Despite the highly publicized sudden cardiac deaths of such celebrities as Russian dissident Andrei Sakharov and Baseball Commissioner Bart Giamatti, there has been little focused research into the cause of sudden cardiac death, and almost no media attention has been paid to this condition, which terminates life in more than 50% of persons with coronary artery disease. Sudden death has been known since antiquity, and this book's historical review of this condition—including the sudden deaths of Count Gaston de Foix in 1391 and John Hunter in 1791—is fascinating. Today, it is known that more than 80% of sudden deaths occur in patients with coronary artery disease and that there are usually no specific anatomic findings that identify these patients.

Monographs and other small books provide an opportunity to review and analyze emerging evidence in important matters, and they focus attention on opportunities in public health that may have escaped widespread appreciation. Such is the case with this book. Ambulatory electrocardiograms recorded during sudden death provide a framework of understanding by dividing deaths into those due to primary ventricular fibrillation (60% to 70% of instances), those associated with torsade de pointes (18%), and those associated with bradyarrhythmias (20.6%). A review of the mechanisms and pathology of sudden death emphasize the "bottom line" of the book, which is that myocardial ischemia and ventricular dysfunction are the underlying causes of the electrical instability that ends in sudden death. The importance of coronary thrombosis to acute myocardial ischemia is reviewed in detail, although the authors could have emphasized that it took decades to go from Herrick's publication of a photograph showing a thrombus in a coronary artery in 1912 to the demonstration by DeWood and colleagues in 1980 that occlusive thrombi appeared to precipitate acute myocardial infarction. Thrombi are not the only problems, however, and a review of the neurophysiologic control of the heart links emotional stress to sudden death and invokes bursts of sympathetic and parasympathetic neural output or even a "manifestation of the primitive medulla-controlled diving reflex." These comments set the stage for the use of ß-blockers to reduce the incidence of sudden death.

The straightforward review of the predictive value of the baseline electrocardiogram, ambulatory monitoring, the exercise test, programmed electrical stimulation, and various imaging tests make the book valuable for all who treat patients with coronary artery disease, particularly physicians in generalist specialties who care for most persons headed for sudden death. Again, ventricular dysfunction and ischemia are the common themes. The significance of prolonged QT intervals, due to drugs and electrolyte abnormalities and congenital or idiopathic factors, leads the reader to realize that part of the electrocardiogram is often overlooked.

One of the most useful sections is that on antiarrhythmic drugs. Beginning with quinidine and procaine amide, physicians have been prescribing antiarrhythmic drugs and assuming that a reduction in arrhythmia predicts a favorable drug response. The Cardiac Arrhythmia Suppression Trial, which studied patients after acute myocardial infarction, showed that flecainide- and encainide-suppressed premature ventricular beats were associated with an excess of arrhythmic death and fatal myocardial infarction. Review of other studies again suggested the importance of ventricular function and ejection fraction in determining the outcome of pharmacologic treatment. Amiodarone, for example, was effective in reducing the incidence of sudden death. It "was effective in most patients with sustained ventricular fibrillation whose ejection fraction was over 30%." In contrast, in patients with ventricular fibrillation and ejection fractions less than 30%, the mortality rate was higher despite amiodarone treatment.

Readers might not select a book on sudden death because they believe that little can be done to prevent such a catastrophic occurrence. A few pages of this useful book, however, will convince them that doing things they are not doing presently, as well as not doing things they presently do, could reduce the incidence of sudden death in their patient population.