Silent ischemia predicts poor outcome in high-risk healthy men.

Myocardial ischemia is well established as a reliable predictor of physiologically significant coronary artery disease (CAD) (1,2). During the past two decades, a large number of epidemiologic studies and prospective observational data have demonstrated that the presence of myocardial ischemia is associated with adverse outcomes in asymptomatic individuals as well as those with established CAD (3–22). The results of these reports emphasizing the prognostic significance of myocardial ischemia in asymptomatic individuals have led the American Heart Association and the American College of Sports Medicine to recommend that apparently healthy men ages $45 years and women .55 years (even those without known cardiovascular risk factors) should undergo a maximal exercise treadmill test before engaging in a vigorous exercise program (23). However, the issue of routine screening of apparently healthy individuals for myocardial ischemia continues to be a controversial issue and a topic of constant debate. This issue is further compounded by the fact that, frequently, myocardial ischemia detected by ST-segment depression during stress testing in healthy individuals is not associated with chest pain. Because of the absence of symptoms, it has been suggested that the ST-segment changes without asso-