Prevalence Of Silent Ischemia Research Articles

Dijagnostika kardiovaskularnih bolesti kod bolesnika sa reumatoidnim artritisom, primarnim Sjegrenovim sindromom, sistemskom sklerozom i sistemskim eritemskim lupusom

Cardiovascular diseases (CVD) are the leading cause of death in the world and the most common type of comorbidity in patients with systemic lupus erythematosus (SLE), primary Sjögren's syndrome (SjS), systemic sclerosis (SSc), and rheumatoid arthritis (RA). Chronic inflammation in systemic rheumatic diseases can contribute to the development of CVD. Although risk factors for the CVD in the general population are well known, in patients with chronic rheumatic diseases risk factors for the CVD have not been specified as well as their connection with traditional risk factors, which would explain the increased incidence of CVD in these patients. Patients with chronic rheumatic diseases (RA, SLE, SjS and SSc) have an increased risk of developing both coronary and carotid atherosclerotic diseases. With the increase of the world's population suffering from rheumatoid autoimmune diseases, and thus increased morbidity and mortality, an adequate diagnostic strategy for the detection of coronary heart disease and risk stratification for their development is necessary. Functional techniques are readily available and can prove the presence of ischemia. In recent years, increasing attention has been paid to anatomical techniques that determine the degree of atherosclerosis. So far, a small number of studies are known that indicate the diagnostic accuracy and importance of functional and anatomical techniques in patients with autoimmune rheumatic diseases. The advantage of anatomical techniques is reflected in the direct visualization of either obstructive or non-obstructive (subclinical) coronary disease, allowing the detection of atherosclerosis in the early subclinical stage. However, information on the hemodynamic consequences of the detected changes remains unknown without functional testing. In asymptomatic patients with autoimmune rheumatic diseases, studies have shown an increased prevalence of silent ischemia and atherosclerosis and thus suggested early screening in the general population. Unfortunately, only a small number of prospective studies that have examined improved prognosis based on screening. Therefore, it is very important to conduct large prospective studies in terms of examining predictive markers of the occurrence and development of coronary heart disease in patients with autoimmune rheumatoid diseases.

Cardiac magnetic resonance for asymptomatic patients with type 2 diabetes and cardiovascular high risk (CATCH): a pilot study

BackgroundStress cardiovascular magnetic resonance (CMR) to screen for silent myocardial ischaemia in asymptomatic high risk patients with type 2 diabetes mellitus (DM) has never been performed, and its effectiveness is unknown. Our aim was to determine the feasibility of a screening programme using stress CMR by obtaining preliminary data on the prevalence of silent ischaemia caused by obstructive coronary artery disease (CAD) and quantify myocardial perfusion in asymptomatic high risk patients with type 2 diabetes.MethodsIn this prospective cohort study, we recruited 63 asymptomatic DM patients (mean age 66 years ± 4.4 years; 77.8% male); with Framingham risk score ≥ 20% from 3 sites from June 2017 to August 2018. Normal volunteers were recruited to determine normal global myocardial perfusion reserve index (MPRI). Adenosine stress CMR and global MPRI was performed and measured in all subjects. Positive stress CMR cases were referred for catheter coronary angiography (CCA) with/without fractional flow reserve (FFR) measurements. Positive CCA was defined as an FFR ≤ 0.8 or coronary narrowing ≥ 70%. Patients were followed up for major adverse cardiovascular events. Prevalence is presented as patient numbers and percentage. Mann–Whitney U test was used to compare global MPRI between patients and normal volunteers.Results13 patients had positive stress CMR with positive CCA (20.6% of patient population), while 9 patients with positive stress CMR examinations had a negative CCA. 5 patients (7.9%) had infarcts detected of which 2 patients had no stress perfusion defects. 12 patients had coronary artery stents inserted, whilst 1 patient declined stent placement. DM patients had lower global MPRI than normal volunteers (n = 7) (1.43 ± 0.27 vs 1.83 ± 0.31 respectively; p < 0.01). After a median follow-up of 653 days, there was no death, heart failure, acute coronary syndrome hospitalisation or stroke.Conclusion20.6% of asymptomatic DM patients (with Framingham risk ≥ 20%) had silent obstructive CAD. Furthermore, asymptomatic patients have reduced global MPRI than normal volunteers.Trial Registration: ClinicalTrials.gov Registration Number: NCT03263728 on 28th August 2017; https://clinicaltrials.gov/ct2/show/NCT03263728.

