Galen's three souls incorporate previously existing ideas of soul. Soul is matter – cum – energy. As matter it is airlike, the finest by nature and as movement, like sound, the form of energy most subtle of its kind. Creator is depicted with Creation as the Cosmic egg and snake as Cosmic soul and the syllable Om, as the word incorporating creative energy. Om as humming sound is symbolized by Bees which produce such sound.
Alchemy as art tries to imitate creation such as spontaneous generation. The magic wands of creation, of Chinese origin, would be a compass and a triangular carpenter's square. Creation is represented by the dual-natured soul, comprising of the spirit (Ruh) and “the” soul (Nafs). The ultimate source is creative energy which emanates form the Divine word of command. Creative energy, in its non-manifest form, would be ultrasonic energy, which can be represented by a humming sourd. This would be sympolized by the humming sound. This would be symbolized by the humming sound of bees represent creative energy and in fig 3 the fiddle, as direct producers of a humming sound.
In China the antecedent of alchemy is represented by the god of longevity emerging from the peach. The first synthetic drug, Kim-Yeh, red colloidal gold, signified gold-cum -herbal juice. Kim-Yeh=Kimiya (Arabic) =chemeia (Greek). Translated this gave Chrusozomion=Gold Ferment, specifying the drug. Rasayana was translated as Chumeia, herbal juice-incorporate and signified the art alchemy. Chemeia was Chinese and Chumeia, Indian. Originally each signified both, a drug of longevity and the art, alchemy. Finally the art of making red gold was misunderstood as the art of making gold itself
Use of simple synthetic drug called Chin – Yeh, Gold – plus – plant juice or red colloidal gold. Gold made body everlasting and the herbal principle, as soul, increased life-span. Dialectally it was called Kim – Iya. Arabicized as Al – Kimiya it finally appeared as Alchemy. Chin – Yeh as drug was only brick – red when mercury, and sulphur – with traces of gold were sublimated there resulted Chin – Tan, Gold – plus – cinnabar. It was blood – red and with redness as soul it became the ideal drug of longevity.
First-degree atrioventricular block (AVB) has traditionally been considered a benign electrocardiographic finding in healthy individuals. However, the clinical significance of first-degree AVB has not been evaluated in patients with stable coronary heart disease. We investigated whether first-degree AVB is associated with heart failure (HF) and mortality in a prospective cohort study of outpatients with stable coronary artery disease (CAD).
Methods and results
We measured the P–R interval in 938 patients with stable CAD and classified them into those with (P–R interval ≥220 ms) and without (P–R interval <220 ms) first-degree AVB. Hazard ratios (HRs) and 95% confidence intervals were calculated for HF hospitalization and all-cause mortality. During 5 years of follow-up, there were 123 hospitalizations for HF and 285 deaths. Compared with patients who had normal atrioventricular conduction, those with first-degree AVB were at increased risk for HF hospitalization (age-adjusted HR 2.33: 95% CI 1.49–3.65; P= 0.0002), mortality [age-adjusted HR 1.58; 95% CI (1.13–2.20); P = 0.008], cardiovascular (CV) mortality [age-adjusted HR 2.33; 95% CI (1.28–4.22); P= 0.005], and the combined endpoint of HF hospitalization or CV mortality (age-adjusted HR 2.43: 95% CI 1.64–3.61; P ≤ 0.0001). These associations persisted after multivariable adjustment for heart rate, medication use, ischaemic burden, and QRS duration. Adjustment for left ventricular systolic and diastolic function partially attenuated the effect, but first-degree AVB remained associated with the combined endpoint of HF or CV death (HR 1.61, CI 1.02–2.54; P= 0.04).
In a large cohort of patients with stable coronary artery disease, first-degree AVB is associated with HF and death.
Stable coronary artery disease; Atrioventricular block; Heart failure
The author traces in this paper the clue of the Tridosha Doctrine consisting of Air, water and heat. Breath contains all the three. Probably the Tridosha doctrine arose while considering breath as soul.
Alterations of glucocorticoid receptor sensitivity have been associated with depression. Thus, variation in the glucocorticoid receptor gene that determines glucocorticoid sensitivity may influence risk for depression.
