A thorough history is vital for the diagnosis of patients with issues such as chest pain, heart failure symptoms, palpitations or syncope. The cardiovascular history may also provide important insight into patients' cardiac status, and their risk of future cardiovascular disease in the future.
The first step is to ask the patient why they presented with their current issue.
- Common cardiovascular symptoms include:
- Chest pain - concerning for coronary ischaemia infarction, though there are a wide variety of causes of chest pain
- Dyspnoea (shortness of breath) - a common symptom of heart failure
- Palpitations - the sensation of fast, slow or irregular beating of the heart
- Presyncope / syncope - the feeling of fainting, or being about to faint
- Peripheral oedema (swelling) - classically a symptom of heart failure
- Lower limb pain
History of Presenting Complaint
When asking for more information about a patientâ€™s symptoms, start by asking general questions such as â€œcould you please tell me more about thatâ€, and then narrow down the questions as more information is provided.
- Generally speaking, the following questions are a good starting point for any type of pain, and may be useful in gaining information about other symptoms:
- Site - localised or generalised; unilateral or bilateral
- Onset - sudden or gradual, and what the situation was (e.g. following trauma)
- Character - sharp, dull, burning or pressure-like
- Radiation - e.g. down the arm or across the back
- Associated symptoms - e.g. fevers, nausea / vomiting, bony pain
- Timing - duration of symptoms, frequency of episodes, changes through the day
- Exacerbating & alleviating factors - e.g. exacerbation with exertion and alleviation with rest
- Severity - on a scale of 1 to 10, with 10 being the worst
Past Medical History
Ask about any medical conditions the patient has previous been diagnosed with, the management of these conditions, and any complications they may have.
- Common cardiovascular conditions include:
- Ischaemic heart disease
- Arrhythmia - e.g. atrial fibrillation, atrial flutter, Wolff-Parkinson-White syndrome
- Heart failure
- Pulmonary hypertension
- Peripheral vascular disease
- Rheumatic heart disease
- Valvular disease - e.g. aortic stenosis, aortic regurgitation, mitral regurgitation
- Congenital heart disease
Finally, ask about any cardiac devices that may be present, such as pacemakers or defibrillators.
Ask about what medications the patient takes regularly, what they take them for, and what side effects they have had.
Ask about family history of cardiac disease, such as ischaemic heart disease, cardiomyopathies or arrhythmias.
Also ask about any sudden cardiac death that may have occurred in the family.
It is important to understand any patientâ€™s social situation when taking their history. This includes key aspects such as their occupation (or previous occupation, if retired), living situation, mobility and ability to perform activities of daily living.
Of particular importance in the cardiovascular history is a patientâ€™s diet and exercise history.
When taking a nutritional history, ask about the number of meals the patient eats per day, any snacking in between, and what they would eat on a usual day. This can provide valuable information about a patientâ€™s cardiovascular risk, particularly in an obese or diabetic patient.
In assessing a patientâ€™s exercise history, ask about the amount of time they spend exercising as well as what type of exercise they perform. A sedentary lifestyle is a strong risk factor for cardiovascular disease.
Smoking is a major risk factor for atherosclerotic disease. Ask about how long a patient has smoked for, how many cigarrettes they smoke per day, and how long since they quit (if appropriate).
Ask about alcohol intake, as alcohol is an important risk factor for hypertenion, dilated cardiomyopathy and atrial fibrillation. Ask how many drinks the patient has per week, what type of drinks, and whether they have considered cutting down their intake if heavy.
Want more info like this?
- Your electronic clinical medicine handbook
- Guides to help pass your exams
- Tools every medical student needs
- Quick diagrams to have the answers, fast
- Quizzes to test your knowledge
Abbott AV. Diagnostic approach to palpitations. Am Fam Physician. 2005 Feb 15;71(4):743-50.Arthur W, Kaye GC. The pathophysiology of common causes of syncope. Postgraduate medical journal. 2000 Dec 1;76(902):750-3.Benditt DG. Neurally mediated syncopal syndromes: pathophysiological concepts and clinical evaluation. Pacing and clinical electrophysiology. 1997 Feb 1;20(2):572-84.Cayley J,William E. Chest pain--tools to improve your in-office evaluation. J Fam Pract. 2014;63:246.
