Hypertension: A Clinician's Guide to Diagnosis and Treatment

By Barry J. Sobel and George L. Bakris. Pp. 149. Price, $22.00. 2d ed. Hanley & Belfus, 210 S. 13th St., Philadelphia, PA 19107, 1999. Phone: 800-962-1892. ISBN: 1-560-53115-0.

Handbook of Antihypertensive Therapy

By Mark C. Houston, Beth Pulliam Meader and Linda Moore Schepani. Pp. 166. Price, $19.95. 9th ed. Hanley & Belfus, 210 S. 13th St., Philadelphia, PA 19107, 1999. Phone: 800-962-1892. ISBN: 1-560-53271-8.

Hypertension is a significant health problem affecting at least 35 million Americans. The end organ effects of hypertension, particularly in the heart, brain and kidneys, can be devastating, leading to premature coronary, cerebral or renal arteriosclerosis. The consequences are myocardial infarction, stroke and renal failure, respectively. With proper recognition and management, blood pressure can be brought below 140/90 mmHg, reducing the risk of vascular complications of hypertension. A variety of factors must be considered in diagnosis and management, and an expanding array of medications with different pharmacologic mechanisms are available.

Because of the large numbers of persons affected, the serious complications and the success of treatment, primary care physicians need ready information at their fingertips. Two new books, Hypertension: A Clinician's Guide to Diagnosis and Treatment, by Sobel and Bakris, and Handbook of Antihypertensive Therapy, by Houston, Meader and Schepani, are now available. Each is about 150 pages in length and each provides important and contemporary references. Both also provide detailed tables focusing on medications, including mechanisms of action, dosage, adverse effects and drug interactions.

The book by Sobel and Bakris has six chapters and 10 appendixes. It is written in outline form, a presentation that I found hard to follow. It presents a number of facts in rapid sequence, with little expansion on the facts or broad principles by which to organize them. With such a method of presentation, it is difficult to distinguish between important or major points and those of lesser significance. No discussion is included of proper measurement of blood pressure or artifacts that may creep in to falsely elevate readings. I was surprised that so much emphasis was given to Cushing's syndrome, hyperaldosteronism and pheochromocytoma, which were in the first three appendixes and appeared before more important parts on medications. A number of useful tables and algorithms are available. A major error is the format of an important table on page 16.

The book by Houston and coauthors has a number of individual sections, many only one page long, which present information and data in a variable format. This format made the book interesting and easy to read and review. I appreciated the presentation of information from various epidemiologic studies in summary form, to illustrate important epidemiologic points or the interrelationships of risk factors. The format made it easy to look up information, particularly that which related to medication.

Both books would provide the primary care physician with accurate information about hypertension. The choice of one text above the other would depend on the way the reader prefers to receive information. I preferred the format of Houston and associates. Others may prefer it as well, since it is now in its ninth edition.

Neurology in Primary Care

By Joseph H. Friedman. Pp. 219. Price, $25.00. Butterworth-Heinemann, 225 Wild-wood Ave., Woburn, MA 01801-2041, 1999. Phone: 800-366-2665. ISBN: 0-750-67036-3.

In the past decade we have witnessed the increasing influence of managed care in the practice of medicine. A consequence of this change has been an expanding role for the primary care physician, both in managing a broad variety of illnesses and in deciding when to consult specialists for advice and help in patient management. More than ever, primary care physicians require knowledge of specialty medicine, particularly specialties not extensively represented in the curriculum of primary care residency programs. Neurology is one specialty in which primary care residents and physicians may feel they lack the necessary experience to manage illness, as well as information about appropriateness of referral. As such, there is a need for instructional material that fulfills these demands.

A problem frequently encountered when one specialty group writes material for another group is understanding the setting in which the instructed group manages patients. Primary care physicians see more patients per hour than neurologists do, and most prefer to evaluate patients from a symptom-oriented approach. The author appreciates this distinction, and his chapter titles (headache, dizziness, backache, neck ache and memory loss) provide an immediate reference to the patient's complaint.

Each of the chapters in this book contains pertinent information about the disorders that result in the symptoms that bring patients to their family physicians. The material is simply, yet adequately, described. The chapter on dizziness does a good job of simplifying a complex subject and, if studied, will provide a good basic understanding of the common disorders that result in headaches. A wealth of information is packed into relatively brief chapters, so reviewing the material will be essential.

Rather than serve as a text enabling primary care physicians to manage neurology patients, the intent of the book is to familiarize the clinician with common neurologic problems and their management, while helping clinicians differentiate these and other common complaints from disorders that are more serious and potentially life-threatening. A chapter on neurologic emergencies describes most of the latter illnesses in greater detail.

A chapter titled “Famous Diseases” describes common neurologic illnesses such as Parkinson's disease and amyotrophic lateral sclerosis. While primary care physicians usually do not manage these disorders, they do care for other illnesses that these patients may have and should have an understanding of the neurologic disease process. The descriptions in this chapter provide just the right amount of information.

The book lacks illustrations, and the section on performing the neurologic examination should serve as a review rather than as a primary resource for learning how to perform this examination. Nevertheless, there are many useful clinical pearls, which, if recalled, will certainly aid in neurologic diagnosis. Appendix 2 lists the commonly used neurologic diagnostic tests and descriptions of the clinical information they provide. The author is honest about the pitfalls in the interpretation of these tests and the way, in some instances, they may not provide the kind of information that will clarify the clinical picture for a primary care physician. It is refreshing to see such information in print.

A useful aspect of this text is its size. The book measures 4 × 6 inches, so it fits in a pocket. This portability will increase its usefulness as a reference source, especially by house officers in residency programs.

Overall, the text is readable and concisely organized. A section titled “Clinical Pearls,” which follows each chapter, lists the most important points in that chapter. The material is up-to-date and follows an increasing trend of using the symptomatic approach to teach primary care physicians. The book reflects the input of an experienced clinician and is a valuable resource.

This book should serve as an example for other specialty authors who want to develop texts for primary care physicians. The salient features to duplicate are simplicity, symptomatic approach, portability and readability. If medicine continues to evolve with primary care as the portal to availability, texts such as these will become vital to the education of primary care providers. They will also serve as a resource for continuing education and as a reference source in the day-to-day management of patients.

In an age of expanding medical knowledge, the primary care physician has a greater need for a broad knowledge base than most specialty physicians. Neurology in Primary Care helps fulfill that need. The author states that “this book is not intended to reduce the role of the neurologist but rather to make the primary care provider better prepared and more confident in a field that many physicians approach with trepidation.” Texts such as this will help clinicians achieve a good comfort level in the management of common neurologic problems while fostering vigilance for initial or evolving clinical features that warrant specialty consultation.