In a cross-sectional genetic association study of 526 white outpatients with chronic coronary heart disease, we examined whether haplotypes of the glucocorticoid receptor gene (NR3C1) are associated with depression. Participants were genotyped for four common glucocorticoid receptor gene polymorphisms (ER22/23EK, BclI C/G, N363S, and 9beta A/G) and haplotype analyses were conducted. Depression was assessed by an interview (Computerized Diagnostic Interview Schedule).
Of the 526 participants, 355 (67.5%) were non-carriers, 153 (29.1%) had one copy, and 17 (3.2%) had 2 copies of the haplotype 3 allele, which includes the minor allele of the 9beta A/G polymorphism and which has been associated with reduced glucocorticoid sensitivity. The prevalence of depression ranged from 24.4% in the non-carriers to 34.4% in heterozygotes to 52.9% in participants homozygous for the haplotype 3 allele (p < 0.01). In logistic regression analyses, carriers of one haplotype 3 allele had an odds ratio of 1.64 (95% CI 1.1–2.5, p = 0.02) for depression, while the odds ratio of homozygous haplotype 3 carriers was 3.52 (95% CI 1.3–9.4, p = 0.01). These associations persisted after adjusting for potentially confounding variables.
Depression; Glucocorticoid receptor; Cortisol; Genetics; Stress
The SOUL protein is known to induce apoptosis by provoking the mitochondrial permeability transition, and a sequence homologous with the BH3 (Bcl-2 homology 3) domains has recently been identified in the protein, thus making it a potential new member of the BH3-only protein family. In the present study, we provide NMR, SPR (surface plasmon resonance) and crystallographic evidence that a peptide spanning residues 147–172 in SOUL interacts with the anti-apoptotic protein Bcl-xL. We have crystallized SOUL alone and the complex of its BH3 domain peptide with Bcl-xL, and solved their three-dimensional structures. The SOUL monomer is a single domain organized as a distorted β-barrel with eight anti-parallel strands and two α-helices. The BH3 domain extends across 15 residues at the end of the second helix and eight amino acids in the chain following it. There are important structural differences in the BH3 domain in the intact SOUL molecule and the same sequence bound to Bcl-xL.
apoptosis; Bcl-xL; Bcl-2 homology 3 domain (BH3 domain); crystal structure; NMR; SOUL; surface plasmon resonance; BH, Bcl-2 homology; HEBP, haem-binding protein; HSQC, heteronuclear single-quantum coherence; MPT, mitochondrial permeability transition; rmsd, root mean square deviation; RZPD, Deutsches Ressouroenzentrum für Genomforschung; SPR, surface plasmon resonance
Lead and mercury are naturally occurring elements in the earth's crust and are common environmental contaminants. Because people concerned about possible exposures to these elements often seek advice from their physicians, clinicians need to be aware of the signs and symptoms of lead and mercury poisoning, how to investigate a possible exposure and when intervention is necessary. We describe 3 cases of patients who presented to an occupational medicine specialist with concerns of heavy metal toxicity. We use these cases to illustrate some of the issues surrounding the investigation of possible lead and mercury exposures. We review the common sources of exposure, the signs and symptoms of lead and mercury poisoning and the appropriate use of chelation therapy. There is a need for a clear and consistent guide to help clinicians interpret laboratory investigations. We offer such a guide, with information about population norms, lead and mercury levels that suggest exposure beyond that seen in the general population and levels that warrant referral for advice about clinical management.
Cancer can lead to spiritual transformation, which can be seen as a form of alchemy. During this process, patients, family members, and even professional caregivers can find themselves having spiritual experiences that go beyond any they had previously encountered. This paper provides qualitative descriptions of the “Field” or “Soul Wisdom” experienced by patients and caregivers.
Mercury is a major toxic metal ranking top in the Toxic Substances List. Cinnabar (contains mercury sulfide) has been used in traditional medicines for thousands years as an ingredient in various remedies, and 40 cinnabar-containing traditional medicines are still used today. Little is known about toxicology profiles or toxicokinetics of cinnabar and cinnabar-containing traditional medicines, and the high mercury content in these Chinese medicines raises justifiably escalations of public concern. This minireview searched the available database of cinnabar, compared cinnabar with common mercurials, such as mercury vapor, inorganic mercury, and organic mercury, and discusses differences in their bioavailability, disposition, and toxicity. The analysis showed that cinnabar is insoluble and poorly absorbed from the gastrointestinal tract. Absorbed mercury from cinnabar is mainly accumulated in kidney, resembling the disposition pattern of inorganic mercury. Heating cinnabar results in release of mercury vapor, which in turn can produce toxicity similar to inhalation of these vapors. The doses of cinnabar required to produce neurotoxicity are thousands 1000 times higher than methyl mercury. Following long-term use of cinnabar, renal dysfunction may occur. Dimercaprol and succimer are effective chelation therapies for general mercury intoxication including cinnabar. Pharmacology studies of cinnabar suggest sedative and hypnotic effects, but the therapeutic basis of cinnabar is still not clear. In summary, cinnabar is chemically inert with a relatively low toxic potential when taken orally. In risk assessment, cinnabar is less toxic than many other forms of mercury, but the rationale for its inclusion in traditional Chinese medicines remains to be fully justified.
