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September 5, 1990, Vol 264, No. 9 >
ARTICLE | September 5, 1990

Silent Myocardial Ischemia: Title and subTitle BreakIs the Person or the Event Silent? FREE

Arthur J. Barsky, MD; Barbara Hochstrasser, MD; N.Anthony Coles, MD; Jerome Zisfein, MD; Christopher O'Donnell, MD; Kim A, Eagle, MD
[+] Author Affiliations

Reprint requests to Primary Care Psychiatry Unit, Wang Ambulatory Care Center—807, Massachusetts General Hospital, Fruit Street, Boston, MA 02114 (Dr Barsky).


JAMA. 1990;264(9):1132-1135. doi:10.1001/jama.1990.03450090068027
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References

The symptoms of organic disease vary widely among patients with the same tissue abnormality, because the experience of a symptom is shaped by the patient's perceptual and cognitive style. Thus, the relationship between myocardial ischemia and chest pain is variable in that many patients experience pain without ischemia and many others exhibit ischemia without pain—termed "silent" or "asymptomatic ischemia." Although the nature of the ischemic event may be important in determining the degree of associated pain, we suggest more study of the individual who perceives the event. Myocardial ischemia may not generate a spontaneous report of chest pain because the patient is generally hyposensitive to visceral sensation; because he or she is coping with the threat of heart disease by denying the evidence of it—ie, denying the pain to deny the disease; or because the patient misunderstands the cause and significance of a vague or ambiguous cardiac sensation, normalizing the symptom and misattributing it to a nonpathologic cause.

(JAMA. 1990;264:1132-1135)

REFERENCES

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2 +
Bodemar G, Walan A.  Maintenance treatment of recurrent peptic ulcer by cimetidine . Lancet . 1978;;1:403-407.
3 +
Hussar AE, Guller EJ.  Correlation of pain and the roentgenographic findings of spondylosis of the cervical and lumbar spine . Am J Med Sci. 1956;;232:518-527.
4 +
Lichtenberg PA, Swensen CH, Skehan MW,  Further investigation of the role of personality, lifestyle and arthritic severity in predicting pain . J Psychosom Res. 1986;;30:327-337.
5 +
Burdon JGW, Juniper EF, Killan KJ, Hargreane FE, Campbell EJM.  The perception of breathlessness in asthma . Am Rev Respir Dis. 1982;;162:825-828.
6 +
Lustman PJ, Clouse RE, Carney RM.  Depression and the reporting of diabetes symptoms . Int J Psychiatry Med. 1988;;18:295-303.
7 +
Zeldis SM, Levine BJ, Michelson EL, et al.  Cardiovascular complaints: correlation with cardiac arrhythmias on 24-hour ECG monitoring . Chest . 1980;;78:456-462.
8 +
Burckhardt D, Luetold BE, Jost MV, Hoffmann A.  Holter monitoring in the evaluation of palpitations, dizziness and syncope . In: Roelandt J, Hugenholtz PG, eds. Long Term Ambulatory Electrocardiography . Dordrecht, the Netherlands: Martinus Nijhoff Publishers; 1982;:29-39.
9 +
Clark PI, Glasser SP, Spoto E.  Arrhythmias detected by ambulatory monitoring . Chest . 1980;; 77:722-725.
10 +
Lipski J, Cohen L, Espinoza J, et al.  Value of Holter monitoring in assessing cardiac arrhythmias in symptomatic patients . Am J Cardiol. 1976;; 37:102-107.
11 +
Epstein SE, Quyyumi AA, Bonow RO.  Current concepts, myocardial ischemia: silent or symptomatic . N Engl J Med. 1988;;318:1038-1043.
12 +
Glazier JJ, Chierchia S, Brown MJ, Maseri A.  Importance of generalized defective perception of painful stimuli as a cause of silent myocardial ischemia in chronic stable angina pectoris . Am J Cardiol. 1986;;58:667-672.
13 +
Kannel WB, Abbott RD.  Incidence and prognosis of unrecognized myocardial infarction: an update on the Framingham study . N Engl J Med. 1984;;311:1144-1147.
