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Triggers of daily life ischaemia
  1. S B Freedman,
  2. C K Wong
  1. The Department of Cardiology, Concord Repatriation General Hospital, and the Hallstrom Institute of Cardiology, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
  1. Professor Ben Freedman, Department of Cardiology, Concord Repatriation General Hospital, Hospital Road, Concord, 2139, Australia. email:ben{at}


Objective To determine the usual triggers of silent and symptomatic ischaemia.

Design Patients wore an ambulatory recorder for 48 hours. The device emitted a tone on detection of ischaemia and patients noted activities, feelings, and symptoms so that ischaemia could be attributed to one of four triggers: physical stress, mental stress, combined physical/mental stress, or no stressor.

Setting Home environment.

Patients Patients (n = 38) with stable coronary disease, positive exercise electrocardiography, and ischaemic episodes on ambulatory electrocardiography.

Main outcome measure Matching ischaemic episodes with perceived triggers.

Results Altogether 257 ischaemic episodes (53% silent) were documented. Triggers were: physical stress, 56%; mental stress, 5%; combined physical/mental stress, 8%; no identifiable trigger, 31%. Episodes associated with mental or no stress were more often silent (69% and 75%, respectively) than those associated with physical stress (45%, p < 0.01), while combined physical/mental stress episodes were usually symptomatic (10% silent, p < 0.01 v other stressors). Although physical stress was less commonly a trigger of silent ischaemia than angina (47%v 65%, p < 0.01), it was still the predominant trigger of silent ischaemia. There was no identifiable trigger in 45% of silent and only 17% of anginal episodes (p < 0.01). Only nine silent episodes involved mental stress alone as a trigger.

Conclusions Daily life ischaemia is usually triggered by physical activity. Mental stress alone is an uncommon trigger of either silent or symptomatic ischaemia, while combined physical/mental stress is a significant but minor trigger of angina. Patients can identify a trigger in 83% of anginal episodes, compared with only half of silent ischaemic episodes.

  • silent ischaemia
  • ambulatory electrocardiography

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