Book Review
ESC Textbook of Cardiovascular Medicine The overall approach to the subject matter concentrates on a
John Camm, Thomas F. Lüscher, Patrick W. Serruys, eds
1136 pages. Oxford, UK: Blackwell Publishing; 2006.
$295. ISBN 1-4051-2695-7
Editor’s Note: In our effort to provide an insightful, balanced,
and constructively critical review of the new first edition of the
ESC Textbook of Cardiovascular Medicine edited by Drs A. John
Camm, Thomas F. Luscher, and Patrick W. Serruys that was
published under the auspices of the European Society of Cardi-
ology by Blackwell Publishing Ltd (2006), we have obtained the
opinions of 3 distinguished senior cardiologists, Drs Gottlieb
Friesinger, Desmond Julian, and Elliot Rapaport, to serve as a
Select Panel for Review. To ensure the book was read in its
entirety, the text was divided into thirds and apportioned equally
to each reviewer; all 3 reviewers were assigned 4 chapters in
common to read as well.
This summary review by 3 individuals, each of whom is
internationally recognized for expertise in the broad field of
general cardiology, is offered in the spirit of helping the ESC
achieve its stated objective of providing a textbook that is
successful in covering the knowledge that should be required of
all general cardiologists.
Panel Report
General Comments
This textbook is primarily targeted at the specific audience of
those wishing to be accredited with the European Board for
Accreditation in Cardiology (EBAC). It is not intended to be a
work of reference, but, as stated in the foreword, of producing “a
Downloaded from http://ahajournals.org by on March 16, 2024
clinically focused resource for general cardiologists and train-
ees.” It presents 36 chapters within 1092 pages, each authored by
anywhere from 2 to 6 multinational collaborating members of the
European Society of Cardiology. One of its remarkable achieve-
ments in addition to the high standard of writing is its superb
illustrations, figures, and tables that appear on virtually every
page. They are well placed within the text and contribute in
making the book easy and interesting to read. A refreshing new
touch to this book is the incorporation in each chapter not only of
a succinct summary at the beginning but also a brief personal
perspective of the future direction of the field by the authors at
the chapter’s end.
With so many authors, the resultant product, as might be
predicted, is somewhat uneven. Many chapters are written by
distinguished leaders in their fields who have collaborated to
write highly authoritative and informative chapters. In other
cases, the chapters are rather poorly balanced, emphasizing
particular areas of authors’ interest rather than serving as an
overall and balanced text. There is great variation in the detail
into which various authors delve. The chapter on acute coronary
syndromes (ACS), for example, has an outstanding section on
pathophysiology, whereas the topic is hardly touched on in that
on chronic coronary heart disease. In the latter case there is
extremely informative detail provided regarding the physiology
of the coronary circulation, but it seems excessive. Overall, most
chapters are completed within 30 pages, but the management of
ACS is dispensed in 16 pages, that of atrial fibrillation within 32
pages, and myocardial disease takes up 53 pages.
(Circulation. 2006;114:e492-e494.)
© 2006 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org
e492
combination of evidence-based medicine, imaging, and interven-
tional cardiology. Important areas of cardiovascular medicine
that represent more recent advances in our understanding of the
field, such as chapters on the Genetics of Cardiovascular Disease
and Clinical Pharmacology of Cardiovascular Drugs, add impor-
tance to this book; there is a striking emphasis on the role of
diagnostic technological procedures. It begins with a chapter on
the morphology of the ECG, which is succeeded by chapters on
cardiac ultrasound, cardiac magnetic resonance, cardiac comput-
erized tomography, nuclear cardiology, and invasive imaging
and hemodynamics.
Little attention is directed at some of the basic tenets of
cardiology. Most notable omissions concern any discussion of
the value of a thorough cardiac history and physical examination.
Significantly, in the printed version, such familiar terms as
systole, diastolic gallop, and palpation, among others, cannot be
located in the index. The emphasis on technological procedures
is an apparent index of our time.
