Cardiovascular History

The structure of the history will follow the usual structure you have been shown:

Introduce yourself

Gain consent to take the cardiovascular history

Presenting complaint

History of presenting complaint

Past history, medical and surgical

Medications and allergies

Social history

Family history

Ideas, Concerns and Expectations

Before taking a cardiovascular history you should be familiar with:

The major Cardiovascular symptoms.

The main risk factors for Cardiovascular disease.

Major Cardiovascular symptoms

Chest pain

Shortness of breath

Ankle swelling

Palpitations

Syncope/fainting/dizziness

Leg/calf pains when walking(Intermittent Claudication)

Tiredness/ Fatigue

Risk factors for Cardiovascular disease

Age (> 55)

Sex (M>F)

Hyperlipidaemia

Smoking

Hypertension

Diabetes Mellitus

Obesity

Family History of heart disease (first degree relative <60)

Lifestyle, lack of physical activity

Introduction and Consent

Introduce yourself, explain your role, obtain patient’s name, age/date of birth and where they are from. Ask their consent to proceed with

history taking.

Presenting Complaint (PC)

The main symptom the patient presents with. It is likely to be one of the cardiovascular symptoms listed above.

‘What problem brought you here today?’ ‘How can I help you?’

History of presenting complaint (HPC)

The background to the presenting complaint/problem.

Through a series of open, and then closed questions, you try to get as much information as you can about the PC.

How/ when the problem started, how it has progressed over time, any pattern that is evident, factors which worsen or ease the problem, why

the patient has now come to discuss it further, how it is impacting on their life/family etc. Any other associated cardiovascular symptoms. Any

history of cardiac problems or previous diagnosis of cardiac disease.

1. Chest pain you want to get more information about the pain to help you determine the likely cause.

Site- cardiac pain is classically central or retrosternal.

Duration- when did this pain begin.

Onset- gradual/sudden.

Nature of the pain or its character-is it crushing/heavy/tight/throbbing/burning….

Radiation- does it move or radiate anywhere (neck or left shoulder).

Associated features-nausea/vomiting/sweating/anxiety (feeling of impending doom)/Shortness of breath/ Palpitations/ Feeling faint.

Time Line- what has happened to the pain since onset. How has it progressed or developed. Is it continuous or does it come and go? If

it comes and goes –how often does it occur and how long does it last for? =Periodicity.

Precipitating factors- did anything seem to bring it on- stress/anxiety/exercise

Exacerbating factors? Anything worsen the pain? e.g. exercise.

Relieving factors- anything help to make it better. Rest / medication /certain positions.

Severity- Ask them to grade the pain from 1 to 10. How does it impact on their life?

Previous similar episodes and how they have progressed. What, if anything, is different about this episode. Any identifiable pattern.

Remember SOCRATES (general history taking)

2. Shortness of breath can be a presenting symptom of CV disease. As with pain you will need to explore the history of the shortness of

breath-

When it started,

How has it progressed,

Is it worsening, improving or staying the same.

What precipitates it e.g. mild exertion, strenuous exertion or does it occur at rest and what relieves it if anything?

Any associated features e.g. dizziness or chest pain?

Have there been similar episodes and what has the pattern been? Is this episode similar or different to previous episodes?

In addition to enquiring if the patient ever feels short of breath it is important to specifically ask about two particular types of shortness of

breath which occur in left heart failure.

Orthopnea or orthopnoea (Greek from ortho, straight + pnoia, breath) is shortness of breath (dyspnea) which occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair.

People with left heart failure can become very short of breath when lying flat. They may sleep propped up on a number of pillows.

The more severe the problem the more pillows they need.

Paroxysmal Nocturnal Dyspnoea : acute dyspnea appearing suddenly at night, usually waking the patient from sleep; caused by pulmonary

congestion with or without pulmonary oedema that results from left-sided heart failure following mobilization of fluid from dependent areas

after lying down.

Sometimes when people do sleep lying flat they may awaken acutely short of breath and have to sit up to breath more

comfortably or may go to the window gasping for air.

3. Ankle swelling with right heart failure the patient may have symptoms in the venous system. One of the first can be ankle swelling. Again

you need to explore this further. When it began, progression, exacerbating or relieving factors, associated symptoms etc.

4. Palpitations. These are an awareness of the heart beating. Try to work out exactly what the patient means by palpitations. Is the heart

beating quickly or slowly? Is it regular or irregular? Does it feel like the heart skips a beat? Any associated features e.g. chest pain,

shortness of breath or dizziness? How long do they last for?

5. Syncope/fainting/dizziness.

Syncope is defined as a transient loss of consciousness resulting from cerebral anoxia, usually due to inadequate cerebral blood flow (a

faint).

