Usefulness of percutaneous transluminal coronary angioplasty in alleviating silent myocardial ischemia in patients with absent or minimal painful myocardial ischemia

To examine the role of percutaneous transluminal coronary angioplasty (PTCA) in patients with silent ischemia, 50 consecutive patients (mean age 54 years, 88% men) with 1-vessel disease and absent or minimal symptoms who underwent PTCA were identified. Nineteen patients (38%) were asymptomatic and 31 patients (62%) had minimal angina (at most 1 episode/month, and with marked exertion only). Exercise-induced ischemia was present in 45 of 49 patients (92%) tested. The remaining 5 patients had a critical stenosis in a vessel supplying a large myocardial territory. A total of 75 lesions were dilated, 71 successfully (95%). There were no procedural deaths or infarctions. The single complication was an urgent bypass operation. After PTCA, only 3 of 46 patients exercised (7%) had inducible ischemia (p < 0.0005 vs before PTCA). At a mean follow-up of 36 months, 46 of 49 patients alive (94%) were asymptomatic (p < 0.0005 vs before PTCA). The 3-year actuarial survival and infarct-free survival were 98 and 96%, respectively. However, 5 patients (10%) crossed over to bypass surgery and 14 patients (28%) underwent repeat PTCA. Progression of native coronary disease was present in 9 of these patients (47%). As in symptomatic patients, elective PTCA can be performed safely and with a high success rate in patients with silent ischemia, and can markedly reduce the incidence of exercise-induced ischemia. With this approach, >90% of the patients were asymptomatic at the 3-year follow-up; however, 34% required a further revascularization procedure for restenosis or progression of native disease or both. A prospective randomized trial is needed to firmly establish the role of PTCA in the treatment of silent ischemia.