Skip to main content
SpringerLink
Log in

Prognostic significance of silent ischemia

  • Original Articles
  • Published:
Journal of Nuclear Cardiology Aims and scope

Abstract

This study examined the prognostic predictors in 521 patients with angiographic evidence of coronary artery disease (CAD). All patients underwent exercise single-photon emission computed tomographic thallium imaging. The patients were divided into those with symptomatic ischemia defined as reversible thallium defects, S-T segment depression (or both) and angina during exercise (n= 210, group 1), and silent ischemia defined as thallium defects or ST segment depression (or both) but no angina during exercise (n = 311, group 2). During a mean follow-up of 24 ±21 months, there were 30 cardiac events (death or nonfatal myocardial infarction). The extent of CAD (2.0 ±0.8 diseased vessels in group 1 and 2.1 ±0.8 diseased vessels in group 2), the left ventricular ejection fraction, the extent of perfusion abnormality (21% ±11% in group 1 and 24% ±12% in group 2), and the peak heart rate and double product were similar in the two groups. Survival analysis showed no significant difference in the event-free survival in patients with symptomatic or silent ischemia. The 2-year event-free survival rate was 95% in group 1 and 94% in group 2 (difference not significant). The extent of perfusion abnormality and history of diabetes mellitus were the most important predictors of events. Thus the prognosis of medically treated patients with CAD is comparable in those patients with silent or symptomatic ischemia and is dependent on the extent of myocardium at risk rather than presence or absence of angina pectoris during exercise.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Cecci AC, Dovellini EV, Marchi F, Pucci C, Santoro CM, Fazzini PF. Silent myocardial ischemia during ambulatory electrocardiographic monitoring in patients with effort angina. J Am Coll Cardiol 1983; 1: 934–9.

    Google Scholar 

  2. Fleg JL, Gerstenblith G, Zonderman AB, et al. Prevalence and prognostic significance of exercise-induced silent myocardial ischemia detected by thallium scintigraphy and electrocardiography in asymptomatic volunteers. Circulation 1990; 81: 428–36.

    PubMed  CAS  Google Scholar 

  3. Lindsey HE, Cohn PF. “Silent” myocardial ichemia during and after exercise testing in patients with coronary artery disease. Am Heart J 1978; 95: 441–7.

    Article  PubMed  Google Scholar 

  4. Panza JA, Diodati JG, Callahan TS, Epstein SE, Quyyumi AA. Role of increases in heart rate in determining the occurrence and frequency of myocardial ischemia during daily life in patients with stable coronary artery disease. J Am Coll Cardiol 1992; 20: 1092–8.

    PubMed  CAS  Google Scholar 

  5. Deedwania PC, Nelson JR. Pathophysiology of silent myocardial ischemia during daily life: hemodynamic evaluation by simultaneous electrocardiographic and blood pressure monitoring. Circulation 1990; 82: 1296–304.

    PubMed  CAS  Google Scholar 

  6. Falcone C, De Servi S, Poma E, et al. Clinical significance of exercise-induced silent myocardial ischemia in patients with coronary artery disease. J Am Coll Cardiol 1987; 295: 9.

    Google Scholar 

  7. Assey ME, Walters GL, Hendrix GH, Carabello BA, Usher BW, Spann JF Jr. Incidence of acute myocardial infarction in patients with exercise-induced silent myocardial ischemia. Am J Cardiol 1987; 59: 497–500.

    Article  PubMed  CAS  Google Scholar 

  8. Cole JP, Ellestad MH. Significance of chest pain during treadmill exercise: correlation with coronary events. Am J Cardiol 1978; 41: 227–32.

    Article  PubMed  CAS  Google Scholar 

  9. Weiner DA, Ryan TH, McCabe CH, et al. Significance of silent myocardial ischemia during exercise testing in patients with coronary artery disease. Am J Cardiol 1987; 59: 725–9

    Article  PubMed  CAS  Google Scholar 

  10. Schalet BD, Kegel JG, Heo J, Segal BL, Iskandian AS. Prognostic implications of normal exercise SPECT thallium images in patients with strongly positive exercise electrocardiograms. Am J Cardiol 1993; 72: 1201–3.

    Article  PubMed  CAS  Google Scholar 

  11. Iskandrian AS, Chae SC, Heo J, Stanberry CD, Wasserleben V, Cave V. Independent and incremental prognostic value of exercise single-photon emission computed tomographic (SPECT) thallium imaging in coronary artery disease. J Am Coll Cardiol 1993; 22: 665–70.

    PubMed  CAS  Google Scholar 

  12. Iskandrian AS, Johnson JH, Heo J, Wasserleben V, Cave V. Comparison of the treadmill exercise score: SPECT thallium imaging predicting prognosis in medically treated patients with coronary artery disease. J Nucl Cardiol (in press).

  13. SAS user’s guide: statistics. 5th ed. Gary, North Carolina: SAS Institute, 1985.

  14. Cohn PF. Silent myocardial ischemia in patients with defective anginal warning system. Am J Cardiol 1980; 45: 697–702.

    Article  PubMed  CAS  Google Scholar 

  15. Heller GV, Garber CE, Connolly MJ, et al. Plasma betaendorphin levels in silent myocardial ischemia. Am J Cardiol 1987; 59: 735–9.

    Article  PubMed  CAS  Google Scholar 

  16. Droste C, Roskamm H. Experimental pain measurement in patients with asymptomatic myocardial ischemia. J Am Coll Cardiol 1983; 1: 940–5.

