 |
|
Detection and Significance of Myocardial Ischemia in Stable Patients After Recovery From an Acute Coronary Event
Arthur J. Moss, MD;
Robert E. Goldstein, MD;
W. Jackson Hall, PhD;
J. Thomas Bigger, Jr, MD;
Joseph L. Fleiss, PhD;
Henry Greenberg, MD;
Monty Bodenheimer, MD;
Ronald J. Krone, MD;
Frank I. Marcus, MD;
Frans J. Th. Wackers, MD;
Jesaia Benhorin, MD;
Mary W. Brown, RN, MS;
Robert Case, MD;
James Coromilas, MD;
Edward M. Dwyer, Jr, MD;
John A. Gillespie, MD;
John J. Gregory, MD;
Robert Kleiger, MD;
Edgar Lichstein, MD;
John O. Parker, MD;
Richard F. Raubertas, PhD;
Shlomo Stern, MD;
Dan Tzivoni, MD;
Lucy Van Voorhees, MD;
the Multicenter Myocardial Ischemia Research Group;
G. Krasicky;
R. Shah;
J. Walroth;
A. Greengart;
M. Moriel;
T. Challis;
D. Blood;
L. Rolnitzky;
G. DePuey;
L. Kuller;
C. Odoroff;
R. Schwartz;
R. Annechiarico;
M. Andrews;
P. Severski;
G. Ma;
J. Edwards;
K. Fischer;
K. Freedland;
L. Cobb;
J. Korsten;
W. Williams;
S. Algeo;
P. Chandysson
JAMA. 1993;269(18):2379-2385.
Abstract
| |
Objective.
—To determine the clinical significance of silent and symptomatic myocardial ischemia detected by noninvasive testing in stable postcoronary patients.
Design.
—Cohort study with a mean 23-month follow-up.
Setting.
—Ambulatory outpatients after recent hospitalization for an acute coronary event.
Patients.
—Nine hundred thirty-six patients (76% male; mean age, 58 years) who were clinically stable 1 to 6 months after hospitalization for acute myocardial infarction or unstable angina.
Interventions.
—Noninvasive testing involved rest, ambulatory, and exercise electrocardiograms and stress thallium-201 scintigraphy.
Main Outcome Measures.
—Cox regression analysis was used to evaluate the risk (hazard ratio) of first recurrent primary events (cardiac death, nonfatal infarction, or unstable angina) or restricted events (cardiac death or nonfatal infarction) associated with ischemic noninvasive test results.
Results.
—ST segment depression on the rest electrocardiogram was the only noninvasive test variable that identified a significantly increased risk (P=.05) for first recurrent primary events (hazard ratio; 95% confidence limits): rest electrocardiogram ST depression (1.5; 1.00,2.25); ambulatory electrocardiogram ST depression (0.86; 0.49,1.51); exercise electrocardiogram ST depression (1.13; 0.82,1.56); and stress thallium-201 reversible defects (1.3; 0.96,1.74). Test results were similar for first recurrent restricted events, and in patients with and without angina. Significantly increased risk (P<.05) was noted when exercise-induced ST depression occurred in patients who also had reduced exercise duration (hazard ratio, 3.4) or when reversible thallium-201 defects occurred in patients who also had increased lung uptake (hazard ratio, 2.8). Each high-risk subset made up less than 3% of the population and contained less than 6% of patients with first primary events.
Conclusion.
—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.
(JAMA. 1993;269:2379-2385)
Author Affiliations
| |
Malcolm Grow Air Force Hospital; Walter Reed Army Hospital, Bethesda, Md; Maimonides Medical Center, Brooklyn, NY; Bikur Cholim Hospital, Jerusalem, Israel; Kingston General Hospital, Kingston, Ontario; Columbia University; Roosevelt-St Luke's Hospital, New York, NY; University of Pittsburgh (Pa) School of Public Health; University of Rochester (NY) Medical Center; United Hospital, St Paul, Minn; Jewish Hospital, St Louis, Mo; Harborview Hospital, Seattle, Wash; Overlook Hospital, Summit, NJ; University of Arizona Medical Center; St Mary's Hospital, Tucson; Washington (DC) Hospital Center
From the University of Rochester (NY) Medical Center (Drs Moss, Hall, and Raubertas and Ms Brown); Uniformed Services University of the Health Sciences, Bethesda, Md (Dr Goldstein); College of Physicians and Surgeons, Columbia University, New York, NY (Drs Bigger, Fleiss, and Coromilas); Roosevelt-St Luke's Hospital, New York, NY (Drs Greenberg, Case, and Dwyer); Long Island Jewish Hospital, New Hyde Park, NY (Dr Bodenheimer); Jewish Hospital, St Louis, Mo (Drs Krone and Kleiger); University of Arizona Health Science Center, Tucson (Dr Marcus); Yale University School of Medicine, New Haven, Conn (Dr Wackers); Bikur Cholim Hospital, Jerusalem, Israel (Drs Benhorin, Stern, and Tzivoni); Highland Hospital, Rochester, NY (Dr Gillespie); Overlook Hospital, Summit, NJ (Dr Gregory); Maimonides Medical Center, Brooklyn, NY (Dr Lichstein); Kingston (Ontario) General Hospital (Dr Parker); and Washington (DC) Hospital Center (Dr Van Voorhees).
