Is a tax on junk food moving a step closer?

Cost is widely acknowledged by public health specialists to have been the single biggest factor in reducing smoking rates in the West.

As the diseases of obesity take over from cigarette smoking as the biggest public health challenge of the twenty-first century, governments are quietly investigating whether price can be used as a way of cutting consumption of junk food in the same way that taxation has been used to cut smoking rates.

Denmark with its small, relatively well-educated population of 5.5 million, last year become the first nation in the world to tax sugar; Romania has introduced a new lower value-added tax (VAT) rate on ‘staple’ foods and New Zealand has sponsored a research project at Oxford University to investigate the social, economic, and health impact of selectively taxing at a higher rate foods with little or no nutritional value.

Although Barack Obama veered away from his pre-election pledge to tax carbonated soft drinks, it is only a matter of time before one of the world's major nations takes on the Goliaths of the food industry.

Diet and health campaigners in Britain are hoping that it might happen there. The UK government's Department for Environment, Food and Rural Affairs is currently sponsoring a study led by Richard Tiffin, professor of food economics at Reading University, an internationally recognized centre of expertise on food policy.

Earlier this year (April), Prof. Sir Nicholas Wald, director of the Wolfson Institute of Preventive Medicine, gave a powerful presentation for the Royal Society of Medicine's annual Jephcott lecture, arguing for an all-embracing SASS (salt, alcohol, sugar, saturated fat) tax. ‘Treating cardiovascular disease and obesity is important, but it's not a satisfactory preventive strategy', he said. ‘The solution is to reduce average consumption of the components of food that are principally responsible for cardiovascular disease, and reduce average calorie intake’.

Taxing these components of manufactured food would, according to Wald, give manufacturers an incentive to reformulate their products to use lower quantities of them.

He maintains that it is the only way to reduce the global epidemic of cardiovascular disease, diabetes, and obesity.

It is an attitude shared by Mike Rayner, director of the Health Promotion Research Unit at Oxford, which is funded by the British Heart Foundation. Rayner is currently doing a junk food tax evaluation for the New Zealand government, and this Spring he gave a presentation of his argument to the Westminster Parliamentary Food and Health Forum—a politicians' debating society. ‘I do share the view that some form of junk food tax will eventually be introduced in Britain, but when and what form it will take, is anyone's guess’, Rayner said.

Richard Tiffin at Reading is investigating price ‘elasticities’ in food—in other words, how much things have to cost before the majority of people start cutting their consumption.

He thinks the most likely government scenario is that efforts will be made first to harmonise Britain's arcane and illogical VAT rates levied on foods, according to whether they are designated luxury, non-essential products, or staple food stuffs.

The system has produced all sorts of anomalies, and a considerable number of expensive legal proceedings, where manufacturers have tried to argue, for example, that potato-based snacks such as the branded product Pringles, are not potato chips on which higher rate VAT is levied, but biscuits which under the current system—provided they do not include icing or chocolate coating, are inexplicably classed as a staple food.

Tiffin is equivocal about the likelihood of the British government taking on the manufacturing food industry, which is one of the nation's major export contributors.

‘I think they might well try to impose VAT on all foods as a means of increasing revenue, and then maybe try to introduce differential rates for “good” and “bad” foods’, he said.

‘We might find that there is an argument that taxing food improves diet because people eat less’.

Others, however, are less enthusiastic about the idea of improving bad diet by taxing junk food—or making healthy food cheaper. Graham MacGregor, a professor of cardiovascular medicine, and founder of the Consensus Action on Salt and Health (CASH) pressure group, believes that persuasion is likely to be more effective than coercion with the food industry.

He points out that voluntary agreements with manufacturers have reduced salt intake from 9.5 g a day to 8.6 g since 1996, with the target of reducing it to 6 g per day by 2012, although he admits that progress in persuading manufacturers to reduce the amount of salt added to bread, breakfast cereal, and ready meals has been slower than hoped. He believes that the manufacturers' favourable response vindicates his argument, but he admits that persuading them to remove high levels of fat and sugar from food products will be more problematic.

Surprisingly, the National Obesity Forum, a group of clinicians campaigning for the nation's weight problem to be taken more seriously, also opposes a ‘fat tax’.