    Article  PubMed  CAS  Google Scholar 

  17. Chierchia S, Lazzari M, Freedman B, Brunelli C, Maseri A. Impairment of myocardial perfusion and function during painless myocardial ischemia. J Am Coll Cardiol 1983; 1: 924–30.

    PubMed  CAS  Google Scholar 

  18. Gasparetti CM, Burwell LR, Beller GA. Prevalence of variables associated with silent myocardial ischemia on exercise thallium-201 stress testing. J Am Coll Cardiol 1990; 16: 115–23.

    Google Scholar 

  19. Mahmarian JJ, Pratt CM, Cocanougher MK, Verani MS. Altered myocardial pefusion in patients with angina pectoris or silent ischemia during exercise as assessed by quantitative thallium-201 single photon emission computed tomography. Circulation 1990; 82: 1305–15.

    PubMed  CAS  Google Scholar 

  20. Van Arnim T, Erath A. Nitrates and calcium antagonists for silent myocardial ischemia. Am J Cardiol 1988; 61: 15E-8E.

    Article  Google Scholar 

  21. Imperi GA, Lambert CR, Coy K, Lopez I, Pepine L. Effects of titrated beta-blockers (metoprolol) on silent myocardial ischemia in ambulatory care patients with coronary artery disease. Am J Cardiol 1987; 60: 519–24.

    Article  PubMed  CAS  Google Scholar 

  22. Parmley WW, Nesto RW, Singh BN, Dearfield J, Gottlieb SD, N-CAP Study Group. Alternative of the circadian pattern of myocardial ischemia with nifedipine GITS in patients with chronic stable angina. J Am Coll Cardiol 1992; 19: 1380–9.

    PubMed  CAS  Google Scholar 

  23. Campbell S, Barry J, Rocco MB, et al. Features of the exercise test that reflects the activity of ischemic heart disease out of hospital. Circulation 1986; 74: 720–8.

    Google Scholar 

  24. Mody F, Nademanee K, Intrachot V, Josephson MA, Robertson HA, Singh BN. Severity of silent myocardial ischemia on ambulatory electrocardiographic monitoring in patients with stable angina pectoris: relationship to prognostic determinants during exercise stress testing and coronary angiography. J Am Coll Cardiol 1988; 12: 1169–76.

    PubMed  CAS  Google Scholar 

  25. Gottlieb SO, Weisfeldt MC, Ouyang P, Mellits P, Gerstenblitz G. Silent ischemia as a marker of early unfavorable outcomes in patients with unstable angina. N Engl J Med 1986; 314: 1214–9.

    PubMed  CAS  Google Scholar 

  26. Rocco MB, Babel E, Campbell S, et al. Prognostic importance of myocardial ischemia detected by ambulatory monitoring in patients with stable coronary artery disease. Circulation 1988; 78: 877–84.

    PubMed  CAS  Google Scholar 

  27. Bonow RO, Bacharach SL, Green MV, LaFremiere RL, Epstein SE. Prognostic implications of symptomatic versus asymptomatic (silent) myocardial ischemia induced by exercise in mildly asymptomatic and in asymptomatic patients with angiographically documented coronary artery disease. Am J Cardiol 1987; 60: 778–83.

    Article  PubMed  CAS  Google Scholar 

  28. Weiner DA, Ryan TJ, McCabe CH, et al. Comparison of coronary artery bypass surgery and medical therapy in patients with exercise-induced silent myocardial ischemia: a report from the Coronary Artery Surgery Study (CASS) Registry. J Am Coll Cardiol 1988; 12: 595–9.

    PubMed  CAS  Google Scholar 

  29. Mark DB, Hlatky MA, Califf RM, et al. Painless exercise S-T deviation on the treadmill: long term prognosis. J Am Coll Cardiol 1989; 14: 885–92.

    Article  PubMed  CAS  Google Scholar 

  30. Hendel RD, Layden JJ, Leppo JA. Prognostic value of dipyridamole-thallium scintigraphy for evaluation of ischemic heart disease. J Am Coll Cardiol 1990; 15: 109–16.

    PubMed  CAS  Google Scholar 

  31. Kamal AM, Fattah AA, Pancholy S, et al. Prognostic value of adenosine SPECT thallium imaging in medically treated patients with angiographic evidence of coronary artery disease.J Nucl Cardiol (in press).

Download references

Author information

Authors and Affiliations

  1. Philadelphia Heart Institute, Presbyterian Medical Center, 51 N. 39th St., 19104, Philadelphia, PA

    Samir B. Pancholy, Bennett Schalet, Valerie Kuhlmeier, Virginia Cave, Jaekyeong Heo & Abdulmassih S. Iskandrian

Authors
  1. Samir B. Pancholy
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Bennett Schalet
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Valerie Kuhlmeier
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Virginia Cave
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jaekyeong Heo
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Abdulmassih S. Iskandrian
    View author publications

    You can also search for this author in PubMed Google Scholar

Additional information

Presented in part at the Sixty-sixth Annual Scientific Sessions of the American Heart Association, Atlanta, Ga., November 1993.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Pancholy, S.B., Schalet, B., Kuhlmeier, V. et al. Prognostic significance of silent ischemia. J. Nucl. Cardiol. 1, 434–440 (1994). https://doi.org/10.1007/BF02961597

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF02961597

Key Words

Search

Navigation