14 +
Quyyumi AA, Mockus L, Wright C, Fox KM.  Morphology of ambulatory ST segment changes in patients with varying severity of coronary artery disease: investigation of the frequency of nocturnal ischemia and coronary spasm . Br Heart J. 1985;;53:186-193.
15 +
Dearfield JE, Maseri A, Selwyn AP, et al.  Myocardial ischemia during daily life in patients with stable angina: its relation to symptoms and heart rate changes . Lancet. 1983;;2:753-758.
16 +
Cohn PF.  Silent myocardial ischemia . Ann Intern Med. 1988;;109:312-317.
17 +
Quyyumi AA, Wright CM, Mockus LJ, Fox KM.  How important is a history of chest pain in determining the degree of ischemia in patients with angina pectoris? Br Heart J. 1985;;54:22-26.
18 +
Tzivoni D, Gavish A, Benhorin J, et al.  Myocardial ischemia during daily activities and stress . Am J Cardiol. 1986;;58:478-450.
19 +
Carboni GP, Lahiri A, Cashman PM, Raftery EB.  Ambulatory heart rate and ST-segment depression during painful and silent myocardial ischemia in chronic stable angina pectoris . Am J Cardiol. 1987;;59:1029-1034.
20 +
Gottlieb SO, Weisfeldt ML, Quyang P, et al.  Silent ischemia as a marker for early unstable outcomes in patients with unstable angina . N Engl J Med. 1986;;314:1214-1219.
21 +
Nademanee K, Intarachot V, Josephson MA, et al.  Prognostic significance of silent myocardial ischemia in patients with unstable angina . J Am Coll Cardiol. 1987;;10:1-9.
22 +
Falcone C, DeServi S, Poma E, et al.  Clinical significance of exercise induced silent myocardial ischemia in patients with coronary artery disease . J Am Coll Cardiol. 1987;;9:295-299.
23 +
Assey ME, Walters GL, Hendrix GH, Carabello BA, Usher BN, Spann JR.  Incidence of acute myocardial infarction in patients with exercise-induced silent myocardial ischemia . Am J Cardiol. 1987;;59:497-500.
24 +
Bonow RO, Bacharach SL, Green MV, Lafreniere RL, Epstein SE.  Prognostic implications of symptomatic versus asymptomatic (silent) myocardial ischemia induced by exercise in mildly symptomatic and in asymptomatic patients with angiographically documented coronary artery disease . Am J Cardiol. 1988;;60:778-783.
25 +
Tzivoni D, Gavish A, Zin D, et al.  Prognostic significance of ischemic episodes in patients with previous myocardial infarction . Am J Cardiol. 1988;;62:661-664.
26 +
Mody FV, Nademanee K, Intarachot V, Josephson MA, Robertson HA, Singh BN.  Severity of silent myocardial ischemia on ambulatory electrocardiographic monitoring in patients with stable angina pectoris: relation to prognostic determinants during exercise stress testing and coronary angiography . J Am Coll Cardiol. 1988;;12:1169-1176.
27 +
Johnson SM, Mauritson DR, Winniford MD, et al.  Continuous electrocardiographic monitoring in patients with unstable angina pectoris: identification of a high-risk subgroup with severe coronary disease, variant angina, and/or impaired early prognosis . Am Heart J. 1982;;103:4-12.
28 +
Gottlieb SO, Gottlieb SH, Achuff SC, et al.  Silent ischemia on Holter monitoring predicts mortality in high-risk postinfarction patients . JAMA . 1988;;259:1030-1035.
29 +
Cohn PF, Sodums MT, Lawson WE, et al.  Frequent episodes of silent myocardial ischemia after apparently uncomplicated myocardial infarction . J Am Coll Cardiol. 1986;;8:982-985.
30 +
Warnes CA, Roberts WC.  Sudden coronary death: relation of amount and distribution of coronary narrowing at necropsy to previous symptoms of myocardial ischemia, left ventricular scarring and heart weight . Am J Cardiol. 1984;;54:65-73.
31 +
Hong RA, Bhandari AK, McKay CR, Au PK, Rahimtoola SH.  Life-threatening ventricular tachycardia and fibrillation induced by painless myocardial ischemia during exercise testing . JAMA . 1987;;257:1937-1940.
