History

Fact Explanation
Chest pain [1] Hypertension is one of the leading preventable causes of premature coronary heart disease and thereby death [10] Angina, a frequent complication of hypertensive heart disease,gives rise to chest pain, often described a heaviness, pressure, and/or a squeezing Radiating to the jaw, neck, upper back, or left arm. Provoked by physical or emotional exertion Relieved with rest or with the use of sublingual nitroglycerin [1]
Symptoms of heart failure: orthopnea,paroxysmal nocturnal dyspnea, fatigue,ankle swelling [2] With time, left ventricular hypertrophy, increasing vascular and ventricular tension ultimately lead to heart failure [2]
Past history of hypertension [3] Hypertension is a major independent risk factor for heart diseases. [3]
Past history of stroke [3] Patients with hypertensive heart diseases may have other associated complications of hypertension such as strokes. [3] It has been reported that a fall of 10 - 20 mmHg in systolic pressure maintained for 5 years could reduce the risks of stroke by40% [7]
History of renal failure [3] Patients with hypertensive heart diseases may have other associated complications of hypertension such as renal failure. [3]
Palpitations, Near or total syncope [4] Patients with hypertension are more prone to get arrhythmia. [4]
Obesity, less exercise [5] Although the main risk factor for hypertensive heart disease is high blood pressure, obesity and less exercise increases the risk. [5]
Family history of hypertension [5] Increases the risk of getting hypertensive heart disease. [5]
History of smoking [5] Increases the risk. [5]
History of dyslipidaemia. diabetes [5] Hypertension, diabetic and dyslipidemia are major risk factors for cardiovascular disease [6] Hypertension is present in 20% to 60% of patients with type 2 diabetes, depending on age, ethnicity, obesity, and the presence of micro or macro albuminuria [10]
Male gender [5] Men are more likely to get heart disease than women, at least until the age of menopause; men and postmenopausal women are equally at risk [5]
Old age [5] Risk for heart disease increases with age [8]
References
  1. ROSENDORFF C., BLACK H. R., CANNON C. P., GERSH B. J., GORE J., IZZO J. L., KAPLAN N. M., O'CONNOR C. M., O'GARA P. T., OPARIL S.. Treatment of Hypertension in the Prevention and Management of Ischemic Heart Disease: A Scientific Statement From the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention. Circulation [online] 2007 May, 115(21):2761-2788 [viewed 24 June 2014] Available from: doi:10.1161/​CIRCULATIONAHA.107.183885
  2. IZZO JOSEPH L., GRADMAN ALAN H.. Mechanisms and management of hypertensive heart disease: from left ventricular hypertrophy to heart failure. Medical Clinics of North America [online] 2004 September, 88(5):1257-1271 [viewed 24 June 2014] Available from: doi:10.1016/j.mcna.2004.06.002
  3. ROSENDORFF C., BLACK H. R., CANNON C. P., GERSH B. J., GORE J., IZZO J. L., KAPLAN N. M., O'CONNOR C. M., O'GARA P. T., OPARIL S.. Treatment of Hypertension in the Prevention and Management of Ischemic Heart Disease: A Scientific Statement From the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention. Circulation [online] 2007 May, 115(21):2761-2788 [viewed 24 June 2014] Available from: doi:10.1161/CIRCULATIONAHA.107.183885
  4. LIP G. Hypertensive heart disease. A complex syndrome or a hypertensive 'cardiomyopathy'?. European Heart Journal [online] 2000 October, 21(20):1653-1665 [viewed 24 June 2014] Available from: doi:10.1053/euhj.2000.2339
  5. RAPSOMANIKI E, TIMMIS A, GEORGE J, PUJADES-RODRIGUEZ M, SHAH AD, DENAXAS S, WHITE IR, CAULFIELD MJ, DEANFIELD JE, SMEETH L, WILLIAMS B, HINGORANI A, HEMINGWAY H. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1?25 million people Lancet [online] , 383(9932):1899-1911 [viewed 24 June 2014] Available from: doi:10.1016/S0140-6736(14)60685-1
  6. CHOUDHURY KN, MAINUDDIN AK, WAHIDUZZAMAN M, ISLAM SM. Serum lipid profile and its association with hypertension in Bangladesh. Vasc Health Risk Manag [online] 2014:327-32 [viewed 14 September 2014] Available from: doi:10.2147/VHRM.S61019
  7. BABAEE BEIGI MA, ZIBAEENEZHAD MJ, AGHASADEGHI K, JOKAR A, SHEKARFOROUSH S, KHAZRAEI H. The effect of educational programs on hypertension management. Int Cardiovasc Res J [online] 2014 Sep, 8(3):94-8 [viewed 14 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25177671
  8. RAPSOMANIKI E, TIMMIS A, GEORGE J, PUJADES-RODRIGUEZ M, SHAH AD, DENAXAS S, WHITE IR, CAULFIELD MJ, DEANFIELD JE, SMEETH L, WILLIAMS B, HINGORANI A, HEMINGWAY H. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million people. Lancet [online] 2014 May 31, 383(9932):1899-911 [viewed 14 September 2014] Available from: doi:10.1016/S0140-6736(14)60685-1
  9. SADEGHI R, ADNANI N, ERFANIFAR A, GACHKAR L, MAGHSOOMI Z. Premature coronary heart disease and traditional risk factors-can we do better? Int Cardiovasc Res J [online] 2013 Jun, 7(2):46-50 [viewed 14 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24757620
  10. LOPEZ-JARAMILLO P, LOPEZ-LOPEZ J, LOPEZ-LOPEZ C, RODRIGUEZ-ALVAREZ MI. The goal of blood pressure in the hypertensive patient with diabetes is defined: now the challenge is go from recommendations to practice. Diabetol Metab Syndr [online] 2014 Mar 4, 6(1):31 [viewed 14 September 2014] Available from: doi:10.1186/1758-5996-6-31

