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Introduction
The cardiovascular history should focus on key system-specific symptoms related to the heart and cardiovascular system.
A cardiovascular history should focus the consultation on the cardiovascular system. This is usually because a patient presents with a cardiovascular problem such as chest pain or palpitations.
The idea of a system-specific history is to explore key factors that are relevant to the affected system during the consultation. In cardiovascular disease, this may include cardiovascular risk factors, medications (i.e. that prevent or provoke cardiovascular disease), lifestyle factors (e.g. obesity, smoking), and relevant family history.
History of presenting complaint
Chest pain can be described using the SOCRATES mnemonic.
Chest pain is one of the most common presenting complaints in patients with cardiovascular disease. It is 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 SOCRATES mnemonic can be used to help take a pain history to get across all the main points.
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. With chest pain, it is essential to determine whether this came on at rest or during exertion.
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:
- Year of diagnosis (i.e. MI in 2007)
- Treatment for condition (i.e. Percutaneous coronary intervention and single stent)
- Any complications (i.e. heart failure, pericarditis)
- 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
In the family history, determine any 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. Draw a family tree if necessary to help establish any conditions that run through the family. Some newer computer systems will automatically create a family tree from the data entered.
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
- Do you have an idea about what could be going on?
- Is there anything that is worrying/concerning you at the moment?
- Is there anything you were hoping for from this consultation?
- Do you have any further questions today?
