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(Circulation. 2002;106:1906.)
© 2002 American Heart Association, Inc.

Clinician Update

Angina Pectoris Without Chest Pain

Clinical Implications of Silent Ischemia

Shlomo Stern, MD

From Bikur Cholim Hospital, Jerusalem, Israel.

Correspondence to Dr Shlomo Stern, Bikur Cholim Hospital, PO Box 492, Jerusalem 91004, Israel. E-mail sh_stern@netvision.net.il

Key Words: angina • exercise • imaging • infarction • ischemia

An extract of the first 250 words of the full text is provided, because this article has no abstract.

	Introduction

 
We may never know whether the accuracy of William Heberden’s description in the 1770s of a new syndrome, centering around pain in the left chest and named by him "angina pectoris," occurred because the author himself experienced the symptoms described.¹ Heberden’s description of the symptoms has prevailed for centuries, as if it were written in stone. Decades later, this "pain in the chest" was clarified as being induced by myocardial ischemia at the time the patient experiences the pain.

Only rarely over the centuries and usually only through anecdotal cases did the medical literature report that ischemia can be present without accompanying pain in the chronic situation of angina pectoris or even during an acute myocardial infarction. Among these sporadic observations, James Herrick described in his historical treatise on acute myocardial infarction in 1912 two of his six patients who experienced no pain during their cardiac events.²

In the 1970s, several groups of investigators began to use ambulatory monitoring of the ECG, and with this new technique, they described that ST depression, a cardinal sign of myocardial ischemia on the ECG, can occur in patients with ischemic heart disease (IHD) without accompanying pain.^3–5 These studies prompted new investigations on the syndrome that is now called silent myocardial ischemia.

	Why Myocardial Ischemia Is Painless in Some Individuals

 
A defective warning mechanism was proposed by some investigators as the reason for the absence of pain, stressing that sensibility to pain differs from patient to patient.⁶ On the basis of pertinent experiments on the pain threshold of patients with IHD, others . . . [Full Text of this Article]

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