22 Station 10 Chest pain history
• Parents, siblings, and children. Ask specifically about heart disease, hypertension, and other
heritable cardiovascular risk factors.
an excellent question to ask in clinical practice, and an even better one to ask in exams.
• Summarise your findings and offer a differential diagnosis.
• State that you would like to examine the patient and possibly order some investigations, in
• ECG to look for or help rule out ischaemic heart disease.
– troponins to look for or help rule out myocardial infarction
– D-dimers for suggestion of a DVT/pulmonary embolism (a negative result excludes the
diagnosis but a positive result does not confirm it)
– inflammatory markers such as white cell count and CRP for suggestion of pneumonia
• Chest X-ray for signs of pneumonia or pneumothorax.
• CTPA or V/Q scan if the history is suggestive of a pulmonary embolism.
Conditions most likely to come up in a chest pain history station
• Heavy retrosternal pain which may radiate into the neck or left arm
• Brought on by effort or emotion and relieved by rest and nitrates
• Risk factors for ischaemic heart disease are likely
• A family history of ischaemic heart disease is likely
• Pain typically comes on over a few minutes
• Pain is similar to that of angina but is typically severe, long-lasting (> 20 minutes), and
• Often associated with sweating, nausea, and breathlessness
• Risk factors for ischaemic heart disease are likely
• A family history of ischaemic heart disease is likely
Cardiovascular and respiratory medicine
Station 10 Chest pain history 23
• Sharp, stabbing, ‘catching’ pain
• May radiate to the back or shoulder
• Typically aggravated by deep breathing and coughing
• Can be caused by pleurisy which can occur with pneumonia, pulmonary embolus, and
pneumothorax, or by pericarditis which can occur post-MI, in viral infections, and in autoimmune
• Pleural pain is localised to one side of the chest and is not position dependent
• Dressler’s syndrome (post-MI syndrome) is characterised by pleuritic chest pain from pericarditis
accompanied by a low-grade fever, and can occur up to three months following an MI
• Sharp, stabbing pain that is of sudden onset
• May be associated with shortness of breath, haemoptysis, and/or pleurisy
• Typically aggravated by deep breathing and coughing
• May be a history of recent surgery, prolonged bed rest, or long-haul travel
Gastro-oesophageal reflux disease:
• Clear relationship with food and alcohol, but no relationship with effort
• May be associated with odynophagia and nocturnal asthma
• Aggravated by lying down and alleviated by sitting up and by antacids such as Gaviscon or milk
Musculoskeletal complaint e.g. costochondritis:
• May be associated with a history of physical injury or unusual exertion
• Pain is aggravated by movement, but is not reliably alleviated by rest
• The site of the pain is tender to touch
• Rapid onset of severe anxiety lasting for about 20–30 minutes
• Associated with chest tightness and hyperventilation
• Sudden onset, sharp, tearing pain that is maximal at the time of onset
If you cannot differentiate angina from gastro-oesophageal reflux disease and there are
no signs of ischaemia on the ECG, advise an exercise ECG stress test. If this is negative,
consider a therapeutic trial of an antacid or a nitrate.
Cardiovascular risk assessment
Cardiovascular risk factors can usefully be divided into fixed (non-modifiable) and modifiable risk
Modifiable risk factors include hypertension, hyperlipidaemia, diabetes, smoking, alcohol, exercise,
and stress. Having one or more of these risk factors does not mean that a person is going to develop
cardiovascular disease, but merely that he is at increased probability of developing it. Conversely,
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain that you are going to ask him some questionsto assess hisrisk of cardiovascular disease
(coronary heart disease, cerebrovascular disease, vascular disease) and obtain consent.
Remember to be tactful in your questioning, and to respond sensitively to the patient’s
ideas, concerns and expectations (ICE).
If this information has not already been provided or disclosed, find out the patient’s reason for
attending. Then note or enquire about:
2. Ethnic background. People from a South Asian background are at a notably higher risk of
events, you are assessing him for secondary rather than primary prevention.
4. Family history. Ask about a family history of cardiovascular disease and risk factors for
cardiovascular disease such as hypertension, hyperlipidaemia and diabetes mellitus.
