F.E.’s electrocardiogram showed Q waves in leads II, III, and aVF, a new right bundle branch block, and mild ST segment elevation in leads V4 through V6. An urgent echocardiogram was ordered to differentiate between pericarditis and ischemia. The echocardiogram showed marked motion abnormalities in the inferior posterior, lateral wall. An initial troponin I was 238 ng/ml (normal range 0–2.5 ng/ml). DSA done, quick consultation for evaluation of risk factors for intervention, informed consent, then the patient was taken for emergent cardiac catheterization. This demonstrated an occluded right coronary artery that was opened with primary angioplasty and stent placement. Questions Is silent ischemia or atypical presentation of myocardial ischemia more common in diabetes? What other disease states may predispose to the development of atypical chest pain syndromes? What is the proposed mechanism for atypical or silent ischemia in diabetes? Which patients with diabetes should undergo myocardial assessment?