Circulation, Vol 89, 1958-1966, Copyright © 1994 by American Heart Association
J Klein, SY Chao, DS Berman and A Rozanski
BACKGROUND: The clinical significance of exercise-induced chest pain
remains controversial, as reflected by sharply discordant clinical results
within the medical literature. Thus, we developed a prospective study to
compare the functional significance of silent versus symptomatic ischemia
and to evaluate whether patient selection biases influence this analysis.
METHODS AND RESULTS: We evaluated 117 patients (mean age, 63 +/- 9 years)
with ischemic ST-segment depression during treadmill testing. Each patient
underwent Tl-201 myocardial perfusion single-photon emission computed
tomography (SPECT) after exercise followed by 24-ambulatory ECG monitoring.
Patients were divided into silent versus symptomatic cohorts and were
compared for the degree of hemodynamic, exercise and ambulatory ECG, and
thallium abnormalities during stress testing. Analyses were repeated as the
patient population became increasingly restricted. Compared with the silent
patients, patients with chest pain during exercise had a shorter exercise
duration (P < .009), lower peak heart rate (P = .009) and double product
(P = .005), lower heart rate threshold for ST depression (P < .05), more
episodes of ambulatory ST-segment depression (P < .05), a higher
frequency of ischemia abnormalities during Tl-201 SPECT (P = .02), and
higher summed Tl reversibility scores (P = .002). As the population became
increasingly restricted, the relative magnitude of differences in silent
versus symptomatic cohorts diminished, whereas the absolute magnitude of
ischemic abnormalities progressively increased in both cohorts. For
example, within the restricted group having ischemia on both exercise and
ambulatory ECG, 50% of the silent cohort had severe ischemia on Tl SPECT
(five or more reversible defects) and more than one third demonstrated the
ominous finding of transient left ventricular dilation after exercise.
CONCLUSIONS: The induction of chest pain is associated with substantially
more functional abnormalities when it is analyzed in a relatively "broad-
spectrum" coronary artery disease population; by contrast, chest pain tends
to lose its apparent value as a clinical test parameter when its analysis
is restricted to coronary artery disease populations with a greater a
priori likelihood of manifesting inducible ischemia. These findings may
help resolve some of the previous discordant literature reports.
ARTICLES
Is 'silent' myocardial ischemia really as severe as symptomatic ischemia? The analytical effect of patient selection biases
Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, Calif.
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