Specific Comments
Chapters 1 to 11
The first 6 chapters comprise the expanded body of imaging
techniques that in a bygone era was known as graphic methods
and have already been singled out for their remarkably clear
illustrations and precise language. However, the chapter Invasive
Imaging and Hemodynamics would appear to fall short in
covering its designated subject. For example, a cardiac trainee
would have difficulty trying to calculate bidirectional shunt
flows in a case of congenital heart disease just from reading the
brief section on “Blood Oxygen Measurements and Flow and
Shunt Calculations.” Chapter 8, on Clinical Pharmacology of
Cardiovascular Drugs, is highly informative, with a particularly
lucid discussion of Clinical Trials and the assessment of evi-
dence. Although it is excellently written and clarifies many
biostatistical terms as well as misconceptions, there are a
multitude of terms and concepts mentioned throughout the text,
such as sensitivity, specificity, or the Bayesian concept of prior
probability that are never explicitly defined. This situation
compels the reader to search the index for this missing informa-
tion, but to no avail; here a glossary of definitions would be most
helpful for the reader. Similarly, an example of unevenness
among chapters is seen in Table 8.1 and the column labeled
“Indications.” The use of clopidogrel under “Secondary Preven-
tion of Vascular Events” lists only its use in patients intolerant to
aspirin, with no mention of its role in preventing major cardiac
events in patients with peripheral arterial disease or who have
had a prior stroke or transient ischemic attack. It seems evident
that the full measure of the success of this textbook will rely on
its ability to update and revise chapters frequently. Chapters 10
and 11 cover the major perils of hypertension and diabetes quite
thoroughly, and both are concise and elegantly illustrated.
Acute Coronary Syndromes
In Chapter 12, the pathological basis of ACS is superb;
however, the clinical picture and its natural course are somewhat
lacking. The actual prognosis and mortality are not mentioned,
although much is said about risk stratification. It is to be noted
that the ESC/ACC diagnostic criteria are accepted without
DOI: 10.1161/CIRCULATIONAHA.106.630764
 Book Review
question. Cross-referencing should be done in several areas such
as including the detailed tables and illustrations from Chapter 1
in the discussion of the ECG, and the section on risk factors
should cross-reference Chapter 9. Surprisingly, smoking is not
listed as an important modifiable risk factor and receives only
scant mention later in this section; considerably more comment is
given on low birth rate than smoking.
The information on management of ACS is described in
Chapter 13 and is derived largely from a MEDLINE search for
“clinical trial,” “meta-analysis,” “review,” and “guidelines.”
Accordingly, the description of antiplatelet, antithrombotic, fi-
brinolytic, and interventional methods is very effectively done,
as are the discussions on ␤-blockers, calcium antagonists, and
ACE inhibitors. The reporting of results of clinical trials is
exemplary, but one might suggest that the use of the number
necessary to treat might be more useful in this chapter than odds
ratios with confidence intervals. It would also seem important to
mention that there is a large elderly group of patients and others
with serious comorbidities who are grossly underrepresented in
randomized, controlled trials. Also, the most important causes of
death in myocardial infarction are ventricular fibrillation, cardio-
genic shock, and acute heart failure. None of these critical
outcomes receives significant attention in this chapter.
Chronic Ischemic Heart Disease
Chapter 14 is well written and comprehensive in many aspects.
It is surprising that variant angina is listed as one of the 4
manifestations of chronic ischemic heart disease because most
would classify this syndrome as an unstable phase of coronary
ischemic heart disease. The section on myocardial blood flow is
extremely informative but could be better oriented toward the
clinicians rather than physiologists, with more attention to issues
Downloaded from http://ahajournals.org by on March 16, 2024
such as the tight coupling of myocardial blood flow and
myocardial oxygen consumption, the recruitment of vessels in
increasing coronary blood flow, and particularly, more attention
to the importance of endothelial function in atherosclerotic
disease as cited in Table 14.1. Here also, cross-referencing to the
chapter on invasive imaging would help the reader understand
the application of coronary flow reserve in this disease state.
When prognosis is discussed, the term “high risk” is used but not
defined. Summary statements and flow diagrams would enhance
this chapter.
Angina Pectoris
Chapter 15 is a well-written discussion of the treatment of
stable angina pectoris. This chapter contains a great deal of
pharmacology information, particularly with reference to the
statin drugs not found in other portions of the text such as the
chapter on risk factor modification or pharmacology. The indi-
cations for coronary arteriography in stable angina (Figure 15.4)
present the actual guidelines, which is extremely useful to the
reader and represents a technique not found in other chapters
where guidelines are cited but not provided.
