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Old 04-26-2006, 08:17 AM   #1
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So what's the latest info on detecting silent ischemia?

I've looked around the 'Net to find as much info as possible on silent ischemia. I'm concerned about my own coronary heart health because of familial risk factors as well as my own lack of attention to diet over the years. (Iím over 50)

In addition, my heart is also compensating for aortic insufficiency due to aortic prolapse. However, due to years of extreme exercise, I also enjoy the effects of an "athlete's heart".

So, my questions revolve around the nature of how my heart has compensated for years of exercise as well as aortic regurgitation.

More specifically, I'm interested in how these factors "play out" in the face on continued "intense" exercise in the absence of Angina or any overt symptoms.

It is my understanding that silent ischemia existed in as many as 25% of the patients diagnosed with heart attacks in non-emergency room settings. (Standard office EKG)

What I want to know is if that statistic applies to active individuals that remain symptom free in the face of intense activity?

In other words, if I'm exercising at maximum heart rate without discomfort are the odds or "chances" of silent ischemia diminished?

If a standard echo doesn't reveal any myopathy visually, will a stress echo or contrast echo, or both confirm the absence or presence of ischemia?

Thank you for any research in this area.

 
Old 04-29-2006, 03:43 PM   #2
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Re: So what's the latest info on detecting silent ischemia?

"So, my questions revolve around the nature of how my heart has compensated for years of exercise as well as aortic regurgitation."

Aerobic exercise conditions the heart to increase the blood/oxygen output as well as more forceful contractions to overcome easier the afterload (resistance).

"It is my understanding that silent ischemia existed in as many as 25% of the patients diagnosed with heart attacks in non-emergency room settings".

That appears to be the an accurate statistic. In my situation, I was dx'd with a past event of an MI in ER for pulmonary edema. I had a silent ischemia that caused a silent MI.

What I want to know is if that statistic applies to active individuals that remain symptom free in the face of intense activity?

In other words, if I'm exercising at maximum heart rate without discomfort are the odds or "chances" of silent ischemia diminished?


I can only speak for myself. I push my cardiac to the max recommended for my age. A recent echo indicated an improved EF to normal as well as a pathological heart size (2 year duration).

If a standard echo doesn't reveal any myopathy visually, will a stress echo or contrast echo, or both confirm the absence or presence of ischemia?"

Yes. There will be a visual display on the screen of perfusion at rest and during exercise.

Last edited by moderator2; 04-29-2006 at 04:24 PM. Reason: please use the reply button - do not use quote for a direct reply

 
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Old 04-30-2006, 06:41 AM   #3
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Re: So what's the latest info on detecting silent ischemia?

burpee...such an interesting and elusive condition. In you case, it would seem to be a disease of by and for an ECG machine.
I'm assuming your diagnosis was by observation of a depressed ST segment.

Often confirmation is by exercise test but it seemingly doesn't show up for you at all.

Should I read between the lines that you are merely HYPOTHESIZING about your having or getting ischemic angina because it really sounds like you might very well not.

Usually people with silent ischemia also suffer bouts of STABLE angina as well.

I read that only a quarter of those who suffered a "silent" heart attack also had silent ischemia beforehand. Thus most silent heart attacks are cause the old fashioned way...with a migrating block of clot caused by the bursting of an unstable plaque, often one that caused no ischemia at all, silent or otherwise.

How extensive is your heart remodelling? Do you know your EF?

Last edited by Lenin; 04-30-2006 at 06:43 AM.

 
Old 04-30-2006, 06:42 AM   #4
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Re: So what's the latest info on detecting silent ischemia?

K, thanks for your comments.

I've altered some of my "search term" usage and have found a bonanza of information that applied to my situation. I used the terms "myocardial perfusion" and "high intensity exercise" - This link is a great resource.
[url]http://www.suddendeathathletes.org/about_sdia.asp#b[/url]

Essentially, what I want to know about my own situation is whether anyone can distinguish my "athlete's heart" development from dangerous hypertrophic cardiomyopathy. (and relative chances of sudden death to general pop)

Clearly, there IS a risk in any "all-out" exercise effort. Clearly, there is increased risk for anyone who has genetic or familial risk factors. Having at least a "minor" valve defect contributes to non-normal left-ventricular compensation and hypertrophy as well. What remains unclear is at what level of certainty can diagnostic tests estimate or discern myopathy or non-reversible ischemia.

