Abstract
BackgroundCurrent guidelines for assessing the risk of experiencing a hospitalized cardiovascular (CV) event discourage stress testing of asymptomatic individuals; however, these recommendations are based on evidence gathered primarily from those aged < 60 years, and do not address the possibility of unrecognized “silent myocardial ischemia” in middle aged and older adults.MethodsWe performed dobutamine cardiovascular magnetic resonance (CMR) stress testing in 327 consecutively recruited participants aged > 55 years without CV-related symptoms nor known coronary artery disease, but otherwise at increased risk for a future CV event due to pre-existing hypertension or diabetes mellitus for at least 5 years. After adjusting for the demographics and CV risk factors, log-rank test and Cox proportional hazards models determined the additional predictive value of the stress test results for forecasting hospitalized CV events/survival. Either stress-induced LV wall motion abnormalities or perfusion defects were used to indicate myocardial ischemia.ResultsParticipants averaged 68 ± 8 years in age; 39% men, 75% Caucasian. There were 38 hospitalized CV events or deaths which occurred during a mean follow-up of 58 months. Using Kaplan-Meier analyses, myocardial ischemia identified future CV events/survival (p < 0.001), but this finding was more evident in men (p < 0.001) versus women (p = 0.27). The crude hazard ratio (HR) of myocardial ischemia for CV events/survival was 3.13 (95% CI: 1.64–5.93; p < 0.001). After accounting for baseline demographics, CV risk factors, and left ventricular ejection fraction/mass, myocardial ischemia continued to be associated with CV events/survival [HR: 4.07 (95% CI: 1.95–8.73) p < 0.001].ConclusionsAmong asymptomatic middle-aged individuals with risk factors for a sentinel CV event, the presence of myocardial ischemia during dobutamine CMR testing forecasted a future hospitalized CV event or death. Further studies are needed in middle aged and older individuals to more accurately characterize the prevalence, significance, and management of asymptomatic myocardial ischemia.Trial registration(ClinicalTrials.gov identifier): NCT00542503 and was retrospectively registered on October 11th, 2007.
Highlights
Current guidelines for assessing the risk of experiencing a hospitalized cardiovascular (CV) event discourage stress testing of asymptomatic individuals; these recommendations are based on evidence gathered primarily from those aged < 60 years, and do not address the possibility of unrecognized “silent myocardial ischemia” in middle aged and older adults
To identify those at risk of a future cardiovascular (CV) event, current guidelines from the American College of Cardiology (ACC), the American Heart Association (AHA), and the European Society of Cardiology (ESC) recommend against stress testing in individuals who do not exhibit anginal symptoms consistent with CV disease. [10, 11] ACC Appropriateness Use Criteria regard the utility of stress testing asymptomatic individuals with multiple risk factors for a CV event as “uncertain” [12,13,14,15]
Of those included in our study identified as having myocardial ischemia, 19 (5.8%) had stress-induced wall motion abnormalities only, 38 (11.5%) had a stress-induced perfusion defect only, and 22 (6.7%) had both a stress-induced wall motion abnormality and a perfusion defect
Summary
Individuals with silent myocardial ischemia have the same level or higher risk for cardiovascular events and mortality as patients who present with typical angina [6,7,8,9]. To identify those at risk of a future cardiovascular (CV) event, current guidelines from the American College of Cardiology (ACC), the American Heart Association (AHA), and the European Society of Cardiology (ESC) recommend against stress testing in individuals who do not exhibit anginal symptoms consistent with CV disease. When following current guidelines, one often does not perform stress testing to identify silent myocardial ischemia unless patients exhibit symptoms that may relate to angina
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