Rational Pharmacotherapy in Cardiology

Advanced search

A New Diagnostic Algorithm for Examining Patients with Suspected Chronic Coronary Syndrome: Questions Remain?

Full Text:


In the new recommendations of the European Society of Cardiology for Chronic Coronary Syndrome, a new diagnostic algorithm is proposed in patients with suspected coronary artery disease (CAD). The purpose of this algorithm was to propose a solution of the accumulated problems in the diagnosis of CAD, in particular, a high frequency of negative non-invasive tests and unchanged coronary arteries during invasive coronary angiography. The new diagnostic algorithm includes a revision of the pre-test probability scale, the introduction of the concept of clinical probability, clarifies the role of various non-invasive tests with the central role of non-invasive testing for myocardial ischemia. However, due to the lack of data on a number of key issues, significant gaps remain that impede the use of this algorithm in practice. This review is devoted to the consideration of problematic issues of the proposed algorithm, while a critical analysis of the algorithm itself and an assessment of recent publications are carried out. Various aspects of the application of a new scale for assessing pre-test probability, determining the clinical probability of CAD, the choice of non-invasive and invasive diagnostic tests, the place of the load electrocardiography test in the diagnosis of coronary heart disease are examined in detail. Gaps in the evidence base and limitations of the algorithm are considered, as well as the possibility of its use in Russian conditions. This review can help in adapting new recommendations to domestic conditions, as well as help practitioners to use it in their daily work.

About the Author

A. N. Sumin
Research Institute for Complex Issues of Cardiovascular Diseases
Russian Federation

Aleksei N. Sumin - MD, PhD, Chief of Department of Multifocal Atherosclerosis, Research Institute for Complex Issues of Cardiovascular Diseases.

Sosnovy bulv. 6, Kemerovo, 650002.


1. Knuuti J., Wijns W., Saraste A., et al.; ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020;41(3):407-77. DOI:10.1093/eurheartj/ehz425.

2. Patel M.R., Peterson E.D., Dai D., et al Low diagnostic yield of elective coronary angiography. N Engl J Med. 2010;362(10):886-95. DOI:10.1056/NEJMoa0907272.

3. Korok E.V., Sumin A.N., Sinkov M.A., et al. The prevalence of intact coronary arteries in relation with indications for scheduled coronary arteriography. Russ J Cardiol. 2016;2:52-9 (In Russ.) doi: 10.15829/1560-4071-2016-2-52-59.

4. Alekyan B.G., Grigor'yan A.M., Staferov A.V., Karapetyan N.G. Endovascular diagnostics and treatment in the Russian Federation (2017). Endovaskulyarnaya hirurgiya. 2018;2:93-240 (In Russ.) DOI:10.24183/2409-4080-2018-5-2-93-240.

5. Montalescot G., Sechtem U., Achenbach S., et al. Task Force Members. 2013 ESC guidelines on the management of stable coronary artery disease: The Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013;34:2949-3003. DOI:10.1093/eurheartj/eht296.

6. Fihn S.D., Gardin J.M., Abrams J., et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2012;60:e44-e164. DOI:10.1016/j.jacc.2012.07.013.

7. Smeeth L., Skinner J.S., Ashcroft J., et al; Chest Pain Guideline Development Group. NICE clinical guideline: chest pain of recent onset. Br J Gen Pract. 2010;60(577):607-10. DOI:10.3399/bjgp10X515124.

8. Timmis A., Roobottom C.A. National Institute for Health and Care Excellence updates the stable chest pain guideline with radical changes to the diagnostic paradigm. Heart. 2017;103(13):982-6. DOI:10.1136/heartjnl-2015-308341.

9. Rio P., Ramos R., Pereira-da-Silva T., et al. Yield of contemporary clinical strategies to detect patients with obstructive coronary artery disease. Heart Int. 2016;10(1):e12-9. DOI:10.5301/heartint.5000224.

10. Tashakkor A.Y., Stone J., Mancini G.B. Is it time to update how suspected angina is evaluated prior to the use of specialized tests implications based on a systematic review. Cardiology. 2016;133(3):181-90. DOI:10.1159/000441562.

11. Nakas G., Bechlioulis A., Marini A., et al. The importance of characteristics of angina symptoms for the prediction of coronary artery disease in a cohort of stable patients in the modern era. Hellenic J Cardiol. 2019;60(4):241-6. DOI:10.1016/j.hjc.2018.06.003.

