Myocardial ischemia without pain or symptoms is common in patients with CAD. The incidence of silent ischemia is high and the outcome unfavorable in patients with unstable angina. Interventional therapy is often recommended. Holter monitoring after noncardiac sur¬gery in patients with stable angina and post myocardial infarction patients has documented a high incidence of silent ischemia within the second to fourth day after surgery.
In the Total Ischemic Burden Bisoprolol Study, both bisoprolol and nifedipine reduced the number and duration of transient ischemic episodes. Bisoprolol was significantly more effective than nifedipine and reduced the morning peak of ischemic activity. This is in keeping with other studies, which indicate that beta-blocking drugs are superior to calcium antagonists in producing salutary effects in patients with silent ischemia, especially in reducing early morning ischemia that may relate to the peak incidence of early morning heart attacks and death.
Patients with evidence of silent ischemia are recom¬mended to be treated with a beta-blocking drug, aspirin, and a statin and investigated with exercise stress testing. Those who show strongly positive exercise tests and/or ejection fractions less than 45% should be submitted to coronary angiography for consideration of an appropriate revascularization procedure.

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