BOOK R EV IEWS

Book Reviews

CHEST PAIN
Edited by J. Willis Hurst and Douglas C. Morris. 514 pp.,
illustrated. Armonk, N.Y., Futura, 2001. $79.
ISBN 0-87993-482-4.

HEST pain is a common presenting symptom in clinical practice, but is there a need for a new book devoted entirely to this subject? The answer is yes, with some
qualifications. Chest Pain, a relatively short book, describes
the multiple cardiac and noncardiac causes of chest pain.
The book has 14 parts, each devoted to diseases or conditions that are related to a specific organ system or anatomical location and that can cause chest pain. The final part
describes chest pain of controversial origin. Not surprisingly, given the editors specialty and the importance of
the cardiac causes of chest pain, the part of the book devoted to heart disease is the largest and most detailed. Overall,
the book is easy to use and provides a practical, clinically
relevant, up-to-date review.
In general, the concise and well-written chapters within
each part of the book provide useful and interesting overviews without excessive detail. Because each chapter has an
identical structure, the style of the chapters is similar even
though the text has multiple authors. Each chapter is an
effective blend of relevant data and the authors own clinical experience. The sections in each chapter on epidemiology (General Considerations and Clinical Setting) and
pathophysiology (Etiology and Basic Mechanisms Responsible for the Pain) are especially interesting and well presented. I particularly appreciate the emphasis on the importance of obtaining and interpreting primary data (the history
and results of physical examination) skills that are in danger of being lost, given our increasing reliance on diagnostic
technology. The book is not an evidence-based treatise, nor
is it a comprehensive specialty textbook. Rather, it is a quick,
practical reference on chest pain. Reflecting this approach,
the reference lists are short. Many of the works cited are textbooks on cardiology or general medicine, and many are classic rather than current. I was an attending physician in our
general-medicine inpatient service while reading this book
and was pleasantly surprised at how often I was able to use
it during teaching rounds.
What are my reservations? Although the identical structure of each chapter, which insists on a statement after each
of 18 subheadings, helps to standardize the style of this
multiauthored book, such a structure also promotes redundancy and results in many chapters in which the subheadings
are almost as long as the text following them. Many of the
subheadings could have been combined without loss of clarity. In addition, some of the structural organization is confusing. In each chapter, the subsection entitled Routine
Laboratory Tests appears under the larger category of Associated Signs, which should be limited to physical findings.
There are two separate subsections addressing laboratory
tests (Routine Laboratory Tests and Other Diagnostic
Tests), when one overall section would suffice. Descrip-

tions of medical treatments are sometimes inappropriately

included in the section called Relief of the Chest Pain
which should be limited in scope to the patients characterization of the pain only to be duplicated in the
separate section on treatment, where they belong. The book
does not specify what constitutes a routine test. I believe
it is debatable whether any test should be considered routine, since all tests perform best when ordered with a specific question in mind.
This book is primarily about differentiating anginal pain
from other causes of chest pain, and the longest chapter,
appropriately, is about this subject. It would have been
helpful if this goal had been stated at the outset of the
book and if the chapters had been ordered to reflect it; for
instance, the chapter on angina pectoris might have been
put first, and each subsequent chapter might have included a specific statement as to how the pain differs from or
is similar to ischemic pain, perhaps with a summary table
pointing out key distinguishing points in the history, findings on physical examination, and laboratory data.
Like many topic-based books, this one assumes that the
reader has already identified the appropriate clinical entities
in the differential diagnosis. Patients present with a symptom or sign, however, rather than with a disease label. A valuable additional chapter would have been a description of
the differential diagnosis of chest pain, perhaps with an algorithm outlining the pertinent initial history, physical examination, and laboratory analysis and then the best method of proceeding, given the results. Such a symptom-based
approach would be clinically useful and practically applicable.
On the whole, this book succeeds as a clinically useful,
well-organized, accessible, and concise summary of the important medical entity of chest pain. It is a book for primary care providers, hospitalists, emergency physicians, and
other physicians who see patients with chest pain, including cardiologists; it may also be appropriate for sophisticated patients.
RICHARD J. HABER, M.D.
University of California, San Francisco
San Francisco, CA 94143-0862
rhaber@itsa.ucsf.edu

STROKE PREVENTION
Edited by John W. Norris and Vladimir Hachinski. 347 pp.
New York, Oxford University Press, 2001. $75.
ISBN 0-19-513382-X.

TROKE is the third leading cause of death in the United States and has resulted in disability in more than
4 million survivors of stroke. The economic burden of the
approximately 700,000 new strokes annually is $20 billion
to $40 billion in direct and indirect costs. Yet few books
deal with the prevention of stroke. For this reason, Stroke
Prevention is a timely and outstanding resource.
Having edited a book on this topic a decade ago (Prevention of Stroke. New York: Springer-Verlag, 1991), Norris
and Hachinski, who are recognized experts in the field of

