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Long term outcome in patients with silent versus symptomatic ischaemia during dobutamine stress echocardiography
  1. E Biagini1,3,
  2. A F L Schinkel1,
  3. J J Bax2,
  4. V Rizzello1,
  5. R T van Domburg1,
  6. B J Krenning1,
  7. M Bountioukos1,
  8. C Pedone1,
  9. E C Vourvouri1,
  10. C Rapezzi3,
  11. A Branzi3,
  12. J R T C Roelandt1,
  13. D Poldermans1
  1. 1Department of Cardiology, Thoraxcentre, Erasmus MC, Rotterdam, the Netherlands
  2. 2Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
  3. 3Institute of Cardiology, S Orsola Hospital, Bologna, Italy
  1. Correspondence to:
    Dr Don Poldermans
    Department of Cardiology, Thoraxcentre Room Ba 300, Erasmus MC, Dr Molewaterplein 40, 3015 GD Rotterdam, Netherlands; d.poldermanserasmusmc.nl

Abstract

Objectives: To compare the long term prognosis of patients having silent versus symptomatic ischaemia during dobutamine stress echocardiography (DSE).

Design: Observational study.

Setting: Tertiary referral centre.

Patients: 931 patients who experienced stress induced myocardial ischaemia during DSE.

Results: Silent ischaemia was present in 643 of 931 patients (69%). The number of dysfunctional segments at rest (mean (SD) 9.6 (5.1) v 8.8 (5.0), p  =  0.1) and of ischaemic segments (3.5 (2.2) v 3.8 (2.1), p  =  0.2) was comparable in both groups. During a mean (SD) follow up of 5.5 (3.3) years, there were 169 (18%) cardiac deaths and 86 (9%) non-fatal infarctions. Multivariable Cox regression analysis showed age (hazard ratio (HR) 1.1, 95% confidence interval (CI) 1.02 to 1.05), previous myocardial infarction (HR 1.4, 95% CI 1.1 to 2.0), and number of ischaemic segments during the test (HR 2.0, 95% CI 1.0 to 3.7) as independent predictors of cardiac death and myocardial infarction. For every additional ischaemic segment there was a twofold increment in risk of late cardiac events. The annual cardiac death or myocardial infarction rate was 3.0% in patients with symptomatic ischaemia and 4.6% in patients with silent ischaemia (p < 0.01). Silent induced ischaemia was an independent predictor of cardiac death and myocardial infarction (HR 1.7, 95% CI 1.1 to 2.0). During follow up symptomatic patients were treated more often with cardioprotective therapy (p < 0.01) and coronary revascularisation (145 of 288 (50%) v 174 of 643 (27%), p < 0.001).

Conclusions: Patients with silent ischaemia had a similar extent of myocardial ischaemia during DSE compared to patients with symptomatic ischaemia but received less cardioprotective treatment and coronary revascularisation and experienced a higher cardiac event rate.

  • silent ischaemia
  • outcome
  • dobutamine stress echocardiography

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