Myocardial Disease
Chapter16, one of the longest chapters, with 62 pages, 286
references, and 8 authors, is comprehensive, well written and,
like many multiauthored chapters, has some unevenness in the
writing and content. Variables useful in assessing prognoses in
the more common forms of cardiomyopathy are well described,
but more quantitative, or at least semiquantitative, information
could be given to help guide the clinical cardiologist in treating
individual patients. Loeffler myocarditis and endocardial fibro-
elastosis are allotted more space than such rare entities justify,
whereas the cardiomyopathies that result from chemotherapeutic
agents used in treating oncologic disease are not included.
e493
Chapters 17 to 24
Chapter 17 is appropriately brief and exceptionally well
illustrated but calls for cross-referencing with the chapters on
imaging. The long-since abandoned Horowitz classification of
pericardial effusion is surprisingly emphasized. The comprehen-
sive tables in this chapter do not meet the quality and clarity
standard found in the rest of this book. Chapter 18 is well written
and is primarily a detailed description of gross anatomy, imag-
ing, and considerable information on histology, but it is ques-
tionable if 18 pages should be devoted to this topic.
The chapter on congenital heart disease focuses 52 pages on
the newborn infant and child, which seems excessive for the
intended readership of general cardiologists. Major clinical
problems in adults with congenital heart disease such as arrhyth-
mias and congestive heart failure are not covered in adequate
detail. The important role of highly specialized centers is only
sparingly mentioned in the text, and guidelines for care of
grown-up congenital heart disease (GUCH) deserve considerably
more emphasis. The chapter on pregnancy and heart disease is
well written, concise, and comprehensive.
Chapter 21, on valvular heart disease, is only partially suc-
cessful in the near-impossible task of adequately covering the
clinical presentation, natural history, and surgical management of
this core subject within the allotted pages. A greater emphasis on
the physical examination and its correlation with homodynamic
findings and echocardiographic estimates would seem important,
considering that global migration is sure to persist throughout
most of this century, making valvular heart disease a subject with
which the general cardiologist must be most familiar. The
chapter on infective endocarditis that follows is a very readable
and informative contribution to this text, with well-written
guidelines that are cited but could be highlighted more.
Chapter 23 covers the epidemiology, pathophysiology, and
diagnostic criteria concerned with heart failure. An informative
and well-written piece, it is enriched by its many excellent tables
and figures. Specific cross-referencing with Chapter 2 on cardiac
ultrasound would further enhance the reader’s experience. The
chapter that follows regarding management explains very thor-
oughly the therapies that are available for heart failure today. It
outlines the mechanism of action of the various drug groups,
although, surprisingly, it includes a number of drugs such as
ibopamine and xamoterol that have been abandoned years ago. It
details the results of clinical trials but sometimes fails to give
absolute as opposed to relative effects. Good practical advice on
drug dosages and the choices of treatment is provided.
Chapters 25 to 36
In Chapter 25, the current knowledge on the genesis, diagno-
sis, and treatment of pulmonary artery hypertension is very fully
reviewed, but only half a page is devoted to chronic lung disease.
In some countries, this is an important cause of heart failure.
Chapter 26 contains a thorough description of exercise physiol-
ogy and the methods of exercise testing and prescription. Other
aspects of rehabilitation such as lifestyle modification and
secondary prevention measures appropriate for patients with
cardiac disease are discussed at length. In the following chapter
on bradycardia, there is a very thorough description of the
indications for pacemaking and of the many different modes of
pacing available. The complications of this procedure are well
described, although, curiously, the actual technique of implanta-
tion is not. The authors of Chapter 28 refer to “the current golden
age of cardiac arrhythmology,” and they justify this claim by an
exceptionally clear account of the different types of supraven-
tricular tachycardia.
In Chapter 29, the point is made that atrial fibrillation is of
great importance because of its frequency and its potential
seriousness. It is also of considerable current interest, owing to
the recent advances in our knowledge of its mechanisms and of
 e494 Book Review
the new and promising forms of treatment. Accordingly, the
discussion is divided into 2 quite lengthy chapters, one dealing
with epidemiology, pathogenesis, and diagnosis and the other
(Chapter 30) with the treatment. The first describes the mecha-
nisms in such detail as would cater to the needs of the specialist
arrhythmologist. The second provides a comprehensive review of
the many current forms of therapy available but pays particular
attention to pulmonary vein ablation—an aspect of the condition
that is barely mentioned in the first chapter. One wonders to what
extent the authors of the 2 chapters conferred.