Screening asymptomatic patients with type 2 diabetes is recommended: Pro

Cardiovascular morbidity is common in type 2 diabetes mellitus (DM) and several epidemiological studies reported that DM is associated with a marked increase in the risk of coronary artery disease (CAD). In 1999, the Finnish diabetologist, Yki-Jarvinen, provocatively stated: ‘‘diabetes is a cardiovascular disease which you diagnose by measuring the blood glucose.’’ In the same year, also the American Heart Association stated that it might be appropriate to say ‘‘diabetes is a cardiovascular disease.’’ At this time, DM is commonly considered as a CAD risk equivalent in many position papers and guidelines. However, screening asymptomatic DM subjects for detection of CAD and subsequent management remains controversial. It is well known that patients with DM and inducible myocardial ischemia are often asymptomatic and when CAD becomes clinically manifest it is frequently in an advance stage. Also episodes of transitory myocardial ischemia may be ‘‘silent’’ and abnormal asymptomatic ST changes may be recorded during ambulatory ECG monitoring. The exact prevalence of silent ischemia in DM remains unidentified. A review of studies assessing the presence of stress-induced ischemia by myocardial perfusion single-photon emission computed tomography (MPS) in asymptomatic diabetic patients with unrecognized CAD reported a prevalence ranging from 4% to 62%, largely due to the different patients characteristics. The annual event rate ranged from 2.4% to 5.8% in subjects with abnormal MPS and from 0.4% to 2.1% in those with normal MPS. At this time, largely based on the results of the Detection of Ischemia in Asymptomatic Diabetics (DIAD) study, the American Diabetes Association does not recommend screening for CAD in asymptomatic patients because it does not improve outcomes as long as cardiovascular risk factors are treated (level of evidence A). However, according to the European Society of Cardiology guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the European Association for the Study of Diabetes, this issue is still under debate and the characteristics of the patients who should be screened for CAD need to be better defined. In addition, the detection of occult CAD might allow the initiation of appropriate therapy at a time point when the disease process is more easily modifiable. Thus, testing of asymptomatic diabetic patients for risk stratification purposes is a paramount objective of cardiovascular imaging and this strategy is expected to lead to declines in cardiac morbidity and mortality. In this context, certain important questions are still to be addressed, such as the potential of coronary revascularization to reduce cardiac events in asymptomatic patients; the yield of non-invasive testing in identifying, reliably, a considerable proportion of those patients likely to benefit from this type of intervention in a cost-effective manner; and the questions of who, when and how to test. The Impact of in Ducible Ischemia by Stress MPS (IDIS) trial was designed to evaluate if in patients with DM the use of an aggregate score incorporating and weighting multiple risk factors could be superior to an approach based on the number of risk factors to define the patient’s risk. This multicentre study enrolled 822 consecutive patients with DM, and risk estimates for a CAD event were categorized as 0% to\3%, 3% to\5%, and C5% per year using Cox proportional hazards models. Model 1 used traditional CAD risk factors and ECG stress test data and model 2 used these variables plus MPS imaging data. CAD death, myocardial infarction, and unstable angina requiring coronary revascularization were the outcome measures. During follow-up (58 ± 11 months), 148 events occurred. Model 2 improved risk prediction compared to model 1 Reprint requests: Alberto Cuocolo, MD, Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy; cuocolo@unina.it J Nucl Cardiol 2015;22:1225–8. 1071-3581/$34.00 Copyright 2015 American Society of Nuclear Cardiology.

