A recent study by Moss et al1 in which the authors evaluated in 966 patients discharged from the coronary care unit, the role of exercise ECG, exercise 201Tl myocardial perfusion imaging, and ambulatory (Holter) ECG recording in detecting silent myocardial ischemia 1 to 6 months after discharge has called into question the prognostic usefulness of stress testing and detection of myocardial ischemia after infarction. The authors noted that the presence of ST-segment depression on the exercise ECG failed to predict recurrent ischemic events. A positive exercise 201Tl myocardial stress test had only a borderline significant effect in predicting ischemic events. The difference between patients with and those without a positive exercise 201Tl stress test was not, however, evident for several years. Similarly, the ambulatory (Holter) ECG used to detect silent myocardial ischemia failed to predict recurrent myocardial infarction. The investigators, however, did note that patients with an exercise duration of <6 minutes and ST-segment depression had a relatively high, threefold to fourfold, incidence of recurrent ischemic events and that those with redistribution of myocardial 201Tl on exercise testing who also had increased lung uptake of 201Tl—suggesting multivessel coronary artery disease, compromised left ventricular function, or both—were at increased risk for recurrent ischemic events. However, these high-risk subsets comprised <3% of the patients studied and accounted for <6% of the recurrent ischemic events. The authors concluded that detection of silent or symptomatic myocardial ischemia by noninvasive testing in stable patients 1 to 6 months after an acute coronary event is not useful in identifying patients at increased risk for subsequent coronary events. Exercise ECG stress testing in patients treated with thrombolytic therapy after infarction also has been shown to have only limited value in identifying patients at risk for recurrent ischemic events.2 In a …