Cinnabar; Traditional medicines; Elementary mercury; Mercuric chloride; Methylmercury; Bioavailability; Disposition; Toxicology
This report summarizes the potential impact of the acid precipitation phenomenon on human health. There are two major components to this phenomenon: the predepositional phase, during which there is direct human exposure to acidic substances from ambient air, and the post-depositional phase, in which the deposition of acid materials on water and soil results in the mobilization, transport, and even chemical transformation of toxic metals. Acidification increases bioconversion of mercury to methylmercury, which accumulates in fish, increasing the risk to toxicity in people who eat fish. Increase in water and soil content of lead and cadmium increases human exposure to these metals which become additive to other sources presently under regulatory control. The potential adverse health effects of increased human exposure to aluminum is not known at the present time.
Mercury is a toxic and non-essential metal in the human body. Mercury is ubiquitously distributed in the environment, present in natural products, and exists extensively in items encountered in daily life. There are three forms of mercury, i.e., elemental (or metallic) mercury, inorganic mercury compounds, and organic mercury compounds. This review examines the toxicity of elemental mercury and inorganic mercury compounds. Inorganic mercury compounds are water soluble with a bioavailability of 7% to 15% after ingestion; they are also irritants and cause gastrointestinal symptoms. Upon entering the body, inorganic mercury compounds are accumulated mainly in the kidneys and produce kidney damage. In contrast, human exposure to elemental mercury is mainly by inhalation, followed by rapid absorption and distribution in all major organs. Elemental mercury from ingestion is poorly absorbed with a bioavailability of less than 0.01%. The primary target organs of elemental mercury are the brain and kidney. Elemental mercury is lipid soluble and can cross the blood-brain barrier, while inorganic mercury compounds are not lipid soluble, rendering them unable to cross the blood-brain barrier. Elemental mercury may also enter the brain from the nasal cavity through the olfactory pathway. The blood mercury is a useful biomarker after short-term and high-level exposure, whereas the urine mercury is the ideal biomarker for long-term exposure to both elemental and inorganic mercury, and also as a good indicator of body burden. This review discusses the common sources of mercury exposure, skin lightening products containing mercury and mercury release from dental amalgam filling, two issues that happen in daily life, bear significant public health importance, and yet undergo extensive debate on their safety.
Elemental mercury; Inorganic mercury compounds; Kidney; Brain; Biomarkers; Public health
In recent years, several hypotheses have emerged to explain the toxicologic activity of particulate matter. Organic compounds, ultrafine particles, biologic components, and transition metals are some of the constituents that reportedly exert some type of adverse effect on human health. A considerable fraction of the urban particulate matter consists of carbon compounds, which originate mostly from anthropogenic sources. The toxicity of organic fractions from particulate matter have been mainly evaluated by considering their mutagenic activity. This research expands on the toxicologic profile of organic compounds adsorbed to particulate matter, specifically in Puerto Rico, by using the cytotoxic neutral red bioassay (NRB). The NRB uses normal human epidermal keratinocytes or other types of cells to measure the effect on cell viability when exposed to organic compounds associated to the particles in the air. We validated the NRB for particulate matter by using a standard reference material (SRM 1649). We used the NRB to determine toxicologic differences of extracts between an urban industrialized site with anthropogenic activity versus a coastal region with less human activity. The cytotoxicity associated with organic compounds in particulate matter collected at the urban industrialized site was detected in both the particulate matter (3/4) 10 microm in aerodynamic diameter (PM(10)) and particulate matter (3/4) 100 microm in aerodynamic diameter (PM(100)). Greater toxic effects were observed in PM(10) extracts than in PM(100) extracts, but PM(10) toxic effects were not significantly different from those in PM(100). The extracts from the industrialized site were more cytotoxic than the extracts from coastal reference site, although in the summer, extracts from both sites were significantly cytotoxic to normal human epidermal keratinocytes. In addition, the nonpolar extracts of both PM(10) and PM(100) exerted the greatest cytotoxicity, followed by the polar, and, finally, the moderately polar extract. This study demonstrates that extracts from the Guaynabo industrialized site were more toxic than similar extracts obtained from a reference coastal site in Fajardo, Puerto Rico.
