Original article Coronary artery disease is common in asymptomatic patients with signs of myocardial ischemia ☆ , ☆☆ Andreas W. Schoenenberger a,b,c , Peiman Jamshidi d , Michel Zuber d , Andreas E. Stuck a,b , Matthias Pfisterer e , Paul Erne d, ⁎ a Department of Geriatrics, University of Bern Hospital Inselspital Bern, Switzerland b Department of General Internal Medicine, University of Bern Hospital Inselspital Bern, Switzerland c Institute of Social and Preventive Medicine, University of Berne, Switzerland d Department of Cardiology, Luzerner Kantonsspital, Switzerland e Department of Cardiology, University Hospital, Basel, Switzerland abstract article info Article history: Received 10 December 2008 Received in revised form 19 March 2009 Accepted 8 April 2009 Available online 8 May 2009 Keywords: Coronary angiography Coronary artery disease Silent ischemia Exercise test Prevalence Background: The incidence of coronary artery disease (CAD) in totally asymptomatic patients with myocardial ischemia during stress testing is unknown. Methods: 54 patients with asymptomatic myocardial ischemia participated in the Swiss Interventional Study on Silent Ischemia type I (SWISSI I). Asymptomatic myocardial ischemia was verified by bicycle ergometry and stress imaging (echocardiography or scintigraphy). Findings from coronary angiographies in the course of the study constituted the main outcome. Results: Of the 54 study participants, 29 patients (53.7%) underwent coronary angiography. CAD was found in 27 of 29 patients (93.1%). In those 27 patients with CAD, 9 patients (33.3%) suffered from single vessel disease, 9 patients (33.3%) from two vessel disease, and 9 patients (33.3%) from triple vessel disease. Two patients showed left main coronary artery stenosis. Conclusion: This study shows a high incidence of relevant CAD among totally asymptomatic patients with myocardial ischemia during stress testing. Previously healthy subjects with exercise-induced ST-segment depression at check-up examinations, even if asymptomatic, should have further diagnostic evaluation. © 2009 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. 1. Introduction Myocardial ischemia may occur in totally asymptomatic patients without a history of an ischemic cardiac event (silent ischemia type I) [1–7]. We have recently shown in the Swiss Interventional Study on Silent Ischemia type I (SWISSI I) that anti-ischemic drug therapy and aspirin in addition to standard risk factor control may improve long- term outcome in patients with silent ischemia type I and at least one risk factor of coronary artery disease (CAD) [5]. Documentation of myocardial ischemia mostly relies upon stress testing, including bicycle ergometry, stress echocardiography, myo- cardial perfusion scintigraphy, and/or radionuclide ventriculography [8]. Only few previous studies in diabetic patients with silent ische- mia correlated findings from stress testing with coronary angiography [9–14]. In these patients with frequent silent ischemia, coronary angiography found a high incidence of CAD. However, there are no data on the prevalence or incidence of CAD in asymptomatic non- diabetic patients who have myocardial ischemia during stress testing. This is due to the difficulty of performing coronary angiography in these asymptomatic and subjectively healthy subjects. Therefore, this study analyzes the findings of coronary angiographies that have been performed during the course of the SWISSI I trial. 2. Materials and methods 2.1. Participants All 54 participants of the SWISSI I trial were included in this analysis. Participants of the SWISSI I trial were recruited from 522 subjects sent for exercise testing to 4 Swiss medical centers (Lucerne, Chur, Zurich, and Basel) between 1992 and 1996 (Fig. 1). Most of them were sent by their primary care physician for life insurance or other check-up investigations. Subjects with at least one cardiovascular risk factor (i.e. smoking, hypertension, diabetes, hypercholesterolemia European Journal of Internal Medicine 20 (2009) 607–610 ☆ Grant support: The Swiss Interventional Study on Silent Ischemia type I was supported by a grant from the von Muralt Stiftung/Swiss Heart Foundation, Berne, Switzerland, and unrestricted grants from Hoechst Pharma Schweiz, Merck Pharma Schweiz, and Pfizer Schweiz. Andreas Schoenenberger was supported by a Forschungs- kolleg Geriatrie Grant from the Robert Bosch Foundation, Stuttgart, Germany. None of the granting institutions had any influence on the study design, data collection, analysis and interpretation. There is no conflict of interest. ☆☆ Trial Registration: ClinicalTrials.gov number, NCT00382421. ⁎ Corresponding author. Department of Cardiology, Luzerner Kantonsspital, CH-6000 Luzern 16, Switzerland. Tel.: +41 41 2055208; fax: +41 41 2055109. E-mail address: Paul.Erne@KSL.CH (P. Erne). 0953-6205/$ – see front matter © 2009 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejim.2009.04.001 Contents lists available at ScienceDirect European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim