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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Cardiovascular history and symptom analysis

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

RapidFull
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Escalate

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.

Synopsis

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

  • 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.

Key red flags

Possible acute coronary syndrome

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 syndrome

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

High-risk syncope

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.

Investigation priorities

01
12-lead ECGFirst step

Identify ischaemia, infarction, conduction disease, pre-excitation, QT abnormality or arrhythmia.

Management branches

Preferred routeAcute chest discomfort

Current or recent symptoms compatible with ACS

  1. Perform ABCDE, observations and a 12-lead ECG without waiting for blood results.
  2. Give aspirin when ACS is suspected unless contraindicated, and follow the STEMI or NSTE-ACS route according to ECG and instability.
  3. Use serial high-sensitivity troponin under the locally validated assay pathway; investigate dangerous alternatives in parallel.
  4. Escalate immediately for persistent pain, dynamic ECG change, shock, pulmonary oedema or malignant arrhythmia.
AlternativeStable exertional chest pain

Symptoms are stable and there is no acute high-risk feature

  1. Classify the symptom pattern and assess cardiovascular risk and non-coronary causes.
  2. Obtain a resting ECG and baseline tests; do not exclude angina because the ECG is normal.
  3. If clinical assessment indicates typical or atypical angina, arrange 64-slice-or-above CT coronary angiography under NICE CG95.
  4. Safety-net any change in frequency, threshold, duration or rest symptoms as possible ACS.
Open full textbook →Answer 2 questionsCardiology check
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 stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom