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Diagnostic and prognostic value of ambulatory ECG (Holter) monitoring in patients with coronary heart disease: a review

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Abstract

Silent ischemia, the most common expression of atherosclerotic heart disease, affects approximately 30–50% of patients during their activities of daily living. The present review provides a comprehensive and practical summary of current knowledge on perioperative myocardial ischemia through MEDLINE searches up to June 2005, using keywords including “silent ischemia,” “transient ischemia,” and “Holter monitoring.” Holter monitoring (i.e., continuous ambulatory ST-segment monitoring) is an effective tool for assessing the frequency and duration of silent transient myocardial ischemia, particularly in patients who are post-acute myocardial infarction (MI), those with acute coronary syndromes (ACS), and in patients in the acute post-operative period. Holter monitoring allows for further risk stratification of patients who have a positive exercise ECG by collecting long-term ECG data on ischemic and arrhythmic events while patients perform routine activities. Both the presence and increased duration of transient ischemia as detected by continuous ST-segment Holter monitoring are associated with increased rates of coronary events and mortality. Holter monitoring may aid in the identification of patients and subgroups of patients with ACS who may derive the greatest benefit from antiplatelet and antithrombotic therapy. Indeed, many ongoing and upcoming trials of pharmacotherapy include ischemia on Holter monitoring as an endpoint.

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References

  1. 1.

    Deedwania PC, Carbajal EV (1991a) Silent myocardial ischemia: a clinical perspective. Arch Intern Med 151:2372–2382

  2. 2.

    Solomon H, DeBusk RF (2004) Contemporary management of silent ischemia: the role of ambulatory monitoring. Int J Cardiol 96:311–319

  3. 3.

    Cohn PF, Fox KM, Daly C (2003) Silent myocardial ischemia. Circulation 108:1263–1277

  4. 4.

    Gottlieb SO, Weisfeldt ML, Ouyang P, Mellits ED, Gerstenblith G (1986) Silent ischemia as a marker for early unfavorable outcomes in patients with unstable angina. N Engl J Med 314:1214–1219

  5. 5.

    Multiple Risk Factor Intervention Trial Research Group (1985) Exercise electrocardiogram and coronary heart disease mortality in the Multiple Risk Factor Intervention Trial. Am J Cardiol 55:16–24

  6. 6.

    Johnson SM, Mauritson DR, Winniford MD et al (1982) Continuous electrocardiographic monitoring in patients with unstable angina pectoris: identification of high-risk subgroup with severe coronary disease, variant angina, and/or impaired early prognosis. Am Heart J 103:4–12

  7. 7.

    Nademanee K, Intarachot V, Josephson MA, Rieders D, Vaghaiwalla MF, Singh BN (1987) Prognostic significance of silent myocardial ischemia in patients with unstable angina. J Am Coll Cardiol 10:1–9

  8. 8.

    Langer A, Freeman MR, Armstrong PW (1989) ST segment shift in unstable angina: pathophysiology and association with coronary anatomy and hospital outcome. J Am Coll Cardiol 13:1495–1502

  9. 9.

    von Arnim T, Gerbig HW, Krawietz W, Hofling B (1988) Prognostic implications of transient—predominantly silent—ischaemia in patients with unstable angina pectoris. Eur Heart J 9:435–440

  10. 10.

    Larsson H, Jonasson T, Ringqvist I, Fellenius C, Wallentin L (1992) Diagnostic and prognostic importance of ST recording after an episode of unstable angina or non-Q-wave myocardial infarction. Eur Heart J 13:207–212

  11. 11.

    Patel DJ, Gomma AH, Knight CJ et al (2001) Why is recurrent myocardial ischaemia a predictor of adverse outcome in unstable angina? Eur Heart J 22:1991–1996

  12. 12.

    Gottlieb SO, Weisfeldt ML, Ouyang P, Mellits ED, Gerstenblith G (1987) Silent ischemia predicts infarction and death during 2 year follow-up of unstable angina. J Am Coll Cardiol 10:756–760

  13. 13.

    Wilcox I, Ben Freedman S, Kelly DT, Harris PJ (1990) Clinical significance of silent ischemia in unstable angina pectoris. Am J Cardiol 65:1313–1316

  14. 14.

