Angina of Micturition

A PATIENT recently came under our care who suffered from angina pectoris which was precipitated by micturitioll. Because of this unusual clinical association and the striking similarity to a famous historical case of angina pectoris, the case history and limited laboratory observation are recorded in detail. Case History R. C., a 46-year-old Negro inale, was admitted to the Duke Medical Center in August 1960, with chest pain, fever, and chills. He had had chorea at age 7 and frequent epistaxis and migratory polyarthritis in early adult life. When 32 years of age, he had an episode of peripheral edema and migratory polyarthritis and was told he had "rheuimatism." Four years later he experienced intermittently for several weeks a dull, aching anterior chest pain without radiation, unrelated to exertion. Three weeks prior to admission he experienced a similar type pain which increased in frequency and was precipitated by exertion. Progressive weakness, loss of energy, anorexia, and occasional chills and fever were experienced. He denied dyspnea, orthopnea, edema, palpitations, or hemoptysis. The patient also had noted some urinary urgency and frequency during the several weeks prior to admission. Physical examination revealed a blood pressure of 110/40/0 mm. Hg, without pulsus alternans or paradox; pulse 94 and regular; respiration 20; temperature 39 C. The patient was a well-developed, well-nourished, acutely and chronically ill Negro male with mild orthopnea. The heart was enlarged to the left, with the apical impulse located in the sixth left intercostal space at the anterior axillary line. Systolic thrills were present over the primary and secondary aortic areas. P2 and M1 were greatly accentuated. There was a grade iv/vi aortic systolic ejection murmur, well transmitted to the neck. A grade iii/vi diastolic 4ecrescendo murmur was present along the left sternal border. A mid-diastolic rumble was heard at the left lowver sternal border and at the apex