- Email: [email protected]
Silent myocardial ischemia: A critical appraisal
182
Silent Myocardial Ischemia: A Critical Appraisal (Advances in Cardiology Vol. 37) Editors: J.J. Kellermann and E. Braunwald S Karger AG, Basle/ Munich/ Paris/ London, 1990; 358 pp; SFr238, DM285, f103.50, $176.50; ISBN 3-8055-5196-7 Though painless or “silent” myocardial ischaemia was described by Master and Geller as long ago as 1969, it is only in recent years that the pathophysiology, frequency and significance of this phenomenon has been explored. In that time, however, there has been an explosion of information on the subject of silent ischaemia. It was timely, therefore, that a review of the topic was undertaken by the International Round Table on Silent Myocardial Ischaemia in Tel Aviv, Israel, in 1989. The proceedings of that round table have now been published as volume 37 of Advances in Cardiology under the Editorship of Drs J.J. Kellermann and E. Braunwald. The volume consists of 30 chapters covering pathophysiology, techniques of measurement, clinical occurrence, prognostic significance, effects of pharmacological and non-pharmacological therapy and implications for management. Contributions come from authorities from the United States of America, Europe and Israel, though the views of certain prominent groups (for example, those of K.M. Fox, London, and C.J. Pepine, Florida) are not represented. The chapters are generally of a high standard. Braunwald sets the scene with an excellent introduction, highlighting questions about silent ischaemia which have been answered, along with those which still have to be answered. There is a group of chapters on techniques of measurement of silent ischaemia. Swan addresses the fundamental questions of for how long ambulatory monitoring should be carried out, what magnitude and configuration of ST segment change should be considered significant, and the variability and reproducibility of the technique. Deanfield and Spiegelhalter also review the latter area and Raby, Barry and Selwym assess the potential of “real-time” digital monitoring of change in the ST segment. Hombath et al. consider other techniques in addition to ambulatory monitoring; Zaret and Kayden concentrate on ambulatory monitoring of left ventricular function, and Galli et al. review thallium scintigraphy. Weiner gives a particularly good overview of the data related to exercise testing.
There is also a large section on the pathophysiology of silent ischaemia, including studies in animal models and humans, covering topics ranging from the role of endothelial dysfunction to the perception of pain. Some of the most interesting chapters concern the detection, frequency of occurrence and prognostic implications of silent ischaemia in different settings. These include asymptomatic patients (Degre et al.), patients undergoing coronary angiography (Anrim et al.), patients with unstable angina (Gottlieb; Degre et al.), patients after myocardial infarction (Galli et al.), following angioplasty and surgery (Kennedy; GohlkeBarwolf et al.: Finci et al.) and patients with diabetes mellitus (Alpert et al.). Kannel examines the Framingham experience; Schlant gives a general overview of silent ischaemia; Tzivoni, Benhorm and Stern review a number of specific clinical areas; and Cohn gives an excellent exposition of the arguments for and against screening the asymptomatic population. Stone has produced one of the most interesting chapters, evaluating the efficacy of different treatments in controlling silent ischaemia. He finds evidence for differences within drug classes (P-blockers and calcium antagonists) and for differences in efficacy between /3-blockers and calcium antagonists. Recent publications appear to confirm this perceptive analysis. Finally, Sopko addresses the issue of clinical trials to determine the significance of silent ischaemia for the management of coronary disease. Disappointingly this chapter shows transatlantic bias in only referring to the ACIP trial funded by the National Institute of Health. Other trials (ASIST), and particularly the European (TIBET) trial, are not mentioned. Is this book worth purchasing? It is difficult to criticise its breadth and depth of content. Its only deficiency is that of any book on a fast moving subject - it becomes quickly outdated. Most chapters do not cite references published after 1989, and several very important contributions to this area have been made in the past two years (such as the importance of the type of exercise test in determining correlation between treadmill and Holter silent ischaemia). Thus, the main role this volume will serve is that of a condensation of existing knowledge prior to 1990 for those who wish to pursue the topic of silent ischaemia henceforth.
Dept. of Cardiology Western Infirmary Glasgow, U.K.
