Angina pain, pain on the chest. Refractory angina pectoris pain is seen as a variety of neuropathic pain. In our clinic we treat neuropathic pains with amongst others the natural and body-own painkiller een PEA-houdend product. Here a presentation of a patient suffering from refractory angina pain, treated with een PEA-houdend product.
In our clinic we saw a 79-old lady, with a history of myocardial infarctions, a pacemaker was implanted, and severe artrosis in various joints as well as a knee replacement. She suffered from angina attacks and was treated with a betablocker and nitroglycerin under the tongue. She came under our care due to severe pain based on a herniated disk at two levels, L4/L5 and L5/S1. We prescribed palmitoylethanolamide 600 mg bid. On the sciatic pain the efects were very modest, but since the beginning of palmitoylethanolamide, now 7 weeks ago, no attacks of angina were seen. She explicitely asked us whether the attacks vanished due to palmitoylethanolamide. The attacks before our treatment were quite frequent, couple of times each week. Due to the fact that mast cells have been found in the coronary system and around nerve endings this by accident therapeutic effect might be a result of the pharmacological action of palmitoylethanolamide on the mast cells.
Kounis syndrome and mast cells
Kounis syndrome is the essence of mast cell degranulation and angina pectoris attacks. Angina pectoris attacks in Kounis syndrome are caused by inflammatory mediators from mast cells, released during an allergic insult. Allergic angina can progress to acute myocardial infarction, which is termed ‘allergic myocardial infarction’. 
Palmitoylethanolamide and a putative new subvariety of angina pectoris: MCMAP, Mast Cell Mediated Angina Pectoris
In the pathogenesis of unstable angina pro-inflammatory cytokines also play a role. These cytokines may also be responsible for the activation of other cells, as neutrophils or mast-cells. Mast cells have been described playing a role in the pathogenesis of angina pectoris already since long. 
Our by chance finding of the anti anginal effect of palmitoylethanolamide might define mast-cell dependent angina pectoris. It provokes us to suggest prescribing palmitoylethanolamide to angina pectoris patients to thus, ex juvantibus, be able to define a subpopulation of angina pectoris patients.
We would suggest to classify this variety of angina pectoris as Mast Cell Mediated Angina Pectoris, MCMAP. We are very much looking forward to experiences of other clinicians using palmitoylethanolamide in angina pectoris.