32 +
Epstein SD, Quyyumi AA, Bonow RO.  Sounding board: sudden cardiac death without warning . N Engl J Med. 1989;;321:320-324.
33 +
Selwyn AP, Ganz P.  Myocardial ischemia in coronary disease . N Engl J Med. 1988;;318:1058-1060.
34 +
Chierchia S, Lazzari M, Freedman SB, Bencivelli W, Maseri A.  Impairment of myocardial perfusion and function during painless myocardial ischemia . J Am Coll Cardiol. 1983;;1:924-930.
35 +
Hauser AM, Gangadharan V, Ramos RG, Gordon S, Timmis GC.  Sequence of mechanical and electrocardiographic and clinical effects of repeated coronary artery occlusion in human beings: electrocardiographic observations during coronary angioplasty . J Am Coll Cardiol. 1985;;5:193-197.
36 +
Hirzel HO, Leutwyler R, Krayenbuehl HP.  Silent myocardial ischemia: hemodynamic changes during dynamic exercise in patients with proven coronary artery disease despite absence of angina pectoris . J Am Coll Cardiol. 1985;;6:275-284.
37 +
Cohn PF, Brown EJ Jr, Wynne J, Holman BL, Atkins HL.  Global and regional left ventricular ejection fraction abnormalities during exercise in patients with silent myocardial ischemia . J Am Coll Cardiol. 1983;;1:91-93.
38 +
Inoue H, Skale BT, Zipes DP.  Effects of ischemia on cardiac afferent sympathetic and vagal reflexes in dog . Am J Physiol. 1988;;255:H26-H35.
39 +
Nabel EG, Rocco MB, Barry J, Campbell S, Selwyn AP.  Asymptomatic ischemia in patients with coronary artery disease . JAMA . 1987;; 257:1923-1928.
40 +
Maseri A, Parodi O, Seneri S, et al.  Transient transmural reduction of myocardial blood flow, demonstrated by thallium-201 scintigraphy, as a cause of variant angina . Circulation . 1976;;54:280-288.
41 +
Holmgreen A.  Hemodynamic sequences in asymptomatic exercise-induced ischemia . In: Rutishauser W, Roskamm H, eds. Silent Myocardial Ischemia . Berlin, West Germany: Springer-Verlag; 1984;:66-70.
42 +
Sigwart U, Grbic M, Payot M, Goy JJ, Essinger A, Fisher A.  Ischemic events during coronary artery balloon obstruction . In: Ruitshauser W, Roskamm H, eds. Silent Myocardial Ischemia . Berlin, West Germany: Springer-Verlag; 1984;:29-36.
43 +
Bland ES, White JC.  Relief of severe angina pectoris in young people with rheumatic heart disease . N Engl J Med. 1936;;215:139-143.
44 +
Mense S.  Basic neurological mechanisms of pain and analgesia . Am J Med. 1983;;75:4-14.
45 +
Malliani A.  Pathophysiology of ischemic cardiac pain . In: von Arnim T, Maseri A, eds. Silent Ischemia: Current Concepts and Management . Darmstadt, West Germany: Seinkopffverlas; 1987;:21.
46 +
Davies G, Bencivelli W, Fragasso G, et al.  Sequence and magnitude of ventricular volume changes in painful and painless myocardial ischemia . Circulation . 1988;;78:310-319.
47 +
Baker DG, Coleridge HM, Coleridge JCG, Nerdum T.  Search for a cardiac nociceptor: stimulation of bradykinin of sympathetic afferent nerve endings in the heart of the cat . J Physiol. 1980;;306:519-536.
48 +
Woolf CJ, Wall PD.  Endogenous opioid peptides and pain mechanisms: a complex relationship . Nature . 1983;;306:739-740.
49 +
Jessell TM.  Pain . Lancet . 1982;;2:1084-1087.
50 +
Roberts MHT, Llewelyn MB.  The supraspinal control of pain . Bioscience . 1982;;32:587-594.
51 +
Levine J.  Pain and analgesia: the outlook for more rational treatment . Ann Intern Med. 1984;;100:269-276.
