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Fibrinolytic and antithrombotic therapy: theory, practice and management
  1. S Goodacre

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    R C Becker. (Pp 756; £39.95). Oxford University Press, 2000. ISBN 0-195-12331-X

    Developments in fibrinolytic and antithrombotic therapy are among the most important recent advances in emergency medicine. This book provides a comprehensive guide from basic principles to clinical practice. Although it may fit into a (large) pocket, this is very much a reference book. The writing is precise and economical, largely unencumbered by conjecture or opinion, allowing vast amounts of factual information to be conveyed. While this creates impressive scope and depth it does little to engage the reader.

    Part I covers the basic science, detailing concepts and diseases vaguely familiar from tortured nights of MRCP revision (and many others that weren't). If you agree that “The prevention and cost-effective management of thrombotic disorders requires a knowledge of fundamental pathobiologic principals...” you will find this section valuable. I must admit that I questioned the relevance of such knowledge the first time I learnt it. As it seems to have suffered disuse atrophy with clinical practice, I remain unconvinced.

    The pharmacological agents are the focus of part II. Data from clinical trials are reproduced with merciless efficiency but little additional interpretation or explanation. Given that such data might rapidly be accessed electronically, I couldn't help feeling that an opportunity had been missed to provide either some guarantee of systematic secondary data collection, or some narrative to lighten the read. Part III (acute coronary syndromes: fundamental concepts) initially used a physiological principle, the open vessel hypothesis, to illustrate practical management issues with good effect. Unfortunately, chapter 18 plunged us back into a tabulated list of clinical trials.

    The second half (parts IV to VI) examines practical management issues. Tables and algorithms are provided to assist the reader. The tables often seem to have been constructed from a pathological, rather than clinical, perspective. Lists are comprehensive but not ordered, and common items may even be neglected. For example, the top three differential diagnoses of chest pain are aortic dissection, expanding thoracic aneurysm and aortic intramural haematoma, while gastro-oesophageal reflux and anxiety are not listed. The algorithms, particularly those involving risk stratification, present a practical and innovative approach to clinical management, but many require adaptation to the more conservative, and resource limited NHS.

    In terms of factual data per square inch of paper, this book is truly awesome. However, A&E clinicians facing the challenge of keeping up to date with a wide array of rapidly changing health technologies will probably prefer a more selective and more readable text.