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The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne

cerebrovascular disease, set out to bring the book up to

date with respect to advances in stroke prevention from an
international perspective. In particular, they wished to focus
on newly identified risk factors for stroke and new therapeutic approaches. Although its emphasis is not explicitly stated, this book deals almost exclusively with ischemic stroke,
which accounts for approximately 80 percent of all strokes.
Multiple authors, selected for their expertise in a particular
area, contributed to the individual chapters. The quality of
the writing and of the information provided is exceptional,
despite an occasional one-sided view of a controversial subject. The authors, who have spent their careers performing
clinical trials in stroke prevention and lecturing on these
topics, provide a novel perspective on the evolution of efforts in stroke prevention over the decades. The inclusion
of authors from outside the United States provides a global dimension to discussions of the issues confronted in
stroke prevention, which are emphasized in the final chapters of the book.
The book has three sections: Primary Prevention,
Secondary Prevention, and Prevention: Policy and Practice. The distinction between primary and secondary prevention can be problematic. Why should the management of
atrial fibrillation be considered primary prevention, whereas
the management of patent foramen ovale or a prosthetic
valve is designated secondary prevention? Since all the conventional vascular risk factors are discussed in the section
on primary prevention, the notion that there may be different goals for secondary prevention is not broached. Secondary prevention is defined by the editors as prevention after patients have had a transient ischemic attack or a stroke,
and although this is a conventional definition, it is clear that
cerebrovascular disease may begin well before symptoms
appear. Research in defining preclinical disease with biologic or genetic markers to effect early intervention is on the
forefront of stroke-prevention efforts.
The inclusion of a section dealing with the implementation of the results of clinical trials and the economics of
stroke prevention is laudable. These subjects are rarely raised
in treatises on stroke prevention, but they are of critical
importance. In chapters dealing with clinical epidemiology
and trial design, there are useful tables defining and summarizing terminology that may be unfamiliar to some readers, such as the measures used to assess the results of screening tests, the classification of diagnostic recommendations
on the basis of the strength of the scientific evidence, and
the phases of clinical trials.
This book comes at an important crossroads in terms of
clinical trials in stroke prevention. Issues regarding carotid
endarterectomy for symptomatic carotid stenosis and the
medical management of atrial fibrillation have largely been
resolved. The statins have emerged as a new class of strokeprevention agents. There are ongoing studies exploring carotid stenting, indications for the use of warfarin, and the
treatment of hyperhomocysteinemia; in the future, one
hopes there will be trials to assess the effects of lifestyle
and dietary modification.
It is important to recognize that the major strength of this
book is its comprehensive review of epidemiologic studies
and clinical trials in the area of stroke prevention. The reference lists are uniformly exhaustive and current. It is less useful as a practical, handbook-style clinical guide, and several

chapters cite consensus guidelines for those seeking such

information.
This book establishes the state of the art for stroke prevention and provides a vision of the research necessary to
further stroke-prevention efforts in the coming years. Since
the publication of this book, several new studies of the effects of antihypertensive therapy, estrogens, and antithrombotic therapy on the risk of stroke have already emerged.
This is a rapidly evolving field of science, one that warrants
this type of routine comprehensive updating.
KAREN FURIE, M.D., M.P.H.
Massachusetts General Hospital
Boston, MA 02114
kfurie@partners.org
Book Reviews Copyright 2002 Massachusetts Medical Society.

N OTICES
Notices submitted for publication should contain a mailing address and
phone number of a contact person or department. We regret we are
unable to publish all notices received. Notices also appear on the
Journals Web site (http://www.nejm.org). The listings can be viewed
in their entirety or searched by location, month, or key word.

A ME R IC A N H E A DAC H E S O C IET Y

The following meetings will be held: 44th Annual Scientific Meeting

of the American Headache Society (Seattle, June 2123) and Scottsdale
Headache Symposium (Scottsdale, Ariz., Nov. 1517).
Contact AHS, 19 Mantua Rd., Mount Royal, NJ 08061; or call (856)
423-3195; or fax (856) 423-0082.
JO H N S H O P K IN S U N IV E R S IT Y

The following courses will be offered in Baltimore, unless otherwise indicated: 19th Annual Medical & Surgical Gastroenterology: A Multidisciplinary Approach (Aspen, Colo., Feb. 38); Cardiovascular Topics at
Johns Hopkins (Feb. 28March 2); Perioperative Management (Marco
Island, Fla., March 36; Aspen, Colo., Aug. 1922); Second Annual
Viva la Vida: Gastroenterology and Hepatology (Las Croabas, Puerto
Rico, March 1416); Targeted Radionuclide Therapy (March 15 and
16); Current Concepts in the Multidisciplinary Management of EarlyStage Breast Cancer (April 5 and 6); and Advanced Pediatric Life Support (June 1012).
Contact Program Coordinator, Office of CME, JHU School of Med.,
Turner 20, 720 Rutland Ave., Baltimore, MD 21205-2195; or call (410)
955-2959; or fax (410) 955-0807; or e-mail cmenet@jhmi.edu; or see
http://www.med.jhu.edu/cme.
A D U LT P R IMA RY C A R E ME D IC IN E

The following courses will be offered in Dedham, Mass.: Mens Health

(Jan. 12); Hematology/Oncology (Feb. 9); Risk Management (March
9); Cardiovascular Medicine (April 13); and Neurology (May 11).
Contact the Core Curriculum Committee, 50 Beacon St., 3rd Fl., Boston, MA 02108; or call (617) 557-7045; or fax (617) 557-7070; or e-mail
tony.alves@healthstream.com; or see http://www.healthstream.com.
21ST A N N UA L EC H O C A R D IO G R A P H Y SY MP O S IU M

The symposium will be held in Coral Gables, Fla., Feb. 8 and 9. It is

sponsored by Baptist Health Systems of South Florida.
Contact Julie Zimmett, Medical Education Dept., Baptist Hospital of
Miami, 8900 N. Kendall Dr., Miami, FL 33176; or call (305) 273-2398;
or fax (305) 273-2769; or e-mail juliez@bbssf.org.

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