A detailed subjective assessment of symptoms can be an invaluable tool for the CR clinician, even in the absence of more accurate scientific risk stratification data. A patient describing nocturnal or resting symptoms will be a significant characteristic. Establishing a baseline pattern of cardiac-related symptoms could include questions on:

• trigger factors, e.g. level of exertion, specific daily activities, stress or emotion

• typical versus non-typical patterns of symptoms

• simple description of site and type of pain

• ability to recognise and manage symptoms or absence of symptoms.

Gathering all this information gives the CR exercise leader and CR team an initial indication of physical and psychological functioning, and of whether symptoms are likely to be a limiting factor. It also enables comparison of these factors pre- and post-rehabilitation, by which time the patient may have learnt to manage symptoms more effectively, have gained confidence and improved level of function.

Within the context of risk stratification, assessing cardiac symptoms directly links the ischaemic burden and functional capacity, if the patient can describe a level of exertion required to bring on symptoms. However, it must be remembered that the relationship between symptoms, functional ability and disease severity is complex; patients with the most severe disease do not always demonstrate the most limitation or disability. Lewin (1997) suggests that other factors, such as health beliefs, anxiety and depression, personality, social support, social class and the patient's own attempts to cope will influence the level of disability demonstrated (see more in Chapter 8).

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