Silent Myocardial Ischemia and Endogenous Pain Modulation.A total of 97 patients with asymptomatic and 69 patients with symptomatic myocardial ischemia and one‐vessel disease were compared with respect to the location of coronary stenosis and left ventricular wall motion abnormalities. All symptomatic and asymptomatic patients exhibited reproducible objective signs of myocardial ischemia in exercise tests, ischemia being always silent in the asymptomatic group. Right coronary artery stenosis (and left circumflex artery stenosis) was more frequently observed in asymptomatic patients, left artery descending stenosis more often in symptomatic patients. Left ventricular wall movement abnormalities with posterobasal or diaphragmatic localization were significantly more often associated with the absence of angina pectoris pain. The present results could contribute to the understanding of the mechanisms underlying the absence of pain in silent myocardial ischemia. A possible explanation for these results would be that stimulation of inhibitory vagal afferents, which are preferentially distributed in the inferior ventricle wall, may play a role of the suppression of pain perception in myocardial ischemi