title: Long term outcome in patients with silent versus symptomatic ischaemia during dobutamine stress echocardiography.
abstract: OBJECTIVE
  To compare the long term prognosis of patients having silent versus symptomatic ischaemia during dobutamine stress echocardiography (DSE).
  
  
  METHODS
  Observational study.
  
  
  METHODS
  Tertiary referral centre.
  
  
  METHODS
  931 patients who experienced stress induced myocardial ischaemia during DSE.
  
  
  RESULTS
  Silent ischaemia was present in 643 of 931 patients (69%). The number of dysfunctional segments at rest (mean (SD) 9.6 (5.1) v 8.8 (5.0), p = 0.1) and of ischaemic segments (3.5 (2.2) v 3.8 (2.1), p = 0.2) was comparable in both groups. During a mean (SD) follow up of 5.5 (3.3) years, there were 169 (18%) cardiac deaths and 86 (9%) non-fatal infarctions. Multivariable Cox regression analysis showed age (hazard ratio (HR) 1.1, 95% confidence interval (CI) 1.02 to 1.05), previous myocardial infarction (HR 1.4, 95% CI 1.1 to 2.0), and number of ischaemic segments during the test (HR 2.0, 95% CI 1.0 to 3.7) as independent predictors of cardiac death and myocardial infarction. For every additional ischaemic segment there was a twofold increment in risk of late cardiac events. The annual cardiac death or myocardial infarction rate was 3.0% in patients with symptomatic ischaemia and 4.6% in patients with silent ischaemia (p < 0.01). Silent induced ischaemia was an independent predictor of cardiac death and myocardial infarction (HR 1.7, 95% CI 1.1 to 2.0). During follow up symptomatic patients were treated more often with cardioprotective therapy (p < 0.01) and coronary revascularisation (145 of 288 (50%) v 174 of 643 (27%), p < 0.001).
  
  
  CONCLUSIONS
  Patients with silent ischaemia had a similar extent of myocardial ischaemia during DSE compared to patients with symptomatic ischaemia but received less cardioprotective treatment and coronary revascularisation and experienced a higher cardiac event rate.
authors.affiliation: Department of Cardiology, Thoraxcentre, Erasmus MC, Rotterdam, The Netherlands.
authors.forename: E
authors.initials: E
authors.lastname: Biagini
authors.forename: A F L
authors.initials: AF
authors.lastname: Schinkel
authors.forename: J J
authors.initials: JJ
authors.lastname: Bax
authors.forename: V
authors.initials: V
authors.lastname: Rizzello
authors.forename: R T
authors.initials: RT
authors.lastname: van Domburg
authors.forename: B J
authors.initials: BJ
authors.lastname: Krenning
authors.forename: M
authors.initials: M
authors.lastname: Bountioukos
authors.forename: C
authors.initials: C
authors.lastname: Pedone
authors.forename: E C
authors.initials: EC
authors.lastname: Vourvouri
authors.forename: C
authors.initials: C
authors.lastname: Rapezzi
authors.forename: A
authors.initials: A
authors.lastname: Branzi
authors.forename: J R T C
authors.initials: JR
authors.lastname: Roelandt
authors.forename: D
authors.initials: D
authors.lastname: Poldermans
mesh_terms: D000787:Angina Pectoris / Q000401:mortality; D016757:Death, Sudden, Cardiac / Q000209:etiology; D025401:Echocardiography, Stress / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality; D017202:Myocardial Ischemia / Q000000981:diagnostic imaging* / Q000401:mortality; D011379:Prognosis; D012307:Risk Factors; D016019:Survival Analysis