Notes on History Taking in the Cardiovascular

System
These notes are designed as a practical supplement to your wider reading on
history taking and clinical examination.
The main cardiovascular symptoms that patients present with are:
1. I have chest pain
2. I am short of breath
3. I am diy ! have passed out ! have palpitations
". #y leg hurts
General Points in the Cardiovascular History
$tart with the main symptom and then go into that in detail
o %or any symptom& remember to record what it takes to bring it on.
o The 'ew (ork )eart *ssociation +'()* class, is an easy way to do
this:
-lass I . )as cardiac disease but no symptoms
-lass II . $ymptoms only on significant activity
-lass III . $ymptoms during normal daily activities
-lass I/ . $ymptoms at rest
If there are other associated symptoms& then try to arrange these
separately
It is helpful to list the cardiovascular risk factors:
o )istory of high blood pressure
o )istory of high cholesterol
o %amily history of cardiovascular disease +significant only if in a first
degree relative who developed it before the age of 00,
o )istory of diabetes
o *ctive smoking +try to record pack years and when stopped,
1ast medical history
o 2ist in date order any cardiac events +eg myocardial infarction, and
any cardiac investigations!treatments +in particular coronary
angiography and cardiac surgery,
#edication
o *lso list drugs that have been tried and not tolerated or which are
contraindicated.
o #ost cardiac patients are taking:
*spirin
3 blocker
*-4 inhibitor
$tatin
If they are not on any of these ask if they have had them before.
Chest pain
most common symptom.
(ou are trying to assess:
1. Is this cardiac or non.cardiac
2. )ow significant!dangerous is this.
2ater ask specific 5uestions to determine:
1osition of the pain
6escription of the pain
7adiation
8hat brought it on
8hat makes it better
8hat makes it worse
Is it similar to any pains in the past
*ny associated features

7emember that pain that occurs at rest is likely to be more serious than pain that
9ust occurs during exercise.
*lso ask specific 5uestions to try to exclude other potential causes
4.g. :Is the pain made worse by breathing;: +pleuritic chest pain, or :is it
associated with eating;:
The main diagnoses that you should be thinking about are:
Typical features of :cardiac pain: might
include:
-entral chest pain
-rushing ! a weight on the chest !
a band around the chest
7adiates to the neck ! 9aw ! teeth !
left arm
<rought on by exertion
7elieved by stopping exercise !
=T' spray ! oxygen
#ade worse by exercise
1. stable angina
2. unstable angina
3. myocardial infarction
". chest infection
0. gastro.oesophogeal reflux
disease
>. pulmonary embolism
?. musculoskeletal
@. dissecting aneurysm
Shortness of breath
This is a more non.specific symptom. It can be due to cardiac causes& such as
heart failure +therefore pulmonary oedema,& respiratory illness& or other
conditions e.g. anaemia.
If it is due to cardiac disease then there is usually a history of cardiovascular
disease. If the patient does not have any history or cardiac disease then this is
either due to an acute cardiac event +e.g. #I, or not cardiac.
(ou will need to take a full respiratory history in addition to a cardiovascular
history.
$pecific features that suggest that the breathlessness is due to pulmonary
oedema are:
Orthopnoea
o this is when someone cannot lie flat without becoming short of
breath
Paroxysmal nocturnal dyspnoea +1'6,
o This is when the patient wakes up in the night short of breath and
has to sit up or stand up to get relief
nkle s!elling
o This is another feature which suggests fluid overload
(ou must define the severity of breathlessness according to the '()* class
classification.
(ou should also decide if it is:
*cute
o 8hat has precipitated it
*cute on chronic
-hronic
o 8hat is the underlying cause
The main diagnoses that you should be thinking about are:
1. -hronic heart failure secondary to:
a. Ischaemic heart disease
b. )ypertension
c. -ardiomyopathy
2. *cute heart failure secondary to:
a. #yocardial infarction
b. *ngina
c. *rrhythmia
d. /alve problems
1. 7espiratory causes:
a. -hest infection
b. -A16
c. 14
d. 1neumothorax
e. 1leural effusion
Palpitations
This is a difficult symptom to get patients to describe.
It is important to get them to say whether the palpitation is:
%aster or slower than normal
7egular or irregular
The best way to do this is to get them to tap out what is happening on a table.
