Evidence of residual ischaemia: real danger or myth?

The extent and severity of residual myocardial ischaemia are well-known as major determinants of mortality after myocardial infarction, and non-invasive assessment of these parameters still plays a critical role in the management of patients. Most of the published data on this topic derive from observations collected before the widespread use of thrombolysis. The results of large multicentre trials assessing the most appropriate therapies after thrombolysis have shown that the more conservative strategy of reserving catheterization and revascularization for patients with recurrent spontaneous or induced ischaemia may be the best approach. Sophisticated techniques to detect more accurately the residual ischaemic burden after infarction have been suggested that would have a major impact on clinical decision making and on the cost of health care. The relative influence of residual ischaemic on the prognosis after myocardial infarction, however, has recently been questioned. The relative risk associated with residual ischaemia seems to be low compared with other predictors of mortality. The progression of coronary artery disease is variable and highly unpredictable, and this may be a major limitation of our ability to predict further ischaemic events.