Related Experiment Videos
Silent myocardial ischemia
S Stern1, P F Cohn, C J Pepine
1Hebrew University, Department of Cardiology Bikur Cholim Hospital, Jerusalem, Israel.
Insights
Detecting myocardial ischemia, symptomatic or silent, is crucial for assessing adverse outcome risk. Objective testing for ischemia guides treatment intensity, not just pain presence, for better cardiovascular disease management.
Area of Science:
- Cardiology
- Diagnostic Testing
- Risk Stratification
Background:
- Abnormalities related to myocardial ischemia, whether symptomatic or silent, are critical for patient risk assessment.
- Treatment decisions for coronary artery disease (CAD) should prioritize risk implications from objective ischemia testing over mere symptom presence.
Purpose of the Study:
- To emphasize the importance of objective testing in identifying and managing myocardial ischemia.
- To guide therapeutic strategies based on detected ischemia, irrespective of symptoms, for improved patient outcomes.
Main Methods:
- Utilizing exercise stress tests to evaluate patients with analyzable ST segments.
- Employing Holter monitoring for detecting asymptomatic ischemia during daily activities.
- Leveraging left ventricular imaging techniques (e.g., echocardiography, angiography) to assess cardiac function and wall motion.
Main Results:
- Ischemic-type ST-segment depression detected during stress testing at low workload or prolonged duration indicates high risk.
- Asymptomatic ischemia identified by Holter monitoring in high-risk patients may confer additional risk.
- Abnormal findings from left ventricular imaging, such as reduced ejection fraction or reversible wall motion abnormalities, also signify high risk.
Conclusions:
- Objective detection of ischemia, symptomatic or silent, mandates a high level of concern and guides treatment intensity.
- Therapy should aim to eliminate transient ischemia, not solely alleviate symptoms.
- Risk factor modification and aspirin are recommended for suspected or detected ischemia; medical therapy or revascularization should be considered for high-risk signals, even in asymptomatic individuals.
Abstract:
The documentation of abnormalities related to myocardial ischemia, whether symptomatic or silent, is of central importance. Whenever this information is available, it should be used in the overall assessment of the patient at risk for adverse outcome. The level of concern for treatment of CAD should be based on the risk implications associated with the ischemia-related abnormalities detected during objective testing rather than on the presence or absence of pain. The exercise stress test is still the single most useful test to begin the evaluation of a patient with an analyzable ST segment. In persons suspected of having CAD, the detection of ischemic-type ST-segment depression, at a low workload (e.g., < 120 beats/min or < 6.5 METS) of > 2 mm magnitude or persisting for more than 6 min implies high risk for adverse outcome. Asymptomatic ischemia during everyday activities, detected by Holter monitoring, in the high-risk patient, most probably adds additional risk beyond the risk of an abnormal stress test alone. Left ventricular imaging by two-dimensional echocardiography, RNA, angiogram, vest, etc, showing an ejection fraction > or = 40%, reversible wall motion abnormalities in multiple regions and redistribution defects or a failure to increase ejection fraction during exercise even if the patient remains asymptomatic, also imply high risk. The presence of any of these abnormal findings, regardless of symptoms, should therefore prompt as high a degree of concern as with ischemia-related signals associated with pain. Thus any therapy chosen should be directed toward elimination of transient ischemia, not just relief of symptoms that may or may not be ischemia related. If this course is chosen, the efficacy of the therapeutic regimen and possible progression of CAD should be assessed with follow-up testing for ischemia. We believe that risk factor modification and aspirin should be considered for most, if not all, patients in whom ischemia, silent or symptomatic, is suspected or detected. If symptoms or ischemia suggesting low risk is present, anti-ischemic medical therapy may be considered, but follow-up is advised. If a high-risk ischemic signal, even without symptoms, is detected, medical therapy should be used to attempt to modify the signal. If the ischemic signal suggesting high risk persists despite medical therapy, revascularization should be considered. Until additional data from large clinical trials are available, this approach appears to have the greatest likelihood of modifying the adverse outcome of CAD.