Silent Ischemia
Open accessAbstract
Myocardial ischemia can occur without overt symptoms. In fact, asymptomatic (or silent) ST-segment depression during ambulatory electrocardiogram monitoring occurs more often than symptomatic ST-segment depression in patients with coronary artery disease. Initial studies documented that silent ischemia provided independent prediction of adverse outcomes in patients with known and unknown coronary artery disease. The ACIP (Asymptomatic Cardiac Ischemia Pilot Study) enrolled patients in the 1990s and found that revascularization was better than medical therapy in reducing silent ischemic episodes and possibly cardiovascular (CV) events. However, the more recent COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial found similar CV event 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 as 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, silent ischemia may persist despite current-era treatment and might still identify patients with increased risk of CV events. Also, silent ischemia is likely to occur frequently in heart transplant patients with denervated hearts and coronary allograft vasculopathy, and future study aimed at improving the management of silent ischemia in this population is warranted. Additionally, future research is warranted to study the effect of newer medical therapies such as ranolazine or selected use of revascularization (for example, guided by fractional flow reserve) in those patients with persistent silent ischemia despite optimal current-era medical therapy.
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For a diagnosis of ischemia, ST-segment depression of at least 0.5-1.0 mV (0.5-1.0 mm) lasting for at least 1 min before returning to normal should be seen.
“For a diagnosis of ischemia, ST-segment depression of at least 0.5-1.0 mV (0.5-1.0 mm) lasting for at least 1 min before returning to normal should be seen (Conti, Bavry, & Petersen, 2012).”
From 2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac monitoring/telemetry (2017) · cites this paper as Conti, Bavry, & Petersen, 2012
In “Definition, Diagnosis, and Mechanism,” the paper gives an example criterion for diagnosing silent ischemia during ambulatory ECG monitoring: ST-segment depression of at least 0.5 mV lasting at least 60 seconds and returning to normal. The citing sentence matches the duration and reversal, but presents the criterion as applying to ischemia generally, adds an unsupported 1.0 mV value, and incorrectly equates 0.5–1.0 mV with 0.5–1.0 mm. (LLM, conf=0.91)
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Research works printed but not linked: 1
- [7]7. Stone PH. ST-segment analysis in ambulatory ECG (AECG or Holter) monitoring in patients with coronary artery disease: clinical significance and analytic techniques. Ann Noninvasive Electrocardiol 2005;10:263-78.
Cited by
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Steinberg, J. S., Varma, N., Cygankiewicz, I., Aziz, P., Balsam, P., Baranchuk, A., Cantillon, D. J., Dilaveris, P., Dubner, S. J., El-Sherif, N., et al. (2017) · Heart Rhythm · doi:10.1016/j.hrthm.2017.03.038 · Cited by 303 · see citing works
- Authors
- Conti, C. R., Bavry, A. A., & Petersen, J. W.
- Affiliations
- University of Florida Health (US)
- Corresponding author
- Petersen, John W.
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2012-01
- Volume
- 59
- Issue
- 5
- Pages
- 435-441
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W3242620
- Cited by
- 84
- References
- 38
- Citations by year
- 2026: 6 · 2025: 3 · 2024: 4 · 2023: 7 · 2022: 4 · 2021: 7 · 2020: 5 · 2019: 7 · 2018: 4 · 2017: 8 · 2016: 7 · 2015: 9 · 2014: 5 · 2013: 5 · 2012: 3
- FWCI
- 1.36
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Coronary Interventions and Diagnostics
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Acute Myocardial Infarction Research
- Keywords
- silent myocardial ischemia, coronary artery disease, COURAGE trial, percutaneous coronary intervention, optimal medical therapy, cardiovascular events, heart transplant recipients, cardiac allograft vasculopathy, denervation, ranolazine, fractional flow reserve
- MeSH terms
- Cardiovascular Agents, Diagnosis, Differential, Exercise Test, Humans, Myocardial Revascularization, Electrocardiography, Ambulatory, Myocardial Ischemia
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