52 +
Droste C, Roskamm H.  Experimental pain measurement in patients with asymptomatic myocardial ischemia . J Am Coll Cardiol. 1983;;1:940-945.
53 +
Droste C, Greenlee MW, Roskamm H.  A defective angina pectoris pain warning system: experimental findings of ischemic and electrical pain test . Pain . 1986;;26:199-209.
54 +
Falcone C, Sconocchia R, Guasti L, Codega S, Montemartini C, Specchia G.  Dental pain threshold and angina pectoris in patients with coronary artery disease . J Am Coll Cardiol. 1988;;12:348-352.
55 +
Heller GV, Garber CE, Connolly MJ, et al.  Plasma beta-endorphin levels in silent myocardial ischemia induced by exercise . Am J Cardiol. 1987;;59:735-739.
56 +
Ellestad ME, Kuan P.  Naloxane and asymptomatic ischemia: failure to induce angina during exercise testing . Am J Cardiol. 1984;;54:982-984.
57 +
Hackett TP, Cassem NH.  Development of a quantitative rating scale to assess denial . J Psychosom Res. 1974;;18:93-100.
58 +
Hackett TP, Cassem NH, Wishnie HA.  The coronary care unit: an appraisal of its psychologic hazards . N Engl J Med. 1986;;279:1365-1370.
59 +
Froese A, Hackett TP, Cassem NH.  Validation of anxiety, depression and denial scales in a coronary care unit . J Psychosom Res. 1974;;18:137-141.
60 +
Folks DG, Freeman AM, Sokol RS.  Denial: predictor of outcome following coronary bypass surgery . Int J Psychiatry Med. 1988;;18:57-66.
61 +
Levenson JL, Kay R, Monteferrante J, Herman MV.  Denial predicts favorable outcome in unstable angina pectoris . Psychosom Med. 1984;;46:25-32.
62 +
Levenson JL, Mishra A, Hamer R, Hastillo A.  Denial and medical outcome in unstable angina . Psychosom Med. 1989;;51:27-35.
63 +
Shaw R, Cohen F, Doyle B, Palesky J.  The impact of denial and repressive style on information gain and rehabilitation outcomes in myocardial infarction patients . Psychosom Med. 1985;;47:262-273.
64 +
Levine J, Warrenburg S, Kerns R, et al.  The role of denial in recovering from coronary heart disease . Psychosom Med. 1987;;49:109-117.
65 +
Rodin J.  Somatopsychics and attribution . Pers Soc Psychol Bull. 1978;;4:531-540.
66 +
Pennebaker JW. The Psychology of Physical Symptoms . New York, NY: Springer-Verlag NY Inc; 1982;.
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Pennebaker JW, Epstein D.  Implicit psychophysiology: effects of common beliefs and idiosyncratic physiological responses on symptom reporting . J Pers. 1983;;51:468-496.
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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Peterson WL, Sturdevant RAL, Frankl HD, et al.  Healing of duodenal ulcer with an antacid regimen . N Engl J Med. 1977;;297:341-345.
2 +
Bodemar G, Walan A.  Maintenance treatment of recurrent peptic ulcer by cimetidine . Lancet . 1978;;1:403-407.
3 +
Hussar AE, Guller EJ.  Correlation of pain and the roentgenographic findings of spondylosis of the cervical and lumbar spine . Am J Med Sci. 1956;;232:518-527.
4 +
Lichtenberg PA, Swensen CH, Skehan MW,  Further investigation of the role of personality, lifestyle and arthritic severity in predicting pain . J Psychosom Res. 1986;;30:327-337.
5 +
Burdon JGW, Juniper EF, Killan KJ, Hargreane FE, Campbell EJM.  The perception of breathlessness in asthma . Am Rev Respir Dis. 1982;;162:825-828.
6 +
Lustman PJ, Clouse RE, Carney RM.  Depression and the reporting of diabetes symptoms . Int J Psychiatry Med. 1988;;18:295-303.
7 +
Zeldis SM, Levine BJ, Michelson EL, et al.  Cardiovascular complaints: correlation with cardiac arrhythmias on 24-hour ECG monitoring . Chest . 1980;;78:456-462.
