Longitudinal (Natural History) Studies of Silent Myocardial Ischemia

  • J. Thomas BiggerJr.
  • The MSSMI Investigators
Part of the Developments in Cardiovascular Medicine book series (DICM, volume 88)


It is known that about 25% of myocardial infarctions occur without associated pain (1). Recent reports of unsuspected, frequent and prolonged episodes of asymptomatic ST depression (ASTD) during Holter recordings made in patients with clinical angina pectoris and positive exercise tests have raised important issues for the evaluation and treatment of coronary disease. The traditional role of angina as the best indicator of myocardial ischemia may have to be reevaluated, since several studies have shown that ASTD occurs more frequently than symptomatic ischemia in many patients with coronary disease (2–11). Atrial pacing in patients with angina pectoris shows that angina is a relatively late event during myocardial ischemia (12). If ASTD reflects clinically meaningful ischemia, then overt angina represents only 25% of the total ischemic burden. Moreover, incomplete data suggest than an increased and clinically unsuspected risk may be conferred on patients who have frequent episodes of ASTD (13,14).


Coronary Artery Bypass Graft Silent Myocardial Ischemia Ischemic Episode Reversible Perfusion Defect Silent Ischemia 
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  1. 1.
    Kannel WB, Abbott RD. Incidence and prognosis of unrecognized myocardial infarction. N Engl J Med 1984; 311:1144–1147.PubMedCrossRefGoogle Scholar
  2. 2.
    Nesto RW, Phillips RT. Asymptomatic myocardial ischemia in diabetic patients. Am J Med 1986; 80(Supp 4C):40–47.PubMedCrossRefGoogle Scholar
  3. 3.
    Cecchi AC, Dovellini E, Marchi F, Pucci P, Santoro G, Fazzini F. Silent myocardial ischemia during ambulatory electrocardiographic monitoring in patients with effort angina. J AM Coll Cardiol 1983; 1:934–939.PubMedCrossRefGoogle Scholar
  4. 4.
    Stern S, Tzivoni D. Early detection of silent ischaemic heart disease by 24-hour electrocar- diographic monitoring of active subjects. Br Heart J 1974; 36:481–486.PubMedCrossRefGoogle Scholar
  5. 5.
    Schang SJ, Pepine CJ. Transient asymptomatic S-T segment depression during daily activity. Am J Cardiol 1977; 39:396–402.PubMedCrossRefGoogle Scholar
  6. 6.
    Cohn PF. Silent myocardial ischemia: to treat or not to treat? Hosp Pract 1983; 125–138.Google Scholar
  7. 7.
    Deanfield JE, Selwyn AP, Chierchia S, Maseri A, Ribiero P, Krikler D. Myocardial ischemia during daily life in patients with stable angina; its relation to heart rate changes. Lancet 1983; 753–758.Google Scholar
  8. 8.
    Chierchia S, Lazzari M, Freedman B, Burnelli C, Maseri A. Impairment of myocardial perfusion and function during painless myocardial ischemia. J Am Coll Cardiol 1983; 1:924–930.PubMedCrossRefGoogle Scholar
  9. 9.
    Deanfield JE, Shea M, Ribiero P, Landsheere C, Wilson R, Horlock P, Selwyn A. Transient ST-segment depression as a marker of myocardial ischemia during daily life. Am J Cardiol 1984; 54:1195–1200.PubMedCrossRefGoogle Scholar
  10. 10.
    Biagini A, Mazzei MG, Carpeggiani C, Testa R, Antonelli R, Michelassi C, L’Abbate A, Maseri A. Vasospastic ischemic mechanism of frequent asymptomatic transient ST-T changes during continuous electrocardiographic monitoring in selected unstable patients. Am Heart J 1982; 103:13–20.PubMedCrossRefGoogle Scholar
  11. 11.
    Deanfield JE, Ribiero P, Oakley K, Krikler D, Selwyn A. Analysis of ST-segment changes in normal subjects: implications for ambulatory monitoring in angina pectoris. Am J Cardiol 1984; 54:1321–1325.PubMedCrossRefGoogle Scholar
