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BOOK REVIEWS SilentMyocardial Ischemia and Infarction. By Peter F. Cohn. New York and Basel: Dekker, 1986. Pp. 236. $45.00. Silent Myocardial Ischemia. Edited by W. Rutishauser and H. Roskamm. Berlin: Springer-Verlag, 1984. Pp. 204. $25.00. Silent or asymptomatic myocardial ischemia is a topic ofrecent and increasing interest to the cardiology community. The phenomenon was described by Herrick in his 1912 paper on coronary thrombosis but has gained widespread recognition only over the past decade. Improvements in noninvasive diagnostic methods for detection of myocardial ischemia and screening of patients at risk for coronary artery disease have made study of the problem possible. Dr. Cohn, a recognized authority on asymptomatic coronary artery disease, presents a review of recent medical literature on the pathophysiology, prevalence , detection, prognosis, and management of silent myocardial ischemia. The monograph is divided into six sections, addressing the aforementioned topics and concluding with comments on future directions for study of the problem. There are 17 chapters, with an average of four to five pages of text each. The text is generally clearly written, and the brevity of each chapter makes the book easy to read in short sittings. The book is liberally illustrated with two to three tables and four to eight figures in each chapter. Figures and tables are reproduced from the medical literature reviewed in the text. Most chapters are divided into sections on asymptomatic individuals with silent ischemia, patients with no symptoms following myocardial infarction, and those with both symptomatic episodes and silent ischemia. Rather than an exhaustive review of the literature relevant to each area, representative articles are summarized to illustrate major points. For example, in the chapter on the sequence of events during episodes of myocardial ischemia, the section titled "Atrial Pacing Studies" describes one investigation and emphasizes the results of the study. Methods are not discussed in detail. This is troublesome in the sections on exercise testing and ambulatory electrocardiography, where issues such as electrocardiographic lead selection, skin preparation, and the details of test interpretation are important and often controversial. There are five to 21 referPermission to reprint a book review printed in this section may be obtained only from the author. 608 Book Reviews enees for each chapter (average 13), and many references reappear in the bibliographies of multiple chapters. The monograph is an excellent overview of the subject for the practicing physician with an interest in the subject and a good starting point for a specialist intending detailed study of asymptomatic ischemia. The introductory section on the pathophysiology and mechanisms of cardiac pain is particularly interesting. The summary of Bayes's theorem and the probability of coronary disease in various populations is clearly written and accessible to readers unfamiliar with the topic. In contrast, some literature is reviewed in an overly abbreviated fashion . For example, in a discussion of sudden death, data on death rates per thousand patients are presented without information on patient selection or populations of patients studied. Clear understanding of the cited literature and its importance requires review of the original material in these instances. The summary and conclusions at the end of each chapter are very general. They provide food for thought but are not guidelines for the practitioner seeking clear advice. The final chapter defines the state of current understanding of the subject: "Despite the numerous studies of asymptomatic coronary artery disease described in the preceding pages, it is clear that there are more unresolved issues that there are resolved issues." The only other book on silent ischemia available at the time of writing this review is the collection of 29 papers given at the International Symposium on Silent Myocardial Ischemia held in 1983 in Geneva, Switzerland. The meeting was held under the auspices of the European Society of Cardiology. There are 79 contributors representing an international spectrum. The papers vary substantially in length, style, and content. Some present original research, some summarize past work done by the authors, and some represent literature reviews or proposals for future research. The amount of detail provided in original research papers is highly variable. For example, while some papers have extensive, careful methods sections, the entire methods section in one reads, "All patients were studied at...


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