What should a comprehensive case history for a patient with a myocardial infarction include?

Comprehensive Case History for Myocardial Infarction

A comprehensive case history for a patient with myocardial infarction must systematically capture demographics, cardiovascular risk factors, family history of premature coronary disease, detailed symptom presentation including atypical manifestations, prior cardiovascular events, medications, and social factors that influence both diagnosis and prognosis. 1

Demographics and Basic Information

• Document: sex, birthdate, race/ethnicity (including birthplace and parents' places of origin), years in current country, primary language, years of education, occupation, literacy level, living situation and independence level, marital status, handedness, and emergency contact person 1

Family History

• Premature coronary artery disease: Any direct blood relatives (parents, siblings, children) with angina, acute myocardial infarction, sudden cardiac death, CABG, or PCI at age <55 years for males or <65 years for females 1
• Other cardiovascular conditions: Family history of cardiomyopathy (dilated, hypertrophic, or arrhythmogenic right ventricular dysplasia), conduction system disease, early-onset arrhythmias, muscular dystrophy 1
• Vascular disease: History of stroke, dementia, other neurological diseases in first-degree relatives, including age at death and age of event 1

Cardiovascular Medical History

Prior Cardiac Events

• Previous myocardial infarction: Document hospital admissions for acute MI, ECG reports indicating old or acute MI, elevated biochemical markers (creatine kinase or troponin), or patient-reported history; record total number of MIs and dates of first and most recent episodes 1
• Angina history: Stable versus unstable angina, with dates of onset for each type 1
• Heart failure: Prior symptoms (dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, fluid retention), physical findings (rales, jugular venous distension, pulmonary edema, S3 gallop), or previous hospitalizations with principal diagnosis of heart failure; date of first onset 1

Prior Interventions

• Coronary revascularization: Previous CABG or PCI (balloon angioplasty, atherectomy, stent); document total number of procedures and year of most recent 1
• Device implantation: Pacemaker or ICD, specifying device type, cardiac chambers involved, and year of implantation 1
• Valve procedures: Each valve repair, valvuloplasty, or replacement, indicating location and type 1

Arrhythmia History

• Atrial arrhythmias: Atrial fibrillation/flutter (paroxysmal versus chronic), atrial tachycardia, sick sinus syndrome, paroxysmal supraventricular tachycardia; document year of first and most recent episodes 1
• Ventricular arrhythmias: Sustained or nonsustained ventricular tachycardia, ventricular fibrillation, specifying whether cardioversion or antiarrhythmic medications were required 1
• Conduction abnormalities: History of AV block (first, second, or third degree), sinus bradycardia, sick sinus syndrome 1

Other Cardiovascular Conditions

• Valvular disease: Documented moderate or severe stenosis or regurgitation, indicating specific valves involved and date of first diagnosis 1
• Cardiomyopathy: Hypertrophic (obstructive versus nonobstructive), dilated, or other specific types; left ventricular systolic dysfunction with ejection fraction <0.40 1
• Peripheral vascular disease: History of peripheral embolic events, peripheral artery disease, presence of bruits or pulse deficits 1
• Congenital heart disease: Specific diagnosis and any prior repairs 1

Cardiovascular Risk Factors

• Hypertension: History diagnosed and treated with medication/diet/exercise, blood pressure ≥140/90 mmHg on at least 2 occasions, or current antihypertensive therapy; document year of onset 1
• Hyperlipidemia: Documented diagnosis and treatment status 1
• Diabetes mellitus: Type, duration, treatment, and control status; note that diabetes is a stronger risk factor in women than men 1, 2
• Smoking: Current or past tobacco use, including pack-years 1
• Obesity: Height, weight, BMI, waist circumference 1

Symptom Presentation

Typical Symptoms

• Chest pain characteristics: Central/substernal compression, crushing, pressure, tightness, heaviness, cramping, burning, or aching sensation; radiation to neck, jaw, shoulders, back, or arms 2, 3
• Associated symptoms: Shortness of breath, diaphoresis (sweating), nausea, vomiting, abnormal heart beating, anxiety, fatigue, weakness 2, 3, 4

