Can we really justify the treatment of silent ischemia in 1992? No!

Since the advent of ambulatory ST-segment monitoring, it has been established that silent ischemia is common in patients with various coronary artery disease syndromes, and such silent episodes represent up to 80% of all ischemic episodes. It appears to be associated with an adverse prognosis when compared with similarly characterized patients without silent ischemia during daily life. Silent ischemia does not, however, bother the patients, by virtue of the fact that it is silent, and therefore treatment of such ischemia must be justified by an improved outlook for the patient, rather than symptom relief. There is no direct evidence to date that silent ischemia is associated with acute myocardial infarction or sudden cardiac death in a cause-and-effect relationship, or that reduction or eradication of silent ischemia will lead to an improved prognosis for the patient; indeed, we have been unable to demonstrate any significant improvement in outlook when using the various antianginal/antiischemic agents at our disposal. Until we can demonstrate a benefit to the patient by detecting and treating silent ischemia, we should not waste large resources attempting to eradicate something whose significance we do not understand.