Incidence and prognostic significance of silent myocardial ischemia in patients after acute myocardial infarction



The incidence and prognostic significance of silent myocardial ischemia in 175 patients who survived a first acute myocardial infarction (AMI) were assessed by means of maximal exercise stress test and 24 hour continuous ECG monitoring performed before discharge. Thirteen patients showed silent ischemia with both techniques, 31 only with stress test, 5 only with ECG monitoring and 8 had a doubtful stress test but showed S-T segment depression during ECG monitoring, 118 were free from ischemia. Ten cardiac deaths and 31 coronary events including unstable angina, by-pass operation, and myocardial infarction occured during the one year follow-up period. S-T segment depression during ECG monitoring showed a lower sensitivity but a higher specificity and predictive accuracy for cardiac death and coronary events than did exercise stress test. When S-T segment depression is detected in the same patient with both techniques the sensitivity is lower and specificity higher. Whenever the presence of S-T segment depression is recorded, it shows a good sensitivity without significantly decreasing the specificity. Classifying patients according to the occurence of S-T segment depression on exercise test and/or ECG ambulatory monitoring, the Yates corrected chi-square test showed a significant pattern when cardiac deaths and coronary events are considered together (p< 0.01). However, the incidence of cardiac deaths and coronary events was comparable in patients with exercise S-T segment depression regardless of the occurence of S-T segment changes during continuous ECG monitoring. All 8 patients who stopped the exercise test before reaching target heart rate for dyspnea (5 patients), arrhythmias (2 patients), and hypertensive response (1 patient) had S-T segment depression during ECG monitoring: 2 of them died during follow-up and 3 suffered from unstable angina. Thus, ECG monitoring of these patients adds same helpful information but is less useful in patients who perform a maximal exercise stress test.