The most common cause for palpitations is ectopics. These are felt as a missed
beat beat. They usually occur in clusters. *s long as they do 'AT occur during
exercise they are probably harmless.
The next most common cause are tachycardias. These may be regular +$/Ts
or sinus tachycardia, or irregular +atrial fibrillation,.
The key 5uestions to ask are whether the palpitation was associated with any
other features. $igns of a serious cause are:
1. associated with:
a. chest pain
b. breathlessness
c. feeling diy +presyncope,
d. passing out +syncope,
2. the presence of underlying heart disease
"radycardias can also be associated with palpitations. They may be felt as a
slow or heavy heart beat. These are usually much clearer from the history. If
they are significant they are usually related to syncope.
Ather 5uestions you should ask are:
precipitating factors
o exercise
o coffee ! tea ! alcohol ! drugs
o eating
o stress
how long did it last
how often is it occurring
associated features
cardiac history
medication
#i$$yness and blackouts
The 3 key 5uestions in someone with a blackout are:
1. is the loss of consciousness due to syncope or not;
2. are there important clinical features in the history that suggest the
diagnosis;
3. is heart disease present or absent;
6efinition of syncope:
$yncope is a symptom& the defining clinical characteristics of which are a
transient& self.limited loss of consciousness& usually leading to falling. The
onset of syncope is relatively rapid& the subse5uent recovery is
spontaneous& complete and usually prompt. The underlying mechanism is
relatively abrupt cerebral hypoperfusion.
%eatures that suggest a non.syncopal attack:
-onfusion after attack for more than 0 minutes +seiure,
1rolonged +greater than 10 sec, tonic.clonic movements starting at the
onset of the attack +seiure,
%re5uent attacks with somatic complaints& no organic heart disease
+psychiatric,
*ssociated with vertigo& dysarthria& diploplia +transient ischaemic attack,
$yncope:
'eurally mediated reflex syncopal syndromes eg. /asovagal carotid sinus&
situational etc.
Arthostatic
-ardiac arrhythmias as primary cause eg bradycardia& tachycardia etc.
$tructural cardiac or cardiopulmonary disease eg. *cute myocardial
infarction!ischaemia& aortic dissection& pulmonary embolism etc.
'on.syncopal attack
6isorders resembling syncope with impairment or loss of consciousness&
eg. $eiure& transient ischaemic attacks etc.
6isorders resembling syncope with intact consciousness eg psychogenic
syncope +somatisation disorders, etc.
#iagnosis
/asovagal syncope is diagnosed if precipitating events such as fear& severe pain&
emotional distress& instrumentation or prolonged standing are associated with
typical prodromal symptoms.
$ituational syncope is diagnosed if syncope occurs during or immediately after
urination& defaecation& coughing or swallowing.
Arthostatic syncope is diagnosed when there is a documentation of orthostatic
hypotension +decrease of $<1 B 2C mm)g or to less than DC mm)g, associated
with syncope or presyncope.
$yncope due to cardiac ischaemia is diagnosed when symptoms are present
with 4-= evidence of acute ischaemia with or without myocardial infarction.
$yncope due to cardiac arrythmia is diagnosed by the 4-= when there is:
$inus bradycardia less than "C beats per min or repetitive sinoatrial
blocks or sinus pauses greater than 3 secs.
*trioventricular block +2
nd
degree #obit II or 3
rd
degree */ block,
*lternating right and left bundle branch block
7apid paroxysmal $/T or /T
1acemaker malfunction with cardiac pauses
%eatures that suggest a cardiac cause:
a. supine
b. during exertion
c. preceded by palpitations
d. presence of severe heart disease
e. 4-= abnormalities:
2. 8ide E7$ complex +greater than 12C msec,
3. */ conduction defects
". $inus bradycardia +less than 0C, or pauses
0. 2ong ET interval
%eatures that suggest a neurally.mediated cause:
1. *fter sudden unexpected unpleasant sight& sound or smell
2. prolonged standing at attention or crowded warm places
3. nausea& vomiting associated with syncope
". within one hour of a meal
0. after exertion
>. temporal relationship with start of medication or changes of dosage
-ardiovascular syncope tends to be sudden and brief. The patient may look pale
and have a very slow pulse for a short time. They usually recover consciousness
rapidly. *ny fitting ! twitching is only short lived.
%emember to ask&
what they were doing 9ust beforehand
has it ever happened before
any warning symptoms
what did any onlookers see
were they really unconscious