Angina pectoris and thyrotoxicosis.

The effects of thyrotoxicosis on the cardiovascular system are well recognized and some are very prominent. Symptoms ascribable to the overaction of the heart such as dyspncea, palpitation, tachycardia, irregularity of the heart, dizziness, and prxcordial pain have been encountered in as many as 80 per cent of a series of 148 cases of thyrotoxicosis (Burnett and Durbin, 1932). The pathological changes in the heart occasionally associated with thyrotoxicosis have been described by Goodpasture (1921) who believed that infection might play a part in their production, and by Goodall and Rogers (1927), who concluded that the perivascular infiltration, fatty degeneration, and fibrosis which they encountered were specific effects of thyroid secretion. This view has been challenged by many authors (Rake and McEachern, 1932; Menne et al., 1932; Means, 1948), and the view that they represent non-specific reactions to prolonged overactivity of the heart is widespread today (White, 1944; Levine, 1945; Means, 1948). When heart disease of rheumatic, hypertensive, arteriosclerotic, or other etiology is present in a person who develops thyrotoxicosis, the diagnosis of the latter may be missed by reason of the pre-eminence of the signs and symptoms of the underlying heart disease. On the other hand, thyrotoxic effects on the cardiovascular system may resemble closely those of organic heart disease especially mitral stenosis and the correct diagnosis may be overlooked (Levine and Sturgis, 1924; Levine and Walker, 1929; Levine, 1930; Rosenblum and Levine, 1933). When coronary arteriosclerosis is present with thyrotoxicosis, angina pectoris may be brought to light, or if this symptom is already present, it may be aggravated by the increased demands on the heart. The frequency and severity of the angina may occasionally so dominate the clinical picture that the thyrotoxic element may pass undetected. The association of these two conditions is said to be uncommon, Means (1948) encountering only one thyrotoxic patient in whom angina pectoris was the presenting symptom. White (1944) states that angina pectoris rarely accompanies thyrotoxicosis, and then only in older persons with underlying coronary artery disease. Only a few reports on the subject have appeared. In a follow-up study of 69 thyrocardiacs on whom subtotal thyroidectomy had been performed, Rosenblum and Levine (1933) reported 9 with angina pectoris; in the course of observation periods ranging from four months to four years, the attacks in every instance either completely disappeared or were greatly improved. Haines and Kepler (1930) described 33 patients with angina pectoris and thyrotoxicosis, 28 of whom were treated by subtotal thyroidectomy; only two of the treated patients failed to improve in their anginal symptoms over periods of four months to seven years after operation. Lev and Hamburger (1932) observed 6 patients with the same combination, 5 of them for two to five years; no further attacks of angina occurred in any of them after subtotal thyroidectomy. Other authors have experienced similar favourable results (Duchosal and Henny, 1941; Fischer, 1941). The present report deals with 24 patients with angina pectoris and thyrotoxicosis, and their main features are summarized in Table I. Seven of them were included in a previous communi-