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← Cardiology indexChapter sections
Purpose and principlesIndications, selection and cautionsMethod and interpretationClinical next stepsRisks, monitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
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Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.

Cardiovascular history and symptom analysis

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Time-critical presentation

Treat ongoing ischaemic-sounding pain, haemodynamic compromise, acute pulmonary oedema, syncope during exertion or sustained tachyarrhythmia as urgent: use ABCDE, obtain a 12-lead ECG promptly and activate the appropriate emergency pathway.

Purpose and principles

Build a time-critical, discriminating cardiovascular history that identifies instability, separates likely mechanisms and directs the next test.

History sets pre-test probability rather than naming a diagnosis. First decide whether the patient is unstable, then define the dominant syndrome and credible dangerous alternatives.

Describe the symptom in the patient's terms before translating it into an anginal, heart-failure, arrhythmic, valvular, aortic or thromboembolic pattern. Sex, age, ethnicity, diabetes and communication barriers can alter presentation without making symptoms 'atypical' or benign.

Close the history with functional impact, baseline exercise tolerance, occupational or driving implications, patient priorities and an explicit safety-net.

Key points

  • Characterise every symptom by onset, provoking and relieving factors, quality, site or radiation, duration, associated features and trajectory.
  • Typical angina has three features: constricting chest or neck, shoulder, jaw or arm discomfort; provocation by exertion; and relief by rest or glyceryl trinitrate within about 5 minutes.
  • Do not use response to glyceryl trinitrate alone to diagnose cardiac pain; oesophageal pain may also improve.
  • Ask directly about dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, oedema, palpitations, presyncope and syncope.
  • Establish vascular risk, prior cardiovascular disease, pregnancy or postpartum status, stimulant use, thrombosis risk and a three-generation sudden-death or cardiomyopathy history where relevant.
  • Medication reconciliation must include adherence, antithrombotics, QT-prolonging drugs, rate-limiting agents, erectile-dysfunction drugs and non-prescribed products.
  • A normal examination or resting ECG never excludes acute coronary syndrome or intermittent arrhythmia.

Indications, selection and cautions

Possible acute coronary syndromeRed flag

New or worsening pressure, heaviness or tightness, especially at rest or with autonomic symptoms, breathlessness or radiation; painless presentations occur, particularly with diabetes or older age.

Possible acute aortic syndromeRed flag

Abrupt severe chest, back or abdominal pain, pulse or neurological deficit, new aortic regurgitation or unexplained hypotension warrants immediate aortic assessment.

Heart-failure pattern

Progressive exertional dyspnoea, orthopnoea, nocturnal breathlessness, rapid weight gain, oedema or early satiety; ask about precipitating infection, ischaemia and medication change.

Arrhythmic pattern

Sudden-onset regular or irregular palpitations with presyncope, syncope or chest pain; capture frequency and duration because these determine monitoring strategy.

High-risk syncopeRed flag

Syncope during exertion, while supine, with structural heart disease, an abnormal ECG or a family history of young sudden death requires urgent specialist cardiovascular assessment.

Method and interpretation

  1. 01
    12-lead ECGFirst step
    Why
    Identify ischaemia, infarction, conduction disease, pre-excitation, QT abnormality or arrhythmia.
    Interpretation and limitations
    Compare with prior traces; repeat during symptoms because a single normal ECG does not exclude ACS or paroxysmal rhythm disease.
  2. 02
    High-sensitivity cardiac troponin
    Why
    Assess myocardial injury when ACS is suspected.
    Interpretation and limitations
    Use the assay-specific serial pathway and clinical context; an elevated value is injury, not automatically type 1 myocardial infarction.
  3. 03
    Chest radiograph
    Why
    Seek pulmonary oedema, alternative pulmonary disease or gross aortic abnormality when clinically indicated.
    Interpretation and limitations
    A normal film neither excludes heart failure nor acute aortic syndrome; do not delay definitive imaging in an unstable patient.
  4. 04
    Transthoracic echocardiogram
    Why
    Assess ventricular function, valves, pericardium and aortic root when symptoms or signs suggest structural disease.
    Interpretation and limitations
    Interpret against loading conditions and image quality; a focused bedside study does not replace a complete accredited examination.
  5. 05

