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 dizzy / have passed out / have palpitations
4. My leg hurts
General Points in the Cardiovascular History
Start with the main symptom and then go into that in detail
o For any symptom, remember to record what it takes to bring it on.
o The New York Heart Association (NYHA class) is an easy way to do
this:
Class I - Has cardiac disease but no symptoms
Class II - Symptoms only on significant activity
Class III - Symptoms during normal daily activities
Class IV - Symptoms at rest
If there are other associated symptoms, then try to arrange these
separately
It is helpful to list the cardiovascular risk factors:
o History of high blood pressure
o History of high cholesterol
o Family history of cardiovascular disease (significant only if in a first
degree relative who developed it before the age of 55)
o History of diabetes
o Active smoking (try to record pack years and when stopped)
Past medical history
o List in date order any cardiac events (eg myocardial infarction) and
any cardiac investigations/treatments (in particular coronary
angiography and cardiac surgery)
Medication
o Also list drugs that have been tried and not tolerated or which are
contraindicated.
o Most cardiac patients are taking:
Aspirin
blocker
ACE inhibitor
Statin
If they are not on any of these ask if they have had them before.

Chest pain
most common symptom.
You are trying to assess:
1. Is this cardiac or non-cardiac
2. How significant/dangerous is this.
Later ask specific questions to determine:
Position of the pain
Description of the pain
Radiation
What brought it on
What makes it better
What makes it worse
Is it similar to any pains in the past
Any associated features

Remember that pain that occurs at rest is likely to be more serious than pain that
just occurs during exercise.
Also ask specific questions to try to exclude other potential causes
E.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:
1. stable angina
2. unstable angina
3. myocardial infarction
4. chest infection
5. gastro-oesophogeal reflux
disease
6. pulmonary embolism
7. musculoskeletal
8. dissecting aneurysm


Typical features of "cardiac pain" might
include:
Central chest pain
Crushing / a weight on the chest /
a band around the chest
Radiates to the neck / jaw / teeth
/ left arm
Brought on by exertion
Relieved by stopping exercise /
GTN spray / oxygen
Made worse by exercise
Associated with nausea / vomiting
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. MI) or not cardiac.
You will need to take a full respiratory history in addition to a cardiovascular
history.
Specific 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 (PND)
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
Ankle swelling
o This is another feature which suggests fluid overload
You must define the severity of breathlessness according to the NYHA class
classification.
You should also decide if it is:
Acute
o What has precipitated it
Acute on chronic
Chronic
o What is the underlying cause
The main diagnoses that you should be thinking about are:
1. Chronic heart failure secondary to:
a. Ischaemic heart disease
b. Hypertension
c. Cardiomyopathy
2. Acute heart failure secondary to:
a. Myocardial infarction
b. Angina
c. Arrhythmia
d. Valve problems
3. Respiratory causes:
a. Chest infection
b. COPD
c. PE
d. Pneumothorax
e. Pleural effusion

Palpitations
This is a difficult symptom to get patients to describe.
It is important to get them to say whether the palpitation is:
Faster or slower than normal
Regular 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. As long as they do NOT occur during
exercise they are probably harmless.
The next most common cause are tachycardias. These may be regular (SVTs
or sinus tachycardia) or irregular (atrial fibrillation).
The key questions to ask are whether the palpitation was associated with any
other features. Signs of a serious cause are:
1. associated with:
a. chest pain
b. breathlessness
c. feeling dizzy (presyncope)
d. passing out (syncope)
2. the presence of underlying heart disease
Bradycardias 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.
Other questions 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
Dizzyness and blackouts
The 3 key questions 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?
Definition of syncope:
Syncope 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 subsequent recovery is
spontaneous, complete and usually prompt. The underlying mechanism is
relatively abrupt cerebral hypoperfusion.
Features that suggest a non-syncopal attack:
Confusion after attack for more than 5 minutes (seizure)
Prolonged (greater than 15 sec) tonic-clonic movements starting at the
onset of the attack (seizure)
Frequent attacks with somatic complaints, no organic heart disease
(psychiatric)
Associated with vertigo, dysarthria, diploplia (transient ischaemic attack)
Syncope:
Neurally mediated reflex syncopal syndromes eg. Vasovagal carotid sinus,
situational etc.
Orthostatic
Cardiac arrhythmias as primary cause eg bradycardia, tachycardia etc.
Structural cardiac or cardiopulmonary disease eg. Acute myocardial
infarction/ischaemia, aortic dissection, pulmonary embolism etc.
Non-syncopal attack
Disorders resembling syncope with impairment or loss of consciousness,
eg. Seizure, transient ischaemic attacks etc.
Disorders resembling syncope with intact consciousness eg psychogenic
syncope (somatisation disorders) etc.
Diagnosis
Vasovagal syncope is diagnosed if precipitating events such as fear, severe
pain, emotional distress, instrumentation or prolonged standing are associated
with typical prodromal symptoms.
Situational syncope is diagnosed if syncope occurs during or immediately after
urination, defaecation, coughing or swallowing.
Orthostatic syncope is diagnosed when there is a documentation of orthostatic
hypotension (decrease of SBP = 20 mmHg or to less than 90 mmHg) associated
with syncope or presyncope.
Syncope due to cardiac ischaemia is diagnosed when symptoms are present
with ECG evidence of acute ischaemia with or without myocardial infarction.
Syncope due to cardiac arrythmia is diagnosed by the ECG when there is:
Sinus bradycardia less than 40 beats per min or repetitive sinoatrial
blocks or sinus pauses greater than 3 secs.
Atrioventricular block (2
nd
degree Mobitz II or 3
rd
degree AV block)
Alternating right and left bundle branch block
Rapid paroxysmal SVT or VT
Pacemaker malfunction with cardiac pauses
Features that suggest a cardiac cause:
a. supine
b. during exertion
c. preceded by palpitations
d. presence of severe heart disease
e. ECG abnormalities:
2. Wide QRS complex (greater than 120 msec)
3. AV conduction defects
4. Sinus bradycardia (less than 50) or pauses
5. Long QT interval
Features that suggest a neurally-mediated cause:
1. After sudden unexpected unpleasant sight, sound or smell
2. prolonged standing at attention or crowded warm places
3. nausea, vomiting associated with syncope
4. within one hour of a meal
5. after exertion
6. temporal relationship with start of medication or changes of dosage
Cardiovascular 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. Any fitting / twitching is only short lived.
Remember to ask:
what they were doing just beforehand
has it ever happened before
any warning symptoms
what did any onlookers see
were they really unconscious