1. Silent Ischemia STABLE CAD
ARTHUR “Cliff” A. BAYANI II, MD
Cardiology Fellow
SLMC

2. 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: /j.jacc
EFFECTIVENESS OF PCI IN PATIENTS WITH SILENT MYOCARDIAL ISCHEMIA
Journal of the American Cardiology 2012; 109;

3. Patient Profile 72
Female
HTN
Diabetic
No Family History CAD

4. Relatively Good Functional Capacity
Patient Profile
Relatively Good Functional Capacity

5. Patient Profile
No Chest Pain
No Palpitations
No DOB

6. Inducible Ischemia on Treadmill Stress Test
Stage 3 Mets 5

7. ECG

8. CXRAY

9. Diagnostic Angiograpy:

10. Clinical Summary 72 years old Female Hypertensive Diabetic
Denies chest pain, dyspnea, palipations, easy fatigability etc.
Inducible ischemia on stress test.
CAD OF LAD

11. ISSUES: What to do? What would you do? What Benefit?
Indication for therapy?
Guidelines?

12. Silent Ischemia
Introduction Asymptomatic ST-segment depression during ambulatory electrocardiogram monitoring occurs more often than symptomatic ST-segment depression in patients with coronary artery disease.
Myocardial ischemia can occur without overt symptoms. In fact….asymptomatic……. Initial studies documented that silent ischemia provided independent prediction of adverse outcomes in patients with kown and unknown coronary artery disease. The ACIP enrolled patients in the 1990s and found that revascularization was better than medical therapy in reducing silent ischemia episodes and possibly CV events. The COURAGE trial found similar CV events rates between patients treated with optimal medical therapy alone and those treated with optimal medical therapy plus percutaneous revascularization….. Therefore, in the current era, medical therapy appears to be effective as revascularization in suppressing symptomatic ischemia and preventing CV events. COURAGE was not designed to evaluate changes in the frequency of silent ischemia. Therefore………..

13. Silent Ischemia
Introduction silent ischemia may persist despite current- era treatment and might still identify patients with increased risk of CV events.

14. 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
Asymptomatic ischemia may be identified during routine daily activities or during stress testing, In the 1970s…… Important work in the 1980s and 1990s……. Further, randomized trials at that time suggested that revascularization of patients with silent ischemia might improve clinical outcomes. However……. Thus, review of……

15. 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.

16. Definition, Diagnosis and Mechanism
After coronary artery occlusion, LV ventricular mechanical abnormalities and ECG abnormalities precede development of symptoms. So, it is not surprising that patients can have evidence of myocardial ischemia without symptoms.

17. 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.

18. 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.
Asymptomatic myocardial ischemia has been shown to occur more often than symptomatic ischemia in patients with stable CAD. With AECG monitoring,……nearly one half………………..depressions that likely represent silent ischemic events…. Similarly. Nearly one-half……. UA will have silent ischemia detected during continuous ECG evaluaton…. Silent ischemia has also been documented in patients who have risk factors for CAD…. For example……15%.....had st segment depression during AECG monitoring or with exercise stress test, also 12%......with no symptoms suggestive of CAD had an abnormal stress ECG, although one half…….

19. 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.

20. 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.
In patients with mild to moderate CAD, silent ischemia provides similar prognostic information for adverse outcomes as does symptomatic ischemia. In patients with…….. However, among patients with medically treated extensive CAD, silent ischemia is associated with worse prognosis than symptomatic ischemia.

21. 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.
Silent Ischemia detected in healthy individuals with no known CAD has also been shown to predict adverse events… According to zellweger…. They evaluated 3,644…… they determined that if a subject had >7.5%..... Then their risk of a CV event was significantly increased.

22. Medical Therapy and Revascularization
The 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
Because silent ischemia has shown to predict poor outcomes, it is not surprising that many investigators have attempted to determine if interventions that reduce silent ischemia improve outcomes. The ACIP study tested various strategies to reduce silent ischemia. Medical therapy was further divided into an anginal-guided strategy with the use of antianginal medications to eliminate symptoms and an ischemia-guided strategy with the use of antianginal medications to eliminate silent ischemia.

23. SWISS INTERVENTIONAL STUDY ON SILENT ISCHEMIA II
201 PATIENTS
3 MONTHS AFTER ACUTE MI
PCI DECREASED LONG TERM EFFECT OF CARDIAC EVENTS

24. 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

25. Thankyou