Detection and Significance of Myocardial Ischemia in Stable Patients After Recovery From an Acute Coronary Event

Moss, Arthur J.; Goldstein, Robert E.; Hall, William J.; Bigger, J. Thomas; Fleiss, Joseph L.; Greenberg, Henry; Bodenheimer, Monty M.; Krone, Ronald J.; Marcus, Frank I.; Wackers, Frans J. Th.; Benhorin, Jesaia; Brown, Mary W.; Case, R. A. M.; Coromilas, James; Dwyer, Edward M.; Gillespie, John A.; Gregory, John J.; Kleiger, Robert E.; Lichstein, Edgar; Parker, John O.; Raubertas, Richard F.; Stern, Shlomo; Tzivoni, Dan; Voorhees, Lucy Van; Krasicky, G.; Shah, Ronak; Walroth, J.; Greengart, Alvin; Moriel, Mady; Challis, T.; Blood, David K.; Rolnitzky, Linda; DePuey, Gordon; Kuller, Lewis H.; Odoroff, Charles L.; Schwartz, Ronald G.; Annechiarico, Robert; Andrews, Mark; Severski, Patricia K.; Ma, Grigorian; Edwards, John S.; Fischer, Krisztina; Freedland, Kenneth E.; Cobb, Leonard A.; Korsten, J.; Williams, William L.; Algeo, S.; Chandysson, P.

doi:10.1001/jama.1993.03500180071037

Cited by 96 publications

(10 citation statements)

References 44 publications

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“…Mortality rate (1-2%) and incidence of non-fatal reinfarction (2-9%) were similar to those reported by previous large studies in low-risk populations of postinfarction patients' 32 '. In keeping with the results of previous studies' 9 " 11 ' 33 ', we found that stress-induced ischaemia was not associated with increased incidence of spontaneous events. Indeed, the link between residual ischaemia and reinfarction is known to be elusive, since an important proportion of myocardial infarctions occur as a consequence of the abrupt development of coronary occlusions from preexisting mildly stenotic plaques without ischaemic potential' 34 ' 35 '.…”

Section: Discussionsupporting

confidence: 92%

Prognostic value of residual ischaemia assessed by exercise electrocardiography and dobutamine stress echocardiography in low-risk patients following acute myocardial infarction

Bigi

Galati

Curti

et al. 1997

European Heart Journal

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Background Risk stratification after uncomplicated myocardial infarction is a major clinical problem. In particular, the prognostic value of residual inducible ischaemia is still controversial. We compared the relative prognostic value of exercise ECG and dobutamine stress echocardiography performed in the early post-infarction period.Methods Four hundred and six patients (53 female) aged 57 ± 9 years, undergoing maximal exercise ECG and dobutamine stress echocardiography within 10 days of an uncomplicated myocardial infarction off therapy, were prospectively followed-up for 8-8 months. Age, sex, diabetes, smoking habit, hypertension, dyslipidaemia, infarct location, thrombolysis and resting wall motion score index were taken into account among clinical variables. Prognostic correlations were made vs spontaneous events (cardiac death, non-fatal reinfarction and unstable angina requiring hospitalization) whilst patients undergoing revascularization (by means of percutaneous transluminal coronary angioplasty or coronary artery bypass surgery) at the time of the procedure were censored.Results One hundred and twenty-seven events occurred during the follow-up: 41 (10%) were spontaneous (five deaths, 12 reinfarctions and 24 unstable angina) and 86 procedural (27 angioplasty and 59 bypass surgery). Spontaneous events were not predicted by any clinical, exercise ECG or dobutamine stress echocardiography variable, but the negative predictive value of both tests was excellent (91% and 90%, respectively). With a multivariate Cox analysis, male gender, positive low-workload (<100W) exercise ECG (/><00001), positive low-dose dobutamine stress echocardiography (P<00001) and reststress wall motion score index variation (P<0001) were found to predict cumulative cardiac events with an independent and additive value. Dobutamine stress echocardiography was significantly more sensitive (P<005) and less specific (P<001) in predicting the outcome of patients with anterior infarction, whilst exercise ECG was significantly more sensitive (P<005) in patients with non-Q wave infarction. Conclusions(1) Spontaneous events are poorly predicted by provocative tests in low-risk patients after uncomplicated myocardial infarction. (2) However, both exercise ECG and dobutamine stress echocardiography can predict a favourable outcome with a very high negative predictive value. (3) Dobutamine stress echocardiography should be considered a secondary option in cases where the exercise ECG is equivocal or when the location of ischaemia is a relevant issue. (4) The possibility that the two tests have a differential utility depending on the infarct location and type (Q wave vs non-Q wave) may be clinically relevant and deserves further evaluation.

