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Revascularization Best for Silent Ischemia.

Patients with ischemia during stress testing and silent ischemia on ambulatory ECG monitoring have a worsened prognosis. The Asymptomatic Cardiac Ischemia Pilot (ACIP) study compared the relative efficacy of three treatment strategies in these patients: 1) angina-guided drug therapy, 2) angina plus ambulatory ECG ischemia-guided therapy, and 3) revascularization with PTCA or CABG.

Five hundred fifty-eight patients were randomized to receive protocol medications including atenolol with the addition of long-acting calcium channel blockers or nitrates as needed to control angina or suppress ischemia on 48-hour ambulatory recordings. In each group, 33 percent had angina during baseline treadmill testing, and all others had asymptomatic ischemia. On ambulatory ECG testing, only 11 percent of patients had symptomatic as well as asymptomatic episodes.

At two years, mortality was significantly lower for the revascularization strategy (1.1 percent) compared with ischemia-guided (4.4 percent) and angina-guided (6.6 percent) medical therapy. Revascularization was also better for the combined endpoint of death and MI (4.7 percent versus 12.1 percent for angina-guided therapy), although the higher event rate for ischemia-guided therapy (8.8 percent) was not statistically different from the rate with revascularization. The benefits of revascularization were concentrated in patients with proximal LAD stenoses and three-vessel disease.

Comment: An initial revascularization strategy improved two-year survival in these patients with objective ischemia even when their angina was well controlled on medication. Because this was a pilot study, the confidence intervals on the magnitude of benefit are wide. In addition, this study was performed before the potent effects of statins were recognized. Nevertheless, these are the first randomized data to demonstrate a survival advantage for revascularization in patients without left main disease or left ventricular dysfunction.

— HC Herrmann

Published in Journal Watch Cardiology May 19, 1997

Citation(s):

Davies RF et al. Asymptomatic cardiac ischemia pilot (ACIP) study two-year follow-up. Circulation 1997 Apr 15 95 2037-2043.

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• Medline abstract (Free)

Killip T. Silent myocardial ischemia: Some good news. Circulation 1997 Apr 15 95 1992-1993.

• Original article (Subscription may be required)
• Medline abstract (Free)