An accessible and thorough reference for physicians focusing on the practical management of patients with high blood pressure. The section on diagnosis covers blood pressure measurement, clinical assessment, investigation of essential hypertension, and diagnostic and treatment thresholds and goals. The section on the context in which hypertension occurs addresses cardiac disease, cerebrovascular disease, and a number of other conditions. Treatment is covered in the final part. Annotation c. Book News, Inc., Portland, OR (booknews.com)
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If one were to draw a map of publications on hypertension showing clumps of textbooks, clusters of manuals, and blocks of volumes of proceedings, this book would occupy a somewhat solitary position. In fact, it is a proper book -- a textbook written by two authors from beginning to end -- and not, against the tide of fashion, a multiauthored rhapsody of different themes. Consequently, it is a slim volume, a welcome feature for everyone busy or overloaded with information. The tone is that of a long essay, the format halfway between a manual and an extended review.
This book possesses the defining quality of the essay: a central thesis or, less ambitiously, a leitmotif. It can be summarized as follows: hypertension is rarely an isolated disorder of blood pressure; on the contrary, it usually occurs together with other diseases that may or may not be pathogenetically related to hypertension. The authors prudently avoid using the term "syndrome," which is prone to overinterpretation, and do not deal, other than in passing, with the etiologic or pathogenetic background of these coexisting conditions. They reason that, because hypertension or coexisting disease is the harbinger of much more disease and premature death, the burden is on the physician to recognize and assess the disease complex and to devise the optimal approach to care for individual patients. The authors emphasize that ignorance of the presence of coexisting disease and its impact cannot be condoned (in other words, treating blood pressure alone and gauging success in terms of the decrease in blood pressure are absolutely and vastly insufficient). Effective management that can save lives and decrease morbidity is indeed available, on the condition that one follows the evidence emerging from controlled clinical trials and not the confusing message emanating from popular beliefs (myths are hard to eradicate), official guidelines (which evolve at a faster rate than the medical profession can digest), and commercial pressure (which can generate ethically elastic waves).
Part 1 of the book describes the essentials of hypertension itself, from the clinical workup of the patient with high blood pressure (curiously, familial hypertension is omitted from the clinical assessment) to the choice of treatment. Here, the authors introduce their preferred approach, which hinges on risk stratification: treatment thresholds and goals are set in reference to a risk matrix consisting of the degree of elevation of initial blood pressure.
Throughout the book, the authors tend to link statistical predictions of risk (from longitudinal studies or trials) to clinical recommendations (in the form of dichotomous flowcharts). Despite its persuasiveness, this approach has obvious limitations. In fact, the list of cardiovascular risk factors can be nonsensically long and should probably be arranged in some hierarchy to reduce redundancy, statistical quirks, and incalculable interactions. Hence, choices may turn into biases. For example, the many risk factors that are usually clustered with obesity are diligently listed, but obesity itself is not rated as an independent cardiovascular risk factor. Also, little mention is made of the distribution of body fat as a risk factor, despite the growing evidence linking the accumulation of visceral fat with cardiovascular abnormalities (including hypertension).
Part 2 of the book deals with coexisting diseases associated with hypertension. The chapters on cardiac and cerebrovascular disease are outstanding, and that on hypertension in women is superb. The chapter on diabetes and insulin resistance could have expanded on the role of microalbuminuria as a marker of cardiovascular risk, the relation of hyperglycemia to endothelial dysfunction (in general, the authors do not seem to be too impressed with the consensus view on the role of endothelial dysfunction), and the effect of antihypertensive treatment of diabetes on cardiovascular outcomes.
Part 3 concentrates on treatment, first according to individual drugs and finally as a global strategy. The authors freely indicate their preferences. Evidence-based preemptoriness gives way to distilled clinical judgment, making this part of the book a pleasure to read.
The style is terse and effective, with occasional repetition (the calculation of alcohol units is given with annoying insistence). Throughout, the use of bulleted lists and shaded boxes directs the reader's focus and helps in memorization. Thus, the book can be read or consulted; either way, it is very useful.
Ele Ferrannini, M.D.
Copyright © 2000 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
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