‘If you tax junk food, you are taxing the people least able to buy any food', said the Forum's spokesman Tam Fry.

But he added: ‘There is no doubt we have a major epidemic on our hands with obesity, and unless we find some way of tackling it, we are going to see young obese people dying before their parents’.

Lois Rogers, international commentator on health science and social policy issues

Cardiology in present-day Slovakia

Less than 20 years old, Slovakian cardiology is making progress for its population.

To appropriately understand the structure of cardiovascular health care in Slovakia, it is necessary to recognize several factors regarding the history and geopolitics of the country. Slovakia is a Central-Eastern European country with 5.5 million inhabitants and with a gross domestic product of 15 906 USD (2010 estimate) per capita. Seventy-five per cent of the population live in small towns and rural areas, with only 25% in cities of more than 100 000 people. Overall standardized cardiovascular mortality is ∼290 and there have been no significant changes during the last decade.

Slovakia gained its independence after separating from the former Czechoslovakia on 1 January 1993, about 3 years after the Velvet Revolution. This resulted in significant challenges and reforms to the new Slovakian health-care system and health-care legislation.

Originally, there was only one institution performing interventional cardiology and cardiac surgery in the country. After independence, three cardiovascular institutes were established: National, Central Slovakia, and Eastern Slovakia Cardiovascular Institutes. Interventional cardiology facilities are now available in six specialized cardiac centres, three of which have cardiac surgery (the above Institutes, Complex Centers on map).

Only four of the cardiac centres have 24 h coverage for acute coronary syndromes, leaving the Northern part of the country without access to primary coronary intervention during evenings, weekends, and holidays. The Slovak Society of Cardiology (SSC) has initiated steps to improve the situation and provide around-the-clock programmes in all cardiac centres. The National Cardiovascular Institute is the most advanced cardiac centre in the country.


Cardiology Centres in Slovakia


National Cardiovascular Institute, Bratislava

It is the centre for paediatric interventional cardiology/surgery, diagnosis and treatment of rare diseases, heart transplantation, and other highly complex procedures. General cardiovascular care is provided by internal medicine departments and affiliated intensive care units in county hospitals. Patients who need intensive diagnostics or interventions are referred to the one of the six cardiac centres.

Postgraduate education in cardiology is a minimum of 5 years and begins 2.5 years after general internal medicine training. It is encouraged that 1 year of this training be spent at one of the cardiovascular institutes. There are 15–20 cardiology graduates each year, the majority aiming for private practice, which has proven difficult over the years. There are many positions for graduate cardiologists at hospitals which are often declined, but at the cardiac centres, opportunities are limited. The current governmental restrictions and limited financial resources leave little room for the creation of new centres and growth of cardiovascular medicine in Slovakia.

Czechoslovakia's division led to the creation of the SSC, now representing 1325 professionals in clinical cardiology, medicine, and research. SSC has 14 working groups and/or associations covering all fields of cardiovascular medicine. The most important scientific and educational activity organized by SSC is its Annual Congress, during October in Bratislava, this year on 6–10 October.

Another popular congress of the SSC is the High Tatra Cardiology Days, held biannually in March, at High Tatra Mountain Resort. This meeting is oriented to postgraduate education. In addition, each working group of the SSC regularly organizes smaller specialized meetings or symposia.

The cornerstone of SSC is the official journal Cardiology Letters (formerly Kardiológia/Cardiology). This multilingual journal is published bi-monthly through the SSC. One of the most unique activities of SSC is the public relations campaign MOST (Month On cardiovascular Topics) organized by the Slovak Heart Foundation, affiliated to SSC. This annual campaign is in September and mainly focuses on the prevention of cardiovascular disease. For more information on SSC and its activities, see

Possibly, the weakest area of Slovak cardiology is in research and development, especially in clinical cardiology. Clinical research has traditionally had its roots in academia with PhD students. Highly specialized cardiology is concentrated in well-equipped institutes which, however, lack the connection to academia. Their main commitment is for therapeutic medicine and they do not undertake research. Conversely, the institutions with responsibility for research often lack necessary and basic equipment. Additionally, due to a shortage of doctors, they have to employ PhD students in therapeutic areas. A lack of communication between clinical departments and the specialized departments of basic science has resulted in an inability to formulate joint research and development plans. This results in an absence of prospective and qualitative clinical research projects and publications.