Examination

Fact Explanation
Irregular pulse [1] Due to occurance of arrhythmia during silent myocardial ischemia [1]
Dyspnea [2] Atypical presentation of acute coronary disease [2]
Fundoscopy examination [1] Since diabetic patients are more prone to get SMI,changes of diabetic retinopathy may be present [1]
Loss of peripheral sensation [1] Patients with neuropathies are more prone to get SMI ( eg: diabetic neuropathy )
Signs of diabetic dermopathy ( loss of body hair, pigmented patches,callous etc) [1] Since diabetic patients are more prone to get SMI,changes of diabetic dermopathy may be present [1]
Surgical scars [2] Patients who had past surgeries for coronary artery disease, may have surgical scars [2]
High blood pressure [2] Blood pressure levels may go up during a SMI [2]
References
  1. STERN S.. Symptoms Other Than Chest Pain May Be Important in the Diagnosis of "Silent Ischemia," or "The Sounds of Silence". Circulation [online] 2005 June, 111(24):e435-e437 [viewed 25 June 2014] Available from: doi:10.1161/​CIRCULATIONAHA.105.550723
  2. AHMED AH, SHANKAR K, EFTEKHARI H, MUNIR M, ROBERTSON J, BREWER A, STUPIN IV, CASSCELLS SW. Silent myocardial ischemia: Current perspectives and future directions Exp Clin Cardiol [online] 2007, 12(4):189-196 [viewed 25 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2359606

Differential Diagnoses

Fact Explanation
Heart failure [1] May present with dyspnea, palpitations. Other features of heart failure such as ankle edema may also be prasent [1]
Silent mitral insufficiency [1] Patient may present with similar symptoms without an audible murmur [1]
Ventricular arrhythmia [1] Present with dyspnea, irregular pulses.Other cardiovascular causes including cardiomyopathies may be present [1]
References
  1. FORRESTER J. S., DIAMOND G., FREEDMAN S., ALLEN H. N., PARMLEY W. W., MATLOFF J., SWAN H. J. C.. Silent Mitral Insufficiency in Acute Myocardial Infarction. Circulation [online] 1971 November, 44(5):877-883 [viewed 26 June 2014] Available from: doi:10.1161/​01.CIR.44.5.877

