Myocardial Ischemia Therapeutic Implications

Although it is now widely accepted that silent myocardial ischemia detected by ambulatory ECG monitoring (AEM) is the most common form of ischemia, the debate regarding the pathophysiological mechanisms responsible for ischemic episodes during daily life is far from being settled.1,2 Because most of the early investigations in this field had reported that the vast majority of transient ischemic episodes (TIEs) occurred during periods of little or no physical activity, it generally was assumed that mechanisms other than an increase in myocardial oxygen demand might be responsible in their genesis.3-5 Although most patients in the earlier investigations had evidence of obstructive lesions secondary to coronary atherosclerosis as well as ischemia secondary to increased oxygen demand during exercise testing, based on relatively lower heart rates during TIEs recorded by AEM, it was suggested that coronary vasoconstriction might play a role in ischemia during daily life.3-6 Little