Abstract
Until recently, our understanding of coronary artery disease has been dominated by the misconception that myocardial ischemia is an inherently painful phenomenon. In 1772, William Heberden described angina pectoris as a “strangling … most disagreeable sensation in the breast,”1 and later in the 18th century C.H. Parry associated angina with narrowing of the coronary arteries.2 It was not until 1950 that silent ischemia was first described when Paul Wood reported 25% of patients with exertional angina who developed asymptomatic repolarization abnormalities of ischemia during exercise electrocardiography.3 Subsequently, data from the Framingham study has demonstrated that 25 % of myocardial infarctions are clinically silent.4 Stem and Tzivoni in 1974 were the first to demonstrate silent ischemia using ambulatory monitoring in coronary patients during normal daily activities.5 Over the past decade silent ischemia has emerged as an important manifestation of ischemic heart disease, and in this chapter we review the current understanding of the pathophysiology, detection, prognostic significance and treatment of this disorder.
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References
Heberden W. Some account of a disorder of the breast. Med Trans Coll Physicians (Lond.) 1772: 2: 59.
Parry C. An inquiry into the symptoms and causes of the syncope anginosa, commonly called angina pectoris. Bath, England: K. Cuttwell, 1799: vol 3 and 4).
Wood P, et al. The effort test in angina pectoris. Br Heart J 1950: 12: 363.
Kannel W, Abbott R. Incidence and prognosis of unrecognized myocardial infraction: an update on the Framingham study. N Engl J Med 1984: 311: 1144.
Stern S, Tzivoni D. Early detection of silent ischaemic heart disease by 24-hour electrocardiographic monitoring of active subjects. Br Heart J 1974: 36: 481.
Nesto R, Kowalchuk G. The ischemic cascade: Temporal sequence of hemodynamic, electrocardiographic and symptomatic expressions of aschemia. Am J Cardiol 1987: 59: 23C–30C.
Maseri A, et al. Mechanisms and significance of cardiac ischemic pain. Prog cardiovasc Dis 1992: 1.
Hartmann A, et al. Stomatic pain threshold and reactive hyperemia in autonomic diabetic neuropathy and silent myocardial ischemia. Int J Cardiol 1993: 42: 121.
Marchant B, et al. Silent myocardial ischemia: Role of subclinical neuropathy in patients with and without diabetes. J Am Coll Cardiol 1993: 22: 1433.
Hikita H, et al. Usefulness of plasma beta-endorphin level, pain threshold and autonomic function in assessing silent myocardial ischemia in patients with and without diabetes mell-itus. Am J Cardiol 1993: 15: 140.
Shakespeare C, et al. Differences in autonomic nerve function in patients with silent and symptomatic myocardial ischaemia. Br Heart J 1994: 71: 22.
Chipkin S, et al. Frequency of painless myocardial ischemia during exercise tolerance testing in patients with and without diabetes mellitus. Am J Cardiol 1987: 59: 61.
Callahan P, et al. Exrcise-induced silent ischemia: Age, diabetes mellitus, previous myocardial ifarction and prognosis. J Am Coll Cardiol 1989: 14: 1175.
Nesto R, et al. Silent myocardial ischemia and infarction in diabetics with peripheral vascular disease: assessment by dipyridamole thallium-201 scintigraphy. Am Heart J 1990: 120: 1073.
Miller P, et al. Beta-endorphin response to exercise and mental stress in patients with ischemic heart disease. J Psychosom Res 1993: 37: 455.
Falcone C, et al. Beta-endorphins during coronary angioplasty in patients with silent or symptomatic myocardial ischemia. J Am Coll Cardiol 1993: 22: 1614.
Marchant B, et al. Rexamination of the role of endogenous opiates in silent myocardial ischemia. J Am Coll Cardiol 1994: 23: 645.
Davies R, et al. Relative importance of psychological traits and severity of ischemia in causing angina during treadmill exercise. J Am Coll Cardiol 1993: 21: 331.
Glazier J, et al. Importance of generalized defective perception of painful stimuli as a cause of silent myocardial ischemia in chronic stable angina pectoris. Am J Cardiol 1986: 58: 667.