We wish to improve our research and development, and we encourage international cooperation in this field.

Eva Goncalvesová, MD, PhD, FESC, President of SSC

Cardiac centre of excellence
Oxford tests the hypothesis that excellent plus excellent is more than twice as good

A wholesale reintegration of the many nuggets of cardiovascular excellence in the university city of Oxford, UK, with extra resources and a new style of leadership, is reshaping a place which has often changed the direction of clinical cardiology, reports Barry Shurlock, PhD.

If the logician John Venn had tried to analyse the structure of medicine in Oxford with his celebrated intersecting circles, the idea would probably never have caught on. There are so many overlapping and interconnected entities in the city that anyone not familiar with its organizational landscape can get engulfed in a miasma of acronyms. It was much simpler 50 years ago, when the Oxford physician cum epidemiologist Sir Richard Doll made a huge contribution to cardiovascular medicine by showing that smoking promotes heart disease.

Since then, in the same city, and more recently in a building named after Doll, the prosaically entitled Clinical Trial Service Unit (CTSU), headed by Prof. Rory Collins, has year after year given the cardiovascular world new findings that have changed thinking and influenced practice. The University Department of Cardiovascular Medicine was recognized as the country's top cardiovascular department in the UK's Research Assessment Exercise (RAE) in 2008. Elsewhere in Oxford, many other important contributions to cardiovascular medicine have been made, but changes in the organization of academic and clinical research seem set to put the University City on a new path of excellence.

Running cardiovascular services in any city is difficult enough, but in a place like Oxford, there are special problems—and extra-special opportunities. This is a world-famous university city with an international reputation; full of intellects and egos, but with a relatively small population of about 600 000. It solves its small city problem by taking another 600 000 patients from a vast rural area, often called Middle Britain. Its relatively static population is a great asset for long-term studies. But within the city itself, there has long been a multiplicity of university departments, hospitals, and research units that individually are world leaders in their field, but often have not capitalized on the huge potential for interdisciplinary interaction.

In recent years, new corporate ideas in Oxford have faced these challenges and in the process changed culture and produced some significant results. Many people have been involved, but two of the drivers are Dr Adrian Banning, Chair of the Division of Cardiology at the John Radcliffe Hospital (JRH, the university hospital), and Prof, Keith Channon, based in the Department of Cardiovascular Medicine of the University of Oxford. Prof. Channon is Director of the Oxford Biomedical Research Centre (BRC), founded in 2007 with funds of £58 million (€70 million) over 5 years. At the last count, Oxford BRC supports 185 different projects in all specialities spread across academic departments and hospitals in Oxford, involving 370 new staff and 75 consultant clinicians with dedicated research time.

The Oxford BRC incorporates many clinical disciplines, but ∼40% of its funding is for cardiovascular research. Its style and philosophy are well demonstrated at its weekly meetings attended by key researchers, clinicians, research nurses, clinical research coordinators, research fellows, and others. The agenda moves from peer review of new projects, to proactive management of ongoing projects, with funding issues and plans for writing papers sandwiched in between, according to Channon, who said: ‘It is very interactive. Our aim is to support the people who are trying to deliver the research that builds on and will improve our clinical services. The problem with clinical research is that it is often challenging to make it happen in the National Health Service (NHS), so the BRC aims to move the good ideas into clinical practice by proactive management. The Oxford BRC increasingly maps onto the clinical structure of the hospital and the academic structure of the university, taking cues from other leading academic medical centres in the USA and Europe’.

In the hospital, Dr Banning and his colleagues are fostering a ‘seamless’ existence that moves easily from research laboratory and academic department to the clinic. In November 2009, clinical cardiology in the city took a great leap forward with the opening of the Oxford Heart Centre (OHC), a £29 million new build equipped with five state-of-the-art cath labs. It is a regional referral centre for the full gamut of medical and surgical services, with the exception of heart transplantation. Banning said: ‘Oxford would not justify a hospital the size of the JRH on its own, so we have to provide excellence at regional and national levels. We therefore do the “simple stuff” very well and the “difficult stuff” that other centres can't do! We have over twenty consultant cardiologists working here and competition for posts is tough. We attract the best and brightest from the UK and Europe—2 of our last 5 appointments were existing consultants in Germany’.