    Patel DJ, Knight CJ, Holdright DR et al (1998) Long-term prognosis in unstable angina. The importance of early risk stratification using continuous ST segment monitoring. Eur Heart J 19:240–249

  15. 15.

    Landesberg G, Luria MH, Cotev S et al (1993) Importance of long-duration postoperative ST-segment depression in cardiac morbidity after vascular surgery. Lancet 341:715–719

  16. 16.

    Gibson CM, Morrow DA, Murphy SA, Palabrica TM, Jennings LK, Stone PH, Lui HH, Bulle T, Lakkis N, Kovach R, Cohen DJ, Fish P, McCabe CH, Braunwald E, TIMI Study Group (2006) A randomized trial to evaluate the relative protection against post-percutaneous coronary intervention microvascular dysfunction, ischemia, and inflammation among antiplatelet and antithrombotic agents: the PROTECT-TIMI-30 trial. J Am Coll Cardiol 47(12):2364–2373 (Jun 20)

  17. 17.

    Ekelund LG, Suchindran CM, McMahon RP et al (1989) Coronary heart disease morbidity and mortality in hypercholesterolemic men predicted from an exercise test: the Lipid Research Clinics Coronary Primary Prevention Trial. J Am Coll Cardiol 14:556–563

  18. 18.

    Rautaharju PM, Prineas RJ, Eifler WJ et al (1986) Prognostic value of exercise electrocardiogram in men at high risk of future coronary heart disease: multiple risk factor intervention trial experience. J Am Coll Cardiol 8:1–10

  19. 19.

    Froelicher VF Jr, Thomas MM, Pillow C, Lancaster MC (1974) Epidemiologic study of asymptomatic men screened by maximal treadmill testing for latent coronary artery disease. Am J Cardiol 34:770–776

  20. 20.

    Fleg JL, Gerstenblith G, Zonderman AB et al (1990) Prevalence and prognostic significance of exercise-induced silent myocardial ischemia detected by scintigraphy and electrocardiography in asymptomatic volunteers. Circulation 81:428–436

  21. 21.

    Kannel WB (1987) Prevalence and clinical aspects of unrecognized myocardial infarction and sudden unexpected death. Circulation 75:II4–II5

  22. 22.

    Sharaf BL, Williams DO, Miele NJ et al (1997) A detailed angiographic analysis of patients with ambulatory electrocardiographic ischemia: results from the Asymptomatic Cardiac Ischemia Pilot (ACIP) study angiographic core laboratory. J Am Coll Cardiol 29:78–84

  23. 23.

    American Heart Association. (2006) Silent Ischemia and Ischemic Heart Disease. Available at http://www.americanheart.org/presenter.jhtml?identifier=4720. Accessed July 25, 2006

  24. 24.

    Deedwania PC, Carbajal EV (1990) Silent ischemia during daily life is an independent predictor of mortality in stable angina. Circulation 81:748–756

  25. 25.

    Mazzone A, Cusa C, Mazzucchelli I et al (2001) Increased production of inflammatory cytokines in patients with silent myocardial ischemia. J Am Coll Cardiol 38:1895–1901

  26. 26.

    Langer A, Freeman MR, Josse RG, Steiner G, Armstrong PW (1991) Detection of silent myocardial ischemia in diabetes mellitus. Am J Cardiol 67:1073–1078

  27. 27.

    Shakespeare CF, Katritsis D, Crowther A, Cooper IC, Coltart JD, Webb-Peploe MW (1994) Differences in autonomic nerve function in patients with silent and symptomatic myocardial ischaemia. Br Heart J 71:22–29

  28. 28.

    Myers J, Oesterle SN, Jones J, Burkoff D (2002) Do transmyocardial and percutaneous laser revascularization induce silent ischemia? An assessment by exercise testing. Am Heart J 143:1052–1057

  29. 29.

    Hughes GC, Landolfo KP, Lowe JE, Coleman RB, Donovan CL (1999) Diagnosis, incidence, and clinical significance of early postoperative ischemia after transmyocardial laser revascularization. Am Heart J 137:1163–1168

  30. 30.

