QUESTIO
NS TO ASK THE PATIENT WITH
HYPERTENSION
1. Do you use much salt in your diet, or eat
salty prepared or snack foods?
2. Have you put on weight recently?
3. How much alcohol do you drink?
4. What sort of exercise do you do and how
much?
5. Do you take your blood pressure at
home? What readings do you get?
6. Are you taking any blood pressure tablets
now? Have you taken these medications
in the past? Do the tablets cause you any
problems?
7. Are you taking arthritis drugs (NSAIDs)?
Steroids?
8. Have you had any kidney problems?
Blood in the urine? Ankle swelling?
Shortness of breath?
QUESTIONS BOX 4.5
i
This means the use of one or more doses of antibiotics given before and
after a procedure, which may lead to bacteraemia (circulation of
microorganisms in the blood) and potential infection of a heart valve
(endocarditis). Having a level of antibiotics present in the blood at the
time of such procedures is thought (but not proven) to prevent
endocarditis.
discriminating than is the presence of risk factors, which
only marginally increase the likelihood that chest pain
is ischaemic.4 Previous ischaemic heart disease is an
exception. Certainly a patient who has had angina
before and says he or she has it again is usually right.
The medications a patient is taking often give a good
clue to the diagnosis. Find out about any ill-effects from
current or previous medications. Ask about previous
procedures or interventions including angioplasty or
coronary artery bypass grafting. If the patient is unable
to provide a history, a midline sternotomy scar and
leg scars (consistent with previous saphenous vein
harvesting) support this diagnosis.
Patients with heart failure may have been advised
to restrict their total daily fluid intake. Ask what volume
has been recommended (often 1500 mL). They may
also have been advised to weigh themselves daily and
to increase their diuretic drug dose if their weight has
increased. Ask what advice has been given about this.
Street drug use is relevant. The use of cocaine or
amphetamines is an important cause of myocardial
infarction in young people.
PAST HISTORY:
Patients with a history of definite previous angina or
myocardial infarction remain at high risk of further
ischaemic events. It is very useful at this stage to find
out how a diagnosis of ischaemic heart disease was
made and in particular what investigations were
undertaken. The patient may well remember exercise
testing or a coronary angiogram, and some patients
can even remember how many coronary arteries were
narrowed, and how many coronary bypasses were
performed (having more than three grafts often leads
to a certain amount of boasting). The angioplasty patient
may know how many arteries were dilated and whether
stents (often called coronary stunts by patients and
cardiac surgeons) were inserted. Acute coronary
syndromes are now usually treated with early coronary
angioplasty.
Patients may recall a diagnosis of rheumatic fever
in their childhood, but many were labelled as having
‘growing pains’.15 A patient who was put to bed for a
long period as a child or who received many painful
buttock injections (of penicillin) may well have had
rheumatic fever. A history of chorea (quick abnormal
involuntary dance-like movements; p 600) is strongly
associated with rheumatic fever in girls. A history of
rheumatic fever places patients at risk of rheumatic
valvular disease.
Hypertension may be caused or exacerbated by
aspects of the patient’s activities and diet (see Questions
box 4.5). A high salt intake, moderate or greater alcoholCHAPTER 4 THE CARdIOvASCulAR HISTORy 71
T&O’C ESSENTIAlS
1. Breathlessness can be a result of cardiac,
respiratory or other problems. A careful history
will often help sort this out. Cardiac dyspnoea (i.e.
breathlessness due to cardiac failure) is worse on
exertion or when the patient lies flat
(orthopnoea).
2. Chest pain can be the result of non-cardiac
problems but the history often contains vital clues
that help sort out the diagnosis.
3. Ischaemic heart disease should be suspected from
the history. When angina is stable, the pain or
discomfort occurs with a predictable amount of
exertion and is relieved by rest. A recent increase
in the frequency or the occurrence of pain at rest
suggests worsening angina.
4. Dizziness and syncope can have cardiac and
non-cardiac causes. Proper history taking will
give the correct diagnosis in many cases and
indicate the best investigations in others.
5. Assessment of cardiac risk factors takes little time
and should be routine.
6. Patients know that cardiac disease can be life
threatening and that it sometimes causes sudden
death. The history should include sympathetic
questions about the effect of the illness.
use, lack of exercise, obesity and kidney disease may
all be factors contributing to high blood pressure.
Non-steroidal anti-inflammatory drugs (NSAIDs) cause
salt and fluid retention and may also worsen blood
pressure. Ask about these, about previous advice to
modify these factors and about any drug treatment of
hypertension when interviewing any patient with high
blood pressure.
SOCIAL HISTORY:
Both ischaemic heart disease and rheumatic heart
disease are chronic conditions that may affect a patient’s
ability to function normally. It is therefore important
to find out whether the patient’s condition has prevented
him or her from working and over what period. Patients
with severe cardiac failure, for example, may need to
make adjustments to their living arrangements so that
they are not required to walk up and down stairs at
home.
Most hospitals run cardiac rehabilitation programs
for patients with ischaemic heart disease or chronic
heart failure. They provide exercise classes that help
patients to regain their confidence and physical fitness,
along with information classes about diet and drug
treatment, and can help with psychological problems.
Find out whether the patient has been enrolled in one
of these and whether it has been helpful. Is this service
used as a point of contact for the patient if he or she
has concerns about new symptoms or the management
of medications?
The return of confidence and self-esteem is a very
important matter for patients and for their families
after a life-threatening illness.
FAMILY HISTORY
Certain heart diseases are genetic. Onset of heart
disease at a young age (e.g. as a result of familial
hypercholesterolaemia) or sudden death in the family
(e.g. hypertrophic cardiomyopathy, Brugada syndrome)
should raise the spectre of genetic disease.