Management of patients with chest pain and hypothyroidism is a clinical dilemma. Thyroid replacement therapy may exacerbate angina pectoris. Administration of a beta blocker such as propranolol (Inderal) concomitantly with thyroid replacement therapy is useful in treatment of angina. However, beta blockers can induce variant angina owing to increased norepinephrine secretion and enhanced alpha-mediated responsiveness in the hypothyroid state. Hypotension and syncopal episodes may develop in the hypothyroid patient after administration of nitrates. Cardiac catheterization and revascularization are well tolerated by myxedematous patients with angina. After surgery, full thyroid replacement therapy should be initiated gradually and with caution.