Medical Management of the Diabetic Patient with Coronary Artery Disease

The prevalence of type 2 diabetes is rising at an alarming rate worldwide. Coronary artery disease (CAD) is the leading cause of morbidity and mortality in the diabetic population. Future CAD risk should be routinely assessed in patients with diabetes as specific subgroups might benefit from information derived from cardiac stress testing and other diagnostic procedures. Risk factor control is of paramount importance in all cases and it usually requires sustained lifestyle modifications, coupled with pharmacological interventions. Statins and angiotensin-converting enzyme (ACE) inhibitors are the first-line agents for the treatment of dyslipidaemia and hypertension, respectively. Microvascular, but not macrovascular, complications of diabetes are effectively prevented by good glycaemic control. Metformin is considered the first-choice agent in overweight diabetic subjects, while the role of thiazolidinediones is currently the focus of medical research. The diagnosis of acute coronary events in patients with diabetes is often challenging because of the high prevalence of silent ischaemia in these subjects. All acute cardiac events need to be promptly treated and myocardial reperfusion attempted without delay. Maintaining glucose levels as close to normal as possible, during and shortly after an acute event, improves prognosis in patients with diabetes. Risk factor control remains the cornerstone of secondary prevention; beta-blockers, ACE-inhibitors and antiplatelet agents confer additional symptomatic and survival benefit. Similar therapeutic principles also apply to patients with type 1 diabetes. This article addresses the complex problem of managing patients with diabetes and coronary artery disease.

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The Prevalence of Silent Ischemia in Turkish Patients with Type 2 Diabetes Mellitus

Cardiovascular disease (CVD) is the major cause of death in patients with type 2 diabetes mellitus. However, the diagnosis of CVD is delayed due to concealment of antecedent symptoms by factors such as autonomic neuropathy. In this study, we aimed to investigate the frequency of silent ischemia by using exercise electrocardiogram (ECG). The present study included 500 Turkish patients with type 2 diabetes (male/female: 222/278), who showed no evidence of CAD and angina pectoris or no sign(s) of ischemic changes in resting ECGs. All patients underwent treadmill exercise test according to Bruce protocol, and 62 cases (12.4%) exhibited abnormal changes. These patients identified by exercise ECG consisted of 28 males (28/222, [12.6%]) and 34 females (34/278, [12.2%]) and were then examined by coronary angiography. CAD was diagnosed in 53 individuals by coronary angiography. The abnormalities of exercise test are associated with the age of the patients or the duration of diabetes (p < 0.05). There is no significant difference in the severity of coronary disease or in the prevalence of silent ischemia between male and female patients. However, among the patients identified by exercise ECG females have higher body mass index than males, suggesting that obesity may represent the risk factor of CAD in women with type 2 diabetes.

Detection of Silent Myocardial Ischemia in Asymptomatic Diabetic Subjects

The DIAD study was designed to investigate the prevalence and predictors of silent ischemia, specifically in asymptomatic patients with type 2 diabetes (1), who often present with advanced coronary artery disease (CAD) without prior angina. The DIAD study did not compare the prevalence of asymptomatic CAD in diabetic and nondiabetic patients. Although the relative prevalence of asymptomatic CAD in nondiabetic patients otherwise well-matched for cardiac risk factors is of interest, it will require a much larger study. Bhalodkar and Blum (2) express concern that the prevalence of silent ischemia in DIAD might be overestimated. We believe this to be unlikely. All single-photon emission–computed tomography …

816-6 Prevalence of silent ischemia in diabetic patients with subclinical atherosclerosis: Detection by stress myocardial perfusion imaging

816-6 Prevalence of silent ischemia in diabetic patients with subclinical atherosclerosis: Detection by stress myocardial perfusion imaging

Silent Myocardial Ischemia

Silent myocardial ischemia is defined as objective documentation of myocardial ischemia in the absence of angina or anginal equivalents. Since its original description in the 1970s, it has undergone intensive investigation, and its clinical significance is now well established. This review will serve as an update on the pathophysiology, detection, prevalence, prognosis, and treatment of silent ischemia in both asymptomatic patients and those with angina, whether stable or unstable. ### Pain Studies No discussion of silent ischemia is complete without consideration of the cardiac pain mechanism. Although much has been learned about this subject, much is still uncertain. The afferent fibers that run in the cardiac sympathetic nerves are usually thought of as the essential pathway for the transmission of cardiac pain (Figure 1). The atria and ventricles are abundantly supplied with sympathetic sensory innervation; from the heart, the sensory nerve endings connect to afferent fibers in cardiac nerve bundles, which in turn connect to the upper 5 thoracic sympathetic ganglia and the upper 5 thoracic dorsal roots of the spinal cord. Within the spinal cord, impulses mediated by this sympathetic afferent route probably converge with impulses from somatic thoracic structures onto the same ascending spinal neurons. This would be the basis for cardiac pain referred to the chest, wall, arm, back etc. In addition to this “convergence-projection theory,” the contribution of vagal afferent fibers must be acknowledged for an explanation of cardiac pain referred to the jaw and neck. How these vagal fibers are activated remains unclear. Furthermore, somatic localization of ischemic pain cannot predict the site of myocardial ischemia (anterior, inferior, or lateral) from one patient to the next. Figure 1. Mechanisms of cardiac pain. From Droste and Roskamm (used with permission).4 The actual “trigger” that stimulates the sensory nerve endings remains elusive. If a chemical pain stimulus is involved, …

