The evaluation of symptoms should be detailed and directed, as many patients are reluctant to volunteer such information. It should be noted whether patients have reduced their activity, perhaps in an effort to ameliorate anginal symptoms or as a symptom of ventricular dysfunction. The adverse prognostic importance of frequent, typical angina in patients with SIHD is evident in both older and newer studies of risk.57,126,127,1231,1232 Motivation and compliance with risk- reduction measures should be carefully assessed. In particu- lar, assistance with smoking cessation by means of a struc- tured program might be necessary for some patients. Careful attention must be paid to concomitant conditions, such as hypertension, diabetes mellitus, dyslipidemia, heart failure, and depression. 6.2.3. Focused Follow-Up Visit: Physical Examination The physical examination should be directed according to the patient s history. Every patient should have weight, BP, and heart rate measured. BMI and waist circumference can provide signs of additional risk. Signs of heart failure, such as elevated jugular venous pressure, hepatojugular reflux, pul- monary crackles, new murmurs or gallops, or edema, should be sought. The vascular examination should identify any change in peripheral pulses or new bruits. Coexistence of SIHD with extracranial carotid disease makes palpation and auscultation of the carotid arteries particularly important, and examination of the abdomen should include special attention to bruits or abnormally prominent pulsations of the abdomi- nal aorta. 6.2.4. Focused Follow-Up Visit: Resting 12-Lead ECG An ECG is necessary when there is a change in anginal pattern, symptoms or findings suggestive of a dysrhythmia or conduction abnormality, and near or frank syncope. 