Painful myocardial infarction in severe diabetic autonomic neuropathy

Summary Two cases are reported of painful myocardial infarction in diabetics with severe autonomic neuropathy confirmed by abnormal autonomic function tests. Painless myocardial infarction in diabetics has traditionally been attributed to damage of cardiac pain fibres by autonomic neuropathy but other factors such as microangiopathy in the myocardium may be responsible. It may simply be that diabetics come into hospital more often for other reasons and a silent myocardial infarction diagnosed incidentally.