6 14 The Heart in Myxedema 



were not prepared to say that it does not exist. When symptoms and signs o£ 

 heart faikire are present, a coexisting hypertension and arteriosclerosis will 

 be found. 



In 1933, Lerman, Clark and Means^^ summarized their subsequent observa- 

 tions as follows: "Myxedema heart" in the sense of cardiac enlargement which 

 undergoes shrinkage on thyroid medication is common. In the sense of Zondek 

 and Fahr, that is, a cardiac enlargement in association with congestive failure, 

 it is rare. The heart changes are part of the picture of myxedema and not a 

 separate cardiac entity. Patients with cardiac failure usually have hypertension 

 and arteriosclerosis. The change in the heart size with thyroid treatment is 

 probably due to increased muscle tone and loss of interstitial edema, occa- 

 sionally to loss of an accumulation of pericardial fluid. 



In 1933, Means" suggested that the cardiac enlargement found in some cases 

 of myxedema may be due either to hypertrophy, dilatation, or edema of the 

 heart muscle. Pericardial effusion may be possible but the X-ray appearance 

 is against it. 



In further studies on the heart in myxedema, Lerman, Clark and Means^' 

 state that all of eighteen patients showed enlargement of the heart which de- 

 creased in size after thyroid medication. None showed congestive failure. All 

 had abnormal electrocardiographic changes. 



Subsequently, Means^" described the state of the heart in myxedema in brief, 

 as due to dilatation and low tonus, but without true insufficiency, since along 

 with the reduction in the heart's capacity for work there goes a parallel reduc- 

 tion in the amount of work it is called upon to perform. "The condition of 

 the heart in myxedema is not a complication, it is part of the disease, myxe- 

 dema of the heart in fact, and whether it is to be looked at as in a state of failure 

 is, to a certain extent, a matter of terminology." As to digitalis, he says, myxe- 

 dematous patients tolerate digitalis badly just as they do morphine. 



In 1932, Fahr" summarized his observations on the heart in seventeen cases 

 of severe and moderately severe myxedema. In thirteen instances or 75 per 

 cent he found signs and symptoms of heart failure, all of which disappeared 

 after giving thyroid. If coronary disease is present he warns that the blood 

 supply to the heart in proportion to the work done may be much less after 

 than before giving thyroid. Provided the heart shows better function and 

 provided no angina pectoris is induced, thyroid may be given. If the coronaries 

 can dilate, anginal attacks may disappear after thyroid treatment is started 

 in myxedema. 



Sturgis and Whiting" reported the sudden death of a myxedematous patient 

 shortly after treatment with thyroid was started. They urge caution in thyroid 

 therapy, especially in myxedematous patients with anemia and recommend 

 preliminary treatment with small transfusions and digitalis. 



Ohler and Abramson^^ report the sudden death of a young myxedematous 

 patient given enormous doses of desiccated thyroid. Less serious unfortunate 

 effects of thyroid therapy, auricular fibrillation (Swan^°) and Stokes-Adams 



