Silent Myocardial Ischemia Research Articles

Performance of the 2019 ESC/EASD guideline strategy for the screening of silent coronary artery disease in patients with diabetes

BackgroundThe 2019 guidelines for cardiovascular risk stratification by the European Society of Cardiology and European Association for the Study of Diabetes (ESC-EASD) suggested screening for silent coronary disease in very high risk patients with severe target organ damage (TOD) (i.e. peripheral occlusive arterial disease or severe nephropathy) or high coronary artery calcium (CAC) score. This study aimed to test the validity of this strategy.MethodsIn this retrospective study, we included 385 asymptomatic patients with diabetes and no history of coronary disease but with TOD or ≥ 3 risk factors in addition to diabetes. CAC score was measured using computed tomography scan and a stress myocardial scintigraphy was performed to detect silent myocardial ischemia (SMI), with subsequent coronary angiography in those with SMI. Various strategies to select patients to be screened for SMI were tested.ResultsCAC score was ≥ 100 Agatston units (AU) in 175 patients (45.5%). SMI was present in 39 patients (10.1%) and among the 30 patients who underwent angiography, 15 had coronary stenoses and 12 had a revascularization procedure. The most effective strategy consisted in performing myocardial scintigraphy in the 146 patients with severe TOD and, among the 239 other patients without severe TOD, in those with CAC ≥ 100 AU: this strategy provided 82% sensitivity for SMI diagnosis, and identified all the patients with stenoses.ConclusionThe ESC-EASD guidelines suggesting SMI screening in asymptomatic patients with very high risk assessed by severe TOD or high CAC score appears effective and could identify all the patients with stenoses eligible for revascularization.

Glial cell activity in cardiovascular diseases and risk of acute myocardial infarction

Growing evidence indicates that the pathophysiological link between the brain and heart underlies cardiovascular diseases, specifically acute myocardial infarction (AMI). Astrocytes are the most abundant glial cells in the central nervous system and provide support/protection for neurons. Astrocytes and peripheral glial cells are emerging as key modulators of the brain-heart axis in AMI, by affecting sympathetic nervous system activity (centrally and peripherally). This review, therefore, aimed to gain an improved understanding of glial cell activity and AMI risk. This includes discussions on the potential role of contributing factors in AMI risk, i.e., autonomic nervous system dysfunction, glial-neurotrophic and ischemic risk markers [glial cell line-derived neurotrophic factor (GDNF), astrocytic S100 calcium-binding protein B (S100B), silent myocardial ischemia, and cardiac troponin T (cTnT)]. Consideration of glial cell activity and related contributing factors in certain brain-heart disorders, namely, blood-brain barrier dysfunction, myocardial ischemia, and chronic psychological stress, may improve our understanding regarding the pathological role that glial dysfunction can play in the development/onset of AMI. Here, findings demonstrated perturbations in glial cell activity and contributing factors (especially sympathetic activity). Moreover, emerging AMI risk included sympathovagal imbalance, low GDNF levels reflecting prothrombic risk, hypertension, and increased ischemia due to perfusion deficits (indicated by S100B and cTnT levels). Such perturbations impacted blood-barrier function and perfusion that were exacerbated during psychological stress. Thus, greater insights and consideration regarding such biomarkers may help drive future studies investigating brain-heart axis pathologies to gain a deeper understanding of astrocytic glial cell contributions and unlock potential novel therapies for AMI.

СЛУЧАЙ ПРЕХОДЯЩЕЙ БЕЗБОЛЕВОЙ ИШЕМИИ МИОКАРДА У ПАЦИЕНТА С ТУБЕРКУЛЕЗОМ ЛЕГКИХ И СОПУТСТВУЮЩИМ САХАРНЫМ ДИАБЕТОМ I ТИПА

The article describes a clinical observation of a patient with concomitant pulmonary TB, type I diabetes mellitus and silent myocardial ischemia (SMI). The results of a diagnostic search and successful drug therapy of SMI in a phthisiology department are represented. Possibilities of electrocardiographic diagnostics, classification, treatment tactics, and prognosis of SMI are discussed.

