This study evaluated daily-life physical and mental triggers of painful and painless myocardial ischemia and of anginal pain in patients with coronary artery disease (CAD) by using ambulatory electrocardiographic monitoring and a structured diary. Eighty-five percent of ambulant ischemic episodes occurred without chest pain; 66% of anginal pain reports were made in the absence of ischemic ST-segment depression. Chest pain reports in the absence of ischemia could not be attributed to "borderline" ST-segment changes. Compared with silent ischemia, painful ischemia was triggered at higher levels of physical activity (p < 0.05) and at higher levels of self-rated effort and negative emotion (p < 0.05). Painful episodes were associated with greater-magnitude ST depression (p < 0.02), but a substantial percentage of episodes with > or = 2 mm and > or = 3 mm ST depression were silent. These results reveal an uncoupling of anginal symptoms from ambulatory ischemic episodes in patients with CAD during daily life. In addition, specific activities and emotions correlate with the presence or absence of anginal symptoms as much as does the presence of ischemic ST depression. These results may have implications for antiischemic and antianginal treatment strategies.