State-of-the-Art Paper
Silent Ischemia: Clinical Relevance

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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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Dr. Bavry has received research support from Novartis Pharmaceuticals and receives consulting fees from the American College of Cardiology Cardiosource. Drs. Conti and Petersen have reported that they no relationships relevant to the contents of this paper to disclose.