Atypical Presentations (Especially in Women, Elderly, Diabetics)

• Women-specific symptoms: Back pain, dizziness, palpitations, unexplained indigestion, belching, epigastric pain, persistent shortness of breath; note that 43% of women with MI have no acute chest pain 2, 5, 6
• Prodromal symptoms in women: Unusual fatigue (70.7%), sleep disturbance (47.8%), shortness of breath (42.1%) occurring more than 1 month before AMI; only 29.7% report chest discomfort 4
• Diabetic presentations: May have atypical symptoms due to autonomic dysfunction 2, 5
• Elderly presentations: Generalized weakness, stroke, syncope, or changes in mental status rather than classic symptoms 2, 5

Critical Pitfall

• Do not use nitroglycerin response as diagnostic criterion: Relief with nitroglycerin is not necessarily diagnostic of myocardial ischemia 2

Cerebrovascular History

• Stroke: Hemorrhagic or ischemic, with dates and residual deficits 1
• Transient ischemic attack: Frequency and dates 1
• Carotid endarterectomy: Date and indication 1

Other Medical History

• Renal disease: Chronic kidney disease, dialysis status 1
• Sleep disorders: Sleep apnea or other conditions 1
• Autoimmune diseases: Specific diagnoses 1
• Hypercoagulable states: Deep vein thrombosis, pulmonary embolus, spontaneous abortion 1
• Chronic infections: Periodontal disease, bronchitis 1
• Depression: Current or past, treatment status 1
• HIV status: HIV seropositive or AIDS 1

Medications

• Complete medication list: All prescription medications, over-the-counter preparations, supplements 1
• Antiplatelet agents: Aspirin, clopidogrel, other P2Y12 inhibitors 7
• Antihypertensives: Beta-blockers, ACE inhibitors (such as lisinopril), calcium channel blockers 8, 3
• Lipid-lowering agents: Statins, other agents 3
• Anticoagulants: Warfarin, direct oral anticoagulants 1
• Prior allergies/hypersensitivity reactions: Including reactions to sulfonamides, NNRTIs, abacavir 1

Social History

• Substance use: Tobacco (current/former, pack-years), alcohol (quantity/frequency), recreational drugs (marijuana, cocaine, methamphetamine, heroin), injection drug use practices 1
• Sexual history: Practices, partner status, condom use (relevant for HIV risk assessment) 1
• Living situation: Housing stability, employment status, family support, whom patient has informed of diagnosis 1
• Diet and lifestyle: Dietary patterns, physical activity level, stress factors 1
• Environmental exposures: Second-hand smoke, pesticides, occupational hazards 1

Physical Examination Findings at Presentation

• Vital signs: Blood pressure in both arms (if dissection suspected), heart rate, temperature, respiratory rate, oxygen saturation, orthostatic blood pressure 1
• Cardiovascular examination: Evidence of LV dysfunction (rales, S3 gallop), acute mitral regurgitation, murmurs, jugular venous distension, peripheral pulses, bruits 1
• Body habitus: Evidence of wasting, obesity, lipodystrophy, lipoatrophy 1
• Signs of complications: Hypotension, evidence of organ hypoperfusion (cardiogenic shock), pulsus paradoxus (tamponade), unequal pulses (dissection), differential breath sounds (pneumothorax) 1, 5

Women-Specific Considerations

• Age difference: Women with MI are typically 8-10 years older than male counterparts 2
• Higher prevalence of traditional risk factors: Hypertension, hyperlipidemia, family history of premature CAD 2
• Alternative mechanisms: Higher proportion of MI caused by plaque erosion, coronary microvascular dysfunction, coronary vasospasm, spontaneous coronary artery dissection, stress-related (Takotsubo) cardiomyopathy rather than classical plaque rupture 2
• Care disparities: Women are less likely to receive timely and appropriate care for heart attacks 2