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  • image A careful history and physical examination are extremely important in diagnosing cardiovascular disease; they should be performed before any testing.

  • image Elevated jugular venous pressure (JVP) is an important sign of heart failure and may be used to assess its severity and the response to therapy.

  • image Heart sounds and heart murmurs are important in identifying heart valve abnormalities and other structural cardiac defects.

  • image Electrocardiography is useful for determining rhythm disturbances (tachy- or bradyarrhythmias).

  • image Exercise stress testing provides important information concerning the presence and severity of coronary artery disease; changes in heart rate, blood pressure, and the electrocardiogram (ECG) are used to assess the response to exercise.

  • image Echocardiography is used to assess valve structure and function as well as ventricular wall motion; transesophageal echocardiography is more sensitive than transthoracic echocardiography for detecting thrombus and vegetations.

  • image Radionuclides, such as technetium-99m and thallium-201, are used to assess myocardial ischemia and myocardial viability in patients with suspected coronary artery disease.

  • image When patients cannot exercise, pharmacologic stress testing is used to assess the likelihood of coronary artery disease.

  • image Cardiac catheterization and angiography are used to assess coronary anatomy and ventricular performance.

In the United States, cardiovascular disease (CVD) afflicts an estimated 85.6 million people (ie, greater than 1 in 3 adults) and accounts for 31% of all deaths. By 2030, 44% of the US population is projected to have some form of CVD. In 2011, the estimated direct and indirect cost of CVD—which includes hypertension, coronary heart disease, heart failure, and stroke—was $320.1 billion.1

Atherosclerosis, the cause of most CVD events, is typically present for decades before symptoms appear. With a thorough history, comprehensive physical examination, and appropriate testing, the individual with subclinical CVD usually can be identified, and the subject with symptomatic CVD can be assessed for the risk of an adverse event and can be managed appropriately.


The elements of a comprehensive history include the chief complaint, current symptoms, medical history, family history, social history, and review of systems.

The chief complaint is a brief statement describing the reason the patient is seeking medical attention. The patient is asked to describe his or her current symptoms, including their duration, quality, frequency, severity, progression, precipitating and relieving factors, associated symptoms, and impact on daily activities.

The medical history may reveal previous cardiovascular problems, conditions that predispose the patient to develop CVD (ie, hypertension, hyperlipidemia, or diabetes mellitus) (Table e11-1), or comorbid conditions that influence the identification or management of CVD. The patient should be asked about social habits that affect the cardiovascular system, including diet, amount of regular physical activity, tobacco use, alcohol intake, and illicit drug use. At present, family history of early onset CVD is the best available screening tool to identify patients with a genetic predisposition for CVD.

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