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Section: Discussionsupporting

confidence: 92%

Prognostic value of residual ischaemia assessed by exercise electrocardiography and dobutamine stress echocardiography in low-risk patients following acute myocardial infarction

Bigi

Galati

Curti

et al. 1997

European Heart Journal

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“…[67][68][69][70][71] Also, although one small study found the presence of ambulatory ischemia after coronary artery bypass graft surgery to be associated with a significant excess of adverse clinical events, 72 this finding was disproved by further larger studies. 73,74 The problem of small size, which plagued earlier investigations, was resolved with the publication during the 1990s of a number of studies [75][76][77][78][79][80] of sufficient magnitude and statistical power (300 to 1000 patients followed up over 1 to 3 years) to answer with confidence the question of the importance of silent ischemia on ambulatory monitoring. The largest of these studies was the Multicenter Study of Myocardial Ischemia (MSMI) study 75 (nϭ943), which demonstrated no significant increase in primary cardiac events associated with ambulatory ischemia in stable patients Ͼ1 month (1 to 6 months) after MI or unstable angina.…”

Section: Patients With Anginamentioning

confidence: 99%

“…The impact of silent ischemia on exercise testing in the population with suspected or confirmed coronary disease is a more challenging question. Over the past 30 years, a large number of studies have been conducted on patients with a history of angina, with or without prior MI, 75,87,88 and in patients after MI, 89 which serve to answer just this question. The presence of inducible ECG features of ischemia, either symptomatic or asymptomatic, on exercise testing has been shown to be associated with adverse outcome.…”

Section: Patients Who Have Had MI or Have Anginamentioning

confidence: 99%

“…Patients with an early positive test, whether painful or painless, are consistently more likely to suffer adverse events. 75,88 In patients with profound (painless) ST depression, exercise duration serves as an effective discriminator between high-and lowrisk subgroups. 92 Painful ischemia is associated with signif- icantly greater functional impairment, as evidenced by shorter exercise duration and shorter time to ischemia and more severe and extensive perfusion defects on thallium scintigraphy in some studies.…”

Section: Patients Who Have Had MI or Have Anginamentioning

confidence: 99%

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Silent Myocardial Ischemia

2003

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“…Therefore a significant minority of stable coronary patients will have recurrent transient ischaemic activity despite medications over the long-term. Despite early reports that stable angina patients with such ambulatory (silent) ischaemic episodes were at increased risk of an adverse short and medium term outcome [19,20] , more recent and larger studies of more unselected stable coronary patients have not borne this out [8,[21][22][23] . Furthermore, of those studies which reported an adverse outcome in patients with recurrent ischaemic episodes [19,20] , none reported the gradual development of left ventricular failure in the absence of an acute event in any case.…”

Section: Effects Of Silent Ischaemia In Stable Angina 1345mentioning

confidence: 98%

Long-term (5 year) effects of transient (silent) ischaemia on left ventricular systolic function in stable angina. Clinical and radionuclide study

Mulcahy

Gunning²,

Knight³

et al. 1998

European Heart Journal

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Aims (a) to assess short (1 year) and long-term (5 year) changes in left ventricular ejection fraction in patients with stable coronary disease with or without ECG evidence of transient ischaemia during daily life on routine therapy, and (b) to assess whether patients with recurrent transient ischaemic episodes have a particular propensity to gradual deterioration in left ventricular ejection fraction in the absence of infarction. Methods and ResultsOne hundred and forty eight patients (127 males; mean age 59 years), part of a natural history cohort of 172 patients who had undergone exercise testing, 48 h ambulatory ST monitoring, and resting radionuclide ventriculography at baseline, and who had not suffered any intervening cardiac event, underwent repeat radionuclide ventriculography at 1 year follow-up on identical or very similar medications. Furthermore, 56 patients (50 males; mean age 65 years) of this cohort, who had ischaemia both on exercise testing and ambulatory monitoring at baseline (n=33), or no ischaemia on either test at baseline (n=23), and who had suffered no intervening event, underwent repeat exercise testing, ambulatory monitoring and radionuclide ventriculography at a mean of 61·8 months follow-up. In 38 of these 56 cases, long-term testing mirrored baseline testing in terms of presence or absence of ischaemia (both tests +, n=25; both tests , n=13). At one year there was no change in left ventricular ejection fraction, either for the whole group (n=148; left ventricular ejection fraction 47=11·6% 47·13+11·07%, P=ns) or for subgroups with (n=62; left ventricular ejection fraction 48+12·1%-48·5+10·5%, P=ns) and without (n=86; left ventricular ejection fraction 46·2+10·4%-46·2+11·3%, P=ns) evidence of transient ischaemia at baseline. At 61 months, there was a small fall in mean left ventricular ejection fraction for the total study group (n=56; left ventricular ejection fraction 45·8+9·3%-42·1+8·8%, P<0·05); however, this fall was not significant for those patients with both baseline and 5 year evidence of transient ischaemia (n=25; left ventricular ejection fraction 44·9+8·7%-41·3+7·5%, P=0·056). ConclusionIn medically treated stable coronary patients who do not suffer any intervening cardiac event, recurrent transient (silent) ischaemic episodes do not, in themselves, lead to gradual deterioration in left ventricular systolic function over a 1-5 year period.

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Detection and Significance of Myocardial Ischemia in Stable Patients After Recovery From an Acute Coronary Event

Cited by 96 publications

References 44 publications

Prognostic value of residual ischaemia assessed by exercise electrocardiography and dobutamine stress echocardiography in low-risk patients following acute myocardial infarction

Prognostic value of residual ischaemia assessed by exercise electrocardiography and dobutamine stress echocardiography in low-risk patients following acute myocardial infarction

Silent Myocardial Ischemia

Long-term (5 year) effects of transient (silent) ischaemia on left ventricular systolic function in stable angina. Clinical and radionuclide study

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