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NONINVASIVE CARDIOVASCULAR DIAGNOSIS: CURRENT CONCEPTS
THE BOOKSHELF CHEST NUCLEAR MEDICI.NE: CASE STUDIES (A Compilation of 54 Case Histories). Edited by MARVIN CUTER and ALDo N. SERAFINI. Garden City, NY, Medical Examination Publishing ce., 1979, 170 pp, $12.00.
Chest Nuclear Medicine: Case Studie, is a small spiral-bound publication which is an excellent introduction to radionuclidic evaluation of the chest. The basic physical, technical, and diagnostic principles are discussed in sufficient detail to enable the practicing clinician to order radionuclidic examinations of the chest in an intelligent manner. The 54 relatively short, wellillustrated case studies allow easy, intermittent, bite-size reading sessions. I believe that this is a worthwhile text for the chest physician who wishes an overview of the diagnostic possibilities afforded by nuclear medicine and for the resident in radiology who is beginning the study of thoracic nuclear medicine. Francia 1. Scholz, M.D.
Bolton
CARDIOVASCULAR CLINICS: EXERCISE AND THE HEART. Edited by NANETTE K. WENGER (Series Editor, Albert N. Brest). Philadelphia, F. A. Davis Co., 1978, 246 pp, $35.00. This is a timely, well-organized, and up-to-date compilation of appropriately selected topics reviewed by knowledgeable experts in the related areas under the superb editorial guidance of Professor Nanette K. Wenger. Clinical aspects of exercise physiology are clearly described; misconceptions about current trends in sports are noted, along with the benefits of exercise conditioning both in experimental animals and in man. The principles of how to achieve the benefits are cited. Exercise testing is briefly considered, but the potential hazards and limitations of end points based on the target heart rate are not stated, even though the decrements with early five-year advance in age are tabulated. ST-segment depression, heart rate, and blood pressure responses are described, and the need for multivariable analysis of significance of these variables is recognized. The advantages of two mutually perpendicular lead axes to identify arrhythmias are documented; the greater prevalence of arrhythmias with treadmill than with bicycle exercise testing is Doted, but the associated differences in blood pressure responses in patients with coronary arterial stenosis are neglected. The complementary value of continuous electrocardiographic monitoring (Holter monitor) of the emotional as well as physical stresses of daily activities and of nocturnal changes is described, along with its advantages in monitoring responses to treabnent with drugs and to rehabilitation. Prescribing programs of exercise must take into account educational and motivational aspects, as well as possible needs for other medical or surgical treatment, before initiating physical training. The latter should emphasize activities of sufBcient intensity, frequency, and duration' to enhance cardiovascular fitness, where the criterion for intensity confirms the ancient principle of Maimonides of exercising to the onset of breathlessness. Hazards of "detraining" and of orthopedic problems are not neglected. Types of exercise to be recommended for the plan of exercise training are considered in relation to the use of arms vs legs, rhythmic vs static exertion, and occupational needs, but the relationships of heart rate to the uptake of oxygen by the total body and by the myocardium are oversimplified, disregarding significant individual variations in blood pressure, stroke volume, and arteriovenous oxygen cillference. Warm-up, conditioning, and cool-down phases are properly emphasized; the value of medically supervised programs is noteworthy. The value of low-level exercise testing early in the course of convalescence is recognized, and the precautions against competitive or stressful sports are timely. Wenger clearly states the physiologic rationale for early ambulation after myocardial Infarction. Differences in cardiovascular responses to static vs dynamic exertion are defined, and the concept of the lowering of the relative aerobic requirements for any submaximal effort as the basis for sparing the heart is explained. Progressive changes in cardiovascular response to serial exercise testing after infarction
34
are described, and some of the predictors of future events are noted; again, the importance of consideration of all available criteria is emphasized. Correlations between ST-segment responses and coronary arteriograms are discussed in relation to the numerous interacting variables involved in clinical material. Cardiovascular surgery is also recognized as another cause of deconditioning, and methods for progressive reconditioning are described. A conservative approach to preoperative and postoperative exercise testing to assess functional capacity stands in contrast to. the prin~ples of ~o~~level exercise testing to assess the safety of mmor ordinary acnvtttes for self-care at home. Applications of testing in patients with valvular heart disease are cited; another chapter describes applications in children with various structural abnormalities of the heart. The design of the study and the initial findings of the National E~ercise ~eart Disease Project are described in detail, together WIth sobenng comments about recruitment of patients and preliminary preparation for well-described controlled studies. Finally, the psychologic problems of anxiety and depression and the use of denial as an initial coping mechanism are described. The psychology of motivating patients with the need to condition themselves as a necessary "tax" (or insurance premium) to delay further manifestations of heart disease is a novel approach. The legal