Environmental pollution caused by heavy metals such as mercury is one of the most important human problems. It might have severe teratogenic effects on embryonic development. Some pharmacological and physiological aspects of fruit flies (Drosophila melanogaster) are similar to humans. So the stages of egg to adult fruit fly, as a developmental model, were employed in the study. Wild adult insects were maintained in glass dishes containing standard medium at 25 °C in complete darkness. Five pairs of 3-day old flies were then transferred to standard culture dishes containing different concentrations of mercury ion. They were removed after 8 hours. We considered the following: The rate of larvae becoming pupae and pupae to adults; the time required for the development; the hatching rate in the second generation without mercury in the culture; the morphometric changes during development in both length and width of the eggs through two generations; larvae, pupae and adult thorax length and width. The results showed that mercury in culture (20–100 mg/l) increase the duration of larvae (p<0.01) and pupae (p<0.01) development, the rate of larvae becoming pupae (p<0.001); pupae maturation (p<0.05), the hatching rate (p<0.01), the length (p<0.05) and width of larvae (p<0.01) and pupae (p<0.001) and the length in the adult thorax (p<0.01) decreased significantly. There was no effect upon the size of eggs. There were also no larvae hatching in concentrations of 200 mg/l of mercury. Negative effects of mercury as a heavy metal are possibly due to the interference of this metal in cellular signaling pathways, such as: Notch signaling and protein synthesis during the period of development. Since it bonds chemically with the sulfur hydride groups of proteins, it causes damage to the cell membrane and decreases the amount of RNA. This is the cause of failure of many enzyme mechanisms.
mercury; fruit fly; larvae; pupae; hatching
A strain of Escherichia coli carrying genes determining mercury resistance on a naturally occurring resistance transfer factor (RTF) converts 95% of 10−5m Hg2+ (chloride) to metallic mercury at a rate of 4 to 5 nmoles of Hg2+ per min per 108 cells. The metallic mercury is rapidly eliminated from the culture medium as mercury vapor. The volatilizing activity has a temperature dependence and heat sensitivity characteristic of enzymatic catalysis and is inducible by mercuric chloride. Ag+ and Au3+ are markedly inhibitory of mercury volatilization.
Low socioeconomic status (SES) is associated with poor health outcomes in patients who have coronary heart disease (CHD). Inflammation is a potential mechanism by which low SES may lead to adverse cardiovascular outcomes, but it is not known whether low SES is associated with inflammation in patients who have CHD. We measured high-sensitivity C-reactive protein (CRP) levels in a cross-sectional study of 985 adults who had CHD. Income and education were determined by self-report. We used ordinal logistic regression to examine the association of income and education with CRP. Of the 985 participants, 390 had high CRP levels (>3 mg/dl). The proportion of participants who had high CRP levels ranged from 30% (103 of 340) in those who had a college degree to 51% (65 of 127) in those who had less than a high school degree (p <0.0001). The proportion of subjects who had a high CRP level ranged from 28% (52 of 183) in those who had annual income >$50,000 to 42% (199 of 974) in those who had an annual income <$20,000 (p <0.001). After adjustment for traditional cardiovascular risk factors and other potential confounding variables, lower income and education remained associated with higher CRP levels. In conclusion, low SES is associated with high CRP levels in patients who have CHD. This observation raises the possibility that inflammation may contribute to the adverse cardiovascular outcomes associated with low SES.
In patients with coronary heart disease (CHD), depression leads to worse cardiovascular outcomes. Depression has been associated with increased cortisol in medically healthy patients, suggesting that cortisol may act as a mediator in the pathway between depression and cardiovascular events. However, it is not known whether depression is associated with elevated cortisol levels in patients with CHD.