8 +
Burckhardt D, Luetold BE, Jost MV, Hoffmann A.  Holter monitoring in the evaluation of palpitations, dizziness and syncope . In: Roelandt J, Hugenholtz PG, eds. Long Term Ambulatory Electrocardiography . Dordrecht, the Netherlands: Martinus Nijhoff Publishers; 1982;:29-39.
9 +
Clark PI, Glasser SP, Spoto E.  Arrhythmias detected by ambulatory monitoring . Chest . 1980;; 77:722-725.
10 +
Lipski J, Cohen L, Espinoza J, et al.  Value of Holter monitoring in assessing cardiac arrhythmias in symptomatic patients . Am J Cardiol. 1976;; 37:102-107.
11 +
Epstein SE, Quyyumi AA, Bonow RO.  Current concepts, myocardial ischemia: silent or symptomatic . N Engl J Med. 1988;;318:1038-1043.
12 +
Glazier JJ, Chierchia S, Brown MJ, Maseri A.  Importance of generalized defective perception of painful stimuli as a cause of silent myocardial ischemia in chronic stable angina pectoris . Am J Cardiol. 1986;;58:667-672.
13 +
Kannel WB, Abbott RD.  Incidence and prognosis of unrecognized myocardial infarction: an update on the Framingham study . N Engl J Med. 1984;;311:1144-1147.
14 +
Quyyumi AA, Mockus L, Wright C, Fox KM.  Morphology of ambulatory ST segment changes in patients with varying severity of coronary artery disease: investigation of the frequency of nocturnal ischemia and coronary spasm . Br Heart J. 1985;;53:186-193.
15 +
Dearfield JE, Maseri A, Selwyn AP, et al.  Myocardial ischemia during daily life in patients with stable angina: its relation to symptoms and heart rate changes . Lancet. 1983;;2:753-758.
16 +
Cohn PF.  Silent myocardial ischemia . Ann Intern Med. 1988;;109:312-317.
17 +
Quyyumi AA, Wright CM, Mockus LJ, Fox KM.  How important is a history of chest pain in determining the degree of ischemia in patients with angina pectoris? Br Heart J. 1985;;54:22-26.
18 +
Tzivoni D, Gavish A, Benhorin J, et al.  Myocardial ischemia during daily activities and stress . Am J Cardiol. 1986;;58:478-450.
19 +
Carboni GP, Lahiri A, Cashman PM, Raftery EB.  Ambulatory heart rate and ST-segment depression during painful and silent myocardial ischemia in chronic stable angina pectoris . Am J Cardiol. 1987;;59:1029-1034.
20 +
Gottlieb SO, Weisfeldt ML, Quyang P, et al.  Silent ischemia as a marker for early unstable outcomes in patients with unstable angina . N Engl J Med. 1986;;314:1214-1219.
21 +
Nademanee K, Intarachot V, Josephson MA, et al.  Prognostic significance of silent myocardial ischemia in patients with unstable angina . J Am Coll Cardiol. 1987;;10:1-9.
22 +
Falcone C, DeServi S, Poma E, et al.  Clinical significance of exercise induced silent myocardial ischemia in patients with coronary artery disease . J Am Coll Cardiol. 1987;;9:295-299.
23 +
Assey ME, Walters GL, Hendrix GH, Carabello BA, Usher BN, Spann JR.  Incidence of acute myocardial infarction in patients with exercise-induced silent myocardial ischemia . Am J Cardiol. 1987;;59:497-500.
24 +
Bonow RO, Bacharach SL, Green MV, Lafreniere RL, Epstein SE.  Prognostic implications of symptomatic versus asymptomatic (silent) myocardial ischemia induced by exercise in mildly symptomatic and in asymptomatic patients with angiographically documented coronary artery disease . Am J Cardiol. 1988;;60:778-783.
25 +
Tzivoni D, Gavish A, Zin D, et al.  Prognostic significance of ischemic episodes in patients with previous myocardial infarction . Am J Cardiol. 1988;;62:661-664.
26 +
Mody FV, Nademanee K, Intarachot V, Josephson MA, Robertson HA, Singh BN.  Severity of silent myocardial ischemia on ambulatory electrocardiographic monitoring in patients with stable angina pectoris: relation to prognostic determinants during exercise stress testing and coronary angiography . J Am Coll Cardiol. 1988;;12:1169-1176.