Presyncope is a transient sensation of weakness without loss of consciousness (feeling faint/light headed but not actually fainting or losing

consciousness).

Getting more information about the syncope may give you a clue as to the underlying cause…

Establish if the patient actually loses consciousness and when the syncope occurs e.g. prolonged standing/sudden emotional stress.

Did they have a warning or feel faint before the syncope?

Did they recover quickly? Or did they take time to recover?

What information can be obtained from witnesses- did they notice any abnormal movements? (differentiate an epileptic fit from a

simple syncope).

Sudden loss of consciousness irrespective of position, can be due to an arrhythmia.

Did it occur with exercise? (consider obstruction to the left ventricular outflow by aortic stenosis or hypertrophic cardiomyopathy).

Patients have different ways of describing syncope. They may call it a blackout or funny turn or faint.

Once again you need to get a full history of this presenting complaint. When it occurs, what precipitates it, what relieves it, any associated

symptoms, previous similar episodes, becoming more or less frequent? Etc.

6. Intermittent claudication peripheral vascular disease, caused by atherosclerotic narrowing of the arteries in the legs.

Ischaemic, cramp like, pain occurs in the legs, calves usually, during exercise and is relieved by rest. (similar to angina but angina in the

legs!)

The distance the person can walk before onset of leg pains usually shortens with time and progression of the peripheral vascular disease

(claudication distance). With further progression of the disease the pain can occur at rest.

Yet again you must explore this further/in detail as outlined above.

7. Fatigue may be associated with a reduced cardiac output and poor blood supply to the muscles. Obviously fatigue can be a symptom of

many conditions and is a nonspecific symptom.

Ask about risk factors

You must fully assess the presence of risk factors

Age (>55)

Sex (M>F)

High cholesterol (on any medications?)

High blood pressure(duration, any medications?)

Smoking (quantify how much, for how long and has it changed?)

Diabetes mellitus (duration, type, remember painless myocardial infarct (MI) with diabetes is a possibility)

Obesity

Lack of physical activity/poor diet/lifestyle

Family history of cardiovascular disease.

Past History : past medical history(PMH), past surgical history (PSH)

Open ended questions initially ‘How is your health generally?’

Does the patient have any known medical problems/illnesses?

Are they attending a doctor regularly- when/ why were they last there?

Have they had any medical investigations?

Have they had any operations at all?

Any previous cardiac problems?

Screen for conditions using closed questions

Have they ever been diagnosed as having:

High blood pressure

High cholesterol

Heart disease/Cerebrovascular disease (angina, heart attacks or strokes)

Diabetes

Depression

Asthma

Epilepsy

Rheumatic Fever

Jaundice

TB

Medication

Are they currently taking any medication / tablets? Any prescribed medicines, over the counter medicines from a pharmacy or health shop or

herbal remedies? Any ‘recreational drug’ use?

If the patient is taking meds you want to know what they are for, who prescribed them and is the patient complying/ taking them as they were

advised.

Allergies

Any known allergies to anything at all – drugs/medications/ latex.

Ask them to explain what they mean by allergy. What exactly happened to them? Nausea/vomiting/rash/swelling/breathing difficulty? This will

help you determine if it was a true allergy.

Social History (SH)

Home situation- Who do they live with. Spouse/ partner/ children/ parents. Any dependants. What support do they have at home? Can

they manage stairs, if present , in their house? Bathroom up/ downstairs?

Occupation? Stress, physical activity, can they manage the work?

Hobbies/sports/sedentary lifestyle?

Smoking History- do they smoke, have they ever smoked, has it changed recently? How much do they smoke and how long have they

smoked for.

Alcohol History- Do they drink alcohol, if so how much. Has this changed? Calculate how many units they drink weekly. 14units is the

recommended maximum for women and 21 units is the max recommended for men.

Glass of beer- 1 unit

Pint beer- 2 units

Glass wine- 1 unit

Measure of spirits- 1 unit

Family History (FH)

Enquire about parents and siblings. Are they alive? If so are they well or do they have any medical problems, in this case do they have any

history of cardiac problems in particular.

If they are deceased you need to ask at what age they died and what was the cause of their death, in particular was there a cardiac cause.

Remember to be sensitive and empathise as appropriate.

Are there any medical conditions which have occurred frequently/run in the family?-esp. diabetes, heart disease, raised blood pressure or

strokes?

Ideas, concerns and expectations

Try to give the patient an opportunity to tell you if there is anything that they want explained or if there is something they are particularly

worried about. For example- they may be terrified that they are having a heart attack as their brother died suddenly of one, or they may be

worried that they have cancer. They may be concerned that if they are unable to work for some time their business will not survive or their

bills will be unpaid. It is important to explore this with the patient at the end of the consultation. E.g. do you have any questions? Is there

anything that you are particularly worried about?