We examined the association between depression (assessed by the Computerized Diagnostic Interview Schedule) and 24-hour urinary cortisol in 693 medical outpatients with known CHD.
Of 693 participants, 138 (20%) had current depression. Depressed participants had greater mean cortisol levels than those without depression (42 ± 25 vs. 36 ± 20 μg/day, p < .01). With each increasing quartile of cortisol concentration the frequency of depression increased (p < .01). Participants in the highest quartile of cortisol had a twofold increased odds of having depression, compared with those in the lowest quartile (odds ratio [OR] 2.1, 95% confidence interval [CR] 1.2-3.6, p = .01). This association remained strong after adjusting for potential confounding variables (OR 2.4, 95% CI 1.3-4.4, p < .01). In this cross-sectional analysis, elevated cortisol was not associated with worse cardiac function.
In patients with CHD, depression is associated with elevated cortisol levels.
Coronary heart disease; cortisol; depression; HPA axis; medical illness; stress
Galen's teaching on anatomy and physiology was generally accepted in the Middle Ages and this applies to the part he thought was played by the pneuma in the functions of the body. In this essay I have outlined the advances made after Galen in the study of the nervous system leading eventually to a time when the soul and the pneuma were no longer thought necessary for the proper functioning of the brain and nerves.
Unrecognized myocardial infarction (MI) carries a poor prognosis in the general population, but its prognostic value is less clear in high-risk patients. We sought to determine whether Q waves on electrocardiogram (ECG), suggestive of unrecognized MI, predict cardiovascular events in patients with stable coronary artery disease (CAD), but without a prior history of MI. We studied 462 patients enrolled in the Heart and Soul Study with stable CAD but without a prior history of MI. All patients had baseline ECGs. The baseline prevalence of unrecognized myocardial infarction was 36%. After a mean of 6.3 years of follow-up, there were a total of 141 cardiovascular events. The presence of Q waves in any ECG lead territory predicted cardiovascular events before (unadjusted HR 1.41, 95% CI 1.01–1.97) and after adjustment for demographics, medical history, diastolic function, and ejection fraction (HR 1.55, 95% CI 1.06–2.26). This association was partly attenuated after adjustment for the presence of inducible ischemia at baseline (HR 1.43, 95% CI 0.96–2.12). When specific territories were analyzed separately, Q waves in anterior leads were predictive of cardiovascular events in both unadjusted and adjusted models (adjusted HR 1.85, 95% CI 1.14–3.00), and this association was partly attenuated after adjustment for inducible ischemia. In conclusion, in patients with CAD but no history of prior MI, the presence of any Q waves or anterior Q waves alone is independently predictive of adverse cardiovascular events.
Q wave; Unrecognized myocardial infarction; Electrocardiogram; Coronary artery disease
We sought to determine whether left atrial (LA) dysfunction predicts heart failure (HF) hospitalization in subjects with preserved baseline ejection fraction (EF).
Among patients with preserved EF, factors leading to HF are not fully understood. Cross-sectional studies have demonstrated LA dysfunction at the time of HF, but longitudinal data on antecedent atrial function are lacking.
We performed resting transthoracic echocardiography in 855 subjects with coronary heart disease and EF≥50%. Left atrial functional index (LAFI) was calculated as [(LA emptying fraction × left ventricular outflow tract-velocity time integral)/(indexed LA end systolic volume)], where LA emptying fraction was defined as (LA end systolic volume - LA end diastolic volume)/LA end systolic volume. We used Cox models to evaluate the association between LAFI and HF hospitalization.
Over a median follow-up of 7.9 years, 106 participants (12.4%) were hospitalized for HF. Rates of HF hospitalization were inversely proportional to quartile of LAFI: Q1: 47 per 1000 person-years; Q2: 18.3; Q3: 9.6; and Q4: 5.3 (p<0.001). Each standard deviation decrease in LAFI was associated with a 2.6-fold increased hazard of adverse cardiovascular outcomes (unadjusted HR: 2.6, 95% CI 2.1–3.3, p<0.001), and the association persisted even after adjustment for clinical risk factors, NT-proBNP, and a wide range of echocardiographic parameters (adjusted HR: 1.5, 95% CI 1.0–2.1, p=0.05).
LA dysfunction independently predicts HF hospitalization in subjects with coronary heart disease and preserved baseline EF. LAFI may be useful for HF risk stratification, and LA dysfunction may be a potential therapeutic target.
