Clinical Evaluation in the Initial Diagnosis of SIHD in Patients With Chest Pain: Recommendations Class I 1. Patients with chest pain should receive a thorough history and physical examination to assess the prob- ability of IHD before additional testing.52 (Level of Evidence: C) 2. Patients who present with acute angina should be categorized as stable or unstable; patients with UA should be further categorized as being at high, moderate, or low risk.4,4a (Level of Evidence: C) The clinical examination is the key first step in evaluating a patient with chest pain and should include a detailed assess- ment of symptoms, including quality, location, severity, and duration of pain; radiation; associated symptoms; provocative factors; and alleviating factors. Adjectives often used to describe anginal pain include squeezing, grip-like, suf- focating, and heavy, but it is rarely sharp or stabbing and typically does not vary with position or respiration. On occasion the patient might demonstrate the classic Levine s sign by placing a clenched fist over the precordium to describe the pain. Many patients do not, however, describe angina as frank pain but as tightness, pressure, or discomfort. Figure 4. Algorithm for guideline-directed medical therapy for patients with SIHD.* *Colors correspond to the class of recommendations in the ACCF/AHA Table 1. The algorithms do not represent a comprehensive list of recommendations (see text for all recommenda- tions). The use of bile acid sequestrant is relatively contraindicated when triglycerides are $200 mg/dL and is contraindicated when triglycerides are $500 mg/dL. Dietary supplement niacin must not be used as a substitute for prescription niacin. 