Abstract
Recent methodologic advances have led to important clinical insights regarding the pathophysiology of myocardial ischemia. Chief among these advances has been the development of accurate ambulatory ECG monitoring of the ST segment. With the use of this new technology, investigators have found that patients with coronary artery disease have frequent episodes of painless myocardial ischemia during daily activity,‘-* a phenomenon that has been termed “silent ischemia.” Silent ischemia frequently occurs at relatively low heart rates and in the absence of exercise.3-7 Investigators are now using a wide variety of techniques to study the pathophysiology of this phenomenon, including ambulatory monitoring, radionuclide imaging, and new means of angiographic assessment, which permit evaluation of coronary vascular endothelial cell function and coronary vascular reactivity. There has also been much recent speculation regarding the potential prognostic implications of silent ischemia. Understandably, there has been little integration of the information regarding this recently studied phenomenon. This article evaluates the current knowledge regarding silent ischemia, with emphasis on potential clinical pitfalls and areas of needed investigation for more adequate characterization of this phenomenon.
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