27 +
Johnson SM, Mauritson DR, Winniford MD, et al.  Continuous electrocardiographic monitoring in patients with unstable angina pectoris: identification of a high-risk subgroup with severe coronary disease, variant angina, and/or impaired early prognosis . Am Heart J. 1982;;103:4-12.
28 +
Gottlieb SO, Gottlieb SH, Achuff SC, et al.  Silent ischemia on Holter monitoring predicts mortality in high-risk postinfarction patients . JAMA . 1988;;259:1030-1035.
29 +
Cohn PF, Sodums MT, Lawson WE, et al.  Frequent episodes of silent myocardial ischemia after apparently uncomplicated myocardial infarction . J Am Coll Cardiol. 1986;;8:982-985.
30 +
Warnes CA, Roberts WC.  Sudden coronary death: relation of amount and distribution of coronary narrowing at necropsy to previous symptoms of myocardial ischemia, left ventricular scarring and heart weight . Am J Cardiol. 1984;;54:65-73.
31 +
Hong RA, Bhandari AK, McKay CR, Au PK, Rahimtoola SH.  Life-threatening ventricular tachycardia and fibrillation induced by painless myocardial ischemia during exercise testing . JAMA . 1987;;257:1937-1940.
32 +
Epstein SD, Quyyumi AA, Bonow RO.  Sounding board: sudden cardiac death without warning . N Engl J Med. 1989;;321:320-324.
33 +
Selwyn AP, Ganz P.  Myocardial ischemia in coronary disease . N Engl J Med. 1988;;318:1058-1060.
34 +
Chierchia S, Lazzari M, Freedman SB, Bencivelli W, Maseri A.  Impairment of myocardial perfusion and function during painless myocardial ischemia . J Am Coll Cardiol. 1983;;1:924-930.
35 +
Hauser AM, Gangadharan V, Ramos RG, Gordon S, Timmis GC.  Sequence of mechanical and electrocardiographic and clinical effects of repeated coronary artery occlusion in human beings: electrocardiographic observations during coronary angioplasty . J Am Coll Cardiol. 1985;;5:193-197.
36 +
Hirzel HO, Leutwyler R, Krayenbuehl HP.  Silent myocardial ischemia: hemodynamic changes during dynamic exercise in patients with proven coronary artery disease despite absence of angina pectoris . J Am Coll Cardiol. 1985;;6:275-284.
37 +
Cohn PF, Brown EJ Jr, Wynne J, Holman BL, Atkins HL.  Global and regional left ventricular ejection fraction abnormalities during exercise in patients with silent myocardial ischemia . J Am Coll Cardiol. 1983;;1:91-93.
38 +
Inoue H, Skale BT, Zipes DP.  Effects of ischemia on cardiac afferent sympathetic and vagal reflexes in dog . Am J Physiol. 1988;;255:H26-H35.
39 +
Nabel EG, Rocco MB, Barry J, Campbell S, Selwyn AP.  Asymptomatic ischemia in patients with coronary artery disease . JAMA . 1987;; 257:1923-1928.
40 +
Maseri A, Parodi O, Seneri S, et al.  Transient transmural reduction of myocardial blood flow, demonstrated by thallium-201 scintigraphy, as a cause of variant angina . Circulation . 1976;;54:280-288.
41 +
Holmgreen A.  Hemodynamic sequences in asymptomatic exercise-induced ischemia . In: Rutishauser W, Roskamm H, eds. Silent Myocardial Ischemia . Berlin, West Germany: Springer-Verlag; 1984;:66-70.
42 +
Sigwart U, Grbic M, Payot M, Goy JJ, Essinger A, Fisher A.  Ischemic events during coronary artery balloon obstruction . In: Ruitshauser W, Roskamm H, eds. Silent Myocardial Ischemia . Berlin, West Germany: Springer-Verlag; 1984;:29-36.
43 +
Bland ES, White JC.  Relief of severe angina pectoris in young people with rheumatic heart disease . N Engl J Med. 1936;;215:139-143.
44 +
Mense S.  Basic neurological mechanisms of pain and analgesia . Am J Med. 1983;;75:4-14.