Evidentally, even newer SPECT based imaging cannot always resolve regions of the myocardium to the degree necessary to predict major infarction.

I currently have concluded that my exercise training is providing superior or at least "normal" perfusion of most of the myocardium and if indeed I am hurting myself, it is more likely the result of undetectable, undiagnosable coronary defects (or other related blood vessels) than physiological compensation brought on by exercise.

I am waiting for the results and interpretations from a recent echo, and after a consult with my regular cardiologist, I may take my results to another doctor who specializes stress based angiography.

Last edited by burpee; 04-30-2006 at 06:48 AM.

 
Old 04-30-2006, 06:57 AM   #5
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Re: So what's the latest info on detecting silent ischemia?

Specifically,

What does your ST segment look like?
With no depression I think you can probably think nothing of regularly exercising to the point of 80% of you maximum heart rate or even somewhat higher, in efffect, ignoring the concept of silent ischemia entirely.

I too am fond of using high intensity repetitive exercise to force growth of microvessels throughout the myocardium. I just wish I hadn't waited quite so late in life to discover the advantages of hard aerobics (I've ALWAYS been fond of intense ANaerobics...but they didn't do much for my heart , just my muscles.)

I would THINK that an experienced cardiologist could determine an athlete's large heart from cardiomyopathetic large one...although I'm sure there are those who cannot and will judge more by looking at the patient...arriving at the doctor's office in Speedos and a worn pair of New Balance is often a clue...with a Zimmer frame (from Brit coms.), yet another.
I'm also sure that someone with a failing remodelled heart from heart failure simply can NEVER perform at high intensity exercise as well as someone with a well trained large heart.

I guess there really isn't too much difference intrinsically between the two causes of heart growth...except for one BIGGIE: the exercised heart gets to rest while the diseased heart must keep overexerting itself 24/7/365 until it is destroyed!

Last edited by Lenin; 04-30-2006 at 07:11 AM.

 
Old 04-30-2006, 07:11 AM   #6
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Re: So what's the latest info on detecting silent ischemia?

L,

Just read your post, I don't know anything about my ECG readings, but understand them to be normal.

Glad you made the remark about "stable" angina, because I haven't really looked into understanding the relationship of overt symptons and disease.

I'm sure all my echo readings will most likely look normal. Except of course for the large LV and regurgitation. My current cardiologist believes a stress echo/ECG would not reveal anything, but maybe you're right.

The "big deal" in any of this to me - is the fact that both of my parents suffered cardiovascular events at the ages of 56 and 58, and I'm over 50....

But, I'm certainly willing to accept the position, I've got nothing to worry about. At least one doctor thinks my exercise and continued athletic ability far outweighs any indicators or "interpretations" of cardiovascular impairment or disease.

PS - my EF was over 70% years ago........

 
Old 04-30-2006, 07:16 AM   #7
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Re: So what's the latest info on detecting silent ischemia?

Quote:
Originally Posted by burpee
L,

Just read your post, I don't know anything about my ECG readings, but understand them to be normal.


PS - my EF was over 70% years ago........
Give no firther thoughts to any possibility of silent ischemia.

Control your cholesterol if you need to, keep up the exercise and you'll leave both your parents in the dust, so to speak!

 
Old 04-30-2006, 09:46 AM   #8
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Re: So what's the latest info on detecting silent ischemia?

"Usually people with silent ischemia also suffer bouts of STABLE angina as well.

I read that only a quarter of those who suffered a "silent" heart attack also had silent ischemia beforehand. Thus most silent heart attacks are cause the old fashioned way...with a migrating block of clot caused by the bursting of an unstable plaque, often one that caused no ischemia at all, silent or otherwise."


It is my understanding and experience that stable angina and silent ischemia are mutually exclusive conditions (how can it be silent if there is pain?). And almost always with silent ischemia there is a slow, unaware progression to the heart failure status. My source states sometimes but not always collateral vessels develop over a period of time to bypass the developing blockage. Further comment it also depends on the location of the developing blockage.

