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Myocardial ischemia without pain
Medical expert of the article
Last reviewed: 07.07.2025
In patients with angina pectoris and/or spontaneous angina (including unstable angina ), up to 50-75% of myocardial ischemia episodes are painless (asymptomatic, "silent"). It can be said that painless myocardial ischemia is the most common manifestation of coronary heart disease. However, in completely asymptomatic individuals, episodes of painless ischemia ("isolated" painless ischemia, as the only manifestation of coronary heart disease) are rarely recorded (in approximately 5% of those examined).
[ Diagnosis of silent myocardial ischemia
The presence of silent ischemia can be detected only by instrumental methods of examination, most often using a test with physical activity and ECG monitoring. A sign of painless ischemia is horizontal or slanting depression of the ST segment. The duration of recording the depression of the ST segment during ECG monitoring should exceed 1 min. There is even a variant of painless ischemia without changes on the ECG - "latent", "secret", "super-silent" ("clandestine") ischemia, which is detected using myocardial scintigraphy.
In approximately 25% of cases, the main factor is the decrease in coronary blood flow, probably due to coronary vasoconstriction. Quite often, the signs of painless ischemia occur during intense mental activity, psychoemotional stress, and smoking. The clinical and prognostic significance of episodes of painless myocardial ischemia is approximately the same as that of angina. The likelihood of complications and the prognosis are determined by the degree of damage to the coronary arteries and myocardium, and not by the severity of the pain syndrome or the magnitude of the ST segment deviation. It has been proven, for example, that the detection of painless ischemia in patients with unstable angina is a very unfavorable prognostic sign.
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Prognosis and treatment of silent myocardial ischemia
Several studies have been conducted to determine whether the elimination of silent ischemia can improve the prognosis in patients with coronary heart disease. The results of these studies are contradictory, but there is more evidence in favor of the need to treat silent ischemia. Beta blockers are the most effective. For example, it has been shown that atenolol is more effective than placebo in the treatment of silent ischemia, and bisoprolol is more effective than prolonged forms of nifedipine.
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