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Thenew england journal of medicine

n engl j med 351;8 www.nejm.org august 19, 2004838

book reviews

secondary hypertension:

clinical presentation,diagnosis, and treatment

(Clinical Hypertension and Vascular Diseases.)Edited by George A. Mansoor. 352 pp., illustrated.

Totowa, N.J., Humana Press, 2004. $99.50.ISBN 1-58829-141-3.

he introduction states that the

aim of this book is to provide the essential

clinical, diagnostic and treatment aspects of sec-ondary hypertension. These topics are covered bysuccinct and authoritative overviews that provide

an agreeable balance between evidence-based med-

icine and skilled clinical experience.Appropriately, the first two chapters deal with re-

fractory and iatrogenic hypertension. Resistance to

treatment, or the exclusion of obvious factors thatcould cause resistance, is among the most impor-tant reasons for starting diagnostic maneuvers to

detect secondary forms of hypertension. Eventhough the two chapters overlap somewhat, they

cover the most important problems, and the uncer-tainties in the definition of refractory hypertension

simply reflect the present state of clinical practice.In my opinion, an experienced practitioner maymake a diagnosis of refractory hypertension only

after a patient has been treated with the right com-bination of three drugs for at least one month and

after the possibilities of nonadherence to treatmentand misleading blood-pressure measurements have

been excluded.Hypertension secondary to renal disease is also

clearly described. The most controversial issue is the

treatment of renovascular hypertension. The fewrandomized trials comparing revascularization with

medical therapy are too small to serve as the basisfor making a meaningful choice between the two

treatments. In the absence of convincing trials, thegood results obtained with angioplasty in fibromus-cular dysplasia favor this treatment for renovascular

hypertension as well. In the case of atheroscleroticrenal-artery stenosis, the decision is more difficult.

Clinical practice and anecdotal observation pointto a subgroup of patients who may benefit from re-

vascularization with stenting to reduce the progres-sion of either renal-artery stenosis or renal failure

(particularly when there is stenosis in both kidneys).

The procedure may also be used to lower blood

pressure in patients already receiving a multidrugcombination or to treat patients with coronary heart

disease, cardiac insufficiency, or hypertensive en-cephalopathy.

The clinical problems associated with disordersof the adrenal cortex receive a well-balanced review.I personally prefer magnetic resonance imaging

over computed tomography for the detection ofmorphologic adrenal abnormalities and the use of

eplerenone over spironolactone for the treatmentof primary aldosteronism (to prevent the side effects

of spironolactone). The ratio of plasma aldosteroneto plasma renin activity, which is still not widelyused in screening for primary aldosteronism, is

thoroughly discussed. I particularly appreciated thechapter on nonprimary aldosteronism for its con-

cise descriptions of all the monogenic or mendelianforms of hypertension. Patients with these forms

of the disease share an abnormality in sodium trans-port across the renal tubuli. In the much more com-mon primary, or essential, hypertension, subtle

abnormalities in renal pathways for sodium trans-port may also be involved.

In patients who have paroxysmal hypertension,palpitations, nervousness, tremor, excessive sweat-

ing, pallor, or erythema (together or in various com-binations), it is not easy to distinguish between

pseudopheochromocytoma due to short-term ac-tivation of the sympathetic nervous system in re-sponse to stressful stimuli (of which not all patients

t

Enlarged Disk with Some Papilledema in a Patient

with Intracranial Hypertension.

By permission of the Wellcome Library, London.

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n engl j med 351;8 www.nejm.org august 19, 2004

book reviews

839

are aware) and the much less frequent classic phe-

ochromocytoma. The two chapters dealing withthis problem are very well written, with discussionsthat are neat and to the point.

Careful clinical evaluation and simple algorithmsare needed to avoid unnecessary tests to make the

diagnosis of secondary forms of hypertension inchildren and adolescents. The chapter dealing with

this topic is very useful, as is the one entitled SleepApnea and Hypertension, which covers important

aspects of the association between breathing dis-orders during sleep and hypertension, a connectionthat is not well recognized in clinical practice.

Since arterial hypertension affects about 30 per-cent of the people in industrialized countries, this

book should be in the library of primary care physi-cians, internists, and specialists in nephrology, car-

diology, and endocrinology.

Giuseppe Bianchi, M.D.

University Vita Salute San Raffaele20132 Milan, Italybianchi.giuseppe@hsr.it

obstetrics, gynaecology,

and womens health

Edited by Vivienne OConnor and Gabor Kovacs. 681 pp.,illustrated. New York, Cambridge University Press, 2003. $45.

ISBN 0-521-81893-1.

ell-being, autonomy, and social

justice are the basis of this books approachto the care of women. This modern textbook of

obstetrics and gynecology sets out an approach tomedical education that pays attention to the process

by which a naive, skeptical medical student can betransformed into a competent, ethical medical pro-

fessional.Medical students typically do better on their ex-

aminations at the end of their clinical rotation in ob-

stetrics and gynecology than they do at the end ofmedical school. The facts we learn do not remain

with us unless we use them, so it is better to learnhow to learn. Most textbooks provide us with facts;

others that purport to teach us how to think oftenprove to be too polemical. Editors OConnor andKovacs, two Australian gynecologic educators, rec-

ognize this problem and give us a bit of each ap-proach. A success, for example, is the section on

how to use the medical literature to consider a clin-ical question. Should the young woman with severe

migraine headaches who needs effective birth con-

trol be allowed to use oral hormonal contraceptives?

The authors provide a model for using a Web site,such as PubMed, and review the articles retrieved insome detail. Such an approach offers the student a

tool for lifelong learning.Despite its strengths, the book falls short in cer-

tain key areas. In the section on unplanned pregnan-cy and medical abortion, the authors present a trun-

cated clinical protocol that misses most of theevidence-based information on medically induced

termination of early pregnancy. In addition, theprostaglandin used in this protocol is not availablein the United States, which renders the protocol

even less useful for American medical students.However, if the book is used as a teaching tool,

these shortcomings can offer the student an unex-pected opportunity to review the evidence-based

approach to medically induced early abortion ateachable moment.

Each chapter emphasizes the importance of thephysicians role in facilitating the autonomy ofpatients, including the need to listen carefully to pa-

tients stories. The authors seek to communicate thismessage through many case examples in every chap-

ter. They focus on the corollary message as well: acompetent doctor must provide the patient with suf-ficiently up-to-date information in order to promote

her participation in her own care. Rather than usingthe differential-diagnosis approach to medical prob-

lem solving, this book focuses more on clinical skillsin decision making. The authors pose a clinical

question and then concentrate on how the student

can find the best information for making an evi-dence-based decision. The editorial work shows a

consistency of style and approach, although termsare occasionally used before they are defined.

Overall, the textbook provides tools for problemsolving but is not intended to be an exhaustive re-

source on evidence-based causes of disease andtreatment options. For instance, resident-level phy-sicians will find the book helpful in researching a

subject such as menorrhagia, for which the booklists pelvic inflammatory disease as an organic

cause. However, if readers wanted to know the evi-dence for making such a diagnosis, they would

then have to go to the literature. This book wouldbe best used as part of a regular tutorial programfor medical students in which the students are as-

signed a clinical problem to solve and use the text-book as a starting point and guide.

Steven Sondheimer, M.D.University of PennsylvaniaPhiladelphia, PA 19104

w

The New England Journal of Medicine

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