5897

[SEPT. 5, 1936

ADDRESSES AND ORIGINAL ARTICLES

TREATMENT OF ANGINA PECTORIS

BY BASIL PARSONS-SMITH, M.D., F.R.C.P. Lond.PHYSICIAN TO THE NATIONAL HOSPITAL FOR DISEASES

OF THE HEART, LONDON

FOR practical purposes angina pectoris may beregarded as a symptom-complex characterised byparoxysmal attacks of substernal pain, constrictivein type. It is more often than not induced bymuscular e:Eort, exposure to cold or mental excite-ment and, in its severer forms, is associated withvarying degrees of circulatory collapse. The treat-ment of angina pectoris in all its forms is primarilydependent on accurate diagnosis and this we must beprepared to establish by consideration of the patient’ssubjective symptoms. It is generally admitted thatno single or specific pathology is concerned in thecondition, and that in a considerable number,probably 25 per cent. of all cases, the cardiovascularexamination is negative to the most careful examina-tion. The patient’s history, in other words, is of

paramount importance, and by careful inquiry it is

possible to assemble a convincing picture of thecondition which, in point of fact, is essentially similarin its modern conception to that originally describedby Heberden in 1768, whose classical and compre-hensive description of angina pectoris has beenaccepted to date without qualification.

Medical Treatment

Although a large number of conflicting theorieshave been, from time to time, propounded in explana-tion of the anginal syndrome, it is unnecessary hereto make other than a brief statement about thecauses that are nowadays generally approved ofand which, incidentally, merit ample considerationwhen one approaches the question of treatment.From the pathological aspect two lesions, coronarysclerosis and myocardial fibrosis, are especially note-worthy, and these in combination induce relativeor absolute ischaemia of the heart-muscle and defectiveremoval of waste products. The result is to stimulatethe afferent pain fibres in the plexus of nerves

surrounding the affected vessels. This being the

acknowledged mechanism of anginal pain one canreadily appreciate that its treatment must inevitablypresent very material difficulty, for in the largemajority of cases the cardiac disability is not onlyirremedial but also progressive.Begimen.-Prevention of attacks will clearly be

an essential consideration in the routine programmeof all patients suffering from anginal symptoms.As far as possible they must be made to appreciatethe significance of their affection, that their circulatoryreserve is to some extent diminished, and that theymust be prepared to adopt restrictions in their modeof life, avoiding more particularly all factors thatthey may have found by experience to producepainful seizures. Under certain circumstances-i.e., if the attacks are becoming increasingly frequentand if they occur when the patient is resting, alsoif there is any suggestion of coronary thrombosis-it will be necessary for the patient to undergo a periodof complete rest. Otherwise, an average case shouldbe encouraged to continue those of his habits andactivities that do not tend to precipitate his attacks,always assuming that he makes such rearrangementsin his mode of life as will exclude excessive physical

strain, prolonged exertion, exposure to weatherextremes and, as far as possible, mental stress. Inall cases it will be necessary to emphasise the valueof adequate relaxation, and, should there be anyquestion of overstrain, either physical or mental,it may be advisable to prescribe a quiet, restfulholiday or a carefully planned sea voyage. Certaindirections about the diet should be laid down as anintegral item of the general treatment and, sincedigestive errors frequently complicate the anginasyndrome, they should be as far as possible relievedon orthodox lines. All patients should be cautionedthat they must take plain, easily digestible food,that they must eat slowly, and that they must make apractice of resting quietly for at least half an hourafter meals. A further detail concerns the questionof smoking, and, although opinion is by no meansunanimous, it would be generally admitted thatstrict moderation should be observed and preferablytotal abstinence.

Drugs.-A large number of drugs have been recom.mended from time to time but, with certain exceptions,they have failed to establish their value. Potassiumiodide has a well-recognised reputation in the treat-ment of arterio-sclerosis, and it is fair to assume thatit may stay the progress of coronary disease, but thegeneral consensus of opinion nowadays is to associatesuccessful iodide therapy in angina cases with pre-existing syphilis. Further remedies which may be

prescribed with some degree of confidence, in thatthey exert a dilating effect on the coronary vesselsquite apart from their eliminatory value, are thexanthine series of drugs. These include Diuretin

