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Although angina pectoris is the most common symptom of coronary artery disease, some patients do not experience angina during ischemic episodes. The effects of asymptomatic (silent) heart disease on patient self-management have rarely been studied. Studies of other patient populations with asymptomatic illnesses indicate that patients with silent myocardial ischemia might adhere less well to a prophylactic medication regimen than would those with symptomatic ischemia. Depression, a state associated with poor adherence to medical regimens, is more common among patients with symptomatic ischemia. For prevention of thromboembolic events, 37 patients with documented ischemic heart disease who denied having anginal symptoms and 28 patients who reported almost daily symptoms were given a 3-week supply of low-dose aspirin packaged in an unobtrusive electronic adherence monitor. All other medications were provided in standard pill bottles. The symptomatic patients removed their prescribed aspirin on 62.4% of the days; the patients with silent ischemia took their medication on 77.3% of the days. Possible explanations for these results, their clinical implications, and directions for future research are discussed.