Математическая модель прогнозирования риска аспиринорезистентности и сердечно-сосудистых осложнений у пациентов с ИБС после коронарного шунтирования

Математическая модель прогнозирования риска аспиринорезистентности и сердечно-сосудистых осложнений у пациентов с ИБС после коронарного шунтирования

Silent myocardial ischemia revisited, another silent killer, emphasis on the diagnostic value of stress echocardiography with focused update and review

Silent myocardial ischemia revisited, another silent killer, emphasis on the diagnostic value of stress echocardiography with focused update and review

Comparison of left ventricular global longitudinal strain by speckle tracking echocardiography in patients with and without diabetes mellitus asymptomatic for coronary artery disease at a tertiary hospital in Nepal

Background: Diabetes mellitus is a major risk factor for cardiovascular events. A significant proportion of diabetics are asymptomatic for ischaemic heart disease either because of the early stage of ischaemia or silent myocardial ischaemia. Global longitudinal strain (GLS) of the left ventricle measured by speckle tracking echocardiography (STE) is a novel method of detecting left ventricular dysfunction due to myocardial ischaemia. Objectives: This study aimed to compare the GLS of type-2 diabetes mellitus (T2DM) and non-diabetic patients who were asymptomatic for coronary artery disease (CAD). Methods: An analytical cross-sectional study was conducted among 52 diabetic and 49 non-diabetic individuals asymptomatic for CAD presenting to a tertiary hospital, between 2022 September to 2022 October. The STE was performed to measure left ventricular GLS of the participants. Their blood and urine samples were sent for measuring glycosylated haemoglobin (HbA1c), total cholesterol, and microalbuminuria. Data were entered and analysed using SPSS v23. Results: Twenty-five (48.1%) diabetics had left ventricular dysfunction (GLS ?18) compared to two (4.1%) non-diabetics. GLS was significantly lower among the diabetic patients, and exhibited significant inverse correlation with the duration of diabetes, age, HbA1c, and microalbuminuria (p <0.001). In multiple linear regression model for GLS, only the duration of diabetes (B = -0.27, p <0.001) and the age of patients (B = -0.057, p = 0.004) retained statistical significance, after adjusting for other covariates. Conclusion: Left ventricular GLS has a significant negative correlation with the duration of diabetes and age of the patients.

Utility of screening for silent myocardial ischaemia in diabetes with an annual electrocardiogram.

Asymptomatic coronary artery disease (CAD) is common in people with diabetes mellitus, but there is a lack of consensus regarding appropriate screening for the condition. We performed a 12-lead electrocardiogram (ECG) on 312 consecutive participants with diabetes mellitus attending for routine annual outpatient review in order to determine the effectiveness of a yearly ECG in screening people with diabetes for asymptomatic CAD. Three of 312 participants (0.96%, 95% CI 0.2%-2.78%) had a newly identified ECG abnormality. One person had newly discovered atrial fibrillation. Two people had abnormalities which prompted further investigation for asymptomatic CAD. One of these participants underwent percutaneous coronary intervention. Seventeen further participants had abnormalities on ECG which had been previously documented, the majority having been present since their diagnosis of diabetes. A low positive yield of routine annual ECG in our study does not support its use as a screening tool for asymptomatic CAD in diabetes. Our findings support advice to perform an ECG at diagnosis of diabetes and to repeat only if a person develops relevant symptoms.