    Deedwania PC (1993) Increased demand versus reduced supply and the circadian variations in ambulatory myocardial ischemia: therapeutic implications. Circulation 88:328–331

  31. 31.

    He ZX, Hedrick TD, Pratt CM et al (2000) Severity of coronary artery calcification by electron beam computed tomography predicts silent myocardial ischemia. Circulation 101:244–251

  32. 32.

    Kwok Y, Kim C, Grady D, Segal M, Redberg R (1999) Meta-analysis of exercise testing to detect coronary artery disease in women. Am J Cardiol 83:660–666

  33. 33.

    Hlatky MA, Pryor DB, Harrell FE Jr, Califf RM, Mark DB, Rosati RA (1984) Factors affecting sensitivity and specificity of exercise electrocardiography. Multivariable analysis. Am J Med 77:64–71

  34. 34.

    Crawford MH, Bernstein SJ, Deedwania PC et al (1999) ACC/AHA guidelines for ambulatory electrocardiography: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee to revise the guidelines for ambulatory electrocardiography). Circulation 100:886–893

  35. 35.

    Patel DJ, Mulcahy D, Norrie J et al (1996) Natural variability of transient myocardial ischaemia during daily life: an obstacle when assessing efficacy of anti-ischaemic agents? Heart 76:477–482

  36. 36.

    Kadish AH, Buxton AE, Kennedy HL et al (2001) ACC/AHA clinical competence statement on electrocardiography and ambulatory electrocardiography. A report of the ACC/AHA/ACP-ASIM Task Force on Clinical Competence (ACC/AHA Committee to Develop a Clinical Competence Statement on Electrocardiography and Ambulatory Electrocardiography). J Am Coll Cardiol 38:2091–2100

  37. 37.

    Smith SC Jr, Amsterdam E, Balady GJ et al (2000) Prevention Conference V: beyond secondary prevention: identifying the high-risk patient for primary prevention: tests for silent and inducible ischemia: Writing Group II. Circulation 101:e12–e16

  38. 38.

    Causse C, Allaert FA, Marcantoni JP, Wolfe JE (2001) Frequency and detection rate of silent myocardial ischemia by Holter monitoring in patients with stable coronary insufficiency under treatment. Study of 95,725 recorded hours. Arch Mal Coeur Vaiss 94:779–784

  39. 39.

    Wackers FJ, Young LH, Inzucchi SE et al (2004) Detection of ischemia in asymptomatic diabetics investigators. Detection of silent myocardial ischemia in asymptomatic diabetic subjects: the DIAD study. Diabetes Care 27:1954–1961

  40. 40.

    Pepine CJ, Cohn P, Deedwania P et al (1994) Effects of treatment on outcome in mildly symptomatic patients with ischemia during daily life. The Atenolol Silent Ischemia Study (ASIST). Circulation 90:762–768

  41. 41.

    Bourassa MG, Pepine CJ, Forman SA et al (1995) Asymptomatic Cardiac Ischemia Pilot (ACIP) study: effects of coronary angioplasty and coronary artery bypass graft surgery on recurrent angina and ischemia. The ACIP investigators. J Am Coll Cardiol 26:606–614

  42. 42.

    Forslund L, HjemdahlP, Held C, Eriksson SV, Bjorkander I, Rehnquist N (1999) Prognostic implications of ambulatory myocardial ischemia and arrhythmias and relations to ischemia on exercise in chronic stable angina pectoris (the Angina Prognosis Study In Stockholm [APSIS]). Am J Cardiol 84:1151–1157

  43. 43.

    Dargie HJ, Ford I, Fox K (1996) Total Ischaemic Burden European Trial (TIBET). Effects of ischaemia and treatment with atenolol, nifedipine SR and their combination on outcome in patients with chronic stable angina. The TIBET Study Group. Eur Heart J 17:104–112

  44. 44.

    Akkerhuis KM, Klootwijk PA, Lindeboom W et al (2001) Recurrent ischaemia during continuous multilead ST-segment monitoring identifies patients with acute coronary syndromes at high risk of adverse cardiac events; meta-analysis of three studies involving 995 patients. Eur Heart J 22:1997–2006

  45. 45.

