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SILENT ISCHEMIA: DATA SUPPORT REVASCULARIZATION.

Silent coronary ischemia -- what should we do about it? These three reports from the Asymptomatic Cardiac Ischemia Pilot (ACIP) study assessed three different strategies (in order of increasing aggressiveness): angina- guided medical therapy, angina-guided therapy plus medical therapy guided by ischemia on ambulatory ECG, and coronary revascularization. The ACIP trial randomized 558 patients who had had at least one episode of asymptomatic cardiac ischemia on ambulatory ECG to one of the three strategies. Peak exercise-test time (in minutes) increased after 12 weeks by 0.5 in the group treated with angina-guided medical therapy, 0.7 in the patients treated with ischemia-guided therapy, and 1.6 minutes in those who underwent revascularization. ST-segment depression decreased in all three groups, but was reduced most dramatically in the revascularization group. None of the patients who had revascularization died during one year of follow-up, compared to four percent of the angina-guided group and two percent of the ischemia-guided group. The proportion of patients who died, had myocardial infarctions or nonprotocol revascularizations, or were hospitalized at one year was also lower for those who underwent revascularization than for those who had angina- or ischemia-guided therapy (18 percent vs. 32 and 31 percent). Within the revascularization group, patients who had coronary-artery bypass-graft surgery had less ischemia during follow-up than those who had angioplasty, even though they had more severe coronary disease before the procedure. Comment: These reports indicate that more aggressive strategies may lead to better clinical outcomes, but a larger trial is necessary before clinicians can recommend revascularization or medical therapy guided by electrocardiographic evidence of ischemia for all their patients with silent ischemia.

— TH Lee

Published in Journal Watch General Medicine September 19, 1995

Citation(s):

Bourassa MG, et al. Asymptomatic Cardiac Ischemia Pilot (ACIP) Study: effects of coronary angioplasty and coronary artery bypass graft surgery on recurrent angina and ischemia. J Am Coll Cardiol 1995 Sep 26 606-614.

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Rogers WJ, et al. Asymptomatic Cardiac Ischemia Pilot (ACIP) Study: outcome at 1 year for patients with asymptomatic cardiac ischemia randomized to medical therapy or revascularization. J Am Coll Cardiol 1995 Sep 26 594-605.

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Chaitman BR, et al. Asymptomatic Cardiac Ischemia Pilot (ACIP) Study: impact of anti-ischemia therapy on 12-week rest electrocardiogram and exercise test outcomes. J Am Coll Cardiol 1995 Sep 26 585-593.

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