PSUN157 SILENT MYOCARDIAL ISCHEMIA IN ELDERLY DIABETIC PEOPLE IN GOOD PHYSICAL CONDITION AND CARDIORESPIRATORY FITNES

Abstract Every year, the INAPAM (National Institute for Elderly People, in México) hosts a "mini olympic games" event with accesible adaptation exercises. In preparing for such "games" the public health institutions hold medical exams to all participants to reduce the risk of any injuries. This study reports the data found on the medical exams performed in one of aforementioned institution. (Pensiones Civiles del Estado de Chihuahua). The medical exams were performed on 46 women and 16 men with an average age of 67 (60 to 79 years of age) including medical history, physical examination and laboratory exams. The subjects were part of a no medical supervising cardiorespiratory fitnes program. The effort perceived during the walking was 4 on the VAS scale (Visual Analogue Scale). We found 29 (46.7%) persons with high blood pressure (BP), 25 (40.3%) with diabetes, 20 (32.3%) smokers, and 15 (24.1%) with hypercholesterolemia. We found on electrocardiogram (EKG) inespecific abnormalities in 24 patients (38.7%), left bundle branch block in 25 patients (40.3%) and left ventricular hypertrophy in 13 patients (20.9%). In 10 persons with high BP did not tolerate to be in guideline target. In 9 diabetic persons had acceptable glycemic levels but slightly elevated A1Cs (glycated hemoglobin). These patients with high BP and diabetes were the older ones in the group. In medical histories of the group it was found, that more than 60% of their doctor's visits the persons were on target lipid levels. On ecocardiogram, ventricular hypertrophy was found in 49 (79%) persons, dyastolic dysfunction in 45 (72%), insignificant valve abnormalities in 50 (80.6%) and no body with wall motion abnormalities of the left ventricle. The stress test reported good physical capability on all persons but was positive with no symptoms in 4 (6.4%). These 4 patients were diabetic and older than 75 years of age. Coronariography was performed on these 4 patients, 3 of whom had revascularization surgery and 1 had a coronary angioplasty. Among of them 4, one who has won first place in these "mini olympic games" previosly. The silent myocardial ischemia reported was similar as in the general literature, depending on the number of risk factors. An altered treshold in the perception of cardiac ischemic pain between diabetic patients and older age patients is to be considered. Due to the persons's cardiovascular fitnes as being part of the walking training program, their BP and heart rates, we thought, contributed to the lack of cardiac ischemic pain. These study is one of the first to report silent myocardial ischemia in people with very good physical and cardiorespiratory fitnes. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Low Levels of Vitamin D and Silent Myocardial Ischemia in Type 2 Diabetes: Clinical Correlations and Prognostic Significance.

Vitamin D deficiency has a pathogenetic and prognostic role in coronary artery disease and a key role in pain transmission. Diabetic patients have a higher risk of silent myocardial ischemia (SMI) due to diabetic neuropathy. We evaluated the correlation between SMI and Vitamin D serum levels in type 2 diabetic patients and assessed whether SMI patients had a worse survival rate than their symptomatic counterpart. We enrolled 253 patients admitted in our Cardiology Unit and compared them with 50 healthy volunteers. We created three sub-groups: symptomatic MI group (125, 32.4%); SMI group (78, 25.7%), and no-MI group (50, 41.9%). 25(OH)D levels (nmol/L) were lower in the SMI group (34.9 ± 5.8) compared to those in the symptomatic MI (49.6 ± 6.1; p = 0.01), no MI (53.1 ± 6.2; p = 0.001), and control groups (62.1 ± 6.7; p = 0.0001). 25(OH)D levels predicted SMI in diabetic patients, with an inverted odds ratio of 1.11 (p = 0.01). Symptomatic MI group survival was higher than the SMI one (6-year survival rate: 83 vs. 69%; p = 0.01). Diabetic patients with SMI had a higher mortality risk and showed lower 25(OH)D levels than the symptomatic group. This suggests the crucial role that vitamin D has in the pathogenesis of SMI.

Quality of life of patients with coronary heart disease treated with the bioresorbable vascular scaffold (ABSORB™): 2-year results from the GABI-R-registry

BackgroundNumerous studies have reported clinical endpoints following coronary revascularization using bioresorbable vascular scaffolds (BVS), while information about the impact on health-related quality of life is sparse. In this analysis of the German-Austrian ABSORB RegIstRy, the 2 year results concerning quality of life development in a large cohort of patients treated with BVS were reported.MethodsData were collected at baseline as well as 30 days, 6 and 24 months after coronary revascularization using BVS. The EQ-5D score, EQ visual analogue scale (VAS) and Seattle Angina Questionnaire (SAQ) were determined for each time point. Patients were categorized according to the indication for coronary revascularization [acute coronary syndrome (ACS), stable angina pectoris (SAP), silent myocardial ischemia (SMI), or other]. Binary logistic regression analysis was performed to determine factors that predict above-average scores two years after implantation.ResultsData from 1317 patients in 88 centres were included. Reasons for revascularization were: ACS (n = 643), SAP (n = 443), SMI (n = 52), and other (n = 179). Mean EQ-5D was significantly increased after six months, while a value comparable to baseline was found two years after implantation. EQ VAS and four of five dimensions of SAQ were significantly improved over baseline at all follow-up surveys. Particularly strong improvements were seen in SAQ scores angina frequency and quality of life. Binary regressions showed different statistically significant predictors in the respective models.ConclusionsFollowing coronary revascularization with BVS strong decrease in self-reported angina frequency and increase of self-reported quality of life were observed with continuous improvements over two years of follow-up.Trial registration ClinicalTrials.gov Identifier: NCT02066623.