    Braunwald E, Antman EM, Beasley JW et al (2000) ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol 36:970–1062

  46. 46.

    Heeschen C, Hamm CW, Bruemmer J, Simoons ML, for the CAPTURE investigators (2000) Predictive value of C-reactive protein and troponin T in patients with unstable angina: a comparative analysis. JAMA 35:1535–1542

  47. 47.

    Goodman SG, Fitchett D, Armstrong PW, Tan M, Langer A (2003) Integrilin and Enoxaparin Randomized Assessment of Acute Coronary Syndrome Treatment (INTERACT) Trial Investigators. Randomized evaluation of the safety and efficacy of enoxaparin versus unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes receiving the glycoprotein IIb/IIIa inhibitor eptifibatide. Circulation 107:238–244

  48. 48.

    Cohn PF (1999) Medical treatment of silent myocardial ischemia. Heart Dis 5:272–278

  49. 49.

    Andrews TC, Fenton T, Toyosaki N et al (1993) Subsets of ambulatory myocardial ischemia based on heart rate activity. Circadian distribution and response to anti-ischemic medication. The Angina and Silent Ischemia Study Group (ASIS). Circulation 88:92–100

  50. 50.

    Mehta JL (1994) Emerging options in the management of myocardial ischemia. Am J Cardiol 73:18A–27A

  51. 51.

    Davies RF, Goldberg D, Forman S et al, for the ACIP Investigators (1997) Asymptomatic Cardiac Ischemia Pilot (ACIP) Study two-year followup. Outcomes of patients randomized to initial strategies of medical therapy versus revascularization. Circulation 95:2037–2043

  52. 52.

    Gibbons RJ, Abrams J, Chatterjee K et al (2003) ACC/AHA 2002 guideline update for the management of patients with chronic stable angina – summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation 107:149–158

  53. 53.

    van Boven AJ, Jukema JW, Zwinderman AH, Crijns HJ, Lie KI, Brushcke AV (1996) Reduction of transient myocardial ischemia with pravastatin in addition to the conventional treatment in patients with angina pectoris. REGRESS Study Group. Circulation 94:1503–1505

  54. 54.

    Andrews TC, Raby K, Barry J, et al (1997) Effect of cholesterol reduction on myocardial ischemia in patients with coronary disease. Circulation 95: 324–328

  55. 55.

    Liem AH, van Boven AJ, Veeger NJ, et al (2002) Effect of fluvastatin on ischaemia following acute myocardial infarction: a randomized trial. Eur Heart J 23: 1931–1937

  56. 56.

    Tzivoni D, Gottlieb S, Khurmi NS, Medina A, Gavish A, Stern S (1992) Effect of benazepril on myocardial ischaemia in patients with chronic stable angina pectoris. Eur Heart J 13:1129–1134

  57. 57.

    Kowey PR, Kocovic DZ (2003) Cardiology patient pages. Ambulatory electrocardiographic recording. Circulation 108:e31–33.

  58. 58.

    Maggioni AP, Schweiger C, Tavazzi, Langiano T, Lucci D, Ramponi C, Repetto F, De Vita C (2000) Epidemiologic study of use of resources in patients with unstable angina: the EARISA registry. On behalf of the EARISA Investigators (Epidemiologia dell'Assorbimento di Risorse nell'Ischemia, Scompenso e Angina). Am Heart J 140(2):253–263

  59. 59.

    Braunwald E, Antman EM, Beasley JW et al (2002) ACC/AHA guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction—2002: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 106(14):1893–1900

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Acknowledgements

The PERFUSE Data Coordinating Center has received research grant support from Schering Plough, Bristol Myers Squibb, Sanofi Aventis, Astra Zeneca, Centocor and Johnson and Johnson.

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Correspondence to C. Michael Gibson.

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Gibson, C.M., Ciaglo, L.N., Southard, M.C. et al. Diagnostic and prognostic value of ambulatory ECG (Holter) monitoring in patients with coronary heart disease: a review. J Thromb Thrombolysis 23, 135–145 (2007). https://doi.org/10.1007/s11239-006-9015-6

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Keywords

  • Silent myocardial ischemia
  • Holter monitoring
  • Transient ischemia