(grs. 10-15) best prescribed in tablet form ;theocalcine (grs. 10-15); theophylline (grs. 5) ;Euphyllin (0-1 g.); Theamin (0-1-0-2 g.); andTheominal (grs.5). All these preparations haveestablished reputations in the treatment of patientssuffering from angina. They are relatively non-toxicand their prescription is otherwise justified in thatthey exert no ill-effects on the kidney structure. Ifnervous symptoms are prominent, as after excessivemental strain, and if insomnia is an obvious factor,short courses of a mild sedative, such as Luminal orbromide or chloral hydrate, are definitely helpful,and as a general rule one should encourage all anginacases to take full advantage of the nitrite preparations,a convenient form of the latter being the nitro-

glycerin tablets (gr. 1/100) which may be used

prophylactically should an attack of pain be expectedor actually threaten to develop.The further indications for drug treatment in

angina pectoris concern more particularly certain ofthe associated conditions which may complicate theissue. These include obesity, syphilis, and hyper-tension, each of which will require appropriateconsideration.Obesity is always considered to be a serious complication

in patients with cardiac affections, and it should becounteracted as far as possible in appropriate and energeticfashion. In an average case the weight should be reducedby roughly a pound a week. This can usually be achievedby moderate restrictions in the fat and carbohydrateintake ; by occasional fast days, say once weekly, on whichthe diet is limited to tea, milk, gravy, and fruit juice ;by suitable exercise and such schemes of physiotherapy(including massage, baths, colonic lavage, diathermy,&c.) as the various spas nowadays provide; and lastlyby the prescription of thyroid extract if the metabolicrate is found to be subnormal.

In syphilis energetic specific treatment should beinstituted without delay. First, a two-months’ course of

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potassium iodide with mercury, these drugs being combinedin a mixture :-

Alternatively it may be preferable to prescribe mercury inthe form of a pill (hyd. c. cret and pulv. ipecac, co. aa gr. 1)or by inunction (ung. hydrarg., 3 i.) or by intramuscularinjection (mercury, gr. 1, either in the form of gray oil ormercury cream). After the course of iodide and mercury,and assuming that the physical signs do not indicateextensive disease in the myocardium or the aorta, it willbe advisable to proceed with arsenical preparations-novarsenobillon or sulpharsphenainine-in minimaldoses (0’15 g. weekly) to begin with, which may beincreased very gradually, according to the patient’stolerance, to a maximum of 0’45 or 0’6 g., the full courseextending over approximately 12 weeks. Certain patients,however, are unable to tolerate arsenic in any form and,bismuth may be substituted, a suitable preparation ofwhich-Bismostab-may be prescribed, 12 doses (0’2 g.intramuscularly) at weekly intervals. According to thepatient’s progress the above courses may need to be

repeated over periods varying from one to two or moreyears, and it is generally felt that the results amply justifysuch a line of treatment.

Hypertension is an outstanding feature of the anginalstate in a considerable number of patients, and the

preventive regimen outlined above is equally applicableto this condition. In addition it should be ensured thatthe patient has efficient elimination by all the naturalroutes. He should be encouraged to take occasionalcourses of treatment at some suitable spa such as Harrogate,Bath, Vichy, Royat, Aix-les-Bains, or Nauheim. If

symptoms of plethora, headache, mental confusion,tinnitus, palpitation, &c., are especially troublesomehe should be subjected from time to time-say at three-monthly intervals-to moderate venesections (12-20 oz.).For the actual attack of angina it is customary

to prescribe the nitrites in some form-a tablet ofnitroglycerin (gr. 1/200-1/50) or an amyl nitrite

capsule (111 3-5), the latter being more especiallyvaluable for the seizures of true spasmodic angina,especially if the blood pressure happens to be raised.When there is flatulence and indigestion a simplecarminative draught is indicated, either peppermintor brandy in hot water, or a medium dose (TTL 20-30)of tinct. camph. co., or a mixture of sodium bicarbonate(grs. 15) with sal volatile (1) 15) in chloroform water(§ i.). These failing, more urgent remedies may beadopted, including a mustard plaster or hot bottlesover the precordium, an inhalation of chloroform,a hypodermic injection of morphia (gr. 4 andoxygen inhalations if cyanosis happens to be a markedfeature.

SurgeryThe above is a synopsis of the treatment of angina

by strictly medical remedies and we may now reviewthe surgical aspects of the problem which have beendeveloping gradually during the past few years.These include cervical sympathectomy, paravertebralinjections of alcohol into the upper dorsal roots, andthyroidectomy.

SYMPATHECTOMY

The operation for cervical sympathectomy wasfirst proposed by Francois Frank in 1899, and later(1916) introduced by Jonnesco. Since his time a

large variety of modifications have been suggested,the extent of the operation varying in the hands ofdifferent surgeons from a simple transection of theleft sympathetic trunk between the superior andmiddle ganglia to the complete removal of the sympa-thetic nerves on both sides, including the superior,

middle, and stellate ganglia. Apart from the factthat troublesome complications may follow cervicalsympathectomy, the operation has not been adoptedto any great extent in this country by reason of theuncertainty of its results. It should neverthelessbe remembered that it is a rational proceeding inthe hands of a competent surgeon for an otherwiseintractable case of angina.

