Article Written by John Bielinski

History is the most important factor in the work up, treatment and evaluation of someone with cardiac ischemia.

The EKG is nice. Lab values are nice. But, most hinges on history then everything else combined. You need to get the history of the events of the chest pain and a good assessment of cardiac risk factors. History, history, history. As any clinician just out of school know the main components of the “history of present illness,” these components can easily be recalled by the mnemonic “COLDER FAST.”

• C=Character
• O=Onset
• L=Location
• D=Duration
• E=Exacerbation
• R=Relief
• F=Frequency
• A=Associate Symptoms
• S=Same Symptoms in the Past
• T=Treatment in the Past

Any person who is reading this blog right now, if they came in with chest pain and saw me in the emergency room, and they had a good enough story, they would be admitted, at least for a 23-hour admission, to have their chest pain worked up with observation, cardiac enzymes and/or non-invasive testing. Even though all the tests could be normal, I have admitted countless number of patients to the hospital for an acute coronary syndrome work-up even though their diagnostic tests were inconclusive or non-diagnostic.

There are good studies that a few percent of acute coronary syndromes are missed, and the only way to not miss these patients are to admit more for further testing. Even if the percent of missed acute coronary syndromes are 1%, I see 200-300 chest pain patients per year.

John is a speaker for the Skin, Bones, Hearts & Private Parts track. See John live at one of DMGCME’s 2014 events.