Long term outcome in patients with silent versus symptomatic ischaemia during dobutamine stress echocardiography

Abstract

Objectives: To compare the long term prognosis of patients having silent versus symptomatic ischaemia during dobutamine stress echocardiography (DSE). Design: Observational study. Setting: Tertiary referral centre. Patients: 931 patients who experienced stress induced myocardial ischaemia during DSE. Results: Silent ischaemia was present in 643 of 931 patients (69%). The number of dysfunctional segments at rest (mean (SD) 9.6 (5.1) v 8.8 (5.0), p = 0.1) and of ischaemic segments (3.5 (2.2) v 3.8 (2.1), p = 0.2) was comparable in both groups. During a mean (SD) follow up of 5.5 (3.3) years, there were 169 (18%) cardiac deaths and 86 (9%) non-fatal infarctions. Multivariable Cox regression analysis showed age (hazard ratio (HR) 1.1, 95% confidence interval (CI) 1.02 to 1.05), previous myocardial infarction (HR 1.4, 95% CI 1.1 to 2.0), and number of ischaemic segments during the test (HR 2.0, 95% CI 1.0 to 3.7) as independent predictors of cardiac death and myocardial infarction. For every additional ischaemic segment there was a twofold increment in risk of late cardiac events. The annual cardiac death or myocardial infarction rate was 3.0% in patients with symptomatic ischaemia and 4.6% in patients with silent ischaemia (p , 0.01). Silent induced ischaemia was an independent predictor of cardiac death and myocardial infarction (HR 1.7, 95% CI 1.1 to 2.0). During follow up symptomatic patients were treated more often with cardioprotective therapy (p , 0.01) and coronary revascularisation (145 of 288 (50%) v 174 of 643 (27%), p , 0.001). Conclusions: Patients with silent ischaemia had a similar extent of myocardial ischaemia during DSE compared to patients with symptomatic ischaemia but received less cardioprotective treatment and coronary revascularisation and experienced a higher cardiac event rate.A lthough angina pectoris is one of the cardinal manifestations of myocardial ischaemia, many patients have ischaemia during stress testing without associated symptoms.1-3 Studies of stress induced silent ischaemia reported discordant results with respect to the extent of ischaemia. Some studies reported a similar extent of ischaemia in patients with and without angina, 4-10 whereas others reported more extensive ischaemia in the presence of angina. 11-16Dobutamine-atropine stress echocardiography (DSE) is commonly used to assess the extent, location, and severity of coronary artery disease.17 18 The diagnosis of myocardial ischaemia during DSE is based on the detection of new or worsening wall motion abnormalities. The extent of these abnormalities is a powerful predictor of adverse outcome. 19 20 A large number of studies have reported discordant data regarding the prognostic importance of stress induced silent ischaemia, the likelihood of future coronary events related to the amount of ischaemic myocardium, and the influence of medical treatment or revascularisation techniques on the outcome of silent stress induced ischaemia. Accordingly, the objective of this study was to compare the long term prognosis of sile...

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