group held in Belfast, Northern Ireland, in 1991, and all the authors are members of that group. The book itself is of a moderate size and is arranged in the standard format. Each chapter is the work of a single author, and each has an extensive bibliography that is, for the most part, contemporary and lists the appropriate references in English-language journals. This does lead to some notable omissions. For example, Chapter 2 includes many references to the Framingham Study and concludes that similar studies will make an impact on mortality, but it fails to mention or to review anywhere the extensive and comprehensive Basler study by L. Widrner. I particularly liked the chapters on carotid endarterectomy, the role of surgery in iliac artery disease, why distal grafts fail, and the treatment of renal artery stenosis. They complied with the stated aims of the book and were eminently readable. The remaining chapters are, for the most part, a reiteration of the present position. Few, if any, questions are raised, and the reader will find nothing that challenges orthodoxy. For example, as a result of three large trials most vascular surgeons (and some neurologists) would agree that for patients with symptomatic carotid artery stenoses of 75% or greater, surgery is better than medical treatment. The strengths and weaknesses of such trials are admirably dealt with in Chapter 3, but none of the authors in this or other chapters questions how accurately we can measure a 75% stenosis. If we are to operate on a 75% stenosis and not a 65% stenosis, can we, on the basis of angiograms and duplex ultrasonograms, reliably distinguish one from the other? What weight should we give to the presence of an ulcerated plaque when we are making the decision to operate? What are the factors that, when present, will predispose to an operative stroke, and how can they be circumvented? Increasingly, one sees patients who have widespread arteriosclerosis, who have symptoms in their legs, and who also have angina pectoris and asymptomatic carotid artery stenoses. The accurate assessment of risk and timing of operations are questions of real interest that are alluded to briefly in several chapters but that might better 1140
have been dealt with as a whole. Surprisingly, there is no review of the whole vexed question of angioplasty. One might expect a scholarly work compiled by surgeons actively engaged in research to take the form of a critique of published works, a clear statement of doubts that remain, and an enumeration of ongoing arguments and remaining questions that require an answer if we are to resolve uncertainties and eventually find the truth. With a few notable exceptions the book fails to do this. Instead, it concentrates on clinical subjects, presents a brief but generally adequate review of each, and provides more answers than questions. David Charlesworth, DSc, MD, FRCS University Hospital of South Manchester Manchester, England
Hyperlipidaemia in practice David Galton, Wilhelm Krone, New York, 1991, Gower Med PubL (distributed by Raven Press), 138 pages, $49.95. This book by Drs. Galton and Krone provides a concise review of the pathophysiology, diagnosis, and treatment of lipid disorders commonly seen by the practitioner. The authors make use of an atlas approach, with numerous straightforward illustrations and case presentations that serve to clarify this complex topic. In the space of 138 pages the authors discuss the biochemistry, inherited defects, and genetics of lipid metabolism. Subsequent chapters examine the clinical manifestations ofhyperlipidemia and its treatment, review findings from recent intervention trials, and describe the function of the lipid clinic. The schematics provided in the sections that cover lipid metabolism are particularly useful for those unfamiliar with lipoprotein biochemistry and assay techniques. The excellent photographs accompanying the chapters on diagnosis clearly illustrate the clinical manifestations of hyperlipidemia. In a book of this size the absence of an involved discussion of the intricacies of lipoprotein metabolism is implicit and was not intended. For example, the chapters on intervention trials and on the epidemiology of lipids and atherosclerosis highlight pertinent findings and do not discuss the particulars of each study. For those who want more detail the authors provide a section on further reading. The stated intent of the authors was to "avoid a text interspersed with long lists of abbreviations" and provide simple diagrams aimed at omitting unnecessary detail but not at the expense of accuracy. Hyperlipidaemia in Practice achieves this goal and is highly recommended to physicians involved in the management of lipid disorders. Tom Iffatsukami, ~ D University of Washington
