Symptoms Other Than Chest Pain May Be Important in the Diagnosis of “Silent Ischemia,” or “The Sounds of Silence”

“Silence like a cancer grows.” — Paul Simon, ©1964 Case presentation: In 2001, on routine testing, a 58-year-old man with a family history of heart disease had an above-normal cholesterol level and high blood pressure. His medical recommendation was to eat fewer fast foods and to take anticholesterol medication, which was stopped when his cholesterol level became lower. His blood pressure problem was treated successfully. His stress test was successful, and he started to exercise 2 to 3 times per week, in addition to adopting the South Beach Diet. The patient did not complain about chest pain, and there was no recommendation for any further cardiac diagnostic testing. Acute shortness of breath and mild chest pain in 2004 prompted a coronary angiogram, which necessitated an immediate quadruple-bypass surgery. The patient later expressed his opinion that people with family history, high cholesterol, and high blood pressure ought to consider an angiogram even if they don’t have symptoms.It is estimated that in the United States today, between 2 and 3 million people with stable coronary artery disease (CAD) have evidence of asymptomatic ischemia. It is accepted that ≈20% of the nonsudden cardiac deaths and nearly half of the sudden cardiac deaths occur with preexisting but undiagnosed CAD.1 An important objective of contemporary clinical cardiology, therefore, should be the uncovering of the silent and therefore unsuspected disease, with the hope of reducing thereby the incidence of cardiovascular events or even death in susceptible individuals. With this in mind, the American Heart Association Prevention V Conference2 proposed the use of office-based testing and additional noninvasive procedures in selected patients.It has become accepted that the presence of 1 or more of the classic risk factors of CAD, even without typical chest pain, and conversely, typical chest pain even without risk factors …