Comprehensive Cardiac Evaluation

History Components

The American Heart Association recommends that personal history should include chest pain/discomfort/tightness/pressure related to exertion, as well as unexplained syncope or near-syncope, in patients with suspected cardiac disease 1, 2
A comprehensive personal history should also include excessive and unexplained dyspnea/fatigue or palpitations associated with exercise, prior recognition of a heart murmur, prior restriction from participation in sports, and prior cardiac testing ordered by a physician 1
Family history should include premature death (sudden and unexpected) before 50 years attributable to heart disease in ≥1 relative, disability from heart disease in close relative <50 years of age, and specific genetic cardiac conditions in family members (hypertrophic or dilated cardiomyopathy, long-QT syndrome, ion channelopathies, Marfan syndrome) 1, 4

Blood pressure measurement in sitting position is essential for a comprehensive cardiac evaluation, as recommended by the American College of Cardiology 1, 5
Heart rate and rhythm assessment, including orthostatic vital signs, should be performed in all patients 2
Physical stigmata of Marfan syndrome should be assessed during the general observation component of the physical examination 1
A comprehensive cardiovascular examination should include heart auscultation with assessment of heart sounds (S1, S2, presence of S3 or S4) and evaluation for heart murmurs with attention to timing, location, radiation, intensity, and quality 1, 5
Femoral pulses should be assessed to exclude aortic coarctation, as recommended by the American Heart Association 1

A 12-lead ECG is essential for a comprehensive cardiac evaluation to identify arrhythmias or conduction abnormalities, ventricular hypertrophy, signs of ischemia or prior infarction, and features suggestive of channelopathies (Brugada syndrome, long QT syndrome) 2
Echocardiography should be performed when indicated, based on abnormal findings on history, physical examination, or ECG, to assess ventricular function, valve function, and cardiac structure 5
The American College of Cardiology recommends that echocardiography be used to evaluate suspected structural heart disease 4, 5

For athletes, additional attention should be paid to specific cardiovascular screening elements as recommended by the American Heart Association (14-element evaluation) 1
The American Heart Association also recommends evaluation for conditions associated with sudden cardiac death in athletes 6
For older adults (≥60 years), a more thorough assessment of cardiovascular risk factors (hypertension, diabetes, dyslipidemia, obesity) should be performed, as recommended by the American College of Cardiology 7
The American College of Cardiology recommends that older adults be evaluated for valvular heart disease, which increases in prevalence with age 5

Inadequate auscultation environment can lead to inaccurate assessment of heart sounds, as noted by the American College of Cardiology 5
Incomplete murmur characterization can result in missed diagnoses, and the American College of Cardiology recommends that timing, location, radiation, and response to maneuvers be documented 5
Discrepancies between physical examination and echocardiography warrant further investigation, as recommended by the American College of Cardiology 5