5. Hypertension. If hypertensive, ask about latest blood pressure measurement, time since first
diagnosis, and any medication being taken.
6. Hyperlipidaemia. If hyperlipidaemic, ask about latest serum cholesterol level, time since first
diagnosis, and any medication being taken.
7. Diabetes mellitus. If diabetic, ask about medication being taken, level of diabetes control
being achieved, time since first diagnosis, and presence of complications.
8. Cigarette smoking. If a smoker or ex-smoker, ask about number of years spent smoking and
9. Alcohol. Ask about the number of units of alcohol consumed in a day and typical week. Note
that depending on the amount and type that is drunk, alcohol can be either protective or a
10. Diet. In particular, ask about fried food and takeaways.
11. Lack of exercise. Ask about amount of exercise taken in a day or week. Does the patient walk
12. Stress. Ask about occupational history and home life.
Cardiovascular and respiratory medicine
Station 11 Cardiovascular risk assessment 25
Table 2. Desirable lipid levels
Total cholesterol < 5.0 mmol/l
LDL ‘bad’ cholesterol (fasting) 3.0 mmol/l
HDL ‘good’ cholesterol 1.2 mmol/l
Total cholesterol/HDL cholesterol < 4.5
Tryglycerides (fasting) < 1.5 mmol/l
NB. Patients at high risk of cardiovascular disease should aim
for even better than these figures.
• If you have time, assess the extent of any cardiovascular disease.
• Ask the patient if there is anything he would like to add that you may have forgotten to ask
• Give him feedback on his cardiovascular risk (e.g. low, medium, high), and, if appropriate,
indicate a further course of action (e.g. further investigations or further appointment to discuss
reducing modifiable risk factors).
• Address any remaining concerns.
• State to the examiner that appropriate investigations include:
– BMI (should be between 18.5kg/m2 and 24.9kg/m2
– waist circumference (should be less than 102cm for men and 89cm for women)
– blood pressure (should be under 140/90mmHg)
– fasting blood glucose levels (should be under 6.0mmol/L)
– fasting lipid levels (see Table 2)
• Suggest calculating the patient’s 10-year cardiovascular risk score using the Framingham risk
• Indicate that the management of cardiovascular risk factors includes lifestyle modification and,
if appropriate, medical intervention (see Table 3).
Table 3. Management of cardiovascular disease
Lifestyle modification Medical intervention
• Reduce alcohol intake (to 3–4 units/day
in men and 2–3 in women, and avoid
• Adopt a healthy diet: reduce saturated
fatty acids, trans-fatty acids and
cholesterol; increase fibre and omega-3
• Take 30–60 minutes of exercise per day.
• Consider statin for secondary prevention
or for primary prevention if 10-year risk is
• Consider anti-platelet drugs e.g. aspirin.
• Consider anti-hypertensive agents.
• If necessary, seek to optimise blood sugar
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain the procedure and obtain his consent.
• Tell him that he might feel some discomfort as the cuff is inflated, and that the blood pressure
measurement may have to be repeated.
in all but children and the obese.
• Position the BP machine so that it is roughly at the level of the patient’s heart.
• Position the measurement column/dial so that it is at eye level (avoids parallax error).
• Position the patient’s right arm so that it is horizontal at the level of the mid-sternum and free
• Locate the brachial artery at about 2 cm above the antecubital fossa.
• Apply the cuff to the arm, ensuring that the arterial point/arrow is over the brachial artery.
the cuff until you can no longer feel it.
• Place the stethoscope over the brachial artery pulse, ensuring that it does not touch the cuff.
• Reduce the pressure in the cuff at a rate of 2–3 mmHg per second.
– the first consistent Korotkov sounds indicate the systolic blood pressure
– the muffling and disappearance of the Korotkov sounds indicate the diastolic blood pressure
• Record the blood pressure as the systolic reading over the diastolic reading. Do not attempt
to ‘round off’ your readings; to an examiner’s ear, 144/88 usually rings more true than 140/90.
• If the blood pressure is higher than 140/90, indicate that you need to take a second reading
after giving the patient a one minute rest.
investigate for postural hypotension: a drop in BP on standing of ≥20mmHg).
• Ensure that the patient is comfortable.
• Document the blood pressure recording in the patient’s notes.
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