The new joined-up direction of research and services in Oxford is bearing fruit. In January 2011, the Oxford Acute Vascular Imaging Centre (OxAVIC)—a world first—opened to provide integrated magnetic resonance (MR) imaging in the cath lab. Patients with acute cardiovascular or neurovascular problems will now be investigated and treated with information from MR images from a 3 T whole-body scanner, located within a biplanar interventional suite. The OxAVIC project was established by Prof. Alastair Buchan who returned to Oxford in 2005, from Canada, and now heads the Medical Sciences Division of the University of Oxford. Other ongoing programmes of research closely integrated with clinical services include OxVASC, directed by Prof. Peter Rothwell, a large study that links the hospital with primary care, which has made huge progress in understanding the causes and improving the management of transient ischaemic attack and stroke. Both OxAVIC and OxVASC are supported by the Oxford BRC.

Also under the Oxford BRC umbrella, with additional funding from the NIHR, and led by Dr Bernard Prendergast, is OxVALVE, an ambitious and unique programme to study valvular heart disease in the community. It starts with echocardiography performed by general practitioners (GPs), followed by more intensive investigation of those with abnormal findings. Prof. Channon said: ‘We know that valvular disease is becoming more common in older people, but we have no idea of its prevalence. We see only the end stage, which is the tip of the iceberg, when management options become very restricted. There is very little understanding of the biology or genetics of valvular heart disease—so OxVALVE works with GPs to identify people with valvular disease before it presents clinically. We're aiming for a cohort of several thousand people and so far have screened about 1,500—surprisingly, about 30% of them have some evidence of valvular heart disease! This will form an invaluable cohort of individuals for long term follow-up studies and subjects for recruitment into clinical studies of new treatments or interventions'.

Channon points to the way that closer links between research and practice have enabled fundamental studies of cardiovascular disease genetics, carried out in Oxford by Prof. Hugh Watkins, to be fed quickly into the UK NHS. At a time when the cost of sequencing the human genome is expected to fall to about $1000, gene testing is increasingly becoming a routine NHS service, and diagnostic tests developed by researchers have already been commissioned into national guidelines. Watkins also directs the Oxford British Heart Foundation Centre of Research Excellence, an overarching scheme involving three other UK centres (Edinburgh, Imperial College, and King's College, London). Channon said: ‘The emphasis with the BHF Centre of Research Excellence is to bring together university departments not usually regarded as part of clinical cardiovascular medicine—such as computation, chemistry, physiology, genetics and pharmacology, in order to apply new specialist knowledge to cardiovascular problems. The BHF Centre of Research Excellence programme also has a major focus on training fellowships that are critical to developing the next generation of leaders in cardiovascular science. People are very enthusiastic about this approach—it's about bringing people together from different disciplines in cross-cutting interactions that would not otherwise have happened'.

Last year, Oxford was chosen as one of only four European locations for the TCT (Transcatheter Cardiovascular Therapeutic) teleconference co-sponsored by the American Association for Thoracic Surgery. And its Oxford Live interventional cardiology courses are a sell-out. It is too early to know the outcome of the new style of joined-up management being rolled out in Oxford, but all the indications are that this jewel in the crown of English medicine is set to have an even larger place on the cardiovascular world map.


Portrait of Clinical Research in Cardiology Journal from Germany

With a steadily rising impact factor, the journal is on course to become one of the leading European journals in cardiology and cardiovascular medicine.


Clinical Research in Cardiology was founded at the same time as the German Society of Cardiology (Deutsche Gesellschaft für Kreislaufforschung) on 15 June 1927. In parallel, an official journal of the society named Zeitschrift für Kreislaufforschung was started. The journal was founded by Stadler, Plauen, and Kisch in Cologne. The precursor of this official journal of the German Cardiac Society was the Zentralblatt für Herz- und Gefäßkrankheiten, founded 1909 by Erben in Vienna. Later, the journal was named Zeitschrift für Kardiologie and this journal published articles only in German. Prominent editors were Franz Loogen from Düsseldorf and Paul Lichtlen from Hannover. Later, Wolfgang Kübler and Thomas Meinertz were editors of this journal. Under the responsibility of Thomas Meinertz from Hamburg, the journal accepted English and German manuscripts. Later, the editorship appointed Michael Böhm, professor of Internal Medicine and Cardiology and director of Internal Medicine (Cardiology, Angiology, and Intensive Care Medicine) at the University of the Saarland in Homburg. ‘In 2005, we stepwise transferred it to a journal exclusively publishing in English and renamed it Clinical Research in Cardiology', says Böhm.


