Alterations in myocardial perfusion during painless ST-segment depression in patients with angina pectoris.

In order to determine whether painless ST changes represent myocardial ischemia, we studied regional myocardial perfusion in patients with angina pectoris who showed painless ST-segment depression during a treadmill exercise test. Twenty-one patients were evaluated by myocardial imaging using thallium-201 injected intravenously during exercise when painless ST-segment depression was evident. The same examination was repeated in 5 of the above patients when they showed ST-segment depression with chest pain. Myocardial images obtained during painless ST-segment depression revealed perfusion defects in 15 of 21 patients (71%). Images obtained during ST-segment depression with chest pain showed perfusion defects in all 5 patients (100%) including 3 patients who demonstrated no defects during painless ST-segment depression. In these 5 patients, the ST-segment depression associated with pain was significantly greater than that without pain (3.4 +/- 1.1 vs 2.1 +/- 1.1 mm, p less than 0.01). These results suggest that the majority of episodes of painless ST-segment depression occurring during exercise are accompanied by regional myocardial perfusion abnormalities and that transient painless ST-segment depression in patients with angina pectoris might represent less severe myocardial ischemia.