Relating to an enlarged heart. The underlying cause would differentiate the prognosis and/or beneficial outcome. A pathological increase in size is also a function of abnormal pressure within the chamber to the point where contractions are negatively effected. There is a medical reference to this phenomenon and it references the mechanical stretching of a spring. To slightly stretch a hand spring it increases the recoil, recoil increases to a point where the spring no longer has the property to recoil. A healthy enlarged heart should never reach the point where the flexibility is impaired, but the contractions are improved.

 
Old 04-30-2006, 10:42 AM   #9
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Re: So what's the latest info on detecting silent ischemia?

They are not mutually exclusive in that one can, at different times, have bouts of painful ischemic angina and also bouts of silent ischemia as evidenced only by an ECG registered depression of the ST segment. (A painful bout of ischemia will also show an ST depression.)

One can't have both at the same instant in time time because a depression of the ST segment WITH pain is ischemic angina or angina pectoris. That would be definitionally impossible. (In other words you can't have A AND B while at the same time having A AND NOT B.)

My mother suffered stable angina, ECG registered silent iscemia and had both a silent heart attack and a dreadfully painful one....poor woman covered all the bases.

<This was edited for clarity! My first post was muddy. Sorry if it slightly distorts the train of thought.>

Last edited by Lenin; 05-04-2006 at 11:46 AM.

 
Old 05-01-2006, 09:10 AM   #10
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Re: So what's the latest info on detecting silent ischemia?

QUOTE: Of course, both silent and stable ischemia wouldn't occur at the same time...that WOULD be definitionally impossible.

I see them as almost the same condition with similar consequences, the only real difference being the perception of pain.

I like the relationship
stable angina: painful heart attack::silent angina: painless heart attack.

A nice balance!


Of no consequence to the subject of silent ischemia and technology's function to dx blocked or partially blocked arteries, unless as it happened to me, the stress test was stopped due to instrument readings (no pain).

The relationship (angina/MI) in your scenario is apples to oranges and that may be the crux of your misunderstanding. Angina means if and only if there is pain (stable, if and only if, during exertion and if and only if pain relief at rest) (unstable, if and only if there is pain with and without exertion). There is another category (no pain with or without exertion: silent ischemia). Stable or unstable angina DOES NOT necessarily mean there has been a heart attack. Heart attack means heart muscle damage (myocardiac infarction).

Lack of pain with either stable or unstable angina is believed to be a neurological/vascular disorder mostly experienced by diabetics and a few others. That is silent ischemia and unfortunately it develops into heart failure without a warning! Perception of pain as you state implies pyschological, I'm saying it is a medical/physical condition.

Last edited by started04; 05-01-2006 at 09:15 AM.

 
Old 05-04-2006, 09:25 AM   #11
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Re: So what's the latest info on detecting silent ischemia?

The journal piece was written as a guide for echo-cardiographers. The article proposes that the chamber size, blood flow or wall thickness-values beyond certain "limits" cannot possibly contribute to increased performance and eventually contribute to unhealthful heart remodeling. Another long-term consideration is my heart's efficiency as it "deconditions" from athlete's heart syndrome.

Very interesting and that is intuitively consistant with an abnormal development from an offensive cause. However, it seems reasonable to also consider the ENTIRE benefit to the complete system's condition and that would offset and regulate heart health. The heart has to enlarge to meet the demand of an increase of muscle mass, and there may be for some... with an inherent (genetic) vulnerability... unable to meet that demand. For evidence there are some deaths related to taking steroids to increase muscle mass, but many who do not have a side effect at least not in short term!

 
Old 05-04-2006, 12:03 PM   #12
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Re: So what's the latest info on detecting silent ischemia?

