What questions should be asked to a chest pain patient with possible cardiovascular disease history?

Essential Questions for Chest Pain Evaluation

Immediate Life-Threatening Assessment

Ask first about symptom onset and duration to identify conditions requiring immediate intervention—sudden onset suggests aortic dissection or pulmonary embolism, while gradual onset over minutes suggests acute coronary syndrome. 1, 2

Critical Timing Questions

• When did the pain start? Sudden onset ("like a light switch") versus gradual buildup over several minutes distinguishes aortic dissection from ACS 2, 3
• How long has it lasted? Prolonged pain (>20 minutes at rest) indicates high-risk unstable angina or myocardial infarction 1, 3
• Is the pain ongoing right now? Ongoing rest pain is a high-risk feature requiring immediate emergency department transfer 2, 3

Pain Characteristics (Six Essential Elements)

The American College of Cardiology mandates systematically capturing these six characteristics in every chest pain patient 1, 2:

1. Quality/Nature of Pain

• "Describe the sensation in your own words" (avoid leading questions) 1
• High probability for ischemia: pressure, squeezing, gripping, heaviness, tightness, constriction, suffocating 1, 2
• Low probability for ischemia: sharp, stabbing, fleeting (seconds only), pleuritic 1, 2
• "Is it sharp or dull?" Sharp pain worsening with breathing suggests pericarditis or pulmonary causes 1, 4

2. Location and Radiation

• "Point with one finger to where it hurts most" 1, 2
• "Does the pain spread anywhere else?" 1
• Cardiac pattern: substernal/precordial radiating to left arm, neck, jaw, or both arms 1, 2
• Non-cardiac: pain localized to very small area or radiating below umbilicus/hip 1, 2
• Aortic dissection: radiation to upper or lower back with "ripping/tearing" quality 2, 4

3. Precipitating Factors

• "What were you doing when it started?" 1
• "Does exertion, emotional stress, or eating bring it on?" 1, 2
• "Does deep breathing, coughing, or changing position make it worse?" 1, 4
• Exertional or stress-related onset strongly suggests angina 1, 2
• Pain worsening with inspiration indicates pericarditis or pleuritic causes 1, 4

4. Relieving Factors

• "Does rest make it better?" Angina typically improves with rest within 5-10 minutes 1
• "Does leaning forward help?" Suggests pericarditis 4
• "Do antacids provide relief?" May indicate GERD but does NOT exclude cardiac causes 4
• Do NOT use nitroglycerin response as a diagnostic criterion—esophageal spasm also responds to nitroglycerin 2, 3, 4

5. Duration

• "How many minutes does each episode last?" 1
• Typical angina: 2-10 minutes 1
• Fleeting pain (seconds only): unlikely ischemic 1, 2
• Prolonged (>20 minutes): suggests myocardial infarction or unstable angina 1, 3

6. Associated Symptoms

• "Do you have shortness of breath, sweating, nausea, lightheadedness, or palpitations with the pain?" 1, 2
• These accompanying symptoms significantly increase ACS likelihood 2, 3
• "Have you vomited or felt like passing out?" 1, 2

Positional and Temporal Pattern Questions

• "Does lying down make it worse or better?" Pain worsening when supine and improving when leaning forward is pathognomonic for pericarditis 4
• "Does the pain change with body position, twisting, or turning?" Suggests musculoskeletal origin 1, 4
• "Can you reproduce the pain by pressing on your chest?" Indicates costochondritis but does NOT exclude cardiac causes 4

Cardiovascular Risk Factor Assessment

The American College of Cardiology requires systematic assessment of all major risk factors 1:

• Age and sex (critical for pretest probability estimation) 1
• "Do you smoke or have you ever smoked?" 1
• "Do you have diabetes, high blood pressure, or high cholesterol?" 1
• "Has anyone in your immediate family had a heart attack before age 55 (men) or 65 (women)?" 1
• "Do you have a history of heart disease, stroke, or peripheral vascular disease?" 1

Special Population-Specific Questions

For Women

Women are at high risk for underdiagnosis and require specific inquiry about atypical presentations 2, 3:

• "Do you have unusual fatigue, jaw pain, neck pain, or upper back pain?" 2, 3
• "Are you experiencing nausea or shortness of breath without typical chest pressure?" 2, 3

For Elderly Patients (≥75 years)

• "Have you had any falls, confusion, or sudden weakness?" ACS may present as syncope, acute delirium, or unexplained falls without classic chest pain 2, 3
• "Are you more short of breath than usual?" Isolated dyspnea may be the only ACS manifestation 2, 3

For Diabetic Patients

• Ask specifically about atypical symptoms as diabetics frequently have silent ischemia or present with epigastric discomfort, nausea, or isolated dyspnea 2, 3

Stability Classification

• "Have your symptoms changed in pattern, frequency, or severity recently?" Accelerating symptoms indicate unstable angina 1, 3
• "Are you having pain at rest or with less activity than before?" Defines unstable angina requiring immediate evaluation 1, 3
• "Have you had these symptoms before, and are they the same or different now?" New-onset symptoms carry higher risk 1, 3

Medication and Substance Use History

• "What medications are you currently taking?" Document anticoagulants, antiplatelets, and erectile dysfunction drugs 3
• "Have you used cocaine or other stimulants recently?" Cocaine causes coronary vasospasm and increased oxygen demand 1
• "Do you take any medications for chest pain or heart problems?" 3

Critical Pitfalls to Avoid

• Never dismiss chest pain in young patients—ACS can occur in adolescents without traditional risk factors 3
• Never assume sharp or pleuritic pain excludes ACS—pericarditis and atypical presentations occur 3, 4
• Never rely on normal physical examination to exclude ACS—physical exam is usually normal in stable ischemic heart disease 1
• Never delay emergency transfer to obtain troponin in office settings when ACS is suspected 2, 3