Abstract
Coronary artery disease (CAD) is a leading cause of death and disability in the elderly. Several recent studies have shown that silent myocardial ischaemia (SMI) is a common manifestation of CAD, especially in the elderly. As many as 40% of elderly patients with no prior history of CAD may have underlying asymptomatic disease and up to 50% of elderly patients with known CAD might have evidence of SMI. The results of studies in elderly patients with CAD have also shown that SMI might exist despite antianginal therapy that is considered adequate for symptom control. In order to diagnose such residual SMI, the clinician would need to perform 24- to 48-hour Holter monitoring in the ambulatory setting while the patient is performing routine daily activities. Although a number of anti-ischaemic drugs have been evaluated for the treatment of SMI, available data suggest that β-blocker given alone or in combination with a nitrate compound or calcium antagonist provides the best therapeutic choice. The long term benefit of SMI suppression in elderly patients has not been established. Future studies need to evaluate the clinical benefits of therapy given for SMI in the elderly.
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Hedblad B, Juul-Moller S, Svensson K, et al. Increased mortality in men with ST segment depression during 24h ambulatory long-term ECG recording: results from prospective population study ‘Men born in 1914’, from Malmo, Sweden. Eur Heart J 1989; 10: 149–58
Fleg JL, Kennedy HL. Long-term prognostic significance of ambulatory electrocardiographic findings in apparently healthy subjects ≥60 years of age. Am J Cardiol 1992; 70: 748–51
Hedblad B, Janzon L. Hypertension and silent myocardial ischemia: their influence on cardiovascular mortality and morbidity. Cardiology 1994; 85Suppl. 2: 16–23
Rautaharju PM, Manolio TA, Furberg CD. Ischemic episodes in 24-h ambulatory electrocardiograms of elderly persons: the Cardiovascular Health Study. Int J Cardiol 1995; 51(2): 165–75
Aronow W, Epstein S. Usefulness of silent myocardial ischemia detected by ambulatory electrocardiographic monitoring in predicting new coronary events in elderly patients. Am J Cardiol 1988; 62: 1295–6
Aronow W, Epstein S, Koenigsberg M. Usefulness of echocardiographic left ventricular hypertrophy and silent ischemia in predicting new cardiac events in elderly patients with systemic hypertension or coronary artery disease. Angiology 1990; 41: 189–93
Aronow W, Mercando A, Epstein W. Prevalence of silent myocardial ischemia detected by 24-hour ambulatory ECG, and its association with new coronary events at 40 months in elderly diabetic and nondiabetic patients with CAD. Am J Cardiol 1992; 69: 555–6
Aronow W, Ahn CH, Mercando A, et al. Prognostic significance of silent ischemia in elderly patients with peripheral arterial disease with and with out previous myocardial infarction. Am J Cardiol 1992; 69: 137–9
Tresch DD. Diagnostic and prognostic value of ambulatory electrographic monitoring in older patients. J Am Geriatr Soc 1995; 43: 66–70
Kannel WB, Abbot RD. Incidence and prognosis of unrecognized myocardial infarction: an update on the Framingham study. N Engl J Med 1984; 311: 1144–7
Reeves T. Relation and independence of angina pectoris and sudden death in persons with coronary atherosclerotic heart disease. J Am Coll Cardiol 1985; 5: 167–74B
Deedwania P, Carbajal E. Silent myocardial ischemia: a clinical perspective. Arch Intern Med 1991; 151: 2373–82
Deanfield J, Maseri A, Selwyn A, et al. Myocardial ischemia during daily life in patients with stable angina: its relation to symptoms and heart rate changes. Lancet 1983; 2: 753–8
Droste C, Roskamm H. Experimental pain measurement in patients with asymptomatic myocardial ischemia. J Am Coll Cardiol 1983; 1(3): 940–5
Sheps D, Adams K, Hinderliter A, et al. Endorphins are related to pain perception in coronary artery disease. Am J Cardiol 1987; 59: 523–7
Deedwania PC, Nelson JR. Pathophysiology of myocardial ischemia during daily life. Circulation 1990; 82: 1296–304
Deedwania P, Carbajal E. Silent ischemia during daily life is an independent predictor of mortality in stable angina. Circulation 1990; 81: 748–56
Raby KE, Goldman L, Creager MA, et al. Correlation between preoperative ischemia and major cardiac events after peripheral vascular surgery. N Engl J Med 1989; 321: 1296–300
Raby KE, Barry J, Creager MA, et al. Detection and significance of intraoperative and postoperative myocardial ischemia in peripheral vascular surgery. JAMA 1992; 268; 222–7
Mangano DT, Browner WS, Hollenberg M, et al. Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. N Engl J Med 1990; 323: 1781–8
Aronow WS, Epstein S. Usefulness of silent ischemia, ventricular tachycardia, and complex ventricular arrhythmias in predicting new coronary events in elderly patients with coronary artery disease or systemic hypertension. Am J Cardiol 1990; 65: 511–2
Aronow WS, Epstein S, Koenigsberg M. Usefulness of echocar-diographic left ventricular ejection fraction and silent myocardial ischemia in predicting new coronary events in elderly patients with coronary artery disease or systemic hypertension. Am J Cardiol 1990; 65: 811–2
Deedwania P. Is there evidence in support of the ischemia suppression hypothesis? J Am Coll Cardiol 1994; 24: 21–4
Deedwania P, Parmley WW. Silent ischemia. In: Parmley WW, Chatterjee K, editors. Cardiology. Philadelphia (PA): Lippincott-Raven, 1997: 1–25
Stone P, Gibson R, Glasser S, et al. Comparison of propranolol, diltiazem and nifedipine in the treatment of ambulatory ischemia in patients with stable angina. Circulation 1990; 82: 1962–72
Deedwania PC, Carbajal EV, Nelson JR, et al. Anti-ischemic effects of atenolol versus nifedipine in patients with coronary artery disease and ambulatory silent ischemia. J Am Coll Cardiol 1991; 17: 963–9
Pepine C, Cohn P, Deedwania P, et al. Effects of treatment on outcome in mildly symptomatic patients with ischemia during daily life: the Atenolol Silent Ischemia Study. Circulation 1994; 90: 762–8
Knatterud G, Bourassa M, Pepine C, et al. Effects of treatment strategies to suppress ischemia in patients with coronary artery disease: 12-week results of the Asymptomatic Cardiac Ischemia (ACIP) study. J Am Coll Cardiol 1994; 24: 11–20
von Arnim T. Medical treatment to reduce total ischemia burden: Total Ischemic Burden Bisoprolol Study (TIBBS), a multicenter trial comparing bisoprolol and nifedipine. The TIBBS Investigators. J Am Coll Cardiol 1995; 25: 231–8
Pepine CJ, Deedwania PC. How do we best treat patients with ischemic heart disease [editorial]? Circulation 1998; 98: 1985–6
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Deedwania, P.C. Silent Myocardial Ischaemia in the Elderly. Drugs & Aging 16, 381–389 (2000). https://doi.org/10.2165/00002512-200016050-00007
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DOI: https://doi.org/10.2165/00002512-200016050-00007