Quote:
Originally Posted by burpee

What I really want to understand is -- if technology exists to identify insufficient regional perfusion during high-intensity exercise that causes myocardial ischemia, and over time, fibrosis in the Left Ventricle. And whether or not an exercise-intensity "peak" exists where perfusion is adequate throughout the myocardium without any resulting ischemia and subsenquent left-ventricular myopathy.
Let me go after the "really want to understand" part of your dilemma.
Does technology exist to identify insufficient regional perfusion?
The answer is yes.
The stress test with nuclear imaging will show the extent of circulation deficiency with or without pain. At the same time a stress test to maximum effort if you choose will continuously record an ECG (or EKG for Germans) that will show any depression of the ST segment, yet another confirmation of ischemia, silent or otherwise. Absent pain,a depressed ST segment or any imaging evidence of impaired arterial circulation, I would think it might be beating a dead horse to look for more elaborate tests.

There is no evidence (that I've seen) that ischemia will lead to cardiac fibrosis.

Talking simply, is your goal to assure yourself that you can exercise to capacity without damaging your heart? Or is it to ease you mind about your heart remodelling, e.g., it's not due to the aortic problem but rather to the heathy effects of exercise?

 
Old 05-04-2006, 03:04 PM   #13
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Re: So what's the latest info on detecting silent ischemia?

L,

Well, I'll be the first to admit I try to use medical terms within context without nearly enough real knowledge to much of what I am talking about. So bear with the techno babble, but I think I'm getting relatively accurate in some areas.

Yes, I'm sure that at least some "experts" in nuclear isotope imaging technologies feel they can defintively rule out ischemia. But my Internet research has left me with the impression that there is considerable room for improvement in distinguishing between truly healthy heart muscle mass and adaptations to the heart that will eventually lead to a less than optimal life-long capacity. (no I don't really know what or why one article mention fibrosis) But I take that to mean unhealthy, yet still alive muscle fibre.

But, afterall as K, put it, a generally accepted notion is that the positives outweigh the negatives when concerning athletic activity and repeated self-generated stress. So, maybe, as you state, I make "much ado about nothing."

So really, I'm just left with original familial risk factors, an aortic defect with life-long compensation, and a whole lot of speculation about whether any coronary defect or some idiopathic defect in regional perfusion will cause parts of my heart muscle to "wear out" early......

Oh, and plus, as far as I know, I'm not the golden low-fat, low cholesterol boy, but the few times it was checked, I think it was normal.....

And that again, is a reminder that my coronary artery capacities are dynamic. And while they may very well be superior at this time, there's no guarantee they will keep pace with the needs of an athletic heart as well as a heart that's compensating for a leaky valve in coming years.

In fact, isn't that what aging is all about? The dissimilar failure of organ systems and tissue regeneration?

What, I'm hoping to do is "kick all this" around with a doctor friend, during a long bike ride. He's not a cardiologist, but at least he can set me straight on whether I am asking intelligent questions.

 
Old 05-05-2006, 04:37 AM   #14
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Re: So what's the latest info on detecting silent ischemia?

Burpee,

Let me repeat my last paragraph:
Quote:
Talking simply, is your goal to assure yourself that you can exercise to capacity without damaging your heart? Or is it to ease you mind about your heart remodelling, e.g., it's not due to the aortic problem but rather to the heathy effects of exercise?
My guess is that you have answered the first in your mind with a YES? But you are not at ease about accepting "door 2." But you'd LIKE to hear that your remodelling was healthy and due to exercise. Did I guess correctly? (Do I win the CAR! )

 
Old 05-09-2006, 02:54 PM   #15
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Re: So what's the latest info on detecting silent ischemia?

Lenin -- No, you don't win the car, and you won't even make the final round of jeopardy..... sorry.

In plain English - my questions are: I want to know if there is anything that can be identified using various imaging technologies/ECG? about my heart that indicates an increased risk for sudden death during intense exercise. (In other words, is my risk greater, lesser or the same as the general population?)

I want to know if the combination of aortic insufficiency and a long life of intense exercise will continue to promote the best possible outcome in terms of longevity and exercise capacity or if certain higher intensities of exercise are promoting less than optimal changes or degenerating heart tissues and function in some way. (In other words, could I be wearing out my heart more quickly - than if I simply exercised moderately?)

I met with another doctor friend, and she said that those are tough questions and in some repsects - there are no answers.

 
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