Acute Myocardial Infarction Cardiac Death Unstable Angina Coronary Event Silent Myocardial Ischemia 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Stern, S. and Tzivoni, D. (1974) “Early detection of silent ischemic heart disease by 24-hour electrocardiographic monitoring of active subjects”, Br Heart J, 36, 481–490.CrossRefPubMedGoogle Scholar
  2. 2.
    Langou, R.A., Huang, E.K., Kelly, M.J., Cohen, L.S. (1980) “Predictive accuracy of coronary artery calcification and abnormal exercise test for coronary artery disease in asymptomatic men”, Circulation, 62, 1196–1203.PubMedGoogle Scholar
  3. 3.
    Deanfield, J.E., Selwyn, A.P., Chierchia, S., et al. (1983) “Myocardial ischemia during daily life in patients with stable angina: its relation to symptoms and heart rate changes”, Lancet, 2, 753–758.CrossRefPubMedGoogle Scholar
  4. 4.
    Deanfield, J.E., Shea, M., Ribeiro, P., de Landsheere, C.M., Horlock, P., Selwyn, P.A. (1984) “Transient ST-segment depression as a marker of myocardial ischemia during daily life”, Am J Cardiol, 54, 1195–1200.CrossRefPubMedGoogle Scholar
  5. 5.
    Cecci, A.C., Dovellini, E.V., Marchi, F., Pucci, P., Santoro, C.M., Fazzini, P.F. (1983) “Silent myocardial ischemia during ambulatory electrocardiophic monitoring in patients with effort angina”, J Am Coll Cardiol, 1, 934–939.CrossRefGoogle Scholar
  6. 6.
    Selwyin, A.P., Fox, K., Eves, M., Oakley, D., Dargie, H.J., Shillingford, J.P. (1978) “Myocardial ischaemia in patients with frequent angina pectoris”, Br Med J, 2, 1594–1596.CrossRefGoogle Scholar
  7. 7.
    Cohn, P.F. (1988) “Silent myocardial ischemia”, Ann Intern Med, 109, 312–317.PubMedGoogle Scholar
  8. 8.
    Figueras, J., Singh, B.N., Ganz, W., Charuzi, Y., Swan, II.J.C. (1979) “Mechanism of rest and nocturnal angina: observations during continuous hemodynamic and electrocardiographic monitoring”, Circulation, 59, 955–962.PubMedGoogle Scholar
  9. 9.
    Muleahy, D., Keegan, J., Cunningham, D., et al. (1988) “Circadian variations of total ischaemic burden and its alteration with anti-anginal agents”, Lancet, II, 755–759.CrossRefGoogle Scholar
  10. 10.
    Singh, B.H., Nademanee, K., Figueras, J., Josephson, M.A. (1986) “Hemodynamic and electrocardiographic correlates jf symptomatic and silent myocardial ischemia: pathophysiologic and therapeutic implications”, Am J Cardiol, 58, 3E–10B.CrossRefGoogle Scholar
  11. 11.
    Mody Vaghaiwalla, F., Nademanee, K., Intarachot, V., Josephson, M.A., Robertson, H.A., Singh, B.N. (1988) “Severity of silent myocardial ischemia on ambulatory electrocardiographic monitoring in patients with stable angina pectoris: relation tc prognostic determinants during exercise stress testing and coronary angiography”, J Am Coll Cardiol, 12, 1169–1176.CrossRefGoogle Scholar
  12. 12.
    Nademanee, K., Intarachot, V., Josephson, M.A., Rieders, D., Mody Vaghaiwalla, F., Singh, B.N. (1987) “Prognostic significance of silent myocardial ischemia in patients with unstable angina”, J Am Coll Cardiol, 10, 1–9.CrossRefPubMedGoogle Scholar
  13. 13.
    Fioretti, P., Brower, R.W., Simoons, M.L., et al. (1985) “Prediction of mortality during the first year after acute myocardial infarction from clinical variables and stress test at hospital discharge”, Am J Cardiol, 55, 1313–1318.CrossRefPubMedGoogle Scholar
  14. 14.
    De Busk, R.F., Kraemer, H.C., Nash, E., Berger, W.E., Lew, H. (1983) “Stepwise risk stratification soon after acute myocardial infarction”, Am J Cardiol, 52, 1161–1166.CrossRefGoogle Scholar
  15. 15.
    Starling, M.R., Crawford, M.H., Kennedy, G.T., O’Rourke, R.A. (1980) “Exercise testing early after myocardial infarction: predictive value for subsequent unstable angina and death”, Am J Cardiol, 46, 909–914.CrossRefPubMedGoogle Scholar
  16. 16.
    Leppo, J.A., O’Brien, J., Rothendler, J.A., Getchell, J.D., Lee, V.W. (1984) “Dipyridamole thallium-201 scintigraphy in the prediction of future cardiac events after acute myocardial infarction”, N Engl J Med, 301, 1014–1018.CrossRefGoogle Scholar
  17. 17.
    Corbett, J.R., Nicod, P., Lewis, S.E., Rude, R.E., Willerson, J.T. (1983) “Prognostic value of submaximal exercise radionuclide ventriculography after myocardial inafrction”, Am J Cardiol, 52, 82A–91A.CrossRefPubMedGoogle Scholar
  18. 18.
    Hakki, A.H., Nestico, P.F., Jleo, J., Unwala, A.A., Iskandrian, A.S. (1987) “Relative prognostic value of rest thallium-201 imaging, radionuclide ventriculography and 24-hour ambulatory electrocardiographic monitoring after acute myocardial infarction”, J Am Coll Cardiol, 10, 25–32.CrossRefPubMedGoogle Scholar
  19. 19.
    Miller, D.H. and Borer, J.S. (1982) “Exercise testing early after myocardial infarction. Risks and benefits”, Am J Med, 72, 427–438.CrossRefPubMedGoogle Scholar
  20. 20.
    Gottlieb, S.O., Weisfeldt, M.L., Ouyang, P., Mellits, E.D., Gerstenblith, G. (1986) “Silent ischemia as a marker for early unfavorable outcomes in patients with unstable angina”, N Engl J Med, 314, 1214–1219.CrossRefPubMedGoogle Scholar
  21. 21.
    Rocco, M.B., Barry, J., Campbell, S., et al. (1987) “Circadian variation of transient myocardial ischemia in patients with coronary artery disease”, Circulation, 75, 395–400.CrossRefPubMedGoogle Scholar
  22. 22.
    Nademanee, K., Intarachot, V., Josephson, M.A., Singh, B.N. (1987) “Circadian variation occurrence of transient overt and silent myocardial ischemia in chronic stable angina and comparison with Prinzmetal angina in men”, Am J Cardiol, 60, 494–499.CrossRefPubMedGoogle Scholar
  23. 23.
    Deanfield, J.E., Shea, M., Kensett, M., et al. (1984) “Silent myocardial ischemia due to mental stress”, Lancet, II, 1001–1005.CrossRefGoogle Scholar

Copyright information

© Kluwer Academic Publishers 1990

Authors and Affiliations

  1. 1.Institute of Internal MedicineSecond School of MedicineNaplesItaly

Personalised recommendations