From the Guidelines
A high yield cardiac history and examination should focus on identifying key symptoms, risk factors, and physical findings that suggest cardiovascular disease, as recommended by the most recent guidelines 1. Begin by asking about chest pain (character, onset, radiation, exacerbating/relieving factors), shortness of breath (at rest or exertion), palpitations, syncope, edema, and exercise tolerance. Inquire about cardiovascular risk factors including hypertension, diabetes, hyperlipidemia, smoking, family history of premature cardiac disease, and previous cardiac events. Medication history should include cardiac medications like beta-blockers (metoprolol 25-200mg daily), ACE inhibitors (lisinopril 5-40mg daily), statins (atorvastatin 10-80mg daily), and antiplatelet agents (aspirin 81-325mg daily). For examination, check vital signs including blood pressure in both arms, heart rate, and respiratory rate. Inspect for jugular venous distension, peripheral edema, and signs of hyperlipidemia. Palpate the precordium for heaves or thrills and assess peripheral pulses. Auscultate for heart sounds (S1, S2, S3, S4), murmurs (timing, location, radiation, intensity), and lung fields for crackles suggesting heart failure. This systematic approach helps identify common cardiac conditions like coronary artery disease, heart failure, valvular disease, and arrhythmias, allowing for appropriate management and further investigations such as ECG, echocardiography, or stress testing when indicated, as supported by the guidelines 1.
Some key points to consider in the history and examination include:
- A thorough history and physical examination to identify cardiac and noncardiac disorders that might lead to the development of heart failure or accelerate its progression 1.
- Initial and ongoing assessment of the patient’s ability to perform routine and desired activities of daily living 1.
- Initial and ongoing assessment of volume status, including orthostatic blood pressure changes, measurement of weight and height, and calculation of body mass index 1.
- Laboratory evaluation, including complete blood count, urinalysis, serum electrolytes, blood urea nitrogen, serum creatinine, fasting blood glucose, lipid profile, liver function tests, and thyroid-stimulating hormone 1.
- Twelve-lead electrocardiogram and chest radiograph (posterior-anterior and lateral) should be performed initially in all patients presenting with heart failure 1.
- Two-dimensional echocardiography with Doppler should be performed during initial evaluation to assess left ventricular function, size, wall thickness, and valve function 1.
By following this approach, clinicians can provide high-quality care for patients with cardiovascular disease, reducing morbidity, mortality, and improving quality of life, as emphasized by the guidelines 1.
From the Research
High Yield Cardiac History
- A comprehensive history is essential in evaluating patients with chest pain, as it helps distinguish between various causes of chest pain, ranging from minor conditions to life-threatening ones 2.
- Certain characteristics of chest pain can decrease the likelihood of acute coronary syndrome (ACS) or acute myocardial infarction (AMI), such as:
- Stabbing pain
- Pleuritic pain
- Positional pain
- Pain reproducible by palpation (likelihood ratios [LRs] 0.2-0.3) 3
- Conversely, chest pain that radiates to one shoulder or both shoulders or arms, or is precipitated by exertion, is associated with increased likelihood of ACS (LRs 2.3-4.7) 3.
High Yield Cardiac Examination
- The physical examination is a crucial component of the evaluation of patients with suspected ACS, but it has limitations in diagnosing ACS or AMI 3, 4.
- The electrocardiogram (ECG) is an essential tool in the initial evaluation of patients with chest pain, as it can help identify patients with ACS or AMI 3, 4.
- New cardiac troponin assays, especially in conjunction with clinical decision algorithms, can help clinicians rapidly exclude acute myocardial infarction 4.
Risk Stratification
- Combinations of elements of the chest pain history with other initially available information, such as a history of coronary artery disease (CAD), can help identify patients who may be safe for discharge without further evaluation 3.
- Stress testing or coronary computed tomography angiography can be used for further risk stratification in patients with chest pain 4.
- Chest pain and dyspnea are independently associated with incident cardiovascular disease, including coronary disease, heart failure, atrial fibrillation, and stroke, over a long-term follow-up period 5.