Mechanisms underlying cardiac pain are of major importance in cardiovascular medicine. In this review we address a fundamental clinical and experimental aspect. In particular neural circuitry involved justify a stepwise involvement of central structures responsible of reflex adjustments initiated by peripheral ischemia that can be associated with pain if a cortex is involved. Ischemic episodes not involving ascending neural circuits limited to the thalamus are not associated to pain. The same sensory inputs, when stimulated, may initiate positive feedback sympathetic reflexes from the heart.