The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery

OBJECTIVEThe aim of this study is to determine the prevalence and prognosis of unrecognized myocardial infarction (MI) and silent myocardial ischemia in vascular surgery patients. METHODSIn a cohort of 1092 patients undergoing preoperative dobutamine stress echocardiography and noncardiac vascular surgery, unrecognized MI was determined by rest wall motion abnormalities in the absence of a history of MI. Silent myocardial ischemia was determined by stress-induced wall motion abnormalities in the absence of angina pectoris. Beta blockers and statins were noted at baseline. During follow-up (mean6±4 years), all-cause mortality and major cardiac events (cardiac death or nonfatal MI) were noted. RESULTSThe prevalence of unrecognized MI and silent myocardial ischemia was 23 and 28%, respectively. Both diabetes and heart failure were important predictors of unrecognized MI and silent myocardial ischemia. During follow-up, all-cause mortality occurred in 45% and major cardiac events in 23% of patients. In multivariate analysis, unrecognized MI and silent myocardial ischemia were significantly associated with increased risk of mortality [hazard ratio (HR), 1.86; 95% confidence interval (CI), 1.53–2.25 and HR, 1.74; 95% CI, 1.46–2.06, respectively] and major cardiac events (HR, 2.15; 95% CI, 1.59–2.92 and HR, 1.86; 95% CI, 1.43–2.41, respectively). In patients with unrecognized MI, β-blockers and statins were significantly associated with improved survival. Statins improved survival in patients with silent myocardial ischemia. CONCLUSIONSIn patients undergoing major vascular surgery, unrecognized MI and silent myocardial ischemia are highly prevalent (23 and 28%) and associated with increased long-term mortality and major cardiac events.