Clinical next steps

01Preferred routeAcute chest discomfortFirst stepPreferredCurrent or recent symptoms compatible with ACS+
  1. 1Perform ABCDE, observations and a 12-lead ECG without waiting for blood results.
  2. 2Give aspirin when ACS is suspected unless contraindicated, and follow the STEMI or NSTE-ACS route according to ECG and instability.
  3. 3Use serial high-sensitivity troponin under the locally validated assay pathway; investigate dangerous alternatives in parallel.
  4. 4EscalationEscalate immediately for persistent pain, dynamic ECG change, shock, pulmonary oedema or malignant arrhythmia.
02AlternativeStable exertional chest painAlternativeSymptoms are stable and there is no acute high-risk feature+

Risks, monitoring and follow-up

  • Repeat observations and symptom assessment when an acute process remains possible.
  • Record symptom frequency, exertional threshold, duration and rescue-nitrate use over time.
  • Review blood pressure, pulse, weight and signs of congestion when heart failure is possible.
  • Reconcile medicines and adverse effects at every transition of care.
  • Check that planned tests, safety-netting and driving advice have been communicated and documented.

Special situations

Angina classification is descriptive

Three classic features suggest typical angina, two atypical angina and zero or one non-anginal pain; this classification does not overrule acute red flags.

Dyspnoea can be an anginal equivalent

Exertional breathlessness may represent ischaemia, but anaemia, lung disease, valve disease and heart failure must remain active alternatives.

Witnesses improve syncope histories

Colour, movements, duration, injury and recovery often distinguish arrhythmic syncope from vasovagal syncope or seizure better than the patient's recall.

Ask what changed

A fall in exercise threshold or new rest symptoms is often more decision-relevant than the absolute pain score.

Family history needs specificity

Record relative, age, event and diagnosis; 'heart problems' is not an adequate sudden-death pedigree.

Common pitfalls

  1. 01

    Calling pain non-cardiac because it is sharp, reproducible or occurs in a woman or younger adult.

  2. 02

    Using a normal ECG or normal examination to close an ACS diagnosis.

  3. 03

    Failing to ask about phosphodiesterase-5 inhibitors before nitrate use.

  4. 04

    Ordering a 24-hour monitor for monthly syncope and then treating a negative result as exclusion.

  5. 05

    Documenting 'no family history' without asking about premature coronary disease, cardiomyopathy and sudden unexplained death.

Practice

Two practice questions

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Question 1 of 2
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CardiologyOriginal SBA

Classifying stable chest pain

A 58-year-old has central constricting discomfort on walking uphill that settles within 3 minutes of rest. Which classification best fits?

Choose one answer, then submit
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE CG95: Recent-onset chest pain of suspected cardiac origin
  • NICE CG109: Transient loss of consciousness in over 16s
  • NICE NG106: Chronic heart failure in adults
  • ESC 2024 Guidelines for chronic coronary syndromes

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom
Ambulatory ECG
Why
Correlate intermittent symptoms with rhythm.
Interpretation and limitations
Choose duration from symptom frequency; symptom-rhythm correlation is stronger than incidental ectopy.
  1. 1Classify the symptom pattern and assess cardiovascular risk and non-coronary causes.
  2. 2Obtain a resting ECG and baseline tests; do not exclude angina because the ECG is normal.
  3. 3If clinical assessment indicates typical or atypical angina, arrange 64-slice-or-above CT coronary angiography under NICE CG95.
  4. 4Safety-net any change in frequency, threshold, duration or rest symptoms as possible ACS.
03EscalationSyncope or palpitationsEscalationTransient loss of consciousness or episodic tachycardia+
  1. 1Document event circumstances, prodrome, posture, exertion, recovery, witness account and family history; obtain ECG and lying-standing blood pressure.
  2. 2Urgently refer when red flags or structural heart disease are present.
  3. 3If arrhythmia remains suspected, select ambulatory monitoring by event frequency rather than defaulting to a 24-hour Holter.
  4. 4Advise on driving only from current DVLA rules and the established diagnosis; document the discussion.