PT - JOURNAL ARTICLE AU - Rupert P Williams AU - Vasiliki Manou-Stathopoulou AU - Simon R Redwood AU - Michael S Marber TI - ‘Warm-up Angina’: harnessing the benefits of exercise and myocardial ischaemia AID - 10.1136/heartjnl-2013-304187 DP - 2014 Jan 15 TA - Heart PG - 106--114 VI - 100 IP - 2 4099 - http://heart.bmj.com/content/100/2/106.short 4100 - http://heart.bmj.com/content/100/2/106.full SO - Heart2014 Jan 15; 100 AB - The phenomenon of warm-up angina was first noted over 200 years ago. It describes the curious observation whereby exercise-induced ischaemia on second effort is significantly reduced or even abolished if separated from first effort by a brief rest period. However, the precise mechanism via which this cardio-protection occurs remains uncertain. Three possible explanations for reduced myocardial ischaemia on second effort include: first, an improvement in myocardial perfusion; second, increased myocardial resistance to ischaemia similar to ischaemic preconditioning; and third, reduced cardiac work through better ventricular–vascular coupling. Obtaining accurate coronary physiological measurements in the catheter laboratory throughout exercise demands a complex research protocol. In the 1980s, studies into warm-up angina relied on great cardiac vein thermo-dilution to estimate coronary blood flow. This technique has subsequently been shown to be inaccurate. However exercise physiology in the catheter laboratory has recently been resurrected with the advent of coronary artery wires that allow continuous measurement of distal coronary artery pressure and blood flow velocity. This review summarises the intriguing historical background to warm-up angina, and provides a concise critique of the important studies investigating mechanisms behind this captivating cardio-protective phenomenon.