Cardiac pain in association with mitral stenosis and congenital heart disease.

The association of angina pectoris with mitral stenosis has interested cardiologists for many years. The first reference seems to be that of Nothnagel (1891) who found anginal pain in 18 per cent of his patients with mitral stenosis. There have been many case reports since that time of angina pectoris occurring in young subjects with mitral stenosis a number of instances normal coronary arteries were revealed at necropsy. For example Blackford (1940) reported two such cases with severe mitral stenosis and normal coronary arteries and found seven previously reported cases in which the results of necropsy were available, and 25 other case reports since 1923. Burgess and Ellis (1942) considered that true angina pectoris was rare with mitral stenosis and confined to older patients, and discussed so-called "hypercyanotic angina" occurring in long attacks unrelated to effort. Levine and Kauvar (1942) studied 38 patients with mitral stenosis and angina pectoris: three were under the age of 40 years, and women predominated over men in the proportion of 2: 1. The average age of onset of angina was 50 years for the women and 54 years for the men. The incidence of angina pectoris among 741 patients with mitral stenosis was 2-6 per cent. In sixteen of their patients the results of necropsy were available; in three of these the coronary arteries were normal. Significant disease of the coronary arteries was found post-mortem in only 5 per cent of 314 cases of mitral stenosis. They concluded that in the majority of such patients mitral stenosis and coronary artery disease merely coexist. This has been the general opinion since that time, and is quoted in most textbooks. The impression that aortic incompetence is the only valvular lesion commonly associated with angina pectoris in young subjects, seems to date from papers by White and Mudd (1927) and by Schwartz (1927). Most of the thirteen patients mentioned by these authors had mitral valve disease as well, and there was no post-mortem confirmation. References to the occurrence of angina pectoris in patients with congenital heart disease are more scanty. Aortic stenosis has only recently been considered a relatively common congenital condition (Campbell and Kauntze, 1953), but the association of angina pectoris with this lesion is well recognized, and it occurred in 11 of the 40 patients reported by these authors. Friedberg (1949) put the incidence of angina of effort in patients with aortic stenosis at 10-20 …