The cardiac system is a vital component of the human organism and failures of both the pump and circulatory elements are significant contributors to illness. Cardiovascular disease, exacerbated by western lifestyles, is the leading cause of death in developed countries. Understanding how symptoms are manifested from the underlying pathophysiology is important in identifying the diagnosis. Carefully exploring signs and symptoms is a key skill as many patients, even those with marked heart disease may present with minimal clues. One of the commonest presenting complaints to emergency departments and the acute medical unit is chest pain, and once declared ‘troponin-negative, non-cardiac’ the search is often given up. This is the wrong approach, and we must endeavour to discover what ails our patients even if it doesn’t fit into a neat box.