Is the Calcium Score Useful for Rheumatoid Arthritis Patients at Low or Intermediate Cardiovascular Risk?

Cardiovascular disease, particularly myocardial infarction, is the leading cause of death of rheumatoid arthritis (RA) patients. The usefulness of the coronary artery calcification score (CACS), determined using cardiac computed-tomography (CT)-scan images, was assessed as a part of a cardiovascular work-up of RA patients at low or intermediate cardiovascular disease risk. This descriptive, cross-sectional, single-center study was conducted on patients with stable RA or that which is in remission. Each patient’s work-up included a collection of cardiovascular risk factors, laboratory analyses, an electrocardiogram, a supra-aortic trunks (SATs) echo-Doppler test and a cardiac CT scan. The primary endpoint was to determine the frequency of patients with a CACS > 100, indicating notable atherosclerosis. Fifty patients were analyzed: mean ± standard deviation age was 53.7 ± 7.5 years, 82% women. The CACS exceeded 100 in 12 (24%) patients (11 were at intermediate risk) and 2 of them underwent angioplasty for silent myocardial ischemia. Cardiovascular risk was reclassified from intermediate to high for 5 patients. Age according to sex and smoking status were significantly associated with that increase; no association was found with RA characteristics or treatments.

Caractéristiques des douleurs thoraciques au cours des syndromes coronariens aigus vus au service de cardiologie de Befelatanana (Madagascar)

IntroductionChest pain is one of the different elements of orientation for the diagnosis of acute coronary syndrome. Sometimes its clinical presentation is misleading. The objective of this study was to describe the characteristics of chest pain during an acute coronary syndrome in the cardiology department of the Joseph Raseta Befelatanana University Hospital Center, Antananarivo, Madagascar. MethodsWe carried out a cross-sectional, descriptive study of 10 months from January 2019 to October 2019. All patients diagnosed with acute coronary syndrome during this period were included. ResultsSixty-five cases were included. A “typical chest pain” was only encountered in 7.7% of cases. Advanced age (p = 0.04) and sedentary lifestyle (p = 0.03) were associated with the occurrence of silent myocardial ischemia, and. hypertension with a prolonged duration (≥15 minutes) of chest pain (p = 0.03). Dyslipidemia was associated with atypical irradiation of chest pain (p = 0.003). Alcoholism had an impact on pain triggered by effort (p = 0.01) and relieved by rest (p = 0.04). ConclusionThe current symptomatology of acute coronary syndrome is increasingly atypical. Knowledge of the factors that can influence the different characteristics of chest pain could serve as a benchmark in clinical practice in our population.

Myocardial perfusion imaging single photon emission computed tomography may detect silent myocardial ischemia in patient with epilepsy.

The aim of the present study was to compare the myocardial perfusion imaging (MPI) with [99mTc]tetrofosmin stress - rest single-photon emission computer tomography (SPECT) of patients with epilepsy with matched control individuals. All 29 adult epileptic patients were receiving antiepileptic drugs (AEDs) for epilepsy. Thirty-two individuals matched for gender and age consisted of the control group. MPIs SPECT were performed, and myocardial summed scores were obtained during stress (SSS) and rest (SRS) images. Abnormal MPI was considered when SSS was ≥ 4. In addition, the difference (SDS) between SSS and SRS was also assessed, which represents a rate of reversibility after stress. Twenty of 29 (68.97%) patients with epilepsy had abnormal MPI and 14/32 (43.75%) of the controls (p = 0.04). Among males, 18/23 patients and 11/25 controls had abnormal MPI (p = 0.01), with quite a significant difference for mean SSS between male patients and controls (p = 0.002). Furthermore, SDS comparison showed that irreversible abnormalities were more common in patients than in control individuals. A difference of inadequately compensated myocardial ischemia between patients treated with enzyme inducing AEDs and patients treated with valproic acid was also detected. Single-photon emission computer tomography (SPECT) may detect increased risk for coronary artery disease and further cardiovascular events in patients with epilepsy. Our findings favor the conclusion that SPECT could be used for the early identification of cardiovascular comorbidity in epilepsy.