responsibilities of physicians and their constituents for any harmful consequences of exercise require high standards of professional care. Accordingly, the practical medicolegal questions to be considered are listed. One of the first protective measures is proper use of an adequately informed statement listing the procedures, purpose, risks, and benefits; the next is to provide appropriate professional supervision. Altogether, this is an excellent survey of a rapidly expanding area of medical and paramedical activities which should be informative to both types of participants. Although there is some repetiti~n from chapter to chapter, this serves the useful purpose of defining the common ground of generally accepted principles and practices; it also reveals differences in orientation, experience, and expectations, which indicate the areas that require further evaluation by many. The text is supplied with clear illustrations, useful tables, and selected references, which reflect well upon Wenger and her numerous collaborators. It should be a valuable text for students as well. Robert A. Bruce, M.D. Seattle
NONINVASIVE CARDIOVASCULAR DIAGNOSIS: CURRENT CONCEPTS. Edited by EDWARD B. DIETHRICH. Baltimore, University Park Press, 1978, 534 pp, $39.50. This volume is a collection of 49 reports presented at an international symposium on noninvasive cardiovascular diagnosis sponsored by the Arizona Heart Institute at Scottsdale in March of 1977. The book is equally divided between noninvasive topics in peripheral vascular and cardiac disease. The volume is organized into eight sections intended to cover major areas of clinical and research interest. Some sections, such as the one on thromboembolism, are disappointingly brief, despite their c1inical importance. The readability and usefulness of the book could have been improved 'with an editorial "overview" at the end of each section. This might have put individual chapters into better perspective, provided some degree of cohesion between chapters, and filled in important omissions in content. As one might expect in such a compendium, there is a wide variation in the contributions. The chapters by Barnes and Jarrett comparing screening techniques in extracranial arterial occlusive disease and the chapter by Strandness on evaluation of the lower extremities are especially worthwhile. Ellestad has contributed two outstanding chapters, one on multivariate analysis of stress testing and a second on the future of noninvasive monitoring; however, most chapters focus on highly specialized areas of research, and there is little apparent relationship of one chapter to the next. The net result is a somewhat random and incomplete compendium of recent work on noninvasive diagnosis of cardiovascular disease. It will be of interest to research workers in the field, but clinicians looking for an authoritative and comprehensive overview of noninvasive diagnostic techniques will find this book of limited value. Bruce S. Cutler, M.D. W orcester, Mass
Continued on page 35
Chest Nuclear Medicine: Case Studie, is a small spiral-bound publication which is an excellent introduction to radionuclidic evaluation of the chest. The basic physical, technical, and diagnostic principles are discussed in sufficient detail to enable the practicing clinician to order radionuclidic examinations of the chest in an intelligent manner. The 54 relatively short, wellillustrated case studies allow easy, intermittent, bite-size reading sessions. I believe that this is a worthwhile text for the chest physician who wishes an overview of the diagnostic possibilities afforded by nuclear medicine and for the resident in radiology who is beginning the study of thoracic nuclear medicine. Francia 1. Scholz, M.D.
Bolton
CARDIOVASCULAR CLINICS: EXERCISE AND THE HEART. Edited by NANETTE K. WENGER (Series Editor, Albert N. Brest). Philadelphia, F. A. Davis Co., 1978, 246 pp, $35.00. This is a timely, well-organized, and up-to-date compilation of appropriately selected topics reviewed by knowledgeable experts in the related areas under the superb editorial guidance of Professor Nanette K. Wenger. Clinical aspects of exercise physiology are clearly described; misconceptions about current trends in sports are noted, along with the benefits of exercise conditioning both in experimental animals and in man. The principles of how to achieve the benefits are cited. Exercise testing is briefly considered, but the potential hazards and limitations of end points based on the target heart rate are not stated, even though the decrements with early five-year advance in age are tabulated. ST-segment depression, heart rate, and blood pressure responses are described, and the need for multivariable analysis of significance of these variables is recognized. The advantages of two mutually perpendicular lead axes to identify arrhythmias are documented; the greater prevalence of arrhythmias with treadmill than with bicycle exercise testing is Doted, but the associated differences in blood pressure responses in patients with coronary arterial stenosis are neglected. The complementary value of continuous electrocardiographic monitoring (Holter monitor) of the emotional as well as physical stresses of daily activities and of nocturnal changes is described, along with its advantages in monitoring responses to treabnent with drugs and to rehabilitation. Prescribing programs of exercise must take into account educational and motivational aspects, as well as possible needs for other medical or surgical treatment, before initiating physical training. The latter should emphasize activities of sufBcient intensity, frequency, and duration' to enhance cardiovascular fitness, where the criterion for intensity confirms