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Denial and Silent Ischemia: Which Comes First?

P. Janne, PhD; C. Reynaert, MD; P. Decoster, MD
JAMA. 1991;265(2):213. doi:10.1001/jama.1991.03460020067023.
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To the Editor. —  In a Special Communication of September 5 about silent myocardial ischemia, Barsky et al1 emphasize the importance of the person in the so-called silent ischemia syndrome. They summarize interesting previous findings about symptom perception, appraisal, and reporting that can be taken into account to explain the absence of anginal symptoms in these patients.However, they state that "a link between denial and silent ischemia is yet to be established." Actually, it has been. We published empirical evidence supporting the hypothesis of such an "undercomplaining behaviour pattern" in silent myocardial ischemia.2 Our answer to the question "What is actually silent in asymptomatic coronary artery disease, the patient himself or the ischemia?" was that patients with silent myocardial ischemia deny not only pain but also sickness, illness seriousness, and even the presence of a cardiac disease.Confirmatory data were published in a second study,3 which


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