  12. 12.
    Parker JO, Chiong MA, West RO, Case RB. Sequential alterations in myocardial lactate metabolism, S-T segments, and left ventricular function during pacing induced angina. Circulation 1969; 40:113–131.PubMedGoogle Scholar
  13. 13.
    Johnson SM, Mauritson DR, Winniford MD, Willerson J, Firth B, Cary J, Hillis D. Continuous electrocardiographic monitoring in patients with unstable angina pectoris; identification of high-risk subgroup with severe coronary disease, variant angina, and/or impaired early prognosis. Am Heart J 1982; 103:4–12.PubMedCrossRefGoogle Scholar
  14. 14.
    Gottlieb SO, Weisfeldt ML, Ouyang P, Mellits D, Gerstenblith G. Silent ischemia as a marker for early unfavorable outcomes in patients with unstable angina. N Engl J Med 1986; 314:12141219.Google Scholar
  15. 15.
    Tzivoni D, Benhorin J, Gavish A, Stern S. Holter recordings during treadmill testing in assessing myocardial ischemic changes. Am J Cardiol 1985; 55:1200–1203.PubMedCrossRefGoogle Scholar
  16. 16.
    Rose GA, Blackburn H. Cardiovascular Survey Methods, World Health Organization, Genva, 1968.Google Scholar
  17. 17.
    Greenberg HM, Gillespie J, Dwyer EM Jr, The Multicenter Post-Infarction Research Group. A new electrocardiographic classification for post-myocardial infarction clinical trials. Am J Cardiol 1987; 59:1057–1063.PubMedCrossRefGoogle Scholar
  18. 18.
    Wackers F, Fetterman RC, Mattera JA, Clements JP. Quantitative planar thallium-201 stress scintigraphy: a critical evaluation of the method. J Nuc Med 1985; 15:46–66.Google Scholar
  19. 19.
    Bodenheimer MM, Banka VS, Fooshee C, Hermann GA, Heifant RH. Relationship between regional myocardial perfusion and the presence, severity and reversibility of asynergy in patients with coronary heart disease. Circulation 1978; 5:789.Google Scholar
  20. 20.
    Madeira SW Jr, Bodenheimer MM, Banka VS, Agarwal JB, Weintraub WS, Heifant RH. Quantitative thallium-201 imaging: limitations in detecting pathophysiologically significant obstructive coronary artery disease. Am Heart J 1984; 108:1448–1454.PubMedCrossRefGoogle Scholar
  21. 21.
    McCarthy DM, Makler PT Jr. Potential limitations of quantitative thallium scanning. Am J Cardiol 1985; 55:215–217.PubMedCrossRefGoogle Scholar
  22. 22.
    Kaul S, Boucher CA, Newell JB, Chesler DA, Greenberg JM, Okada RD, Strauss HM, Dinsmore RE, Pohost GM. Determination of the quantitative thallium imaging variables that optimize detection of coronary artery disease. J Am Coll Cardiol 1986; 7:527–537.PubMedCrossRefGoogle Scholar
  23. 23.
    Hinkle L, Thaler HT. Clinical classification of cardiac death. Circulation 1982; 65:457–461.PubMedCrossRefGoogle Scholar
  24. 24.
    Cox DR. Regression models and life-tables. J Stat Soc (B) 1972; 34:187–220.Google Scholar
  25. 25.
    Fleiss JL. Statistical methods for rates and proportions. 2nd ed. New York, John Wiley, 1981; 138–143.Google Scholar
  26. 26.
    Gibson R, Watson D, Craddock G, Crampton R, Kaiser D, Denny M, Beller G. Prediction of cardiac events aftr uncomplicated myocardial infarction: a prospective study comparing predischarge exercise thallium-201 scintigraphy and coronary angiography. Circulation 1983; 68:321–336.PubMedCrossRefGoogle Scholar

Copyright information

© Kluwer Academic Publishers, Boston 1988

Authors and Affiliations

  • J. Thomas BiggerJr.
    • 1
    • 2
  • The MSSMI Investigators
    • 1
    • 2
  1. 1.Department of MedicineColumbia UniversityNew YorkUSA
  2. 2.The Arrhythmia Control UnitColumbia-Presbyterian Medical CenterNew YorkUSA

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