ALCOHOL INJECTION

The paravertebral injection of 85 per cent. alcoholinto the upper five or six dorsal roots aims at thedestruction of the sympathetic nerve connexions;the operative technique is difficult and although inmy experience results have been somewhat disappoint-ing, others have had more encouraging experienceand, as a method of relief in cases which fail to respondto the usual therapy, the injection treatment iscertainly worthy of consideration. a

THYROIDECTOMY

In the treatment of angina pectoris thyroidectomyis a relatively modern conception which has beengradually evolved by accurate clinical investigationand which may nowadays be recognised to have adefinitely sound foundation ; outstanding historicaldetails in the history of its application to heartcases include the following : (1) The report of Kocher’scases in some of which the disappearance of heartfailure following thyroidectomy was described. 7

(2) The observations of Hamilton on the result ofthyroidectomy in patients with hyperthyroidism andcardiac failure.s 5 (3) The clinical studies by Blumgartand Levine,3 who associated the improvement in

thyrotoxic patients suffering from heart failure withthe induction of a lowered metabolic rate followingthyroidectomy, and suggested that cardiac patientswith a normal metabolism might show improvementif it were artificially lowered, the demands of thetissues being reduced to the extent of renderingan adequate adjustment for the slowed circulation.(4) The further observation by Blumgart and his

colleagues that patients suffering from myxcedema,in whom the metabolic rate is subnormal and the

velocity of the blood stream is materially slowed,show no signs of circulatory incompetence, the loweredspeed of the blood flow being adequate for the reduceddemands of the tissue metabolism.These being the material facts, one can readily

appreciate the potential value of thyroidectomy inpatients suffering from anginal symptoms. Thecondition is expressive of defective circulation indiseased coronary vessels, of myocardial ischsemia.secondary thereto, and consequently of a discrepancyin the supply of the tissue demands. Under thesecircumstances it is conceivable that a reduction inthe metabolic rate might indirectly compensate forthe inadequate state of the coronary circulation bylowering the range of the tissue requirements to alevel more compatible with the impaired blood-supply,and incidently also by implementing a definite reduc-tion in the amount of work which the heart is calledupon to perform.The value of thyroidectomy in the treatment of

intractable cases of angina pectoris can best beassessed by reference to the actual results obtainedfollowing the operation. Blumgart and hisco-workers 4 have published a series of 31 cases oftotal thyroidectomy for angina pectoris, the analysisof which can be summarised briefly as follows :-

Of the cases 12 recovered sufficiently to be able toreturn to work, which was impossible before operation,7 of these remaining free from attacks for periods ranging

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over 3-18 months; 5 cases were relieved for periodsof 3-9 months before the attacks recurred.Pain was relieved in 3 cases, their activity continuing

to be restricted by reason of myocardial failure. Of the

remaining 11 cases, 5 were materially better following theoperation and 3 died.

A further series of 23 cases was reported by Levineand Eppinger,8 the analysis of their results beingas follows :-

Excellent in 8 cases, good in 6, moderately good in 4,fair in 1 ; and 4 fatal cases, 2 following the operation and2 from coronary thrombosis at a later date.

It would be unwise at the present time to attemptany final assessment of the significance of theseresults, and, although one cannot fail to be impressedby the beneficial effects which followed extirpationof the thyroid gland in certain of the above-mentionedcases, it is nevertheless obvious that this method oftreatment is, as yet, in the experimental stage. Finaldecisions on the efficacy of this operation for therelief of angina must be deferred pending furtherclinical investigations.

COLLATERAL CIRCULATION

In concluding the surgical aspect of the therapyof angina, special mention should be made of recentwork in regard to the value of grafting operations forcoronary disease-in other words the provision of acollateral vascular bed for the myocardium when’the efficiency of its natural circulation is prejudicedby progressive circulatory incompetence. The pioneerwork of Beck, Tichy, Hudson, Moritz, Wearn, andLeriche is worthy of very special note ; Beck and

