title: Silent ischemic interval on exercise test is a predictor of response to drug therapy: a randomized crossover trial of metoprolol versus diltiazem in stable angina.
abstract: OBJECTIVE
  There is no method available to predict the relative antianginal efficacy of beta blockers and calcium-channel antagonists. The present study was undertaken to assess the role of silent ischemic interval (SII) on exercise treadmill test (ETT) as a predictor of response to therapy with metoprolol and diltiazem in patients with stable angina.
  
  
  METHODS
  Thirty-four patients with stable angina were divided into two groups depending upon the presence or absence of an SII gap of at least 1 min between onset of ST depression and appearance of angina on ETT. Metoprolol (50-100 mg twice daily) and diltiazem (60-120 mg three times daily) were randomly assigned for 6 weeks to patients in each group, and then patients were crossed over for further 6 weeks after a washout period of 2 weeks. Antianginal efficacy was assessed by clinical and exercise parameters.
  
  
  RESULTS
  In patients with SII, the clinical responder rate was better with metoprolol than with diltiazem (90 vs. 60%, respectively), and on ETT, metoprolol produced significant improvement in the total exercise time (p< 0.01), time to 1 mm ST depression (p <0.01), time to angina (p <0.01), and a significant decrease in peak rate-pressure product (p<0.001), whereas diltiazem had no significant effect on exercise parameters. However, in patients without SII, metoprolol and diltiazem had a similar clinical responder rate (57%), and both produced a significant increase in total exercise time (p < 0.01), time to 1 mm ST depression (p < 0.01), and time to angina (p < 0.01). In addition, metoprolol had a significant effect on peak rate-pressure product (p < 0.001).
  
  
  CONCLUSIONS
  Silent ischemic interval on ETT can be a predictor of response to antianginal therapy in stable angina, as patients with SII respond better to metoprolol and those without SII respond equally to both metoprolol and diltiazem.
authors.affiliation: Department of Cardiology, King George Medical College, Lucknow, UP, India.
authors.forename: S K
authors.initials: SK
authors.lastname: Dwivedi
authors.forename: R K
authors.initials: RK
authors.lastname: Saran
authors.forename: S
authors.initials: S
authors.lastname: Mittal
authors.forename: R
authors.initials: R
authors.lastname: Gupta
authors.forename: V S
authors.initials: VS
authors.lastname: Narain
authors.forename: V K
authors.initials: VK
authors.lastname: Puri
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000328:Adult; D000368:Aged; D000787:Angina Pectoris / Q000175:diagnosis / Q000188:drug therapy*; D002121:Calcium Channel Blockers / Q000627:therapeutic use*; D018592:Cross-Over Studies; D004110:Diltiazem / Q000627:therapeutic use*; D004562:Electrocardiography; D005080:Exercise Test; D005260:Female; D006801:Humans; D008297:Male; D008790:Metoprolol / Q000627:therapeutic use*; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000209:etiology; D011897:Random Allocation
chemical_list: D000319:Adrenergic beta-Antagonists; D002121:Calcium Channel Blockers; D004110:Diltiazem; D008790:Metoprolol