Feb 26

Chest Pain

Chest 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. Descriptions of medical treatments are sometimes inappropriately included in the section called “Relief of the Chest Pain” — which should be limited in scope to the patient’s 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.
Copyright © 2002 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

Review
“This book…is worth owning. It is not going out of date next year!”William C. RobertsAmerican Journal of Cardiology

“This book…is worth owning. It is not going out of date next year!”

William C. Roberts
American Journal of Cardiology

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