New guidelines for the diagnostics of coronary artery disease

The discussion on justification for the use of invasive methods of cardiac examination led to the update of the standards and recommendations for the cardiovascular diseases diagnostics. In Deutsches Ärzteblatt (Dtsch Arztebl Int 2017, 114 (42): 712-9), the National Guidelines for the Management of Patients with Chronic Ischemic Heart Disease (CAD) (Nationale Versorgungs Leitlinie Chronische Koronare Herzkrankheit (KHK)) have been published. The amendments made by Christian Abus (University Clinic of Cologne) mainly concerned the problems of cardiac diagnostics.

New guidelines recommend using the full range of non-invasive procedures, which are also characterized by high sensitivity and specificity, before the transition to the invasive procedures.

On the first stage of diagnostics, the attending physician should take an accurate history and assess the results, according to the updated scale of the IHD probability for patients with chest pain-Marburg Heart Score, which was included in this guideline.

To apply the scale, it is necessary to identify the presence of the following factors:

  • Age/sex.
  • Known clinical vascular disease.
  • Pain worse with exercise.
  • Pain not reproducible by palpation.
  • Patient assumes cardiac origin of pain.

1 point is assigned for each score variable, then the scores are summed and the resulting figure is correlated with the risk value: if the sum is 2 out of 5, the IHD development due to stenosis of the coronary vessels is low (<5%).

If a stable IHD is suspected, this guideline recommends to undergo a coronary angiography only if a revascularization is expected. It is possible to identify IHD, which developed due to coronary artery stenosis, using non-invasive diagnostic procedures with sensitivity and specificity of up to 85%. However, it should not be overlooked that if the probability of IHD development on the basis of a physical examination is less than 15% or more than 85%, the results can be either false-positive or false-negative. Non-invasive procedures include: CT angiography, stress ECG, myocardial perfusion SPECT study, cardiac stress perfusion MRI, dobutamine stress cardiac MRI. If the probability of IHD developing varies within 15% -30%, a stress ECG test can also be used.

For the first time in the guideline, an assessment of the psychological state was included, i.e. the physician should initially collect data on the patient’s mental, physical and social status. The best prognostic criteria is depressive disorder after an acute coronary syndrome.