Tichy 2 recognised three main sources of blood-supplyto the myocardium : (1) the coronary vessels, (2) thethebesian vessels, and (3) the extracardiac anasto-moses between the coronary system and other branchesof the aorta in the fatty tissues at the base of theheart. 6 They commented on the case recorded byThorel of a patient with complete obliteration ofboth coronary arteries in whom the blood-supplyto the heart was maintained by vascular adhesionsfrom the pericardium and, experimenting on dogs,they contrived an operation to produce a collateralvascular bed for the heart, using for this purposethe parietal pericardium, the pericardial fat, and themediastinal tissues. Their investigations led to thefollowing conclusions : (1) Almost total occlusionof both coronary arteries was compatible with lifeif the heart had been previously provided with acollateral vascular bed. (2) The stimulus that wasrequired to bring about continuity between the extra-cardiac and the cardiac beds was a reduced pressurein the major coronary vessels, which they ingeniouslyeffected by the use of periosteal bands or silver clips.These results led finally to trial of the operation onhuman beings, the first recorded example beingthat of a man, aged 48, who had 9 years’ history ofangina pectoris. A pedicle graft of the left pectoralismajor, including the internal mammary artery, wassutured to the inner surface of the parietal peri-cardium ; this and the epicardium were roughenedwith a burr, and the medial edge of the pectoralismuscle was attached to the outer surface of theparietal pericardium. The patient was entirelyfree from pain and able for light work 3! monthsafter the operation ; 3 months later he was in regularemployment as a gardener and regarded himself ascured. Subsequently 5 other patients were subjectedto a similar operation, the result being excellent in1, fairly satisfactory in another, and as yetundetermined in the remaining 3.

A further series of animal experiments has beenrecorded by L. O’Shaughnessy,9 who applied pediclegrafts of omentum to the myocardium followingpreliminary myocardial infarction. Improvement inthe exercise tolerance suggested that the grafts wereefficient, and at autopsy injections of dye confirmedthe existence of vascular channels from the graftsto the myocardium.One may summarise these researches by noting

that certain operations have recently been devisedwith a view to revascularisation of the myocardiumby grafts for the relief of myocardial ischsemia.These operations must be submitted to further

experimental investigation before their value in thetreatment and prophylaxis of angina pectoris can

be adequately assessed.REFERENCES

1. Beck, C. S. : Ann. of Surg., 1935, xxxii., 801.2. Beck, C. S., and Tichy, V. L. : Amer. Heart Jour, 1935,

x., 849.3. Blumgart, H. L., Levine, S. A., and Berlin, D. D. : Arch.

Internal Med., 1933, li., 866.4. Blumgart, H. L., Riseman, J. E. F., Davis, D., and Wein-

stein, A. A. : Amer. Heart Jour., 1935, x., 596.5. Hamilton, B. E. : Boston Med. and Surg. Jour., 1922,

clxxxvi., 216.6. Hudson, C. L., Moritz, A. R., and Wearn, J. T. : Jour.

Exper. Med., 1932, vol. lvi.,7. Kocher, A. : Mitt. a. d. Grenzgeb. d. Med. u. Chir.,

1902, i., 1.8. Levine, S. A., and Eppinger, E. C. : Amer. Heart Jour.,

1935, x., 736.9. O’Shaughnessy, L. : Brit. Jour. Surg., January, 1936, p. 665.

10. Wearn. J. T. : Jour. Exper. Med., 1928, xlvii., 293.

CHOICE OF PATIENTS, WITH ANGINAOF EFFORT, FOR THYROIDECTOMY

BY GEOFFREY BOURNE, M.D., F.R.C.P. Lond.PHYSICIAN WITH CHARGE OF OUT-PATIENTS, AND IN

CHARGE OF THE CARDIOGRAPHIC DEPARTMENT,ST. BARTHOLOMEW’S HOSPITAL, LONDON

IN considering treating patients with cardiac painby thyroidectomy one of the first essentials is thatthe patient should have a reasonably healthy myo-cardium. This is desirable from two points of view :first, that the patient may survive the operation ;and, secondly, that a reasonable spell of post-opera-tive health may follow. The case here describedproves how difficult the evaluation of the state ofthe myocardium may be in these patients.

CASE RECORD

A man, aged 58, came under my care complaining ofprecordial pain.

History of the present condition.-Four years previouslyhe had suffered from a sudden very severe attack of pre-cordial pain at night. This persisted for three or fourdays, during which period it slowly subsided. He wasforced to remain in bed. Following this attack of coronarythrombosis he suffered from considerable shortness ofbreath on exertion, but slowly made a complete clinicalrecovery. He continued his work as a motor engineerfor 18 months without pain. At the end of this periodhe began to suffer from pain, which was localised to theprecordium. This pain was substernal and produced byexercise. It was proportional to exertion and disappearedon resting. It was relieved by nitroglycerin tablets. Atthe time of the examination he stated that the slightestexertion would produce pain, and that this pain for thepast two months had extended down both arms. For the

previous two weeks he might get it even at rest, especiallyif he were lying flat upon his back. He suffered from noshortness of breath while remaining still.

Past History.-There was no history of any previousdisease. Habits : 6-7 cigarettes a day.On clinical examination there was no shortness of breath,

orthopnoea, cyanosis, pallor, or excessive pulsation. The