Droste C, Roskamm H. Experimental pain measurement in patients with asymptomatic myocardial ischemia. J Am Coll Cardiol 1983: 1: 940.
Chierchia S, et al. Impairment of myocardial perfusion and function during painless myocardial ischemia. J Am Coll Cardiol 1983: 1: 924.
Deedwania P, Carbajal E. Prevalence and patterns of silent myocardial ischemia during daily life in stable angina patients receiving conventional antianginal drug therapy. J Am Cardiol 1990: 65: 1090.
Kurata C, et al. Exercise-induced silent myocardial ischemia: Evaluation by thallium-201 emission computed tomography. Am Heart J 1990: 119: 557.
Cecchi A, et al. Silent myocardial ischemia during ambulatory electrocardiographic monitoring in patients with effort angina. J Am Coll Cardiol 1983: 1: 934.
Weiner D, et al. The role of exercise-induced silent myocardial ischemia in patients with abnormal left ventricular function. A report from the Coronary Artery Surgery Study (CASS) registry. Am Herat J 1989: 118: 649.
Fleg J, et al. Prevalence and prognostic significance of exercise-induced myocardial ischemia detected by thallium scintigraphy and electrocadriography in asymptomatic volunteers. Circulation 1990: 81: 428.
Deanfield J, et al. Transient ST-segment depression as a marker of myocardial ischemia during daily life. Am J Cardiol 1984: 54: 1195.
Rozanski A, et al. Mental stress and the induction of silent myocfardial ischemia in patients with coronary artery disease. N Engl J Med 1988: 318: 1005.
Deanfield J, et al. Silent myocardial ischemia due to mental stress. Lancet 1984: 2: 1001.
Schang CJ, Pepine C. Transient asymptomatic ST segment depression during daily activity. Am J Cardiol 1977: 39: 396.
Deanfield J, et al. Myocardial Ischemia during daily life in patients with stable angina: Its relation to symptoms and heart rate changes. Lancet 1983: 2: 753.
Chierchia S, et al. Role of heart rate in pathophysiology of chronic stable angina. Lancet 1984: 2: 1353.
Banai S, et al. Changes in myocardial ischemic threshold during daily activities. Am J Cardiol 1990: 66: 1403.
Chierchia S, et al. Role of the sympathetic nervous system in the pathogenesis of chronic stable angina. Implications for the mechanism of action of Beta-blockers. Circulation 1990: 82(suppl II): II71.
Quyyumi A, et al. Mechanisms of nocturnal angina pectoris: Importance of increased myocardial oxygen demand in patients with severe coronary artery disease. Lancet 1985: 1: 1207.
Quyyumi A, et al. Nocturnal angina: Precipitating factors in patients with coronary artery disease and those with variant angina. Br Heart J 1986: 56: 346.
Deedwania P. Nelson J. Pathophysiology of silent myocardial ischemia during daily life. Circulation 1990: 82: 1296.
Stone PH, et al. Comparison of propanolol, diltiazem, and nifedipine in the treatment of ambulatory ischemia in patients with stable angina. Circulation 1990: 82: 1962.
Andrews TC, et al. Subsets of ambulatory myocardial ischemia based on heart rate activity: Circadian distribution and response to anti-ischemic medication. Circulation 1993: 88: 92.
Rocco M, et al. Circadian variation of transient myocardial ischemia in patients with coronary artery disease. Circulation 1987: 75: 395.
Mulcahy D, et al. Circadian variation of total ischemic burden and its alteration with antianginal agents. Lancet 1988: 1: 755.
Nademanee K, et al. Circadian variation in occurence of transient overt amd silent myocardial ischemia in chronic stable angina and comparison with Prinzmetal angina in men. Am J Cardiol 1987: 60: 494.
Muller JE, et al. Circardian variation in the frequency of onset of acute myocardial infarction. N Engl J Med 1985: 313: 1315.
Marler J, et al. Morning increase in onset of ischemic stroke. Stroke 1989: 20: 473.
Muller JE, et al. Circedian variation in the frequency of sudden cardiac death. Circulation 1987: 75: 131.
