Does the Brain Know When the Heart Is Ischemic?
Authors: Carl J. Pepine
Journal: Annals of Internal Medicine (1996)

Editorials1 June 1996Does the Brain Know When the Heart Is Ischemic?Carl J. Pepine, MDCarl J. Pepine, MDUniversity of Florida Gainesville, FL 32610-0277Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-124-11-199606010-00009 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Chest pain has traditionally been accepted as the principal warning of ischemic heart disease, but doubts were raised long ago about whether severe ischemia is always signaled by chest pain [1]. With better ambulatory and in-hospital monitoring, it has become apparent over the years that patients who have angina, have had infarction, or are elderly have most of their ischemic episodes without chest pain [2-6]. It follows that the objective signals of cardiac ischemia (such as transient electrocardiographic ST-segment depression, perfusion, or wall motion abnormalities) are more closely linked with adverse outcomes than either the presence or severity of chest ...References1. Gorham LW, Martin SJ. Coronary occlusion with and without pain. Arch Intern Med. 1938; 62:821-39. Google Scholar2. Schang SJ Jr, Pepine CJ. Transient asymptomatic S-T segment depression during daily activity. Am J Cardiol. 1977; 39:396-402. Google Scholar3. Aronow WS, Epstein S. Usefulness of silent myocardial ischemia detected by ambulatory electrocardiographic monitoring in predicting new coronary events in elderly patients. Am J Cardiol. 1988; 62:1295-6. Google Scholar4. Gottlieb SO, Gottlieb SH, Achuff SC, Baumgardner R, Mellits ED, Weisfeldt ML, et al. Silent ischemia on Holter monitoring predicts mortality in high-risk postinfarction patients. JAMA. 1988; 259:1030-5. Google Scholar5. Langer A, Freeman MR, Armstrong PW. ST segment shift in unstable angina: pathophysiology and association with coronary anatomy and hospital outcome. J Am Coll Cardiol. 1989; 13:1495-502. Google Scholar6. Bugiardini R, Borghi A, Pozzati A, Ruggeri A, Puddu P, Maseri A. Relation of severity of symptoms to transient myocardial ischemia and prognosis in unstable angina. J Am Coll Cardiol. 1995; 25:597-604. Google Scholar7. Tzivoni D, Weisz G, Gavish A, Zin D, Keren A, Stern S. Comparison of mortality and myocardial infarction rates in stable angina pectoris with and without ischemic episodes during daily activities. Am J Cardiol. 1989; 63:273-6. Google Scholar8. Deedwania PC, Carbajal EV. Silent ischemia during daily life is an independent predictor of mortality in stable angina. Circulation. 1990; 81:748-56. Google Scholar9. Yeung AC, Barry J, Orav J, Bonassin E, Raby KE, Selwyn AP. Effects of asymptomatic ischemia on long-term prognosis in chronic stable coronary disease. Circulation. 1991; 83:1598-604. Google Scholar10. de Marchena E, Asch J, Martinez J, Wozniak P, Posada JD, Pittaluga J, et al. Usefulness of persistent silent myocardial ischemia in predicting a high cardiac event rate in men with medically controlled, stable angina pectoris. Am J Cardiol. 1994; 73:390-2. Google Scholar11. Hedblad B, Juul-Moller S, Svensson K, Hanson BS, Isacsson SO, Janzon L, et al. Increased mortality in men with ST segment depression during 24 h ambulatory long-term ECG recording. Results from prospective population study ‘Men born in 1914’, from Malmo, Sweden. Eur Heart J. 1989; 10:149-58. Google Scholar12. Colbeck EH. Angina pectoris: a criticism and an hypothesis. Lancet. 1903; 1:793-5. Google Scholar13. Lewis T. Pain in muscular ischaemia—its relation to anginal pain. Arch Intern Med. 1932; 49:713-27. Google Scholar14. Malliani A, Pagani M, Lombardi F, Cerutti S. Cardiovascular neural regulation explored in the frequency domain. Circulation. 1991; 84:482-92. Google Scholar15. Droste C, Roskamm H. Psychophysiological mechanisms in silent myocardial ischaemia. Eur Heart J. 1987; 8:99-108. Google Scholar16. Ammons WS, Blair RW, Foreman RD. Vagal afferent inhibition of primate thoracic spinothalamic neurons. Neurophysiol. 