45 +
Malliani A.  Pathophysiology of ischemic cardiac pain . In: von Arnim T, Maseri A, eds. Silent Ischemia: Current Concepts and Management . Darmstadt, West Germany: Seinkopffverlas; 1987;:21.
46 +
Davies G, Bencivelli W, Fragasso G, et al.  Sequence and magnitude of ventricular volume changes in painful and painless myocardial ischemia . Circulation . 1988;;78:310-319.
47 +
Baker DG, Coleridge HM, Coleridge JCG, Nerdum T.  Search for a cardiac nociceptor: stimulation of bradykinin of sympathetic afferent nerve endings in the heart of the cat . J Physiol. 1980;;306:519-536.
48 +
Woolf CJ, Wall PD.  Endogenous opioid peptides and pain mechanisms: a complex relationship . Nature . 1983;;306:739-740.
49 +
Jessell TM.  Pain . Lancet . 1982;;2:1084-1087.
50 +
Roberts MHT, Llewelyn MB.  The supraspinal control of pain . Bioscience . 1982;;32:587-594.
51 +
Levine J.  Pain and analgesia: the outlook for more rational treatment . Ann Intern Med. 1984;;100:269-276.
52 +
Droste C, Roskamm H.  Experimental pain measurement in patients with asymptomatic myocardial ischemia . J Am Coll Cardiol. 1983;;1:940-945.
53 +
Droste C, Greenlee MW, Roskamm H.  A defective angina pectoris pain warning system: experimental findings of ischemic and electrical pain test . Pain . 1986;;26:199-209.
54 +
Falcone C, Sconocchia R, Guasti L, Codega S, Montemartini C, Specchia G.  Dental pain threshold and angina pectoris in patients with coronary artery disease . J Am Coll Cardiol. 1988;;12:348-352.
55 +
Heller GV, Garber CE, Connolly MJ, et al.  Plasma beta-endorphin levels in silent myocardial ischemia induced by exercise . Am J Cardiol. 1987;;59:735-739.
56 +
Ellestad ME, Kuan P.  Naloxane and asymptomatic ischemia: failure to induce angina during exercise testing . Am J Cardiol. 1984;;54:982-984.
57 +
Hackett TP, Cassem NH.  Development of a quantitative rating scale to assess denial . J Psychosom Res. 1974;;18:93-100.
58 +
Hackett TP, Cassem NH, Wishnie HA.  The coronary care unit: an appraisal of its psychologic hazards . N Engl J Med. 1986;;279:1365-1370.
59 +
Froese A, Hackett TP, Cassem NH.  Validation of anxiety, depression and denial scales in a coronary care unit . J Psychosom Res. 1974;;18:137-141.
60 +
Folks DG, Freeman AM, Sokol RS.  Denial: predictor of outcome following coronary bypass surgery . Int J Psychiatry Med. 1988;;18:57-66.
61 +
Levenson JL, Kay R, Monteferrante J, Herman MV.  Denial predicts favorable outcome in unstable angina pectoris . Psychosom Med. 1984;;46:25-32.
62 +
Levenson JL, Mishra A, Hamer R, Hastillo A.  Denial and medical outcome in unstable angina . Psychosom Med. 1989;;51:27-35.
63 +
Shaw R, Cohen F, Doyle B, Palesky J.  The impact of denial and repressive style on information gain and rehabilitation outcomes in myocardial infarction patients . Psychosom Med. 1985;;47:262-273.
64 +
Levine J, Warrenburg S, Kerns R, et al.  The role of denial in recovering from coronary heart disease . Psychosom Med. 1987;;49:109-117.
65 +
Rodin J.  Somatopsychics and attribution . Pers Soc Psychol Bull. 1978;;4:531-540.
66 +
Pennebaker JW. The Psychology of Physical Symptoms . New York, NY: Springer-Verlag NY Inc; 1982;.
67 +
Pennebaker JW, Epstein D.  Implicit psychophysiology: effects of common beliefs and idiosyncratic physiological responses on symptom reporting . J Pers. 1983;;51:468-496.
68 +
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To understand the clinical management of acute heart failure syndromes.
Accreditation Information The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
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NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
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