Michael Böhm, Chief Editor

The journal addresses cardiologists and young physicians in training for cardiology and internal medicine. It covers the whole range of original papers from clinical research and also interesting reports which are published in the sections as letters to the editors. The journal's goal is to provide readers with interesting original work on timely clinical topics, as well as to provide medical education addressed in case reports, review articles, and critical perspective articles. The journal provides a forum for publication of Clinical Research in Cardiology for European authors. It is a sister journal of Basic Research in Cardiology edited by G. Heusch, which mainly focuses on basis science aspects.

Clinical Research in Cardiology receives about 400 manuscripts yearly. The number of manuscripts published in 2010 was 98. This translates to an acceptance rate of 25–30% which has been stable from 2006 to 2010. The first impact factor, awarded in 2007, was 1.44. It has increased steadily to 2.44 in 2008 and 2.96 in 2009. Böhm says: ‘The steady increase led us to hope that we will achieve a higher impact factor in 2010 and 2011'.

The journal has an office in Homburg/Saar and an affiliate in Heidelberg led by Hugo Katus. About 80 reviewers are used to evaluate the manuscripts. The in-house team consists of secretarial support by Birgit Kratz and by Jan-Christian Reil, and special support comes from members of the editorial board. Furthermore, close collaborations have been established with its sister journal Basic Research in Cardiology. Gerd Heusch from Essen and Thomas Eschenhagen from Hamburg are associate editors who give support for special topics.

Böhm hopes that the journal will develop to become one of the leading European journals in cardiology and cardiovascular medicine. In future, it will accept more trial designs and probably also original work from larger randomized trials. Böhm says: ‘We try to achieve this by close collaborations with other European journals which are under the umbrella of the European Society of Cardiology journals'.

J. Taylor, MPhil

Reflection on Professor Sir Magdi Yacoub: a pioneering cardiac surgeon

Having performed the first ‘piggy-back’ heart donor, Sir Magdi is now working with stem-cell research.


Prof. Yacoub is renowned for his amazing and dedicated work in cardiac surgery especially transplant surgery. In 1980, he was instrumental in the restart of the UK transplant programme at the Harefield Hospital, and in the following decade, he and his team carried out 1000 transplants. The professor was born in Belbis, Egypt, and studied medicine at Cairo University, graduating in 1957. He moved to Britain in 1962 to become Senior Surgical Registrar at the National Heart and Chest hospitals in London. In 1969, he moved to the USA as Assistant Professor and Instructor at the University of Chicago and in 1973 returned to the UK to take up the position of Consultant Cardiac Surgeon at the Brompton and Harefield National Heart hospitals, London.

However, in 2001, the concept of ‘retirement’ did not suit a man of such experience and a determination to overcome the problems that occur when the heart weakens and fails.

I recently interviewed Prof. Yacoub to find out more of the events, inspiring characters and thought processes that have produced this determined and inspirational man, who welcomes and promotes the role that the Arts play in vital scientific developments. He much admires the sculpture of Antony Gormley who donated one of his works to the Heart Sciences Centre in London. Writing in The Guardian newspaper (2 February 2007), ‘we need a lot of experts from different fields but we also need a lot of imagination and a lot of understanding of how form interacts with function. Art gives a lot of inspiration and beauty, and beauty is part of science’.

We are often curious as to what in an individual's early life may have influenced the choosing of a particular field of study. Prof. Yacoub explained that it was the death of his 22-year-old aunt in childbirth (from mitral stenosis) that had set him on the path of cardiology and cardiac surgery. Although interested in nephrology and orthopaedics, cardiology was fortunately his choice. Notwithstanding retirement, he continues with stem-cell research to grow human heart valves. This he sees as the answer to the ever-growing need for transplant organs which are in such short supply.

