What is the best approach to gather a comprehensive cardiac history for a patient with potential heart conditions, considering their demographic information, medical history, symptoms, laboratory results, and current medications?

Comprehensive Cardiac History Collection

A comprehensive cardiac history must systematically document cardiovascular diagnoses, prior interventions with ventricular function assessment, all cardiovascular risk factors, current symptoms with functional impact, and complete medication reconciliation to guide risk stratification and management decisions. 1

Core Cardiovascular History Elements

Prior Cardiovascular Diagnoses and Interventions

• Document all previous myocardial infarctions including dates of first and most recent episodes, with confirmation by hospital admission records, ECG findings showing old or acute MI, or elevated cardiac biomarkers (creatine kinase or troponin) consistent with MI 2
• Record history of other coronary artery disease including prior CABG, prior PCI with dates, angiographically documented stenosis ≥50%, positive stress tests (specify imaging modality), or angina pectoris 2
• Capture previous cardiac procedures with specific dates: most recent PCI, most recent CABG, valve interventions (repair, valvuloplasty, or replacement with location and type), pacemaker insertion (device type, chambers involved, year of implantation), and ICD insertion 2
• Document heart failure history including physician documentation of dyspnea, fluid retention, low cardiac output secondary to cardiac dysfunction, or physical findings of rales, jugular venous distension, or pulmonary edema, plus any previous hospital admission with principal diagnosis of heart failure 2

Valvular and Structural Heart Disease

• Record valvular heart disease with documented moderate or severe stenosis or regurgitation, indicating which valves are involved and date of first diagnosis 2
• Document cardiomyopathy including left ventricular systolic dysfunction with ejection fraction <0.40, hypertrophic cardiomyopathy (obstructive or nonobstructive types) established by echocardiography, or congenital heart disease with cardiac anomalies present from birth 2

Arrhythmia History

• Capture complete arrhythmia history including atrial fibrillation, atrial flutter, frequent PVCs, sinus tachycardia, ventricular tachycardia, history of sinus bradycardia/sick sinus syndrome, AV block, supraventricular tachycardia, and any prior ablation procedures 2

Cardiovascular Risk Factors and Comorbidities

Hypertension Assessment

• Document hypertension defined by history of diagnosis treated with medication/diet/exercise, blood pressure ≥140 mm Hg systolic or ≥90 mm Hg diastolic on at least 2 occasions, or current antihypertensive pharmacological therapy 2
• Record most recent blood pressure including both systolic and diastolic readings during the current visit 2

Lipid Disorders

• Document dyslipidemia based on history diagnosed/treated by physician or National Cholesterol Education Program criteria: total cholesterol >200 mg/dL, LDL ≥130 mg/dL, HDL <40 mg/dL in men or <50 mg/dL in women, or current antilipidemic treatment 2
• Record most recent lipid values including LDL and HDL measurements from medical records prior to current evaluation 2

Diabetes and Metabolic Disorders

• Document diabetes mellitus regardless of duration or need for antidiabetic agents, including fasting blood sugar >126 mg/dL or 7 mmol/L, specifying whether insulin-requiring or noninsulin-requiring (exclude gestational diabetes) 2

Renal Disease

• Capture renal disease history including acute renal failure (reduced renal function with GFR >30 for <3 months with year and precipitant), and chronic kidney disease staged 0-5 based on GFR and kidney damage markers 2

Cerebrovascular Disease

• Document cerebrovascular disease including CVA (loss of neurological function with residual symptoms ≥24 hours from vascular etiology), TIA (abrupt neurological function loss with complete return within 24 hours), noninvasive/invasive carotid testing showing ≥80% occlusion, or previous carotid artery surgery/intervention 2
• Record history of intracranial hemorrhage with categories including hemorrhagic conversion of ischemic stroke, subarachnoid hemorrhage, intracerebral hemorrhage, subdural/epidural hematomas, and residual deficits documented by CT or MRI 2
• Document systemic peripheral embolism with abrupt vascular insufficiency and clinical/radiological/pathological evidence of arterial occlusion outside cerebrovascular system, indicating site 2

