SUPPRESSION OF INDUCIBLE PAINLESS MYOCARDIAL-ISCHEMIA BY CONVENTIONALMEDICAL THERAPY - EFFECT ON SHORT-TERM OUTCOME AND LEFT-VENTRICULAR SYSTOLIC FUNCTION

To test the hypothesis that abolition of exercise-induced painless myo cardial ischemia by anti-ischemic medication improves prognosis in pat ients with medically treated coronary artery disease, we studied such patients with painless ischemia during exercise radionuclide ventricul ography performed after temporary discontinuation of medication. The t est was repeated while patients received conventional medical therapy that rendered angina no worse than New York Heart Association class I. The relative risk of adverse cardiac events was reduced by >5-fold wh en painless ischemia was abolished by symptom-dictated therapy. Thus, the abolition of exercise-induced painless ischemia by conventional me dical therapy carries a better short-term prognosis in medically treat ed coronary artery disease, suggesting that therapeutic efficacy may n eed to be assessed by titration against ischemia and not angina. In pa tients without overt cardiac events, there were no significant differe nces between baseline and 12-month measurements of ejection fraction a t rest, peak exercise, and the change in ejection fraction from rest t o exercise. Thus, In those who remain asymptomatic and event-free, pai nless ischemia that is easily inducible at baseline despite medication does not lead per se to deterioration of left ventricular systolic fu nction at rest or during exercise over 12 months. Such an effect, a ev ident as early as at 12 months, would favor a strategy of early revasc ularization over medical treatment in asymptomatic patients who have i nducible painless ischemia despite medication.