Tofler G, et al. Concurrent morning increase in pletelet aggregability and the risk of myocardial infarction and sudden cardiac death. N Engl J MeD 1987: 316: 1514.
Turton M, Deegan T. Circadian variations of plasma catecholamines, Cortisol and immunor-eactive isnulin concentrations in supine subjects. Clin Chem Acta 1974: 55: 389.
Quyyumi A, et al. Circadian variation in ischemic events: Causeal role of variation in vascular resistance. Circulation 1988: 78(Suppl II): II–.
Panza J, Epstein S, Quyyumi A. Circadian variation in vascular tone and its relation to alpha-sympathetic vasoconstrictor activity. N Engl J Med 1991: 325: 986.
Fujita M, Franklin D. Diurnal changes in coronary blood flow in conscious dogs. Circulation 1987: 76: 488.
Parker J, et al. Morning increase in ambulatory ischemia in patients with stable coronary artery disease. Circulation 1994: 89: 604.
Giagnoni E, et al. Prognostic value of exercise ECG testing in asymptomatic normotensive subjects: A prospective matched study. N Engl J Med 1983: 309: 1085.
Ekelund L, et al. Coronary heart disease morbidity and mortality in hypercholesterolemic men predicted from an exercise test: The Lipid Research Clinics Coronary Primary Prevention Trial. J Am Coll Cardiol 1989: 14: 556.
McHenry P, et al. The abnormal exercise electocardiogram in apparently healthy men: a predictor of angina pectoris as an initial coronary event during long-term follow-up. Circulation 1984: 62: 522.
Froelicher V, Maron D. Exercise testing and ancillary techniques to screen for coronary heart disease. Prog Cardiovasc Dis 1981: 24: 261.
Bruce R, et al. Enhanced risk assessment of primary coronary heart disease events by maximal exercise testing: 10 years experience of Seattle Heart Watch. J Am Coll Cardiol 1983: 2: 565.
Multiple Risk Factor Intervention Trial Research Group. Exercise electrocardiogram and coronary heart disease mortality in the Multiple Risk Factor Intervention Trial. Am J Cardiol 1985: 55: 16.
Hedblad B, et al. Increased mortality in men with ST segment depression during 24 hour ambulatory long-term ECG recording. Eur Heart J 1989: 10: 149.
Weiner D, et al. Significance of silent myocardial ischemia during exercise testing in coronary artery disease. Am J Cardiol 1987: 59: 725.
Weiner D, et al. Prognostic importance of a clinical profile and exercise test in medically treated patients with coronary artery disease. J Am Coll Cardiol 1984: 3: 722.
Dagenais G, et al. Survival of patients with a strongly positive exercise electrocardiogram. Circulation 1982: 65: 452.
Rocco M, et al. Prognostic importance of myocardial ischemia detected by ambulatory monitoring in patients with stable coronary artery disease. Circulation 1988: 78: 877.
Yeung A, et al. Effects of asymptomatic ischemia on long-term prognosis in chronic stable coronary disease. Circulation 1991: 83: 1598.
Deedwania P, Carbajal E. Silent ischemia during daily life is an independent predictor of mortality in stable angina. Circulation 1990: 81: 748.
Tzivoni D, et al. Comparison of mortality and myocardial infarction rates in stable angina pectoris with and without ischemic episodes during daily activities. Am J Cardiol 1989: 63: 273.
Quyyumi A, et al. Prognostic implications of myocardial ischemia during daily life in low risk patients with coronary artery disease. J Am Coll Cardiol 1993: 21: 700.
Gandhi M, Wood D, Lampe F. Characteristic and clinical significance of ambulatory myocardial ischemia in men and women in the general population presenting with angina pectoris. J Am Coll Cardiol 1994: 23: 74.
Theroux P, et al. Prognostic value of exercise testing soon after myocardial infarction. N Engl J Med 1979: 301: 341.
Gottlieb S, et al. Silent ischemia predicts infarction and death during 2 year follow-up of unstable angina. J Am Coll Cardiol 1987: 10: 756.
Gottleib S, et al. Silent ischemia as a marker for early unfavorable outcomes in patients with unstable angina. N Engl J Med 1986: 314: 1214.
