Version July 2025
| Cause | History | Physical exam findings | Additional findings |
| Hypertrophic cardiomyopathy | Positive family history Exercise intolerance Exertional chest pain Atypical chest pain Angina Palpitations Syncope and/or arrhythmia | Dynamic systolic murmur | Laboratory: Not helpful ECG: Left ventricular hypertrophy or left axis deviation ST segment or T wave changes P-wave abnormalities Q waves Arrhythmias, premature ventricular beats |
| Dilated cardiomyopathy | Family history Decreased exercise tolerance, syncope Heart failure symptoms | Gallop Mitral regurgitation murmur | Laboratory (insufficient for diagnosis): Elevated D-dimer, BNP, and/or cardiac troponin I and T if ischemia and/or heart failure ECG: Intraventricular conduction delay High or low QRS voltages T-wave inversion Arrhythmia, premature ventricular beats |
| Anomalous coronary artery origin | Exertional chest pain Exertional syncope | Usually normal | Laboratory and ECG: Usually normal, unless coronary ischemia (refer to coronary ischemia below) |
| Coronary ischemia | Predisposing conditions:
| Tachycardia Tachypnea New murmur or gallop | Laboratory: Elevated cardiac troponin I and T ECG: ST segment depressions or elevation T wave changes Q waves |
| Severe left ventricular outflow tract obstruction | Exertional symptoms Exertional syncope | Loud systolic murmur | Laboratory: Not helpful ECG: Left ventricular hypertrophy Left ventricular strain pattern |
| Arrhythmia | Palpitations Syncope Positive family history | Irregular rhythm | Laboratory studies: Check serum potassium and calcium levels ECG: Atrial arrhythmia Ventricular arrhythmia Premature contractions Ventricular pre-excitation (Wolff-Parkinson-White) |
| Pericarditis | Positional chest pain Predisposing factors:
| Pericardial friction rub Tachycardia/tachypnea Distant heart sounds, JVD | Laboratory: elevated CRP, ESR, WBC (nonspecific) Elevated cardiac troponin I and T (minority of patients) ECG: PR-segment depression ST-segment:
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| Myocarditis | Fever Viral prodrome Short duration of symptoms New onset heart failure symptoms | Tachycardia Tachypnea With or without gallop rhythm, ventricular ectopy Cardiovascular collapse | Laboratory studies: Elevated cardiac troponin I and T, elevated BNP ECG: Diffuse ST segment changes T wave inversions Ventricular ectopy Low QRS voltages |
| Aortic dissection | Personal or family history of bicuspid aortic valve or connective tissue disorders (Marfan, Loeys-Dietz, Ehlers-Danlos type IV, others) Acute onset sharp or tearing type of pain | Marfanoid body habitus Bifid uvula | Refer to coronary ischemia above |
| Pulmonary embolus | Pain description: Acute onset, pleuritic, associated dyspnea Calf or thigh pain/swelling Personal or family risk factors (inherited thrombophilia, hypercoagulable states, immobilization, medications) | Tachypnea Right ventricular heave (elevated pulmonary artery pressure) Loud and/or unsplit S2 (if right ventricular pressure elevated) | Laboratory studies (insufficient for diagnosis): Decreased pulse oximetry, decreased PaO2 Elevated D-dimer, BNP, and/or cardiac troponin I and T ECG: Right ventricular hypertrophy Non-specific ST-segment and T wave changes; minority with S1Q3T3 pattern |