Bearing in mind the target audience, Chapter 31, on syncope,
is a model of its kind. Lucidly written and practical, it contains
enough but not too much information for the aspiring cardiolo-
gist. In the chapter that follows on ventricular tachycardia, there
is no description of ventricular ectopic beats (premature depo-
larizations, extrasystoles) and no entries in the index of these
terms. This approach differs from those dealing with supraven-
tricular tachycardias that devote almost 2 pages to atrial extra-
systoles. There is a good account of the various types of
ventricular tachycardia and their treatment, although one might
have liked a more detailed description of and better illustration of
torsades de pointes. The contribution on the implantable
cardioverter-defibrillator is well balanced, but there is consider-
able overlap with the section on this technique in the following
excellent chapter on sudden cardiac death and resuscitation.
Chapter 34 provides a very up-to-date perspective on diseases
of the aorta and trauma to the heart and is both well illustrated
and well referenced. As the authors point out, there are new
endovascular concepts that are likely to affect management.
Chapter 35, on peripheral arterial disease, provides a very
informative contribution and, as the authors point out, because of
limitations of space, it is regrettable the role of surgery could not
be considered. The final chapter on venous thromboembolism
Downloaded from http://ahajournals.org by on March 16, 2024
emphasizes the importance of clinical evaluation of this common
cardiovascular disorder and stresses the increasing place of
home-based management rather than hospital-based
management.
Electronic Version
One of the most valuable features of The ESC Textbook of
Cardiovascular Medicine is the electronic version, provided its
full potential is appropriately used to enter prompt corrections,
timely updates, and facile revisions. To do so will be no easy
task, even with the resources of an international society. Fortu-
nately, it appears that the editors have provided a solid founda-
tion on which to build an electronic edifice that will not be
outdated. They also seem to have mastered the technological
state-of-the art such that the user can navigate through any of the
36 chapters from virtually any sentence in the book in a most
friendly fashion. Although the cross-referencing throughout the
text is rather parsimonious, it works quite well where it appears.
The electronic images, illustrations, and tables are very im-
pressive, and the search facility built into the full text makes for
an individualized index that is not only extremely efficient but
also enjoyable to use. Looking for “murmurs” in the printed
version was unsuccessful, whereas the electronic version imme-
diately disclosed ⬎100 references to “heart murmurs.” Links
from the reference list of every chapter to PubMed are very
useful and probably overly tempting. A novel feature introduced
by an accrediting body, EBAC, is the provision of high-quality
continuing medical education for cardiologists and trainees after
specified chapters with multiple choice questions relating to the
chapters content, which are scored and displayed with feedback
given on the correctly answered questions.
Editor’s Summary Statement: Akin to the multiauthored ESC
Textbook, this multiauthored review has several distinct advan-
tages and some obvious but unavoidable disadvantages. Those
aside, there are 2 sources of bias in the selection of reviewers for
which I offer no apology; one is generational and the other
geographical. As for age beyond 3 score and 15 years, only then
can one begin to experience true wisdom; as for residing in a
West meridian, it matters not at all.
What does matter is that the readership of Circulation be
informed of the merits and some apparent limitations of the first
printing of the ESC Textbook of Cardiovascular Medicine. The
reviewers seem to agree that the future impact of this meritorious
first edition will be dependent on the frequency, extent, and
caliber of the electronic updating that is promised.
-Thomas J. Ryan, MD
Book Review Editor
Disclosures
Dr Rapaport has served on a speaker’s bureau for Bristol Myers
Squibb, Sanofi Aventis, Astra, and Novartis. He has served as
co-chair on a Data and Safety Monitoring Board for Bristol Myers
Squibb. The other authors report no conflicts.
Gottlieb C. Friesinger, MD
Professor of Medicine (Cardiology) Emeritus
Vanderbilt University
Nashville, Tenn
Desmond G. Julian, MD
Emeritus Professor of Cardiology
University of Newcastle-Upon-Tyne
Newcastle-Upon-Tyne, United Kingdom
Elliot Rapaport, MD
Professor Emeritus of Medicine
University of California at San Francisco
San Francisco, Calif