title: Inducible ischemia and the risk of recurrent cardiovascular events in outpatients with stable coronary heart disease: the heart and soul study.
abstract: BACKGROUND
  Current guidelines do not recommend routine cardiac stress testing in patients with stable coronary heart disease (CHD) unless they report symptoms of angina. Our objective was to compare the prognosis of self-reported angina symptoms, inducible ischemia, or both in patients with stable CHD.
  
  
  METHODS
  We measured self-reported angina by questionnaire and inducible ischemia using treadmill stress echocardiography in 937 outpatients with stable CHD. We used Cox proportional hazard models, adjusted for traditional cardiovascular risk factors, to evaluate the independent association of angina and inducible ischemia with CHD events (myocardial infarction or CHD death) during a mean of 3.9 years of follow-up.
  
  
  RESULTS
  Of the study participants, 129 (14%) had angina alone, 188 (20%) had inducible ischemia alone, and 40 (4%) had both angina and ischemia. Recurrent CHD events occurred in 7% of participants without angina or inducible ischemia, 10% of those with angina alone, 21% of those with inducible ischemia alone, and 23% of those with both angina and inducible ischemia (P < .001). The presence of angina alone was not associated with recurrent CHD events (adjusted hazard ratio, 1.4; 95% confidence interval, 0.7-2.9) (P = .31). However, the presence of inducible ischemia without self-reported angina strongly predicted recurrent CHD events (adjusted hazard ratio, 2.2; 95% CI, 1.4-3.5) (P = .005).
  
  
  CONCLUSIONS
  We found that 24% of patients with stable CHD had inducible ischemia, and more than 80% of these patients did not report angina. The presence of inducible ischemia without self-reported angina is associated with a greater than 2-fold increased rate of recurrent CHD events.
authors.affiliation: Division of Cardiology, Emory University Hospital, 1364 Clifton Rd NE, Ste 424, Atlanta, GA 30322, USA. anilgehi@gmail.com
authors.forename: Anil K
authors.initials: AK
authors.lastname: Gehi
authors.forename: Sadia
authors.initials: S
authors.lastname: Ali
authors.forename: Beeya
authors.initials: B
authors.lastname: Na
authors.forename: Nelson B
authors.initials: NB
authors.lastname: Schiller
authors.forename: Mary A
authors.initials: MA
authors.lastname: Whooley
mesh_terms: D000367:Age Factors; D000787:Angina Pectoris / Q000175:diagnosis / Q000401:mortality / Q000523:psychology; D002423:Cause of Death; D015331:Cohort Studies; D016001:Confidence Intervals; D003327:Coronary Disease / Q000175:diagnosis* / Q000209:etiology / Q000401:mortality* / Q000523:psychology; D015150:Echocardiography, Doppler; D005080:Exercise Test / Q000009:adverse effects*; D005260:Female; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000175:diagnosis / Q000401:mortality / Q000523:psychology; D017202:Myocardial Ischemia / Q000175:diagnosis / Q000401:mortality / Q000523:psychology; D011237:Predictive Value of Tests; D011336:Probability; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D012737:Sex Factors; D016019:Survival Analysis