Arterial and cardiac aging: major shareholders in cardiovascular disease enterprises: Part I: aging arteries: a "set up" for vascular disease.

Our population is aging; in the United States today there are 35 million people 65 years of age or older. That number will double by the year 2030 (Figure 1). Although epidemiological studies have discovered that lipid levels, diabetes, sedentary lifestyle, and genetic factors are risk factors for coronary disease, hypertension, congestive heart failure, and stroke, the quintessential cardiovascular diseases within our society, advancing age unequivocally confers the major risk. The incidence and prevalence of these diseases increase steeply with advancing age (Figure 2). Not only does clinically overt cardiovascular disease increase dramatically with aging, but so do subclinical or occult diseases, such as silent coronary atherosclerosis. Figure 3 (top) shows that a substantial percentage of older, community-dwelling, otherwise healthy volunteers have evidence of inducible ischemia during combined thallium/ECG treadmill stress testing, and their prognosis is poor compared with their counterparts without subclinical coronary disease (Figure 3, bottom). Figure 1. The demographic imperative. Numbers of persons 65 years of age or older (light bars) and 85 years of age or older in the United States from 1900 through 2030. Data taken from the US Census Bureau data with projections for 2030. Figure 2. A, Prevalence of hypertension, defined as systolic blood pressure ≥140, diastolic blood pressure ≥90, or current use of medication for purposes of treating high blood pressure. Data are based on National Health and Nutrition Examination Survey III (1988–1991) (Burt VL, Whelton P, Roccella EJ, et al. Prevalence of hypertension in the US adult population: results from the Third National Health and Nutrition Examination Survey, 1988-1991. Hypertension . 1995;25:305–313). B, Incidence of atherothrombotic stroke (per 1000 subjects per year) by age in men (light bars) and women (dark bars) from the Framingham Heart Study. Data from Wolf PA. Lewis A. Conner lecture: contributions of epidemiology to the …

Exercise-Induced Silent Myocardial Ischemia in Master Athletes

High-physical activity levels are associated with reduced risk of symptomatic coronary artery disease (CAD). However, there are a number of reports of exercise-related sudden death and myocardial infarction in aerobically trained athletes. This study compared the prevalence of exercise-induced silent myocardial ischemia on maximum graded exercise tests with tomographic thallium scintigraphy in 70 master male athletes (63 ± 6 years, mean ± SD) (maximum aerobic capacity, V̇O 2max >40 ml/kg/min) and in 85 healthy untrained men (61 ± 7 years) with no history of CAD. The prevalence of silent ischemia (exercise-induced ST-segment depression on electrocardiogram and perfusion abnormalities on thallium scintigraphy) was similar in athletes and untrained men; 16% of the athletes (11 of 70) had silent ischemia compared with 21% of the untrained men (chi-square = 0.81, p = 0.36). No athletes had hyperlipidemia, systemic hypertension, or diabetes mellitus. However, the apolipoprotein E4 allele was present in 9 of the 11 athletes with silent ischemia compared with 2 of 32 athletes with normal exercise tests (chi-square = 24, p = 0.0001). These results suggest that older male athletes with the apolipoprotein E4 allele are at increased risk for the development of exercise-induced silent ischemia.