ОДНОФОТОННАЯ ЭМИССИОННАЯ КОМПЬЮТЕРНАЯ ТОМОГРАФИЯ В ПРОБАХ С ФИЗИЧЕСКОЙ НАГРУЗКОЙ ПРИ БЕЗБОЛЕВОЙ ИШЕМИИ МИОКАРДА

Abstract. Introduction. In the diagnosis of silent myocardial ischemia, single-photon emission computed tomography is of great importance. One of the methods for detecting silent myocardial ischemia is the assessment of its perfusion. For this, single-photon emission computed tomography is considered to be a highly sensitive method. It is the "gold standard" in the diagnosis of transient myocardial ischemia due to both coronary and non-coronary causes. Aim. The aim of the study was to analyze the data of single-photon emission computed tomography at rest and after a stress test in patients with silent myocardial ischemia and the usual form of angina pectoris. Material and methods. 78 case histories of patients with silent and ordinary myocardial ischemia were analyzed. Bicycle ergometry was used as a stress test. The dynamics of perfusion, contractility and electrocardiographic picture were evaluated. Statistical analysis was carried out using parametric and nonparametric criteria. Results and discussion. Patients with silent myocardial ischemia are significantly less likely to undergo coronary stenting and coronary bypass grafting compared to the group with typical angina pectoris. The most common reason for stopping the exercise test in the group with silent myocardial ischemia is ST depression, which occurs 6 times more often than in patients with the usual form of angina. In the group with silent myocardial ischemia, a decrease in myocardial contractility is observed 20% more often, 2.5 times less often there are ventricular extrasystole, 3 times more often there is a hypertonic type of reaction to physical activity than in patients with the usual form of angina pectoris. Conclusion. Single photon emission computed tomography using stress tests reveals differences in patients with silent and ordinary forms of myocardial ischemia.

Chronic kidney disease is a key predictive factor for potential myocardial ischaemia and poor prognosis in asymptomatic patients with diabetes mellitus

Some asymptomatic patients with diabetes mellitus (DM) have critical coronary artery disease (CAD), although the guidelines do not recommend aggressive screening for CAD in asymptomatic patients. Chronic kidney disease (CKD) is among the serious co-morbidities of severe systemic atherosclerosis. Thus, CKD may be associated with potential myocardial ischaemia. Therefore, the present study aimed to determine the impact of CKD on the incidence of silent myocardial ischaemia (SMI) and the long-term outcomes in asymptomatic patients with DM. This study investigated 461 consecutive patients with DM. All patients who were asymptomatic and self-sufficient in daily life underwent the ergometer exercise (ERG) test. Coronary angiography was performed if the stress test was positive, or if the patient did not achieve 90% of the target heart rate. The primary end point included major adverse cardiac and cerebrovascular events (MACCE) including death, non-fatal myocardial infarction and stroke. The median follow-up duration after study enrolment was 35 months for the entire cohort of 461 patients. Eighty-one patients were diagnosed with SMI. The estimated glomerular filtration rate was significantly lower in the SMI group (70.5 ± 23.8 vs. 81.8 ± 30.0 mL/min/1.73 m2, P < 0.001). SMI occurred more frequently in patients with advanced CKD [27/103, (26.2%) in stages 3–5], whereas only 5/68 (7.3%) patients without CKD, 13/81 (16.0%) patients with stage 1 CKD and 36/209, (17.2%) in stage 2, had SMI. The Kaplan–Meier curves revealed that, patients with SMI had poor clinical outcomes (log-rank: P = 0.016). The incidence of MACCE (log-rank: P = 0.009) was higher in patients with severe CKD > stage 3a in the SMI subgroup. Urinary albumin (mg/gCr) was associated with MACCE in the SMI subgroup [HR 3.37, 95%CI (1.170–9.521), P = 0.025] after adjusting for age, sex, and conventional risk factors. SMI was more prevalent in patients with CKD and the incidence was proportional to the CKD stage in asymptomatic patients with DM. Those Patients with CKD and SMI exhibited poor clinical outcomes. CKD may be a key factor for the identification and management of SMI in asymptomatic patients with DM in routine clinical practice.Trial Registration: UMIN000038340.