One of Prof. Yacoub's most inspiring operations was on young Hannah Clark born with cardiomyopathy. At age 2 years, her life expectancy was limited. She received a donor heart which Prof. Yacoub sutured on to her own heart that became known as ‘piggy-backing’ of the donor heart. Later, she developed a rare malignancy that necessitated a reduction in her immunosuppressant drugs, which led to the donor heart failing. So, 11 years after the transplant, Prof. Yacoub came out of retirement to assist in removing the donor heart. The amazing result of the ‘piggy-backing’ was that Hannah's own heart had recovered, and now some 4 years later, she is leading a normal and happy life.

Allowing recovery of the human heart is desirable to delay or avoid transplantation. An editorial in the EHJ ‘The Holy Grail of Left Ventricular Assist Device (LVAD)-induced Reversal of Severe Chronic Heart Failure: the Need for Integration’ by Prof. Yacoub and Cesare Terracciano considers the merits of LVADs to unload the left ventricle so as to avoid or delay transplantation, and ‘provide an innervated heart capable of providing normal power output’. However, the authors point out that analysis of the study is hampered by the small number of patients.

One of Prof. Yacoub's main research interests is human stem-cell technology to successfully grow heart valves. Artificial valves may save lives but they do not perform the more sophisticated functions of living tissue. In ‘The Lancet’ online on 3 August 2010, Prof. Yacoub and his team compare the ‘Long-term outcomes after autograft versus homograft aortic root replacement in adults with aortic valve disease in a randomised controlled trial’. Two hundred and twenty-eight patients, male and female aged less than 69 years requiring aortic valve surgery, were randomly assigned to receive an autograft or a homograft aortic root replacement at one UK centre. ‘All patients underwent total aortic root replacements. For the autograft the pulmonary root was harvested in a scalloped fashion’. In the article's ‘discussion’ section, we learn that the autograft (Ross procedure) improved survival compared with the homograft, reduced the risk of reoperation, and resulted in better quality of life. Stem-cell research is very valuable in the ever-increasing need for replacing heart valves.

Prof. Yacoub is involved in many charitable organizations, the main one being the ‘Chain of Hope’ which he set up in 1995 and is designed most importantly, to provide vital health care and cardiac surgery for children in the most needy parts of the world.


Chain of Hope-humanitarian mission in Africa

Since 1995, the object has been to provide outside expertise and teaching for local cardiac teams to help them deal with their many local demands. The setting up of hospitals and research centres is also important in the Chain of Hope.

Prof. Yacoub swims daily and grows orchids for respite from his demanding life in medicine. Influential in his life and work were Lord Russell Brock and Sir Peter Medawar, especially the latter's study and discovery of acquired immune tolerance, so fundamental to the practice of tissue and organ transplant.

Most people would describe Sir Magdi Yacoub as a truly inspirational person and long may that continue.

D. Berry, MA

Book Review
The expanding universe of non-cardiac vascular diseases captured in time

A new and unique textbook on ‘Vascular Disease: Diagnostic and Therapeutic Approaches’ edited by Michael R. Jaff and Christopher J. White.


Historically, the prevalence of vascular disease could be predictably extrapolated based on risk-factor assessment and as a function of ageing. However, alarming increases in obesity and diabetes within all age strata of the population are resulting in an even greater number of patients developing vascular diseases at an earlier age. As a result, the temporal shift in the aetiology of vascular disease is certain to perpetuate the current epidemic and place a great burden on Vascular Specialists.

Today, nearly every clinician encounters patients with vascular disease given its prevalence and systemic nature. Advances in the diagnosis and treatment of vascular disease are of great benefit to patients and physicians alike. Furthermore, recent progress in non-invasive imaging and the expansion of endovascular strategies for treating vascular disease has created an explosion of interest within the physician community. Given the abundance of information and technologies available, there is a need for education to prepare clinicians for the increasing number of patients with vascular disease.

Vascular Disease: Diagnostic and Therapeutic Approaches is a comprehensive textbook on diagnostic and therapeutic approaches for patients with vascular diseases. Many of their respected colleagues from the USA contributed to the chapters, and it offers a profound and practical overview of diagnostic approaches as well as contemporary and emerging treatment strategies for arterial and venous diseases. It addresses an educational need for medical students, physicians-in-training, and practicing clinicians alike.

