Three-year follow-up of patients with silent ischemia in the subacute phase of myocardial infarction after thrombolysis and early coronary intervention

In order to assess the prognostic value of silent myocardial ischemia in ac ute myocardial infarction after thrombolysis and early coronary angiography (14-48 h after start of thrombolysis) including percutaneous transluminal coronary angioplasty, if indicated, 126 patients underwent 24 h-Holter-moni toring in the early postinfarction period. The 24 h-Holter-recording was in itiated directly after early coronary intervention (40+/-11 h after onset o f symptoms). Of the 126 patients initially eligible for the study 29 had to be excluded from further analysis for clinical or methodical reasons. Of t he remaining 97 patients, 10 (10%) had silent ischemia (group A) and 87/97 (90%) patients showed no significant ST-segment alterations. Both groups di d not significantly differ from each other with regard to baseline clinical characteristics, severity of coronary artery disease and frequency of succ essful percutaneous transluminal coronary angioplasty. The left ventricular ejection fraction showed a trend towards lower values in patients with tha n in those without silent ischemia (47 +/- 15% vs. 55 +/- 13%: p =0.07). Wh en both silent ischemia and left ventricular ejection fraction <40% were pr esent, a subset of patients at high risk for cardiac death could be identif ied (specificity: 98%, positive predictive accuracy: 75%). By Kaplan-Meier analysis, significantly more cardiac deaths occurred in group A than in gro up B (30% vs. 6%, p<0.01) during the three-year follow-up (950+/-392 days) after acute myocardial infarction, Regarding the cardiac events during long -term follow-up (emergency percutaneous transluminal coronary angioplasty, coronary artery bypass grafting, non-fatal reinfarction, and cardiac death) there was no significant difference between both groups (30% vs. 18%, NS). In conclusion, Holter monitor-detected silent ischemia in the subacute pha se of myocardial infarctionI after thrombolysis followed by early delayed c oronary intervention occurs in 10% of the patients indicating either a resi dual ischemia in the infarcted zone despite a combined reperfusion strategy or a remote ischemic potential in case of multivessel disease. In this sma ll selected group of infarct patients too, silent ischemia is to be conside red as an important non-invasive parameter to predict cardiac death during long-term follow-up and provides valuable complementary information to left ventricular dysfunction, a well established prognostic marker in the posti nfarction period. (C) 1999 Elsevier Science Ireland Ltd. All rights reserve d.