Multi-Modality Imaging for Prevention of Coronary Artery Disease and Myocardial Infarction in the General Population: Ready for Prime Time?

Cardiovascular disease (CVD) remains a leading cause of death and disability worldwide. Acute myocardial infarction (AMI) causes irreversible myocardial damage, heart failure, life-threatening arrythmias and sudden cardiac death (SCD), and is a main driver of CVD mortality and morbidity. To control the forecasted increase in CVD burden for both the individual and society, improved strategies for the prevention of AMI and SCD are required. Current prevention of AMI and SCD is directed towards risk-modifying interventions, guided by risk assessment using clinical risk prediction scores (CRPSs) and the coronary artery calcium score (CACS). Early detection of more advanced coronary artery disease (CAD), beyond risk assessment by CRPSs or CACS, is a promising strategy to allow personalized treatment for the improved prevention of AMI and SCD in the general population. We review evidence for further testing, beyond CRPSs and CACS, and therapies focusing on promising targets, including subclinical obstructive CAD, high-risk plaques, and silent myocardial ischemia. We also evaluate the potential of multi-modality imaging to enhance the conduction of adequately powered trials to provide high-quality evidence on the impact of add-on tests and therapies in the prevention of AMI and SCD in asymptomatic individuals. To conclude, we discuss the occurrence of AMI and SCD in individuals currently estimated to be at “low-risk” by the current strategy based on CRPSs, and methods to improve prevention of AMI and SCD in this “low-risk” population.

Silent Myocardial Ischemia in Patients after Permanent Coronary Intervention

Frequency and timing of appearance of myocardial ischemia, including silent ischemia, were analyzed in published scientific sources. Silent myocardial ischemia is risk factor for stent restenosis after percutaneous coronary interventions. Patients with silent ischemia lack clinical symptoms while perfusion, metabolic and electrical activity of their myocardium may be compromised. These patients do not have warning clinical symptoms during physical exercise and do not stop inappropriate activity. Silent myocardial ischemia itself can indicate severity of atherosclerosis in coronary arteries. High probability of stent restenosis can be assessed by exercise tests prior to coronary angiography. These tests also allow to reveal clinically silent myocardial ischemia. Quarter of patients after coronary intervention develop silent myocardial ischemia. Silent myocardial infarction comprises 22-78 % of all infarctions after coronary interventions. Exercise tests based on single-photon emitting computed tomography can be used in diagnosing stent restenosis, silent ischemia and assessment of cardiovascular risk in patients after coronary interventions. Its results can be used as indications for repeated coronary interventions and for prognosis after revascularization. Exercise tests are recommended in two years after revascularization in absence of ischemic symptoms. Early tests are recommended in cases of high cardiovascular risk, suboptimal revascularization, stenting of arteries with small diameter or at bifurcation. Diagnosis of silent myocardial ischemia by single-photon emitting computed tomography in patients after coronary revascularization is significant for clinical practice.

Optimising screening of intermediate to high-risk asymptomatic sportsmen with exercise electrocardiogram. The SEEPRED study