Left Atrial Function; Heart Failure with Preserved Ejection Fraction; Left Atrial Functional Index; Heart Failure Hospitalization; Coronary Heart Disease
Siddha is a traditional medical system of India. According to siddha system of medicine, chendooram is a red colour powder generally made of metallic compounds. Mercury is used in the form of rasa chendooram (red oxide of mercury). This paper deals with the standardization of Kantha chendooram. It is a Siddha preparation of 8 ingredients, viz. 1. Purified Lode Stone, 2. Purified Sulphur, 3. Lead wort root powder, 4. Eclipta juice, 5. Lime juice, 6. Milk, 7. Egg albumin, 8. Madar Latex. In this study an attempt was made to standardize Kantha chendooram which has not been attempted by researchers earlier. Standardization of Kantha chendooram was in terms of its organoleptic characters, qualitative identification of phytochemical constituents, metallic quantification and in terms of pharmacognostical standardization.
Environmental contamination has exposed humans to various metal agents, including mercury. This exposure is more common than expected, and the health consequences of such exposure remain unclear. For many years, mercury was used in a wide variety of human activities, and now, exposure to this metal from both natural and artificial sources is significantly increasing. Many studies show that high exposure to mercury induces changes in the central nervous system, potentially resulting in irritability, fatigue, behavioral changes, tremors, headaches, hearing and cognitive loss, dysarthria, incoordination, hallucinations, and death. In the cardiovascular system, mercury induces hypertension in humans and animals that has wide-ranging consequences, including alterations in endothelial function. The results described in this paper indicate that mercury exposure, even at low doses, affects endothelial and cardiovascular function. As a result, the reference values defining the limits for the absence of danger should be reduced.
To prepare measures for practical policy utilization and the control of heavy metals, hazard control related institutions by country, present states of control by country, and present states of control by heavy metals were examined. Hazard control cases by heavy metals in various countries were compared and analyzed. In certain countries (e.g., the U.S., the U.K., and Japan), hazardous substances found in foods (e.g., arsenic, lead, cadmium, and mercury) are controlled. In addition, the Joint FAO/WHO Expert Committee on Food Additives (JECFA) recommends calculating the provisional tolerable weekly intake (PTWI) of individual heavy metals instead of the acceptable daily intake (ADI) to compare their pollution levels considering their toxicity accumulated in the human body. In Korea, exposure assessments have been conducted, and in other countries, hazardous substances are controlled by various governing bodies. As such, in Korea and other countries, diverse food heavy metal monitoring and human body exposure assessments are conducted, and reducing measures are prepared accordingly. To reduce the danger of hazardous substances, many countries provide leaflets and guidelines, develop hazardous heavy metal intake recommendations, and take necessary actions. Hazard control case analyses can assist in securing consumer safety by establishing systematic and reliable hazard control methods.
Hazardous substances; Risk management; Case analysis; Heavy metal
To compare the prognosis of stable coronary heart disease (CHD) patients with self-reported angina symptoms, inducible ischemia, or both.
Current guidelines do not recommend routine cardiac stress testing in patients with stable CHD unless they report symptoms of angina.
We measured self-reported angina by questionnaire and inducible ischemia using treadmill stress echocardiography in 937 outpatients with stable CHD. We used Cox proportional hazards models to evaluate the independent association of angina and inducible ischemia with CHD events (myocardial infarction or CHD death) during an average 3.9 years of follow-up, adjusted for traditional cardiovascular risk factors.
Of the study participants, 129 (14%) had angina alone, 188 (20%) had inducible ischemia alone, and 40 (4%) had both angina and ischemia. Recurrent CHD events occurred in 7% of participants without angina or inducible ischemia, 10% of those with angina alone, 21% of those with inducible ischemia alone, and 23% of those with both angina and inducible ischemia (p<0.0001). The presence of angina alone was not associated with recurrent CHD events (HR 1.4, 95% CI 0.7–2.9; p=.3). However, the presence of inducible ischemia without self-reported angina strongly predicted recurrent CHD events (HR 2.2, 95% CI, 1.4–3.5; p=.001).
We found that 24% of patients with stable CHD have inducible ischemia and over 80% of these do not report angina. The presence of inducible ischemia without self-reported angina is associated with a greater than 2-fold increased rate of recurrent CHD events.