Mental status and pain perception during stressor tests in patients with coronary artery disease

Asymptomatic myocardial ischaemia is frequently observed in patients with coronary artery disease (CAD), both during daily life and during stressor tests. Psychological mechanisms seem to be involved in the lack of pain during myocardial ischaemia. The aim of this study was to verify in a selected population of CAD patients whether mental status might influence the pain perception during different stressor tests. The study population contained 73 male patients (mean age 52±8 years) with stable angina during daily life, reproducible exercise-induced myocardial ischaemia during ergometric stress test (EST) and angiographically documented CAD. All patients underwent cold pressor test (CPT), mental arithmetic stress test (MST), hyperventilation test (HT) and mental stress in association with cold pressor test (combined test, MST + CPT). During the stressor tests, myocardial ischaemia was induced in 15 73 (21%) patients by CPT, in 18 73 (25%) by MST, in 15 73 (21%) by HT and in 19 73 (26%) by MST + CPT. Out of the patients with stressor test-induced myocardial ischaemia, silent ischaemia was observed in 43 73 (59%) during EST, in 10 15 (67%) during CPT, in 16 18 (89%) during MST, in 7 15 (47%) during HT and in all patients during MST+CPT (100%). Among the ischaemic symptomatic patients during stressor tests, the lowest anginal pain intensity was experienced during MST (4.0±2.2) and the highest during EST, both at peak exercise and at the ischaemia threshold (6.6±2.9 and 5.9±2.7, respectively, p<0.05). During MST, the prevalence of silent ischaemia was higher than was observed during the other tests. All study patients remained asymptomatic when myocardial ischaemia was induced by MST + CPT. Even the intensity of CPT induced hand pain was significantly higher during CPT alone than during MST+CPT. These results confirm that mental status may influence pain modulation.

Valor diagnóstico do teste ergométrico na detecção da isquemia miocárdica silenciosa no paciente idoso com hipertensão sistólica

To evaluate the diagnosis value of exercise testing for silent myocardial ischemia in systolic hypertension of the elderly. We compared 110 patients with systolic hypertension (group A) with 104 patients without hypertension (group B). They were submitted to an exercise test according to the Bruce protocol, between January/91 to December/94. Exercise was discontinued if target heart rate was achieved, or fatigue, dyspnea, severe arrhythmia, hypotension or significant ST segment depression > or = 2 mm/0.2 mV developed. Exercise testing showed ischemic ST depression in 22 (20%) of the elderly patients with hypertension systolic and 12 (11.5%) of control elderly patients. The exercise time was shorter in the hypertensives 7.1 +/- 2.9 min vs 8.8 +/- 2.5 min. The ST depression was greater in the hypertensives than the control group: 2.5 +/- 0.8 min vs 1.9 +/- 0.4 min. Also the duration or ischemic ST depression was longer in the hypertensive patients than the control group 5.4 +/- 2.8 min vs 3.4 +/- 1.9 min. Elderly hypertensive patients with systolic hypertension have more silent myocardial ischemia than elderly without hypertension. Among the elderly hypertensive patients there was a prevalence of silent ischemia that was 1.7 times higher than in the normotensive elderlies (20% vs 11.5% P < 0.003).

Silent myocardial ischaemia in untreated essential hypertensives.

In hypertension, hypertrophy of the left ventricle might enhance the risk of ischaemia because of an augmented oxygen demand and an insufficient oxygen supply. The aims of the study were to estimate the prevalence of silent ischaemia in a group of untreated hypertensives with Holter monitoring and 3 different stress tests, and to look for a possible association between the presence of ischaemia and the blood pressure level as well as the left ventricular mass. The prevalence of silent ischaemia was tested in a group of 34 untreated hypertensives by Holter monitoring and by bicycle ergometer test, hyperventilation and captopril tests. 68% of the patients exhibited silent ischaemic periods during Holter monitoring. There was a trend towards a higher 24-hour SBP and DBP level in patients with ischaemia (p < 0.05), in addition to a tendency towards a higher catecholamine excretion in patients with ischaemia (p < 0.05), and a higher left ventricular mass (NS). Silent ischaemic episodes during ergometer exercise test were found in 27%. Only 3% had ischaemia during hyperventilation and captopril tests. In conclusion, the prevalence of ischaemia during the various stress tests was low, whereas Holter monitoring revealed signs of silent ischaemia in a substantial proportion of the patients. Patients with ischaemia tended to present more severe degrees of hypertension.

