Free Examination Medicine: A Guide to Physician Training by Nicholas J. Talley, Simon O’connor

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    4. Next ask standard questions about risk factors in addition to age and male sex. Remember that risk factors are of vital importance to long-term prognosis, but add little to the likelihood that undiagnosed chest pain is ischaemic. Risk factors include:
    • previous ischaemic heart disease
    • hyperlipidaemia
    • diabetes mellitus (the increased risk in these patients is as high as that in non-diabetics who have already had an ischaemic event)
    • hypertension
    • family history (in particular, first-degree relatives with ischaemic heart disease before the age of 60; 92-year-old great-uncles with heart trouble do not count)
    • smoking
    • use of oral contraceptives or premature onset of menopause
    • obesity and physical inactivity
    • high serum homocysteine levels, which may have been measured if the patient has premature coronary disease and few other risk factors – levels in the top population quintile increase coronary risk twofold; trials of treatment (mostly with folate), however, have been negative and routine treatment is not recommended
    • long-term use, in high doses, of cyclo-oxygenase 2 (COX-2) inhibitors or other non-steroidal anti-inflammatory drugs (NSAIDs) (which should be stopped)
    • erectile dysfunction (which often precedes symptomatic ischaemic heart disease and is a marker of endothelial dysfunction). Remember that the presence of multiple risk factors is more than additive.
    5. Then find out whether risk factor control has been successful. Remember the important results of recent secondary prevention trials.
    a. Aggressive cholesterol lowering to below a level of 4 mmol/L of total cholesterol (LDL <1.8) is now considered appropriate for patients with established coronary disease.
    b. There is some evidence that statins have beneficial effects beyond their effect on cholesterol levels (pleotrophic effects).
    6. Find out what investigations the patient can remember.
    a. An echocardiogram may have been performed to assess ventricular function and possible complications of infarction, such as a pericardial collection, a left ventricular thrombus, mitral regurgitation or a ventricular septal defect (VSD).
    b. An exercise test, a sestamibi or a stress echocardiogram may have been performed to assess ischaemia or myocardial viability (MRI scan).
    c. Cardiac catheterisation is perhaps the most memorable of the investigations for ischaemic heart disease.
    The patient may know how many coronaries are abnormal and whether angioplasty was performed. Ask whether a drug-eluting stent (DES) was used and for how long dual anti-platelet treatment was recommended. Remember clopidogrel, and most PPIs, use the same metabolic pathway in the liver and if used together may result in a theoretical loss of anti-platelet benefit. The clinical relevance of this is disputed.

    7. Complications such as acute mitral regurgitation or an infarct-related VSD are usually treated surgically but have a relatively poor prognosis. All complications are less common if early coronary patency and normal flow have been achieved.

    The examination
    Examine the cardiovascular system (Ch 16).

    1. Note the presence of intravenous treatment. This might include heparin, nitrates, inotropes, vasopressors or antiarrhythmic drugs.
    2. Record the blood pressure.
    3. Look for signs of valvular heart disease, cardiac failure, rhythm disturbances (e.g. atrial fibrillation, frequent ectopic beats) and murmurs suggesting mitral regurgitation or a VSD caused by an infarct.
    4. There may be spectacular bruises at venepuncture or femoral puncture sites if the patient has had thrombolytic treatment. Abdominal wall bruising suggests subcutaneous low-molecular-weight heparin therapy, and a bruise (sometimes very large) over one of the femoral arteries suggests cardiac catheterisation or angioplasty. If radial angiography was performed there may be a bruise over the radial artery at the wrist. Occasionally the radial