Investigations - for Diagnosis

Fact Explanation
Bed side electrocardiography (ECG) monitoring [1] Continuous ECG monitoring is the mainstay of cardiac monitoring.The sensitivity and accuracy of detecting ST-T changes suggestive of ischemia (ST elevations and depressions) depend on the number of leads used during ECG monitoring [2]
Exercise stress testing [2] Exercise stress testing combined with ECG testing has been used for the detection of ST-T changes secondary to myocardial ischemia and infarction [2]
Ambulatory ECG monitoring [2] Helps to stratify the risk of serious events (intense activity,psychological stresses etc.) in patients with various forms of heart disease [2] Accuracy of the Holter monitor is greatly increased when the diagnosis of silent myocardial ischemia is limited to the following conditions: (1) at least 0.5 mm ST segment depression (2) duration of ST segment depression >60 s (3) reversibility of ST segment depression [3]
Radionuclide imaging techniques [2] Ischemia may also be detected by radionuclide perfusion scanning [2]
Intra cardiac monitoring [2] includes an integrated, implantable lead and electronic processing box implanted in the subclavian area. The lead may be positioned in the right ventricular apex and can continuously measure more reliable physiological and hemodynamic parameters, as well as intra-cardiac electrograms relevant to the detection of myocardial ischemia [2]
Near-infrared spectroscopy [2] Intravascular near-infrared spectroscopy is an emerging tool for the detection of myocardial ischemia. The intravascular near-infrared spectral analysis of the coronary sinus blood with a fibre optic catheter can be a reliable diagnostic tool for the on-line detection and follow-up of acute myocardial ischemia [2]
Computed tomography (CT) [2] Recently, multislice computed tomography (CT) has been shown to be capable of visualizing not only the coronary arteries (wall and lumen), but also the cardiac muscle, with high spatial resolution.Noninvasive visualization of the coronary arteries and accurate detection of stenosis are now possible with ECG-gated 16-slice CT [2]
Coronary angiography [1] Detection of the blocks, narrowing in the coronary vessels [2]
References
  1. COHN P. F.. Silent Myocardial Ischemia. Circulation [online] 2003 August, 108(10):1263-1277 [viewed 25 June 2014] Available from: doi:10.1161/​01.CIR.0000088001.59265.EE
  2. AHMED AH, SHANKAR K, EFTEKHARI H, MUNIR M, ROBERTSON J, BREWER A, STUPIN IV, CASSCELLS SW. Silent myocardial ischemia: Current perspectives and future directions Exp Clin Cardiol [online] 2007, 12(4):189-196 [viewed 25 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2359606
  3. GUTTERMAN DAVID D.. Silent Myocardial Ischemia. Circ J [online] 2009 December, 73(5):785-797 [viewed 25 June 2014] Available from: doi:10.1253/circj.CJ-08-1209

Investigations - Fitness for Management

Fact Explanation
Lipid profile [1] Assess other co morbid conditions. Dyslipidemia increases the risk of getting silent myocardial ischemia (SMI) [1]
Full blood count [2] To check for hemoglobin levels as anemia may further worsen the cardiac function [2]
Fasting blood sugar [1] To assess other co morbid conditions.Diabetes is a major risk factor which gives rise to silent myocardial infarction [3]
References
  1. AHMED AH, SHANKAR K, EFTEKHARI H, MUNIR M, ROBERTSON J, BREWER A, STUPIN IV, CASSCELLS SW. Silent myocardial ischemia: Current perspectives and future directions Exp Clin Cardiol [online] 2007, 12(4):189-196 [viewed 25 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2359606
  2. GUTTERMAN DAVID D.. Silent Myocardial Ischemia. Circ J [online] 2009 December, 73(5):785-797 [viewed 25 June 2014] Available from: doi:10.1253/circj.CJ-08-1209
  3. LOPEZ-JARAMILLO P, LOPEZ-LOPEZ J, LOPEZ-LOPEZ C, RODRIGUEZ-ALVAREZ MI. The goal of blood pressure in the hypertensive patient with diabetes is defined: now the challenge is go from recommendations to practice. Diabetol Metab Syndr [online] 2014 Mar 4, 6(1):31 [viewed 14 September 2014] Available from: doi:10.1186/1758-5996-6-31

Investigations - Followup

Fact Explanation
Ambulatory ECG monitoring [1] Helps to stratify the risk of serious events (intense activity,psychological stresses etc.) in patients with various forms of heart disease [1]
Lipid profile [2] Low density lipoprotein levels are expected to be kept <100mg/dl in patients with coronary artery disease as dyslipidemia increases the risk of silent myocardial infarction[2]
Fasting blood sugar [1] Patients with diabetes and silent myocardial infarction (SMI) have a very poor prognosis, as reflected by adverse cardiac events or death.Therefore tight glycemic control is expected. Normal FBS-<126mg/dl [1]
Echocardiogram [2] To check for left ventricular function by assessing ejection fraction as the patients with coronary heart disease may go into heart failure [2]
Hemoglobin A1C levels [2] Silent ischemia is also associated with higher hemoglobin A1C levels, reflecting the importance of achieving and maintaining euglycemia [2]
References
  1. AHMED AH, SHANKAR K, EFTEKHARI H, MUNIR M, ROBERTSON J, BREWER A, STUPIN IV, CASSCELLS SW. Silent myocardial ischemia: Current perspectives and future directions Exp Clin Cardiol [online] 2007, 12(4):189-196 [viewed 25 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2359606
  2. GUTTERMAN DAVID D.. Silent Myocardial Ischemia. Circ J [online] 2009 December, 73(5):785-797 [viewed 25 June 2014] Available from: doi:10.1253/circj.CJ-08-1209

