SILENT ISCHEMIASTABLE CAD

ARTHUR “Cliff” A. BAYANI II, MDCardiology FellowSLMC

Objectives

To present a case of a patient with silent ischemia.

To present management regarding silent ischemia.

SILENT ISCHEMIA Journal of the American College of Cardiology Vol.59,No. 5, 2012© 2012 by the American College of Cardiology Foundation Published by Elsevier Inc. doi:10.1016/j.jacc.2011.07.050

EFFECTIVENESS OF PCI IN PATIENTS WITH SILENT MYOCARDIAL ISCHEMIAJournal of the American Cardiology 2012; 109;954-959

Patient Profile

72

Female

HTN

Diabetic

No Family History CAD

Patient Profile

Relatively Good Functional Capacity

Patient Profile

No Chest Pain

No Palpitations

No DOB

Inducible Ischemia on Treadmill Stress Test

Stage 3 Mets 5

ECG

CXRAY

Diagnostic Angiograpy:

Clinical Summary

72 years old Female Hypertensive Diabetic Denies chest pain,

dyspnea, palipations, easy fatigability etc.

Inducible ischemia on stress test.

CAD OF LAD

ISSUES:

What to do?

What would you do?

What Benefit?

Indication for therapy?

Guidelines?

Silent Ischemia

IntroductionAsymptomatic ST-segment depression during ambulatory electrocardiogram monitoring occurs more often than symptomatic ST-segment depression in patients with coronary artery disease.

Silent Ischemia

Introductionsilent ischemia may persist despite current-era treatment and might still identify patients with increased risk of CV events.

Silent ischemia

1970s, asymptomatic ST segment depression during ambulatory ECG monitoring > symptomatic ST segment depression in patients with CAD.

1980s and 1990s, silent ischemia was associated with adverse events

Review of clinical significance is warranted

Definition, Diagnosis, and Mechanism

May be detected in patients:

1.) no symptoms during an exercise or pharmaceutical stress test but do have transient ST-segment changes,

2.) perfusion defects, 3.)or reversible regional wall motion

abnormalities.

Definition, Diagnosis and Mechanism

Definition, Diagnosis and Mechanism

The combination of an increasing demand and an altered supply secondary to abnormal microvascular and endothelial response is a possible explanation for the mechanism of silent ischemia.

Prevalence

Nearly one-half of patients with stable CAD are shown to have transient ST-segment depressions.

One-half of patients admitted with UA

Have risk factors for CAD : 15% with mild-to-moderate hypertension who had no signs nor symptoms of CAD, 12% of NIDDM. Half of these patients were found to have perfusion defects during thallium scintigraphy.

Prevalence

Even healthy patients without risk factors for CAD have been shown to have silent ischemia.

24% of apparently healthy individuals either had an abnormal stress test or perfusion study.

Prognosis of Patients with Silent Ischemia

Patients with stable CAD In patients with

medically managed CAD, the likelihood of death or myocardial infarction during the 7 years of follow up was similar between patients with asymptomatic ST segment depression with exercise.

Prognosis of Patients with Silent Ischemia

Healthy Subjects

Zellweger et al. 3,664 consecutive asymptomatic patients without known CAD who had undergone myocardial perfusion imaging.

> 7.5% ischemic myocardium, increased risk of CV events.

Medical Therapy and RevascularizationThe ACIP trial

(Asymptomatic Cardiac Ischemia Pilot Study)

618 Participants were randomized to medical therapy vs. revascularization.

Conclusion: ACIP demonstrated increased suppression of ischemic episodes and decreased CV outcomes in PCI group

SWISS INTERVENTIONAL STUDY ON SILENT ISCHEMIA II 201 PATIENTS

3 MONTHS AFTER ACUTE MI

PCI DECREASED LONG TERM EFFECT OF CARDIAC EVENTS

Effectiveness of PCI in Patient with Silent Ischemia(Post Hoc Analysis of the Courage Trial) 2280

Major Cardiac events: 12 % PCI + OMT vs. OMT alone

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