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CLINICAL STUDY

Exercise-induced silent myocardial ischemia and coronary morbidity and mortality in middle-aged men

Jari A. Laukkanen, MD^*, Sudhir Kurl, MD^*, Timo A. Lakka, MD, PhD^*, Tomi-Pekka Tuomainen, MD^*, Rainer Rauramaa, MD, PhD, MSc, Riitta Salonen, MD, PhD^* , Jaakko Eränen, MD and Jukka T. Salonen, MD, PhD, MScPH^{* ||}

^* Research Institute of Public Health, University of Kuopio, Kuopio, Finland
Kuopio Research Institute of Exercise Medicine and the Departments of Clinical Physiology and Nuclear Medicine, University Hospital of Kuopio, Kuopio, Finland
Departments of Public Health and General Practice, University of Kuopio, Kuopio, Finland
Department of Medicine, University Hospital of Kuopio, Kuopio, Finland
^|| Inner Savo Health Centre, Suonejoki, Finland

Manuscript received September 20, 2000; revised manuscript received February 6, 2001, accepted March 28, 2001.

Reprint requests and correspondence: Prof. Jukka T. Salonen, Research Institute of Public Health, University of Kuopio, P.O. 1627, 70211 Kuopio, Finland
Jukka.Salonen{at}uku.fi

OBJECTIVES

We investigated the prognostic significance of exercise-induced silent myocardial ischemia in both high and low risk men with no prior coronary heart disease (CHD).

BACKGROUND

Silent ischemia predicts future coronary events in patients with CHD, but there is little evidence of its prognostic significance in subjects free of CHD.

METHODS

We investigated the association of silent ischemia, as defined by ST depression during and after maximal symptom-limited exercise test, with coronary risk in a population-based sample of men with no prior CHD followed for 10 years on average.

RESULTS

Silent ischemia during exercise was associated with a 5.9-fold (95% CI 2.3 to 11.8) CHD mortality in smokers, 3.8-fold (95% CI 1.9 to 7.9) in hypercholesterolemic men and 4.7-fold (95% CI 2.4 to 9.1) in hypertensive men adjusting for other risk factors. The respective relative risks (RRs) of any acute coronary event were 3.0 (95% CI 1.7 to 5.1), 1.9 (95% CI 1.2 to 3.1) and 2.2 (95% CI 1.4 to 3.5). These associations were weaker in men without these risk factors. Furthermore, silent ischemia after exercise was a stronger predictor for the risk of acute coronary events and CHD death in smokers and in hypercholesterolemic and hypertensive men than in men without risk factors.

CONCLUSIONS

Exercise-induced silent myocardial ischemia was a strong predictor of CHD in men with any conventional risk factor, emphasizing the importance of exercise testing to identify asymptomatic high risk men who could benefit from risk reduction and preventive measures.

Abbreviations and Acronyms   AMI = acute myocardial infarction   BMI = body mass index   CHD = coronary heart disease   CI = confidence interval   CVD = cardiovascular disease   ECG = electrocardiogram   FINMONICA = Finnish part of WHO-MONICA   HDL = high density lipoprotein   ICD = International Classification of Diseases   KIHD = Kuopio Ischemic Heart Disease risk factor study   LDL = low density lipoprotein   RR = relative risk   SBP = systolic blood pressure   WHO-MONICA = World Health Organization-Monitoring of Trends and Determinants in Cardiovascular Diseases

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