the ancient principle of Maimonides of exercising to the onset of breathlessness. Hazards of "detraining" and of orthopedic problems are not neglected. Types of exercise to be recommended for the plan of exercise training are considered in relation to the use of arms vs legs, rhythmic vs static exertion, and occupational needs, but the relationships of heart rate to the uptake of oxygen by the total body and by the myocardium are oversimplified, disregarding significant individual variations in blood pressure, stroke volume, and arteriovenous oxygen cillference. Warm-up, conditioning, and cool-down phases are properly emphasized; the value of medically supervised programs is noteworthy. The value of low-level exercise testing early in the course of convalescence is recognized, and the precautions against competitive or stressful sports are timely. Wenger clearly states the physiologic rationale for early ambulation after myocardial Infarction. Differences in cardiovascular responses to static vs dynamic exertion are defined, and the concept of the lowering of the relative aerobic requirements for any submaximal effort as the basis for sparing the heart is explained. Progressive changes in cardiovascular response to serial exercise testing after infarction
34
are described, and some of the predictors of future events are noted; again, the importance of consideration of all available criteria is emphasized. Correlations between ST-segment responses and coronary arteriograms are discussed in relation to the numerous interacting variables involved in clinical material. Cardiovascular surgery is also recognized as another cause of deconditioning, and methods for progressive reconditioning are described. A conservative approach to preoperative and postoperative exercise testing to assess functional capacity stands in contrast to. the prin~ples of ~o~~level exercise testing to assess the safety of mmor ordinary acnvtttes for self-care at home. Applications of testing in patients with valvular heart disease are cited; another chapter describes applications in children with various structural abnormalities of the heart. The design of the study and the initial findings of the National E~ercise ~eart Disease Project are described in detail, together WIth sobenng comments about recruitment of patients and preliminary preparation for well-described controlled studies. Finally, the psychologic problems of anxiety and depression and the use of denial as an initial coping mechanism are described. The psychology of motivating patients with the need to condition themselves as a necessary "tax" (or insurance premium) to delay further manifestations of heart disease is a novel approach. The legal responsibilities of physicians and their constituents for any harmful consequences of exercise require high standards of professional care. Accordingly, the practical medicolegal questions to be considered are listed. One of the first protective measures is proper use of an adequately informed statement listing the procedures, purpose, risks, and benefits; the next is to provide appropriate professional supervision. Altogether, this is an excellent survey of a rapidly expanding area of medical and paramedical activities which should be informative to both types of participants. Although there is some repetiti~n from chapter to chapter, this serves the useful purpose of defining the common ground of generally accepted principles and practices; it also reveals differences in orientation, experience, and expectations, which indicate the areas that require further evaluation by many. The text is supplied with clear illustrations, useful tables, and selected references, which reflect well upon Wenger and her numerous collaborators. It should be a valuable text for students as well. Robert A. Bruce, M.D. Seattle
NONINVASIVE CARDIOVASCULAR DIAGNOSIS: CURRENT CONCEPTS. Edited by EDWARD B. DIETHRICH. Baltimore, University Park Press, 1978, 534 pp, $39.50. This volume is a collection of 49 reports presented at an international symposium on noninvasive cardiovascular diagnosis sponsored by the Arizona Heart Institute at Scottsdale in March of 1977. The book is equally divided between noninvasive topics in peripheral vascular and cardiac disease. The volume is organized into eight sections intended to cover major areas of clinical and research interest. Some sections, such as the one on thromboembolism, are disappointingly brief, despite their c1inical importance. The readability and usefulness of the book could have been improved 'with an editorial "overview" at the end of each section. This might have put individual chapters into better perspective, provided some degree of cohesion between chapters, and filled in important omissions in content. As one might expect in such a compendium, there is a wide variation in the contributions. The chapters by Barnes and Jarrett comparing screening techniques in extracranial arterial occlusive disease and the chapter by Strandness on evaluation of the lower extremities are especially worthwhile. Ellestad has contributed two outstanding chapters, one on multivariate analysis of stress testing and a second on the future of noninvasive monitoring; however, most chapters focus on highly specialized areas of research, and there is little apparent relationship of one chapter to the next. The net result is a somewhat random and incomplete compendium of recent work on noninvasive diagnosis of cardiovascular disease. It will be of interest to research workers in the field, but clinicians looking for an authoritative and comprehensive overview of noninvasive diagnostic techniques will find this book of limited value. Bruce S. Cutler, M.D. W orcester, Mass
Continued on page 35