Constant J. The diagnosis of nonanginal chest pain. Â Keio J Med. 1990;39:187-192.Cotter L. History and Examination of the Cardiovascular System. Medicine. 2010; 38(7): 344-347.Eriksson B, Vuorisalo D, Sylven C. Diagnostic potential of chest pain characteristics in coronary care. Â J Intern Med. 1994;235:473-478Faselis C, Doumas M, Papademetriou V. Common secondary causes of resistant hypertension and rational for treatment. International journal of hypertension. 2011 Mar 2;2011.
Kass S. Pleurisy. Am Fam Physician. 2007;75:1357.Khot UN, Khot MB, Bajzer CT, Sapp SK, Ohman EM, Brener SJ, Ellis SG, Lincoff AM, Topol EJ. Prevalence of conventional risk factors in patients with coronary heart disease. Jama. 2003 Aug 20;290(7):898-904.Kim EJ, Kim BH, Seo HS, Lee YJ, Kim HH, Son HH, Choi MH. Cholesterol-induced non-alcoholic fatty liver disease and atherosclerosis aggravated by systemic inflammation. PloS one. 2014 Jun 5;9(6):e97841.Mak SM, Strickland N, Gopalan D. Complications of pulmonary hypertension: a pictorial review. The British journal of radiology. 2017 Feb;90(1070):20160745.
Miller TH, Kruse JE. Evaluation of syncope. Am Fam Physician. 2005 Oct 15;72(8):1492-500.
Mosterd A, Hoes AW. Clinical epidemiology of heart failure. Heart. 2007 Sep 1;93(9):1137-46.National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular disease risk. 2012.
Onusko E. Diagnosing secondary hypertension. American family physician. 2003 Jan;67(1):67-74.Payne RA. Cardiovascular Risk. British Journal of Clinical Pharmacology. 2012; 74(3): 396-410.Petersen P. Thromboembolic complications in atrial fibrillation. Stroke. 1990 Jan;21(1):4-13.
Schoenkerman A, Goldschlager N. Chest Pain: Does This Patient Have Cardiac Ischaemia? Consultant. 2013; 53(8): 556-560.Simonneau G, Gatzoulis MA, Adatia I, Celermajer D, Denton C, Ghofrani A, Sanchez MA, Kumar RK, Landzberg M, Machado RF, Olschewski H. Updated clinical classification of pulmonary hypertension. Journal of the American College of Cardiology. 2013 Dec 24;62(25 Supplement):D34-41.Susanto M. Dizziness: if not vertigo could it be cardiac disease?. Australian family physician. 2014 May;43(5):264.Swap CJ, Nagurney JT. Value and Limitations of Chest Pain History in the Evaluation of Patients With Suspected Acute Coronary Syndromes. JAMA. 2005;294:2623-2629.Vodnala D, Rubenfire M, Brook RD. Secondary causes of dyslipidemia. The American journal of cardiology. 2012 Sep 15;110(6):823-5.Wahls SA. Causes and evaluation of chronic dyspnea. American family physician. 2012 Jul 15;86(2).Watson RD, Gibbs CR, Lip GY. ABC of heart failure: clinical features and complications. BMJ: British Medical Journal. 2000 Jan 22;320(7229):236.Weber BE, Kapoor WN. Evaluation and outcomes of patients with palpitations. The American journal of medicine. 1996 Feb 29;100(2):138-48.
Wexler RK, Pleister A, Raman S. Outpatient approach to palpitations. heart disease. 2011 Jul 1;100:6.Yuan G, Al-Shali KZ, Hegele RA. Hypertriglyceridemia: its etiology, effects and treatment. Cmaj. 2007 Apr 10;176(8):1113-20.Zimetbaum P, Josephson ME. Evaluation of patients with palpitations. New England Journal of Medicine. 1998 May 7;338(19):1369-73.