Vascular surgery: Current questions Aires A. B. Barros D'Sa, Peter R. F. Bell, Simon G. Darke, Peter L. Harris, Stoneham, 1991, Butterworth Heinemann, 257 pages, $115. In his preface the editor writes, "There is a need to explore specific topics which arouse controversy and provoke debate. The purpose is to raise current questions." He also states that the book is aimed at practicing vascular surgeons and higher surgical trainees whose interests are in vascular surgery. We can assume then that the readers will have some considerable knowledge of the subject and will benefit from reading the book, because it highlights what is not known. The chapters in this book are based on presentations made at a meeting of the Joint Vascular Research Group held in Belfast, Northern Ireland, in 1991, and all the authors are members of that group. The book itself is of a moderate size and is arranged in the standard format. Each chapter is the work of a single author, and each has an extensive bibliography that is, for the most part, contemporary and lists the appropriate references in English-language journals. This does lead to some notable omissions. For example, Chapter 2 includes many references to the Framingham Study and concludes that similar studies will make an impact on mortality, but it fails to mention or to review anywhere the extensive and comprehensive Basler study by L. Widrner. I particularly liked the chapters on carotid endarterectomy, the role of surgery in iliac artery disease, why distal grafts fail, and the treatment of renal artery stenosis. They complied with the stated aims of the book and were eminently readable. The remaining chapters are, for the most part, a reiteration of the present position. Few, if any, questions are raised, and the reader will find nothing that challenges orthodoxy. For example, as a result of three large trials most vascular surgeons (and some neurologists) would agree that for patients with symptomatic carotid artery stenoses of 75% or greater, surgery is better than medical treatment. The strengths and weaknesses of such trials are admirably dealt with in Chapter 3, but none of the authors in this or other chapters questions how accurately we can measure a 75% stenosis. If we are to operate on a 75% stenosis and not a 65% stenosis, can we, on the basis of angiograms and duplex ultrasonograms, reliably distinguish one from the other? What weight should we give to the presence of an ulcerated plaque when we are making the decision to operate? What are the factors that, when present, will predispose to an operative stroke, and how can they be circumvented? Increasingly, one sees patients who have widespread arteriosclerosis, who have symptoms in their legs, and who also have angina pectoris and asymptomatic carotid artery stenoses. The accurate assessment of risk and timing of operations are questions of real interest that are alluded to briefly in several chapters but that might better 1140
have been dealt with as a whole. Surprisingly, there is no review of the whole vexed question of angioplasty. One might expect a scholarly work compiled by surgeons actively engaged in research to take the form of a critique of published works, a clear statement of doubts that remain, and an enumeration of ongoing arguments and remaining questions that require an answer if we are to resolve uncertainties and eventually find the truth. With a few notable exceptions the book fails to do this. Instead, it concentrates on clinical subjects, presents a brief but generally adequate review of each, and provides more answers than questions. David Charlesworth, DSc, MD, FRCS University Hospital of South Manchester Manchester, England
Hyperlipidaemia in practice David Galton, Wilhelm Krone, New York, 1991, Gower Med PubL (distributed by Raven Press), 138 pages, $49.95. This book by Drs. Galton and Krone provides a concise review of the pathophysiology, diagnosis, and treatment of lipid disorders commonly seen by the practitioner. The authors make use of an atlas approach, with numerous straightforward illustrations and case presentations that serve to clarify this complex topic. In the space of 138 pages the authors discuss the biochemistry, inherited defects, and genetics of lipid metabolism. Subsequent chapters examine the clinical manifestations ofhyperlipidemia and its treatment, review findings from recent intervention trials, and describe the function of the lipid clinic. The schematics provided in the sections that cover lipid metabolism are particularly useful for those unfamiliar with lipoprotein biochemistry and assay techniques. The excellent photographs accompanying the chapters on diagnosis clearly illustrate the clinical manifestations of hyperlipidemia. In a book of this size the absence of an involved discussion of the intricacies of lipoprotein metabolism is implicit and was not intended. For example, the chapters on intervention trials and on the epidemiology of lipids and atherosclerosis highlight pertinent findings and do not discuss the particulars of each study. For those who want more detail the authors provide a section on further reading. The stated intent of the authors was to "avoid a text interspersed with long lists of abbreviations" and provide simple diagrams aimed at omitting unnecessary detail but not at the expense of accuracy. Hyperlipidaemia in Practice achieves this goal and is highly recommended to physicians involved in the management of lipid disorders. Tom Iffatsukami, ~ D University of Washington