This hard-cover textbook with 600 pages, and 350 illustrations, figures and tables, encompass the broad continuum of vascular medicine, from diagnosis and medical management to endovascular and surgical therapy. The rapid development of non-invasive imaging techniques and novel revascularization strategies are systematically discussed in a well-designed format of 8 parts and 26 chapters.

Parts I and II provide methods for patient evaluation and assessment of peripheral arterial disease (PAD). The initial chapter offers an introduction on the clinical approach to evaluating patients with vascular disease. The authors emphasize the need for a comprehensive physical examination and review of patients' vascular history. This is especially important given the increasing use of ‘high-tech’ medicine in place of traditional ‘high-touch’ practices.

Part II has two chapters and begins with a discussion of peripheral perfusion evaluation methods such as ankle–brachial index measurements, pulse volume recordings, and exercise treadmill testing. This focuses primarily on patients with PAD, which is one of the most prevalent vascular diseases in our increasing elderly population. The final chapter of Part II is dedicated to using vascular imaging to better determine the cause and extent of vascular disorders. It provides an overview of the standard imaging techniques of duplex sonography, magnetic resonance angiography, computed tomography angiography, and peripheral angiography. Additionally, detailed insight pertaining to complications arising from peripheral angiography is also discussed.

Parts III–V are nearly two-thirds of the textbook and provide a comprehensive review of atherosclerotic arterial diseases. All extra-cardiac vascular branches, from the carotids and aortic arch to thoraco-abdominal aorta, renal, visceral, and lower extremity arteries are included. Each chapter discusses the specific vascular territories and issues related to medical history, clinical examination, functional evaluation, and diagnostic evaluation. Thereafter, endovascular and surgical therapy options are discussed based on the diagnosis with examples of: carotid artery stenosis, vertebrobasilar insufficiency, thoracic outlet syndrome, haemodialysis access interventions, thoraco-abdominal dissection and aneurysm, chronic mesenteric ischaemia, renal artery disease, and acute and chronic limb ischaemia being addressed.

The book also provides comprehensive information on the increasing endovascular treatment options for patients with lower extremity arterial disease including acute limb ischaemia, occlusive diseases of the abdominal aorta and iliac arteries, femoropopliteal disease, critical limb ischaemia, and vascular access complications. Tables and figures are used to show data from recent clinical trials and are well integrated to offer rapid comprehension of each topic. All recent and emerging endovascular treatment options are discussed and include: balloon angioplasty, cryoplasty, drug-eluting balloons and stents, stent grafts, and atherectomy. Treatment strategies for limb salvage and a primer on the emerging field of angiogenesis are also discussed.

Non-atherosclerotic arterial diseases according to their prevalence are thoroughly covered in Part VI of the textbook. Four chapters contain and discuss thrombangitis obliterans, systemic vasculitides, vasospastic disorders, and fibromuscular dysplasia, respectively.

Part VII contains four chapters related to venous diseases. Topics include venous thrombosis with pulmonary embolism, superior vena cava syndrome, chronic venous insufficiency, and varicose veins. One chapter includes uncommon congenital venous disorders such as Klippel–Trenaunay syndrome, Parkes Weber syndrome, and Kasabach–Merritt syndrome and acquired venous disorders such as atypical venous thrombosis of cerebral venous sinus, the mesenteric veins, and Lemierre's syndrome.

Part VIII contains the final two chapters that focus on coagulation disorders and other environmental or inherited vascular disorders. Examples include erythromelalgia, pernio, frostbite, and Marfan's syndrome. These last two chapters are rather brief, but given the low prevalence of these diseases, it is appropriate and well within the scope of the textbook.

In summary, Michael R. Jaff and Christopher J. White and colleagues have created an outstanding textbook on the expanding universe of non-cardiac vascular diseases. It will serve as an excellent and welcome library addition for clinicians, irrespective of medical background, and benefit patients in need of care for vascular disease.

Marc Husmann, MD, Department of Angiology/Vascular Medicine,

University Hospital Zurich

CardioPulse contact: Andros Tofield, MD, FRCS, FACEP, Managing Editor CardioPulse, EHJ. Email: