Silent Cardiac Ischemia after an Ischemic Stroke of the Right Hemisphere

A patient is described who previously had daily complaints of angina pectoris, yet no longer experienced chest pain after an ischemic stroke of the right hemisphere, despite several recorded episodes of electrocardiographic changes and an elevation of cardiac enzymes compatible with myocardial ischemia. The cingulate gyrus is involved in spatial attention and neglect, and is, according to positron emission tomography studies, less activated in silent myocardial ischemia. We suggest that this patient was not aware of the angina because of putamen ischemia and secondary disturbed projection to the cingulate gyrus and no longer felt or experienced this referred pain.