What is the systematic approach to taking a cardiac history?

Systematic Approach to Cardiac History Taking

A comprehensive cardiac history should systematically capture symptom characteristics, cardiovascular risk factors, prior cardiac disease, functional capacity, medications, and family history to guide risk stratification and diagnostic testing. 1, 2

1. Chief Complaint and Symptom Characterization

Chest Pain/Discomfort Quality

• Document the exact descriptors patients use: pressure, tightness, heaviness, strangling, constricting, squeezing, or burning—many patients do not spontaneously use the word "pain," so explicitly ask about "discomfort." 1, 3
• Sharp, tearing, or ripping pain decreases likelihood of coronary disease, while retrosternal pressure or heaviness increases it. 1

Location and Radiation

• Record whether pain is retrosternal, extends to the left arm, jaw, neck, or intrascapular region (increases coronary likelihood), versus right-sided or shifting location (decreases likelihood). 1, 3

Duration and Temporal Pattern

• Typical angina lasts less than 10 minutes with exertion and resolves within 1-5 minutes after rest or sublingual nitroglycerin. 1, 3
• Pain lasting only seconds is unlikely to be angina, while persistent symptoms raise concern for acute coronary syndrome. 1
• Document onset date, frequency, and whether symptoms are stable, worsening, or new-onset (recent changes suggest plaque destabilization). 1

Triggers and Relieving Factors

• Elicit specific triggers: physical exertion (quantify the level—running, walking uphill, walking on flat surface, dressing, standing), heavy meals, cold weather, strong winds, emotional distress, anxiety, anger, or nightmares. 1, 3
• Document relief patterns: subsiding with rest, accelerated relief with sublingual nitroglycerin (supports angina), versus relief with antacids or milk (suggests gastrointestinal cause). 1
• Pain reproducible by palpation or occurring with deep inspiration/coughing decreases coronary likelihood. 1

Associated Symptoms

• Systematically ask about sweating, nausea, dyspnea, syncope, fatigue, or sense of impending doom. 3

2. Dyspnea Assessment

• Dyspnea at rest: uncomfortable awareness of breathing while sitting (document onset and duration). 1
• Dyspnea on exertion: specify the degree of activity required—running, walking up incline with distance, walking on flat surface with distance, stopping to rest while dressing, or standing with time duration. 1
• Orthopnea: uncomfortable breathing in supine position, requiring 3 or more pillows or sleeping in a chair/recliner, or recurrent supine cough without other cause. 1
• Paroxysmal nocturnal dyspnea: awakening suddenly from sleep with breathing discomfort or distress relieved by upright position, lasting greater than 5 minutes. 1

3. Other Cardiac Symptoms

• Weight changes: amount in pounds or kilograms and timeframe over which change occurred. 1
• Swelling: patient-reported puffiness in extremities, abdomen, or other areas with onset and duration. 1
• Fatigue: unusual tiredness and inability to perform usual activities with onset and duration. 1
• Syncope: detailed history regarding nature of episodes, triggers, postural changes, frequency, duration, recovery, pre-syncopal events, and fluid intake. 1

4. Functional Capacity Assessment

Canadian Cardiovascular Society Angina Classification

• Grade I: angina only with strenuous exertion 1, 2
• Grade II: angina with moderate exertion 1, 2
• Grade III: angina with mild exertion 1, 2
• Grade IV: angina at rest 1, 2

Activity-Specific Inquiry

• Document the patient's capacity to perform common daily tasks, as functional capacity predicts perioperative cardiovascular risk. 1

5. Prior Cardiovascular History

Previous Cardiac Events

• All prior myocardial infarctions: dates of first and most recent episodes, confirmed by hospital records, ECG findings, or elevated cardiac biomarkers. 2
• Coronary artery disease: prior CABG with dates, prior PCI with dates, angiographically documented stenosis ≥50%, positive stress tests, or angina pectoris. 2
• Recent MI: defined as more than 7 days but ≤30 days, which represents active cardiac condition requiring evaluation before elective procedures. 1

Cardiac Procedures

• Record dates of most recent PCI, most recent CABG, valve interventions, pacemaker insertion, and ICD insertion. 2