1983; 59:926-40. Google Scholar17. Sheps DS, Adams KF, Hinderliter A, Price C, Bissette J, Orlando G, et al. Endorphins are related to pain perception in coronary artery disease. Am J Cardiol. 1987; 59:523-7. Google Scholar18. Rosen SD, Paulesu E, Nihoyannopoulos P, Tousoulis D, Frackowiak RS, Frith CD, et al. Silent ischemia as a central problem: regional brain activation compared in silent and painful myocardial ischemia. Ann Intern Med. 1996; 124:939-49. Google Scholar19. Coghill RC, Talbot JD, Evans AC, Meyer E, Gjedde A, Bushnell MC, et al. Distributed processing of pain and vibration by the human brain. J Neurosci. 1994; 14:4095-108. Google Scholar20. Mittleman MA, Maclure M, Sherwood JB, Mulry RP, Tofler GH, Jacobs SC, et al. Triggering of acute myocardial infarction onset by episodes of anger. Determinants of Myocardial Infarction Onset Study Investigators. Circulation. 1995; 92:1720-5. Google Scholar21. Helmers KF, Krantz DS, Merz CN, Klein J, Kop WJ, Gottdiener JS, et al. Defensive hostility: relationship to multiple markers of cardiac ischemia in patients with coronary disease. Health Psychol. 1995; 14:202-9. Google Scholar22. Pepine C, Bertolet B, Cohen J, Goldberg D, Taylor H, Becker L, et al. Psychophysiological Investigations of Myocardial Ischemia (PIMI): Initial results on mechanisms of cardiac ischemia. J Am Coll Cardiol. 1995; 25:6A. Google Scholar23. Maixner W. Interactions between cardiovascular and pain modulatory systems: physiological and pathophysiological implications. J Cardiovasc Electrophysiol. 1991; 2:S3-S12. Google Scholar24. Imperi GA, Lambert CR, Coy K, Lopez L, Pepine CJ. Effects of titrated β blockade (metoprolol) on silent myocardial ischemia in ambulatory patients with coronary artery disease. Am J Cardiol. 1987; 60:519-24. Google Scholar Author, Article, and Disclosure InformationAuthors: Carl J. Pepine, MDAffiliations: University of Florida Gainesville, FL 32610-0277Corresponding Author: Carl J. Pepine, MD, Division of Cardiovascular Medicine, University of Florida, Box 100277, Gainesville, FL 32610-0277. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoSilent Ischemia as a Central Problem: Regional Brain Activation Compared in Silent and Painful Myocardial Ischemia Stuart D. Rosen , Eraldo Paulesu , Petros Nihoyannopoulos , Dimitris Tousoulis , Richard S.J. Frackowiak , Christopher D. Frith , Terry Jones , and Paolo G. Camici Unexplained Chest Pain: The Hypersensitive, Hyperreactive, and Poorly Compliant Esophagus Satish S.C. Rao , Hans Gregersen , Bernard Hayek , Robert W. Summers , and James Christensen Diagnostic Value of Esophageal Studies in Patients with Angina-like Chest Pain and Normal Coronary Angiograms Ole Frobert , Peter Funch-Jensen , and Jens Peder Bagger Match and Mismatch: Identifying the Neuronal Determinants of Pain Kenneth L. Casey Metrics Cited byGender-Related Differences in Chest Pain Syndromes in the Frontiers in CV Medicine Special Issue: Sex & Gender in CV MedicineGender in cardiovascular medicine: chest pain and coronary artery diseaseNociceptive and Neuropathic Pain Qualities in Men and Women with Acute Coronary Syndromes: A Complex Pain PresentationRandomized Controlled Trial of a Psychoeducation Program for the Self-Management of Chronic Cardiac PainThe Editor’s Roundtable: Chronic Stable Angina PectorisDolores tor?cicosCerebral cortical hyperactivation in response to mental stress in patients with coronary artery diseaseExtent of ischemic stimulus and plasma β-endorphin levels in silent myocardial ischemiaIschemic Burden in Silent and Painful Myocardial Ischemia: A Quantitative Exercise Sestamibi Tomographic Study 1 June 1996Volume 124, Issue 11Page: 1006-1008KeywordsArrhythmiaBlood pressureBrainCardiovascular therapyElectrocardiographyHeartIschemiaPerceptionPsychologyThalamus ePublished: 15 August 2000 Issue Published: 1 June 1996 Copyright & PermissionsCopyright © 1996 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...