John McMurray BHF Research Fellow/ Senior Registrar
Silent Myocardial Ischemia: A Critical Appraisal (Advances in Cardiology Vol. 37) Editors: J.J. Kellermann and E. Braunwald S Karger AG, Basle/ Munich/ Paris/ London, 1990; 358 pp; SFr238, DM285, f103.50, $176.50; ISBN 3-8055-5196-7 Though painless or “silent” myocardial ischaemia was described by Master and Geller as long ago as 1969, it is only in recent years that the pathophysiology, frequency and significance of this phenomenon has been explored. In that time, however, there has been an explosion of information on the subject of silent ischaemia. It was timely, therefore, that a review of the topic was undertaken by the International Round Table on Silent Myocardial Ischaemia in Tel Aviv, Israel, in 1989. The proceedings of that round table have now been published as volume 37 of Advances in Cardiology under the Editorship of Drs J.J. Kellermann and E. Braunwald. The volume consists of 30 chapters covering pathophysiology, techniques of measurement, clinical occurrence, prognostic significance, effects of pharmacological and non-pharmacological therapy and implications for management. Contributions come from authorities from the United States of America, Europe and Israel, though the views of certain prominent groups (for example, those of K.M. Fox, London, and C.J. Pepine, Florida) are not represented. The chapters are generally of a high standard. Braunwald sets the scene with an excellent introduction, highlighting questions about silent ischaemia which have been answered, along with those which still have to be answered. There is a group of chapters on techniques of measurement of silent ischaemia. Swan addresses the fundamental questions of for how long ambulatory monitoring should be carried out, what magnitude and configuration of ST segment change should be considered significant, and the variability and reproducibility of the technique. Deanfield and Spiegelhalter also review the latter area and Raby, Barry and Selwym assess the potential of “real-time” digital monitoring of change in the ST segment. Hombath et al. consider other techniques in addition to ambulatory monitoring; Zaret and Kayden concentrate on ambulatory monitoring of left ventricular function, and Galli et al. review thallium scintigraphy. Weiner gives a particularly good overview of the data related to exercise testing.
There is also a large section on the pathophysiology of silent ischaemia, including studies in animal models and humans, covering topics ranging from the role of endothelial dysfunction to the perception of pain. Some of the most interesting chapters concern the detection, frequency of occurrence and prognostic implications of silent ischaemia in different settings. These include asymptomatic patients (Degre et al.), patients undergoing coronary angiography (Anrim et al.), patients with unstable angina (Gottlieb; Degre et al.), patients after myocardial infarction (Galli et al.), following angioplasty and surgery (Kennedy; GohlkeBarwolf et al.: Finci et al.) and patients with diabetes mellitus (Alpert et al.). Kannel examines the Framingham experience; Schlant gives a general overview of silent ischaemia; Tzivoni, Benhorm and Stern review a number of specific clinical areas; and Cohn gives an excellent exposition of the arguments for and against screening the asymptomatic population. Stone has produced one of the most interesting chapters, evaluating the efficacy of different treatments in controlling silent ischaemia. He finds evidence for differences within drug classes (P-blockers and calcium antagonists) and for differences in efficacy between /3-blockers and calcium antagonists. Recent publications appear to confirm this perceptive analysis. Finally, Sopko addresses the issue of clinical trials to determine the significance of silent ischaemia for the management of coronary disease. Disappointingly this chapter shows transatlantic bias in only referring to the ACIP trial funded by the National Institute of Health. Other trials (ASIST), and particularly the European (TIBET) trial, are not mentioned. Is this book worth purchasing? It is difficult to criticise its breadth and depth of content. Its only deficiency is that of any book on a fast moving subject - it becomes quickly outdated. Most chapters do not cite references published after 1989, and several very important contributions to this area have been made in the past two years (such as the importance of the type of exercise test in determining correlation between treadmill and Holter silent ischaemia). Thus, the main role this volume will serve is that of a condensation of existing knowledge prior to 1990 for those who wish to pursue the topic of silent ischaemia henceforth.
Dept. of Cardiology Western Infirmary Glasgow, U.K.
John McMurray BHF Research Fellow/ Senior Registrar