Langer A, Freeman M, Armostrong P. ST segment shift in unstable angina: Pathophysiology and association with coronary anatomy and hospital outcome. J Am Cardiol 1989: 13: 1495.
Nadamanee K, et al. Prognostic significance of silent myocardial ischemia in patients with unstable angina. J Am Coll Cardiol 1989: 13: 1495.
Johnson S, et al. Continuous electrocardiographic monitoring in patients with unstable angina: Identification of high-risk subgroups with severe coronary disease, variant angina, and/or impaired early prognosis. Am Heart J 1982: 103: 4.
Gottlieb S, et al. Silent ischemia on holter monitoring predicts mortality in high-risk post-infraction patients. JAMA 1988: 259: 1030.
Tzivoni D, et al. Prognostic significance of ischemic episodes in patients with previous myocardial infarction. Am J Cardiol 1988: 62: 661.
Solimene M, et al. Prognostic significance of silent myocardial ischemia after a first uncomplicated myocardial infarction. Int J Cardiol 1993: 38: 41.
Goldberg A, et al. ST depression of Holter monitor during hospitalization for acute myocardial infarction does not predict subsequent cardiac events. J Am Coll Cardiol 1991: 17: 66.
Moss A, et al. Detection and significance of myocardial ischemia in stable patients after recovery from an acute coronary event. JAMA 1992: 69: 2379.
Raby K, et al. Correlation between preoperative ischemia and major cardiac events after peripheral vescular surgery. N Engl J Med 1989: 321: 1296.
Mangano D, et al. Association pf perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. N Engl J Med 1990: 323: 1781.
Landesberg G, et al. Importance of long-duration postoperative ST-segment depression in cardiac morbidity after vascular surgery. Lancet 1993: 341: 715.
Raby K, et al. Long-term prognosis of myocardial ischemia detectedby holter monitoring in peripheral vascular disease. Am J Cardiol 1990: 66: 1309.
Mangano D, et al. Long term cardiac prognosis following noncardiac surgery. JAMA 1992: 268: 233.
Raby K, et al. Detection and significance of intraoperative and postoperative ischemia in peripheral vascular surgery. JAMA 1992: 268: 222.
Nabel E, et al. Effects of dosing intervals on the development of tolerance to hogh-dose transdermal nitroglycerine. Am J Cardiol 1989: 63: 663.
Nesto R, et al. Effect of nifedipine on total ischemic activity and circadian distribution of myocardial ischemic episodes in angina pectoris. Am J Cardiol 1991: 67: 128.
Imperi G, et al. Effects of titrated beta blockade (metoprolol) on silent myocardial ischemia in ambulatory patients with coronary artery disease. Am J Cardiol 1987: 60: 519.
Rogers W, et al. Asymptomatic Cardiac Ischemia Pilot (ACIP) Study: 1 year follow-up. Circulation 1994: 90: i–17
Pepine C, et al. Effecfts of treatment on outcome in mildly symptomatic patients with ischemia during daily life. The Atenolol Silent Ischemia Study (ASIST). Circulation 1994: 90: 762.
Pepine C, et al. The Asymptomatic Cardiac Ischemia Pilot (ACIP) study: Design of a randomized clinical trial, baseline data and implications for a long-term trial. J Am Coll Cardiol 1994: 24: 1.
Knatterud G, et al. Effects of treatment strategies to suppress ischemia in patients with coronary artery disease: 12-week results of the Asymptomatic Cardiac Ischemia Pilot (ACIP) study. J Am Coll Cardiol 1994: 24: 11.
Andrews T, et al. Identification of treatment of myocardial ischemia in patients undergoing peripheral vascular surgery. J Vase Med Biol 1994: 5: 8.
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Schafer, B.P., Andrews, T.C., Stone, P.H. (1999). Silent Myocardial Ischemia. In: Contemporary Concepts in Cardiology. Developments in Cardiovascular Medicine, vol 217. Springer, Boston, MA. https://doi.org/10.1007/978-1-4615-5007-5_5
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DOI: https://doi.org/10.1007/978-1-4615-5007-5_5
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