Investigations - Screening/Staging

Fact Explanation
Bed side electrocardiography (ECG) monitoring [1] Continuous ECG monitoring is the mainstay of cardiac monitoring.The sensitivity and accuracy of detecting ST-T changes suggestive of ischemia (ST elevations and depressions) depend on the number of leads used during ECG monitoring [2]
Ambulatory ECG monitoring [2] Helps to stratify the risk of serious events (intense activity,psychological stresses etc.) in patients with various forms of heart disease [2]
Fasting blood sugar [1] To diagnose udetected diabetes (FBS >126mg/dl with symptoms of diabetes). Diabetic patients are more prone to get silent myocardial infarctions [2]
Lipid profile [2] To screen for dyslipidemia. Dyslipidemia increases the risk of getting SMI. Low density lipoprotein levels are expected to be kept <100mg/dl in patients with coronary artery disease [2]
References
  1. COHN P. F.. Silent Myocardial Ischemia. Circulation [online] 2003 August, 108(10):1263-1277 [viewed 25 June 2014] Available from: doi:10.1161/​01.CIR.0000088001.59265.EE
  2. AHMED AH, SHANKAR K, EFTEKHARI H, MUNIR M, ROBERTSON J, BREWER A, STUPIN IV, CASSCELLS SW. Silent myocardial ischemia: Current perspectives and future directions Exp Clin Cardiol [online] 2007, 12(4):189-196 [viewed 25 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2359606

Management - General Measures

Fact Explanation
Dietary modifications [1] Diet low in cholesterol,sugar and low in alcohol consumption [1]
Exercise [2] Regular exercise, such as walking, running, cycling, or swimming has been shown to improve cardiovascular well-being [2]
Control of other factors which may increase the risk [2] Hypercholesterolemia, high blood sugar,cigarette smoking are potentially modifiable risk factors [2]
Patient education [2] Educate regarding the risk factors, controlling of other co morbid conditions,avoiding the events which may lead to myocardial ischemia [2]
References
  1. AHMED AH, SHANKAR K, EFTEKHARI H, MUNIR M, ROBERTSON J, BREWER A, STUPIN IV, CASSCELLS SW. Silent myocardial ischemia: Current perspectives and future directions Exp Clin Cardiol [online] 2007, 12(4):189-196 [viewed 25 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2359606
  2. COHN P. F.. Silent Myocardial Ischemia. Circulation [online] 2003 August, 108(10):1263-1277 [viewed 25 June 2014] Available from: doi:10.1161/​01.CIR.0000088001.59265.EE

Management - Specific Treatments

Fact Explanation
Beta blockers [1] Beta blockers reduce the incidence, frequency, duration, and severity of silent ischemia in a dose-dependent manner. Furthermore,have been shown to blunt the circadian pattern of transient ischemia, particularly the morning peak of ischemic activity, which closely mirrors the circadian incidence of acute myocardial infarction and sudden death. [1]
Calcium antagonists [1] Act as vasodilators and relieve the ischemia [1]
Surgical treatment [2] Revascularization, particularly surgery, was superior to pharmacological therapy in improving prognosis. Primary coronary intervention, coronary by pass grafting is generally more effective in reducing silent ischemic episodes [2]
References
  1. COHN P. F.. Silent Myocardial Ischemia. Circulation [online] 2003 August, 108(10):1263-1277 [viewed 25 June 2014] Available from: doi:10.1161/​01.CIR.0000088001.59265.EE
  2. GUTTERMAN DAVID D.. Silent Myocardial Ischemia. Circ J [online] 2009 December, 73(5):785-797 [viewed 25 June 2014] Available from: doi:10.1253/circj.CJ-08-1209