Should silent ischemia be treated in asymptomatic individuals?
In the United States, there may be as many as two million totally asymptomatic men with silent myocardial ischemia due to coronary artery disease. Because detection of such patients is often fortuitous, a rigorous screening protocol has been suggested for high-risk subgroups (i.e., persons with multiple coronary risk factors and/or family histories of premature coronary artery disease). At present, the initial procedure of choice for a screening protocol is the exercise test, followed by radionuclide procedures to differentiate true-positive from false-positive responses if coronary angiography is being considered. Holter monitoring is useful in documenting out-of-hospital ischemic events in asymptomatic patients with documented coronary artery disease. Prognostic studies in patients with and without coronary angiographic data indicate that asymptomatic patients with an ischemic ST-segment depression on exercise tests comprise a high-risk subgroup that has a well-defined morbidity and mortality due to future cardiac events. The angiographic surveys show that the greatest risk is in those individuals with more extensive disease. Treatment in asymptomatic persons requires the use of objective measurements as end points. Several reports have demonstrated the efficacy of beta-blockers, calcium channel blockers, and coronary angioplasty in this population, at least so far as reducing total ischemic activity is concerned. How nonsurgical therapy will affect ultimate prognosis is still unclear. However, surgical therapy in asymptomatic patients with left main coronary artery disease and triple-vessel disease has been reported to improve long-term survival.
Department of Medicine, State University of New York Health Sciences Center, Stony Brook 11794.
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Cohn
D000792:Angiography; D003327:Coronary Disease / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D015716:Electrocardiography, Ambulatory; D004812:Epidemiologic Methods; D005080:Exercise Test; D006801:Humans; D011379:Prognosis