The Tromsø study: the prevalence of exercise-induced silent myocardial ischaemia and relation to risk factors for coronary heart disease in an apparently healthy population.

A random population sample of 294 men and 312 women aged 20-64 years, all apparently healthy, were examined following a screening to determine the prevalence of silent ischaemia and its relations to coronary risk factors. Based on exercise testing, the prevalence of silent ischaemia was 2.5% in men and 3.4% in women. In men, silent ischaemia was positively related to systolic blood pressure (P less than 0.001). The other risk factors did not show any significant associations with silent ischaemia. However, the men with silent ischaemia had a higher coronary heart disease risk score, and a tendency towards more symptoms and signs suggesting a poorer health status than the other men and the women. In the 21 men classified as 'hypertensives', silent ischaemia was more common than in the normotensive men (14% versus 2%, P less than 0.001). No such difference was observed in women. In conclusion, silent ischaemia may be a sign of hypertension and a generally increased risk of coronary heart disease in men, but probably not in the majority of women. This further supports that exercise electrocardiography has no role in screening asymptomatic persons for coronary heart disease, probably with the exception of middle-aged men with an increased risk.

Silent ischaemia in diabetic men with autonomic neuropathy.

Autonomic neuropathy is associated with an increased incidence of silent myocardial infarction and sudden death. The purpose of this study was to investigate the prevalence of silent myocardial ischaemia in diabetic patients with autonomic neuropathy and without. Five standard autonomic function tests were performed on 41 men with diabetes: postural change in blood pressure, postural change in heart rate, heart rate response to deep breathing, heart rate response to Valsalva's manoeuvre, and blood pressure response to sustained handgrip. There were 17 patients with autonomic neuropathy (group A) and 24 with normal autonomic function (group B). All patients underwent 24 hour ambulatory electrocardiographic monitoring to detect silent ischaemia. There was no significant difference in risk factors for coronary artery disease or history of angina pectoris between these groups. The prevalence of silent ischaemia was 64.7% in group A (95% confidence interval (95% CI) 38.33 to 85.79%) and 4.1% in group B (95% CI 0.11 to 21.12%). This represents a relative risk of 42.2 (95% CI 4.5 to 39.4, p less than 0.001). These results are consistent with the concept that autonomic neuropathy may prevent the development of anginal pain and thus obscure the presence of ischaemic heart disease. Twenty four hour ambulatory electrocardiographic monitoring may identify a subgroup of diabetic patients with autonomic neuropathy who have myocardial ischaemia and to whom treatment may be offered.

Prevalence of silent ischemia. Myocardial hypertrophy and LV systolic dysfunction in asymptomatic insulin dependent diabetic patients with and without nephropathy

Prevalence of silent ischemia. Myocardial hypertrophy and LV systolic dysfunction in asymptomatic insulin dependent diabetic patients with and without nephropathy

Prevalence of silent ischemia during holter monitoring in diabetic versus non-diabetic patients with stable angina

Prevalence of silent ischemia during holter monitoring in diabetic versus non-diabetic patients with stable angina

Exercise-induced silent ischemia: Age, diabetes mellitus, previous myocardial infarction and prognosis

The purposes of this study were 1) to determine the prognosis of silent ischemia in an unselected group of patients referred for exercise testing, and 2) to assess whether age or the presence of myocardial infarction or diabetes mellitus influences the prevalence of silent myocardial ischemia during exercise testing.The design was retrospective, with a 2 year mean follow-up period. The study group consisted of 1,747 predominantly male in-patients and outpatients referred for exercise testing at a 1,200 bed Veterans Administration hospital. The main result was that the mortality rate was significantly greater (p = 0.02) among patients with abnormal ST segment depression than in patients without ST depression. The presence or absence of angina pectoris during exercise testing was not significantly related to death. The prevalence of silent ischemia was not significantly different among patients categorized according to myocardial infarction or diabetes mellitus status, but was directly related to age.It is concluded that, in patients with an ischemic ST response to exercise testing, the presence or absence of angina pectoris during the test does not alter the risk of death. The prevalence of silent ischemia during exercise testing is not statistically different among patients with recent, past or no myocardial infarction or with insulin-dependent or noninsulin-dependent diabetes mellitus.