Summary
In patients with coronary artery disease, angina pectoris provides an unreliable underestimation of disease activity and risk. Unheralded myocardial infarction and sudden death are common clinical presentations. Furthermore, objective testing, in hospital and more recently during the patient's normal daily activities, has demonstrated frequent and asymptomatic episodes of ischemia, as indicated by transient ST-segment depression. Since the underlying pathophysiologic disturbances of myocardial perfusion appear to be similar in painful and painless episodes, it seems appropriate to consider them together as the “total ischemic burden” on the myocardium. Research into this functional expression of coronary disease has indicated that active ischemia is associated with an increased risk of morbid events in all clinical subgroups of patients, including those with stable angina, unstable angina, peripheral vascular disease and following myocardial infarction. If this is confirmed in prospective trials, the assessment of total ischemic burden is likely to become part of the clinical investigation of patients with coronary disease. Clinical trials testing the efficacy of interventions will need to examine the effect on ischemic activity during normal daily life, in addition to symptoms and exercise tolerance. Evidence is still required to demonstrate whether therapy aimed at reducing the total ischemic burden will prolong life. The total ischemic burden provides a marker to follow the dynamic changes of the atherosclerotic lesion. Future research may have to concentrate on treatment aimed at altering the natural history of obstructive coronary atherosclerosis in order to affect the long-term outlook for patients with coronary artery disease.
Similar content being viewed by others
References
Shang SJJr, Pepine CJ. Transient asymptomatic ST segment depression during daily activity. Am J Cardiol 1977;39:396–402.
Stern S, Tzivoni D Early detection of silent ischaemic heart disease by 24 hour electrocardiographic monitoring of active subjects. Br Heart J 1974;36:481–486.
Selwyn AP, Deanfield JE, Shea M, et al. Differences in pathophysiology between painful and silent transient myocardial ischemia in coronary artery diseases. Br Heart J In press.
Cohn PF. Prognostic significance of asymptomatic coronary artery disease. Am J Cardiol 1986;58:51B-56B.
Kannel WB, Abbot RD. Incidence and prognosis of unrecognized myocardial infarction: An update on the Framingham study. N Engl J Med 1984;311:1144–1147.
Sharma B, Asinger R, Francis GS, et al. Demonstration of exercise-induced painless myocardial ischemia in survivors of out-of-hospital ventricular fibrillation. Am J Cardiol 1987;59:740–745.
Bruce RA, Hossack KF, DeRouen TA, et al. Enhanced risk assessment for primary coronary heart disease events by maximal exercise testing: Ten years' experience of Seattle Heart Watch. J Am Coll Cardiol 1983;2:565–573.
Weiner DA, Ryan TJ, McCabe CH, et al. Significance of silent myocardial ischemia during exercise testing in patients with coronary artery disease. Am J Cardiol 1987;59:725–729.
Bragg-Remschel DA, Anderson CM, Winkle RA. Frequency response characteristics of ambulatory ECG monitoring systems and their implications for ST segment analysis. Am Heart J 1982;103:20–31.
Armstrong WF, Jordan JW, Morris SN, et al. Prevalence and magnitude of S-T segment and T wave abnormalities in normal men during continuous ambulatory electrocardiography. Am J Cardiol 1982;49:1638–1642.
Quyyumi AA, Wright C, Fox K. Ambulatory electrocardiographic ST segment changes in healthy volunteers. Br Heart J 1983;50:460–464.
Deanfield JE, Ribiero P, Oakley C, et al. Analysis of ST segment changes in normal subjects: Implications for ambulatory monitoring in angina pectoris. Am J Cardiol 1984;54:1321–1325.
Deanfield JE, Shea M, Ribiero P, et al. Transient ST segment depression as a marker of myocardial ischemia during daily life. Am J Cardiol 1984;54:1195–1200.
Levy RD, Shapiro LM, Wright C, et al. The haemodynamic significance of asymptomatic ST segment depression assessed by ambulatory pulmonary artery pressure monitoring. Br Heart J 1986;56:526–530.
Deanfield JE, Maseri A, Selwyn AP, et al. Myocardial ischaemia during daily life in patients with stable angina: Its relation to symptoms and heart rate changes. Lancet 1983;2:753–758.
Gottlieb SO, Weisfeldt ML, Ouyang P, et al. Silent ischemia as a marker for early unfavorable outcomes in patients with unstable angina. N Engl J Med 1986;314:1214–1219.
Nesto RW, Phillips RT. Asymptomatic myocardial ischemia in diabetic patients. Am J Med 1986:80(Suppl C):40–47.
Tzivoni D, Gavish A, Zin D, et al. Prognostic significance of ichemic episodes in patients with previous myocardial infarction. Am J Cardiol 1988;62:661–664.