Additional Risk Factors

• Record family history of coronary artery disease in first-degree relatives (parents, siblings, children) with angina, MI, CABG, PCI, or sudden cardiac death at age <55 years 2
• Document tobacco use specifying current use (within 1 month), former use (>3 months prior), never, or unknown, including all forms (cigarettes, cigars, tobacco chew) 2
• Capture history of asthma or bronchospasm particularly relevant for stress testing and cardiac imaging 2

Current Symptoms and Functional Status

Symptom Characterization

• Document cardiac symptoms including dyspnea, orthopnea, paroxysmal nocturnal dyspnea, weight changes, swelling, fatigue, chest pain or discomfort (substernal, provoked by exertion or emotional distress, relieved by rest/nitroglycerin), with onset and duration for each 2, 3
• Classify angina type as atypical chest pain, stable angina, unstable angina, or myocardial infarction based on symptom characteristics 2

Functional Assessment

• Assign NYHA functional class for heart failure patients: Class I (no limitation of physical activity), Class II (slight limitation, comfortable at rest), Class III (marked limitation, comfortable at rest), or Class IV (inability to carry on any physical activity without discomfort, symptoms at rest) 2
• Assign Canadian Cardiovascular Angina Class for angina patients: 0 (asymptomatic), 1 (ordinary activity does not cause angina), 2 (slight limitation of ordinary activity), 3 (marked limitation), 4 (inability to perform any physical activity without discomfort), or 5 (N/A) 2

Risk Stratification

Cardiac Event Risk Assessment

• Calculate estimated cardiac event risk using Framingham criteria for 10-year risk of MI or cardiac death: Low (<10%), Intermediate (10-20%), High (>20% or coronary risk equivalent such as diabetes or peripheral arterial disease) 2
• Determine pre-test probability of coronary artery disease for patients with chest pain: Low (<10%), Intermediate (10-90%), High (>90%), Known CAD, or N/A if no chest pain 2

Medication Reconciliation

• Obtain complete medication history including aspirin, clopidogrel, β-blockers, lipid-lowering agents, ACE inhibitors or angiotensin receptor blockers, ensuring appropriate dosing per ACC/AHA guidelines 1
• Evaluate each medication for risk-benefit ratio, possible interactions and adverse effects, adherence to treatment, and unmet needs 1
• Utilize pharmacist involvement as pharmacists obtain better medication histories than physicians and reduce medication errors during acute admissions 1

Physical Examination Components

• Assess cardiopulmonary systems including pulse rate and regularity, blood pressure, auscultation of heart and lungs, palpation and inspection of lower extremities for edema and arterial pulses, post-cardiovascular procedure wound sites, orthopedic and neuromuscular status, and cognitive function 1

Diagnostic Testing History

• Document previous diagnostic tests within 24 months including stress SPECT MPI, stress TTE, TTE, TEE, CACS, CCTA, CMR, invasive coronary angiography, or ECG-only stress test with dates 2
• Record previous test results including coronary artery stenosis ≥50%, stenosis <50%, myocardial ischemia, scar/MI, cardiac mass/thrombus/vegetation, significant LV systolic dysfunction, pericardial disease, valvular heart disease, congenital heart disease, or nondiagnostic findings 2
• Obtain resting 12-lead ECG and determine if interpretable for ischemia (not interpretable if resting ST-segment depression ≥0.10 mV, complete LBBB, pre-excitation, left ventricular hypertrophy, digoxin use, or paced rhythm) 2, 1

Common Pitfalls to Avoid

• Do not overlook functional impact as the effect of symptoms on daily activities provides crucial context for treatment decisions and risk stratification 4
• Do not neglect modifying factors as information about what improves or worsens symptoms offers diagnostic clues and guides management 4
• Do not miss relevant risk factors as individualized risk assessment is essential for accurate diagnosis and appropriate intervention 4
• Avoid incomplete medication reconciliation as medication errors are common and pharmacist involvement significantly reduces these errors 1