ABC of Antithrombotic TherapyEditors: GregoryY H Lip, BlannD Andrew67 pp Price £16.95 ISBN 0-7279-1771-4 (p/b) London: BMJ Books, 2003
Authors: Simon Stern
Journal: Journal of the Royal Society of Medicine (2003)

An admittedly unscientific survey of fellow district general hospital consultant haematologists has confirmed my impression that the subject about which we receive the most requests for an opinion is, by some distance, anticoagulation in all its guises. These inquiries emanate from clinical teams from the full range of specialties, general practice and, increasingly, nurse-led preadmission surgical clinics. A worrying lack of understanding of the basic principles and practice of antithrombotic therapy is regularly conveyed, often by senior clinicians, so there is no doubt that the publication of this monograph, a compilation of reviews originally published in the BMJ's popular ABC of... series is timely.

The editors and most of the authors work as academics and clinicians within the Haemostasis, Thrombosis and Vascular Biology Unit at the City Hospital in Birmingham. The unit's aim of synthesizing basic scientific research and clinical practice is certainly met in the book. I was particularly pleased to see only key and up-to-date references at the end of each chapter, thus sparing the non-specialist reader the quality-control tasks imposed by the endless lists in larger works.

The book starts with an overview of antithrombotic therapy, concentrating on the modes of action and potential bleeding risks of the increasing number of therapeutic agents. This is followed by very succinct chapters on the role of anticoagulant drugs in venous thromboembolism, cardiac arrhythmias and arterial disease. Finally, the increasing use of antithrombotic therapy in special circumstances, such as pregnancy, cancer and the thrombophilias, is dealt with. As one would expect from the publishing track record of the City Hospital unit, the chapters on antithrombotic therapy in atrial fibrillation are particularly informative. They outline a useful risk-stratified approach to deciding which subgroups of the very heterogeneous mass of patients with this arrhythmia should be treated, and give a clear explanation of the relative efficacy of warfarin and aspirin. As a non-cardiologist, I was also grateful for the lucid up-to-date overview of the respective merits of the various thrombolytic and antiplatelet agents now used in myocardial infarction and acute coronary syndromes.

I cannot unfortunately offer quite such fulsome praise to those chapters more closely related to my daily workload. Although it might appear churlish to criticize a necessarily concise monograph for its omissions, one would have expected more than a few paragraphs on the management of patients taking warfarin who undergo surgical or other invasive procedures. This clinical dilemma must now be faced several times per week in most general hospitals, and I feel that an opportunity was lost to publicize the growing body of evidence suggesting that, other than in high-risk patients (such as those with a metal mitral valve replacement or within three months of a venous thrombosis), surgery can safely be covered by prophylactic doses of either unfractionated or low-molecular-weight heparin. Full perioperative anticoagulation with intravenous heparin, and its associated major bleeding risk, can therefore be avoided in the majority.

With the use of low-molecular-weight heparins now so widespread in the treatment of venous thrombosis, I was also disappointed not to find any information on the reversal of over-anticoagulation with these preparations. As I have discovered from recent experience, this is much trickier than dealing with overdoses of intravenous unfractionated heparin, owing to the long half-life and subcutaneous mode of administration of the low-molecular-weight products. Over-anticoagulation with warfarin is also dealt with in a rather cursory fashion when we consider the large number of patients who now present with gastrointestinal or other bleeding as a consequence.

This well-illustrated book will undoubtedly succeed in bringing an up-to-date, easily digested, overview of antithrombotic therapy to a wide audience. I would be happy for all the preregistration house officers and the nurse practitioners in my Trust to read it from cover to cover. It does have shortcomings, however, several of which might have been avoided by the inclusion of (dare I say it?) a card-carrying haematologist among the authors.