Campbell S, Barry J, Rebecca GS, et al. Active transient myocordial ischaemia during daily life in asymptomatic patients with positive exercise tests and coronary artery disease. Am J Cardiol 1986;57:1016–1026.
Selwyn AP, Allan RM, L'Abbate A, et al. Relation between myocardial uptake of rubidium82 and perfusion: Absolute reduction of cation uptake in ischemia. Am J Cardiol 1982;50:112–121.
Chierchia S, Gallino A, Smith G, et al. Role of heart rate in pathophysiology of chronic stable angina. Lancet 1984; 1:1353–1357.
Deanfield JE, Shea M, Kensett M, et al. Silent myocardial ischemia due to mental stress. Lancet 1984;2:1001–1005.
Deanfield JE, Wright C, Krikler S, et al. Cigarette smoking and the treatment of angina with propranolol, atenolol and nifedipine. N Engl J Med 1984;310:951–954.
Furchgott RF and Zawadzki JV. The obligatory role of endothelial cells in the relaxation of arterial smooth muscle by acetylcholine. Nature 1980:288;373–376.
Ludmer PL, Selwyn AP, Shook TL, et al. Paradoxical vasoconstriction induced by acetylcholine in atherosclerotic coronary arteries. N Engl J Med 1986;315:1046–1051.
Gage JE, Hess OM, Murakami T, et al. Vasoconstriction of stenotic coronary arteries during dynamic exercise in patients with classic angina pectoris. Reversibility by nitroglycerin. Circulation 1986;73:865–876.
Nabel EG, Ganz P, Gordon JB et al. Dilation of normal and constriction of atherosclerotic coronary arteries caused by the cold pressor test. Circulation 1988;77:43–52.
Gordon JB, Ganz P, Nabel EG, et al. Endothelial function influences the coronary vasomotor response to exercise (abstract). Circulation 1987;76:IV238.
Campbell S, Barry J, Rocco MB, et al. Features of the exercise test that reflect the activity of ischemic heart disease out of hospital. Circulation 1986;74:72–80.
Mulcahy D, Keegan J, Cunningham D, et al. Circadian variation in total ischemic burden and its alteration with anti-ischemic agents. Lancet 1988;2:755–759.
Muller JE, Ludmer PL, Willich SN, et al. Circadian variation in the frequency of sudden death. Circulation 1987;75:131–138.
Muller JE, Stone PH, Turzi ZG, et al. Circadian variation in the frequency of onset of acute myocardial infarction. N Engl J Med 1985;313:1315–1322.
Gottlieb SO, Weisfeldt ML, Ouyang P, et al. Silent ischemia predicts infarction and death during 2 year follow-up of unstable angina. J Am Coll Cardiol 1987;10:756–760.
Nadamanee K, Intarachot V, Josephson MA, et al. Prognostic significance of silent myocardial ischemia in patients with unstable angina. J Am Coll Cardiol 1987;10:1–9.
Rocco M, Nabel E, Campbell C, et al. Prognostic importance of myocardial ischemia detected by ambulatory monitoring in patients with stable coronary artery disease. Circulation 1988;78:877–884.
Raby KE, Goldman L, Creager MA, et al. Correlation between preoperative ischemia and major cardiac events after peripheral vascular surgery. N Engl J Med 1989;321:1296.
Deedwania P, Carbajal E, Nelson J, Linn L. Silent ischemia during daily life is an independent predictor of survival in stable angina (abstract) J Am Coll Cardiol 1989;13:3A.
Deanfield JE, Spiegelhalter D. Variability of myocardial ischemia in chronic stable angina. In: vonArnim T, Maseri A, eds, Silent ischemia. Current concepts and manaement. Darmstadt: Steinkopff, 1987:203–207.
Nabel EG, Barry J, Rocco MB, et al. Variability of transient myocardial ischemia in ambulatory patients with coronary artery disease. Circulation 1988;78:60–67.
Quyyumi AA, Mockus L, Wright C, et al. Morphology of ambulatory ST segment changes in patients with varying severity of coronary artery disease. Investigation of the frequency of nocturnal ischemia and coronary spasm.
Lynch P, Dargie H, Krikler S, Krikler D. Objective assessment of anti-anginal treatment: A double blind comparison of propranolol, nifedipine and their combination. Br Med J 1980;281:184–187.
Ribiero P, Shea M, Deanfield JE, et al. Different mechanisms for the relief of angina after eoronary bypass surgery: Physiological versus anatomical assessment. Br Heart J 1984;52:502–509.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Deanfield, J.E. Total ischemic burden in patients with coronary artery disease. Cardiovasc Drug Ther 4 (Suppl 4), 833–839 (1990). https://doi.org/10.1007/BF00051289
Issue Date:
DOI: https://doi.org/10.1007/BF00051289