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STATE-OF-THE-ART PAPER

Silent Ischemia

Clinical Relevance

Department of Medicine, University of Florida College of Medicine, Gainesville, Florida

Manuscript received June 7, 2011; revised manuscript received July 11, 2011, accepted July 18, 2011.

^_* Reprint requests and correspondence: Dr. John W. Petersen, University of Florida College of Medicine, 1600 SW Archer Road, PO Box 100277, Gainesville, Florida 32610 (Email: john.petersen{at}medicine.ufl.edu).

Myocardial ischemia can occur without overt symptoms. In fact, asymptomatic (or silent) ST-segment depression during ambulatory electrocardiogram monitoring occurs more often than symptomatic ST-segment depression in patients with coronary artery disease. Initial studies documented that silent ischemia provided independent prediction of adverse outcomes in patients with known and unknown coronary artery disease. The ACIP (Asymptomatic Cardiac Ischemia Pilot Study) enrolled patients in the 1990s and found that revascularization was better than medical therapy in reducing silent ischemic episodes and possibly cardiovascular (CV) events. However, the more recent COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial found similar CV event rates between patients treated with optimal medical therapy alone and those treated with optimal medical therapy plus percutaneous revascularization. Therefore, in the current era, medical therapy appears to be as effective as revascularization in suppressing symptomatic ischemia and preventing CV events. COURAGE was not designed to evaluate changes in the frequency of silent ischemia. Therefore, silent ischemia may persist despite current-era treatment and might still identify patients with increased risk of CV events. Also, silent ischemia is likely to occur frequently in heart transplant patients with denervated hearts and coronary allograft vasculopathy, and future study aimed at improving the management of silent ischemia in this population is warranted. Additionally, future research is warranted to study the effect of newer medical therapies such as ranolazine or selected use of revascularization (for example, guided by fractional flow reserve) in those patients with persistent silent ischemia despite optimal current-era medical therapy.

Key Words: asymptomatic • coronary artery disease • ischemia • myocardial • silent ischemia

Abbreviations and Acronyms   ACE = angiotensin-converting enzyme   AECG = ambulatory electrocardiogram   CABG = coronary artery bypass graft   CAD = coronary artery disease   CV = cardiovascular   ECG = electrocardiogram   PCI = percutaneous coronary intervention

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