Footnotes
Additional members of the Multicenter Myocardial Ischemia Research Group are listed in the acknowledgments.
Reprint requests to PO Box 653, University of Rochester Medical Center, Rochester, NY 14642 (Dr Moss).
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati  Twitter
What's this?
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Variation in the use of stress testing and outcomes in patients with non-ST-elevation acute coronary syndromes: insights from GUSTO IIb
Mehta et al.
Eur Heart J 2008;29:880-887.
ABSTRACT
| FULL TEXT
The return of silent ischaemia? Not really
Mulcahy
Heart 2005;91:1249-1250.
ABSTRACT
| FULL TEXT
Exercise versus recovery electrocardiography in predicting mortality in patients with uncomplicated myocardial infarction
Bigi et al.
Eur Heart J 2004;25:558-564.
ABSTRACT
| FULL TEXT
Silent Myocardial Ischemia
Cohn et al.
Circulation 2003;108:1263-1277.
FULL TEXT
Coronary Risk Evaluation in Patients With Transient Ischemic Attack and Ischemic Stroke: A Scientific Statement for Healthcare Professionals From the Stroke Council and the Council on Clinical Cardiology of the American Heart Association/American Stroke Association
Adams et al.
Circulation 2003;108:1278-1290.
FULL TEXT
Coronary Risk Evaluation in Patients With Transient Ischemic Attack and Ischemic Stroke: A Scientific Statement for Healthcare Professionals From the Stroke Council and the Council on Clinical Cardiology of the American Heart Association/American Stroke Association
Adams et al.
Stroke 2003;34:2310-2322.
FULL TEXT
Incremental prognostic value of stress echocardiography as an adjunct to exercise electrocardiography after uncomplicated myocardial infarction
Bigi et al.
Heart 2001;85:417-423.
ABSTRACT
| FULL TEXT
Independent Prognostic Value of Elevated C-Reactive Protein in Unstable Angina
Ferreiros et al.
Circulation 1999;100:1958-1963.
ABSTRACT
| FULL TEXT
Can Ambulatory Monitoring Identify High-Risk Patients With Stable Coronary Artery Disease?-Reply
Quyyumi and Mulcahy
JAMA 1997;277:1760-1761.
ABSTRACT
Ischemia During Ambulatory Monitoring as a Prognostic Indicator in Patients With Stable Coronary Artery Disease
Mulcahy et al.
JAMA 1997;277:318-324.
ABSTRACT
Heart Rate Variability Assessment Early After Acute Myocardial Infarction : Pathophysiological and Prognostic Correlates
Singh et al.
Circulation 1996;93:1388-1395.
ABSTRACT
| FULL TEXT
Prognostic Importance of Myocardial Ischemia Detected by Ambulatory Monitoring Early after Acute Myocardial Infarction
Gill et al.
NEJM 1996;334:65-71.
ABSTRACT
| FULL TEXT
Evaluation of the Postinfarct Patient
Pitt
Circulation 1995;91:1855-1860.
FULL TEXT
Fortnightly Review: Management of patients after their first myocardial infarction
Flapan
BMJ 1994;309:1129-1134.
FULL TEXT
Noninvasive Testing for Silent Myocardial Ischemia in Stable Coronary Patients
Leppo et al.
JAMA 1993;270:1809-1809.
ABSTRACT
Noninvasive Testing for Silent Myocardial Ischemia in Stable Coronary Patients
Thompson
JAMA 1993;270:1809-1810.
ABSTRACT
SILENT ISCHEMIA IS NOT IMPORTANT IN STABLE PATIENTS
JWatch General 1993;1993:1-1.
FULL TEXT
Postinfarction Risk Stratification: Is Preventive War Winnable?
Diamond
JAMA 1993;269:2418-2419.
ABSTRACT
|
