What is the approach to a comprehensive cardiac assessment?

From the Guidelines

A comprehensive cardiac assessment should begin with a detailed medical history and physical examination, followed by diagnostic testing such as electrocardiogram (ECG), echocardiography, stress testing, and laboratory tests, as outlined in the most recent guidelines 1. The approach to cardiac assessment involves several key steps, including:

• Obtaining a detailed medical history, focusing on cardiac symptoms and risk factors, as recommended by the European Association of Preventive Cardiology 1
• Performing a physical examination, including vital signs, heart auscultation, lung examination, and assessment of peripheral pulses
• Utilizing diagnostic testing, such as ECG, echocardiography, stress testing, and laboratory tests, to evaluate cardiac structure and function, as outlined in the 2019 ACC/AHA/ASE advanced training statement on echocardiography 1
• Tailoring the assessment to the patient's specific presentation, with more focused testing for those with clear symptoms and broader evaluation for those with atypical presentations or multiple risk factors, as recommended by the American College of Cardiology/American Heart Association task force on practice guidelines 1 The goal of cardiac assessment is to accurately diagnose cardiac conditions, correlate symptoms with objective findings, and enable appropriate treatment planning, ultimately improving patient outcomes in terms of morbidity, mortality, and quality of life. Key considerations in cardiac assessment include:
• Estimating perioperative risk of major adverse cardiac events (MACE) in patients undergoing noncardiac surgery, as outlined in the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management 1
• Determining the need for further testing, such as coronary angiography, based on patient risk factors and clinical presentation, as recommended by the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons 1
• Integrating patient preferences and values into decision-making, as emphasized in the European Association of Preventive Cardiology guidelines 1.

From the Research

Approach to Comprehensive Cardiac Assessment

The approach to a comprehensive cardiac assessment involves various diagnostic tools and techniques to evaluate the heart's structure and function. The following are key components of a comprehensive cardiac assessment:

• Medical history: A thorough medical history is essential to identify risk factors and symptoms of cardiac disease 2.
• Physical examination: A physical examination can help identify signs of cardiac disease, such as murmurs or abnormal heart sounds 2.
• Electrocardiogram (ECG): An ECG is a non-invasive test that measures the heart's electrical activity and can help diagnose arrhythmias and other cardiac conditions 3, 2.
• Echocardiogram: An echocardiogram is a non-invasive test that uses ultrasound to visualize the heart's structure and function 3, 2.
• Stress testing: Stress testing, such as exercise stress testing or stress echocardiography, can help evaluate the heart's function under stress and diagnose coronary artery disease 4, 5, 6, 3.
• Cardiac computed tomography angiography (CTCA): CTCA is a non-invasive test that uses computed tomography to visualize the coronary arteries and diagnose coronary artery disease 4, 5, 3.

Diagnostic Accuracy of Cardiac Assessment Tools

The diagnostic accuracy of cardiac assessment tools varies:

• Stress ECG has a sensitivity of 47% and specificity of 53% for diagnosing significant coronary artery stenosis 3.
• CTCA has a sensitivity of 96% and specificity of 65% for diagnosing significant coronary artery stenosis 3.
• Stress echocardiography has excellent clinical efficacy and is safe and cost-effective for diagnosing coronary artery disease 6.

Clinical Utility of Cardiac Assessment Tools

The clinical utility of cardiac assessment tools depends on the patient's risk factors and symptoms:

• CTCA is a useful tool for diagnosing coronary artery disease in patients with suspected coronary artery disease 4, 5.
• Stress echocardiography is a useful tool for diagnosing coronary artery disease in patients with known or suspected coronary artery disease 6.
• A comprehensive cardiac screening protocol, including history, physical examination, ECG, and limited echocardiogram, can help identify cardiac abnormalities associated with an elevated risk for sudden cardiac death in adolescent athletes 2.