Heart Failure

• Document physician documentation of dyspnea, fluid retention, low cardiac output, or physical findings of rales, jugular venous distension, or pulmonary edema. 2
• Assign NYHA functional class: Class I (no limitation), Class II (slight limitation), Class III (marked limitation), or Class IV (symptoms at rest). 2

Valvular and Structural Disease

• Record moderate or severe stenosis or regurgitation, indicating which valves are involved and date of first diagnosis. 2
• Document cardiomyopathy including left ventricular systolic dysfunction, hypertrophic cardiomyopathy, or congenital heart disease. 2

Arrhythmias

• Capture complete arrhythmia history: atrial fibrillation, atrial flutter, frequent PVCs, sinus tachycardia, ventricular tachycardia, and any prior ablation procedures. 2
• Identify significant arrhythmias: high-grade AV block, Mobitz II AV block, third-degree heart block, symptomatic ventricular arrhythmias, supraventricular arrhythmias with uncontrolled ventricular rate (HR >100 bpm at rest), symptomatic bradycardia, or newly recognized ventricular tachycardia. 1

6. Cardiovascular Risk Factors

Hypertension

• Document history of diagnosis, blood pressure ≥140/90 mm Hg on ≥2 occasions, or current antihypertensive therapy. 3, 2
• Record most recent blood pressure including both systolic and diastolic readings. 2

Dyslipidemia

• Document history diagnosed by physician or National Cholesterol Education Program criteria. 2
• Record most recent LDL and HDL measurements from medical records. 2

Diabetes Mellitus

• Document regardless of duration or need for antidiabetic agents, including fasting blood sugar >126 mg/dL or 7 mmol/L. 2

Smoking

• Quantitative assessment of prior and current tobacco use to make the risk factor evident to the patient. 1

Obesity and Sedentary Lifestyle

• Calculate BMI and document physical activity level. 1, 3

Family History

• Detailed family history of premature cardiovascular disease: defined as CVD in first-degree male relative <55 years or first-degree female relative <65 years, which increases baseline risk 1.5-2.0 fold. 1, 4
• Document sudden cardiac death, aborted sudden death, hyperlipidemia, or pulmonary hypertension in family members. 1, 4
• Almost 75% of individuals with premature coronary heart disease have a positive family history. 4

7. Comorbidities

Renal Disease

• History of chronic renal insufficiency, dialysis (hemodialysis or peritoneal), with year of onset. 1, 3

Pulmonary Disease

• Chronic lung disease (COPD, chronic bronchitis, emphysema) or chronic treatment with inhaled or oral pharmacological therapy. 1

Other Conditions

• Dementia, depression, liver disease, collagen vascular disease, musculoskeletal disease, malignancy: document with year of onset. 1
• Thyroid disease, anemia, infection, fever, or other metabolic disorders that can precipitate or exacerbate cardiac symptoms. 3

8. Medication Reconciliation

• Complete list of current medications: aspirin, clopidogrel, β-blockers, lipid-lowering agents, ACE inhibitors or angiotensin receptor blockers, with specific drug, dose, and frequency. 2
• Document prescription medications, over-the-counter drugs, herbal supplements, and nutraceuticals, as many can elicit or exacerbate bradyarrhythmias. 1
• Evaluate each medication for risk-benefit ratio, possible interactions and adverse effects, adherence to treatment, and unmet needs. 2

9. Immunization Status

• History of influenza immunization with month and year of most recent immunization. 1
• History of pneumococcal immunization with month and year of most recent immunization. 1

10. Prior Diagnostic Testing

• Document tests within 24 months: stress SPECT MPI, stress TTE, TTE, TEE, coronary artery calcium score, coronary CT angiography, cardiac MRI, 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

11. Contextual and Triggering Factors

• Relationship of symptoms to: medications, meals, medical interventions, emotional distress, physical exertion, positional changes, and specific triggers (urination, defecation, cough, prolonged standing, shaving, tight collars, head turning). 1
• Document circumstances surrounding symptom onset to narrow the differential diagnosis. 1

12. Risk Stratification

• Calculate estimated cardiac event risk using Framingham criteria for 10-year risk of MI or cardiac death: Low, Intermediate, or High risk. 2
• Determine pre-test probability of coronary artery disease for patients with chest pain: Low, Intermediate, High, Known CAD, or N/A. 2