Abstract Funding Acknowledgements Type of funding sources: None. Background The importance of exercise electrocardiogram (ECG) is still controversial in the prevention of cardiovascular events among sportsmen. The aim of this study was to assess the relevance of exercise ECG as a significant prognostic marker for cardiovascular events when any CVD risk factors are present. Methods The SEEPRED cohort study included leisure time asymptomatic sportsmen over 35 years old, referred from 2011 to 2016 in the Sports Medicine Unit of our university hospital. Major adverse cardiovascular events (MACE) and atrial fibrillation were collected 5 years after exercise ECG using a phone questionnaire. Multivariate logistic regression models were performed to predict positive exercise ECG, suspected and confirmed silent myocardial ischemia (SMI) and cardiovascular events. Results Of the cohort of 2457 sportsmen (1898 men; mean age 50.2 ± 9.4 years; physical activity level 29.4 ± 25.1 MET-h/week), 1482 (60%) had at least one cardiovascular disease (CVD) risk factor and 52 (2%) had a SCORE&amp;gt;5%. A total of 256 exercise ECGs (10%) were defined as positive, most of them due to SMI (n = 196; 8%). SMI was an indication for coronary angiography in 43 cases, leading to 33 documented SMIs (1%), including 23 significant stenoses requiring revascularization. In multivariate logistic regression analysis, having at least 2 CVD risk factors was independently associated with (1) positive exercise ECG [OR=1.80 (CI 95%: 1.29-2.52), p=0.0006], with (2) suspected SMI [OR=2.57 (CI 95%: 1.10-6.02), p=0.0304], with (3) confirmed SMI [OR=8.20 (CI 95%: 3.46-19.46), p&amp;lt;0.0001] and with (4) cardiovascular events (MACE or atrial fibrillation) [OR=6.95 (CI 95%: 3.49-13.81), p&amp;lt;0.0001]. Conclusions The study supports the European recommendations for the use of exercise ECG in evaluation of asymptomatic leisure time sportsmen over 35 years. Having at least 2 CVD risk factors was the best predictors for presence of coronary lesions at risk for events.

Unusual syncope due to silent coronary vasospasm: a case description and an overview of coronary vasospasm

Variant angina is a condition triggered by the transient vasospasm of epicardial coronary arteries, which usually causes chest pain episodes and may be associated with dangerous arrhythmias. Among patients with coronary artery vasospasm, a non-negligible subset experiences silent myocardial ischemia, defined as the objective documentation of myocardial ischemia in the absence of angina or anginal equivalents. This condition is associated with the increased cardiac mortality and incidence of acute cardiac events. Herein, we described the case of a 65-year-old man who was admitted to our Emergency Department (ED) for syncope. He reported palpitations before the event but did not complain of chest pain. Baseline electrocardiogram (ECG) showed that troponin values of biphasic T waves in V2-V6 were normal. The patient was admitted to our coronary care unit (CCU) for monitoring. Immediately after hospital admission, he developed dynamic ST segment elevation and non-sustained polymorphic ventricular tachycardia, being symptomatic only for palpitations. Both ECG abnormalities and symptoms quickly resolved after the administration of intravenous nitrates and oral calcium channel blockers. Coronary angiography showed a critical non-occlusive fixed stenosis at the proximal right coronary artery (RCA). The lesion was treated by angioplasty and stenting, and the patient was discharged on dual antiplatelet therapy, statins and oral high-dose calcium-channel antagonist.

SILENT MYOCARDIAL ISCHEMIA AMONG ASYMPTOMATIC TYPE-2 DIABETIC PATIENTS

Objective: To determine the frequency of silent myocardial ischemia among asymptomatic type-2 diabetes mellitus patients. Methodology: This was a Cross sectional descriptive study conducted, after approval from the institutional ethical and research committee. A total of 90 asymptomatic type-2 diabetic patients were recruited for the present study. After informed written consent participants were subjected to a symptom-limited exercise tolerance test to detect the presence of silent myocardial ischemia. Descriptive statistics were applied to find frequencies and percentages for qualitative variables, and mean and standard deviation was used for quantitative variables. SPSS version22 was used for data analysis. Results: Among 90 type-2 asymptomatic diabetic patients, the frequency of silent myocardial ischemia was 36.7% (n=33). The frequency of silent myocardial ischemia among males and females was 57.6% and 42.4% respectively. Frequency of silent myocardial ischemia was found significantly more among patients with family history of CAD (60.6% vs 39.4%; p=0.029), prolonged duration of diabetes (15.2% vs 22.2% vs 63.6%; p=0.026) and group of patients with older age (9% vs 39.4 vs 51.6%; p=0.034). With respect to hypertension, smoking, obesity, and gender didn’t show statistically significant variation in the occurrence of silent myocardial ischemia. Conclusion: More than one third patients of asymptomatic type-2 diabetes mellitus had silent myocardial ischemia. Those with a family history of CAD, prolonged duration of diabetes, and participants with older age were more at risk of underlying silent myocardial ischemia.