Cardiovascular

Notes

Introduction

Cardiovascular histories should focus on key system-specific symptoms related to the heart, cardiovascular risk factors, medications, lifestyle factors & relevant family history

History of presenting complaint

Chest pain can be described using the SOCRATES mnemonic. It is particularly important to determine the nature of the pain (i.e. central, crushing chest pain) in addition to the presence of any associated symptoms (i.e. nausea, sweating, clammy).

The key symptoms to determine in a cardiovascular history include:

  • Chest pain
  • Dyspnoea (breathlessness)
  • Palpitations (awareness of one's heart beating)
  • Orthopnoea (breathless lying flat)
  • Pedal oedema (ankle swelling)
  • Dizziness
  • Syncope (transient loss of consciousness)
  • Claudication (cramping pain in the legs on exercise)

The presence of breathlessness, orthopnoea and ankle swelling should make you think about heart failure as a possible diagnosis. It is important to determine whether palpitations are associated with features of dizziness, syncope or chest pain, which suggest a more sinister arrhythmia.

Risk factors

There are five critical cardiovascular risk factors that should be determined in every history.

  • Hypertension (high blood pressure)
  • Hypercholesterolaemia (high cholesterol)
  • Family history (heart attack < 60 years old in biological relative)
  • Smoking
  • Diabetes

Past medical history

It is important to ascertain any previous cardiovascular history such as a myocardial infarction (heart attack), arrhythmias (e.g. atrial fibrillation), or previous treatments (e.g. pacemaker, stenting).

When discussing previous medical problems always establish:

  1. Year of diagnosis (i.e. MI in 2007)
  2. Treatment for condition (i.e. Percutaneous coronary intervention and single stent)
  3. Any complications (i.e. heart failure, pericarditis)
  4. Last follow-up & recommendations

Drug history

It is important to determine which medications the patient is taking related to their condition and whether they are experiencing any side-effects?

For example, 

  • Are they on an anti-coagulants for atrial fibrillation?
  • Are they on a beta-blocker, angiotensin-converting enzyme inhibitor (ACE-i), or diuretic for heart failure?
  • Are they on thyroxine for thyroid problems?

Family history

The critical things to pick up in the family history  are underlying genetic conditions, heart disease at a young age (i.e. < 60) or sudden cardiac death (SCD).

Genetic conditions may include familial hyperlipidaemias. The presence of sudden cardiac death may be concerning for an underlying condition like long-QT syndrome or hypertrophic cardiomyopathy.

Social history

Enquire about the functional impact of their cardiovascular complaint on their life.

This could be angina (chest pain) limiting them from working, heart failure causing significant breathlessness or intermittent claudication limiting their exercise. 

Always discuss:

  • Smoking
  • Alcohol
  • Recreational drug use (i.e. cocaine) especially in young patients with chest pain
  • Exercise tolerance
  • Driving status (Will need to inform the DVLA with most cardiovascular conditions)
  • New York Heart Association grade (I-IV) - if heart failure symptoms

ICE

Always end by discussing the patient's ideas, concerns & expectations

  1. Do you have an idea about what could be going on?
  2. Is there anything that is worrying/concerning you at the moment?
  3. Is there anything you were hoping from this consultation?
  4. Do you have any further questions today?

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