To the Editor.
—The study by Dr Mulcahy and colleagues1 adds to a substantial body of evidence that the risk of acute coronary events cannot be reliably predicted based on the evidence and extent of myocardial ischemia. Given that acute ischemic syndromes mostly occur because of fissuring or rupture of atherosclerotic plaque, these findings are not surprising.2 However, it is disconcerting to note that, based primarily on the risk of coronary events (myocardial infarction and unstable angina) and an extremely low incidence of cardiac mortality, the investigators have reached sweeping conclusions to negate the prognostic importance of ischemia detected by exercise testing and Holter monitoring. In fact, there is plenty of evidence to support that ischemia does portend poor prognosis.3Results from several studies, including ours,4 in patients with stable coronary artery disease (CAD) and ischemia during Holter monitoring revealed higher rates of coronary events and
Deedwania PC, Carbajal EV. Can Ambulatory Monitoring Identify High-Risk Patients With Stable Coronary Artery Disease?. JAMA. 1997;277(22):1760. doi:10.1001/jama.1997.03540460026020