12. Sechtem U., Mahrholdt H., Ong P., et al. Testing in patients with stable coronary artery disease - The debate continues. Circ J. 2016;80(4):802-10. DOI:10.1253/circj.CJ-16-0220.

13. Camici P.G., Crea F., Ferrari R. Commentary: The new ESC guidelines for the diagnosis and management of chronic coronary syndromes. Int J Cardiol. 2019;297:19-21. DOI:10.1016/j.ijcard.2019.10.001.

14. Russian National Congress of Cardiology. September 24-26, 2019, Ekaterinburg. Video broadcast. Available from: ttps:// nacionalnyy_kongress_kardiologov_2019/videotranslyaciya/ (In Russ.)

15. Cheng V.Y., Berman D.S., Rozanski A., et al. Performance of the traditional age, sex, and angina typicality-based approach for estimating pretest probability of angiographically significant coronary artery disease in patients undergoing coronary computed tomographic angiography: results from the multinational coronary CT angiography evaluation for clinical outcomes: an international multicenter registry (CONFIRM). Circulation. 2011;124:2423-32,1-8. DOI:10.1161/CIRCULATIONAHA.111.039255.

16. Reeh J., Therming C.B., Heitmann M., et al. Prediction of obstructive coronary artery disease and prognosis in patients with suspected stable angina. Eur Heart J. 2019;40(18):1426-35. DOI:10.1093/eurheartj/ehy806.

17. Foldyna B., Udelson J.E., Karady J., et al. Pretest probability for patients with suspected obstructive coronary artery disease: re-evaluating Diamond-Forrester for the contemporary era and clinical implications: insights from the PROMISE trial. Eur Heart J Cardiovasc Imaging. 2019;20(5):574-81. DOI:10.1093/ehjci/jey182.

18. Winther S., Nissen L., Westra J., et al. Pre-test probability prediction in patients with a low to intermediate probability of coronary artery disease: a prospective study with a fractional flow reserve endpoint. Eur Heart J Cardiovasc Imaging. 2019;20(11):1208-18. DOI:10.1093/ehjci/jez058.

19. Juarez-Orozco L.E., Saraste A., Capodanno D., et al. Impact of a decreasing pre-test probability on the performance of diagnostic tests for coronary artery disease. Eur Heart J Cardiovasc Imaging. 2019;20(11):1198-207. DOI:10.1093/ehjci/jez054.

20. Genders T.S., Steyerberg E.W., Alkadhi H., et al. A clinical prediction rule for the diagnosis of coronary artery disease: Validation, updating, and extension. Eur Heart J. 2011;32:1316-30. DOI:10.1093/eurheartj/ehr014.

21. Genders T.S., Steyerberg E.W., Hunink M.G., et al. Prediction model to estimate presence of coronary artery disease: retrospective pooled analysis of existing cohorts. BMJ. 2012;344:e3485. DOI:10.1136/bmj.e3485.

22. Sumin A.N. The assessment of pretest probability in obstructive coronary lesion diagnostics: unresolved issues. Russ J Cardiol. 2017;11(151):68-76 (In Russ.) DOI:10.15829/1560-4071-2017-11-68-76.

23. Genders T.S.S., Coles A., Hoffmann U., et al.; CAD Consortium and the PROMISE Investigators. The external validity of prediction models for the diagnosis of obstructive coronary artery disease in patients with stable chest pain: insights from the PROMISE trial. J Am Coll Cardiol Img. 2018;11(3):437-46. DOI:10.1016/j.jcmg.2017.02.020.

24. R0nnow Sand N.P., Nissen L., Winther S., et al. Prediction of Coronary Revascularization in Stable Angina: Comparison of FFR CT With CMR Stress Perfusion Imaging. JACC Cardiovasc Imaging. 2020;13(4):994-1004. DOI:10.1016/j.jcmg.2019.06.028.

25. Sonck J., Miyazaki Y., Collet C., et al. Feasibility of planning coronary artery bypass grafting based only on coronary computed tomography angiography and CT-derived fractional flow reserve: a pilot survey of the surgeons involved in the randomized SYNTAX III Revolution trial. Interact Cardiovasc Thorac Surg. 2019 Mar 18. pii: ivz046. DOI:10.1093/icvts/ivz046.

26. Therming C., Galatius S., Heitmann M., et al. Low diagnostic yield of non-invasive testing in patients with suspected coronary artery disease: results from a large unselected hospital-based sample. Eur Heart J Qual Care Clin Outcomes. 2018;4(4):301-8. DOI:10.1093/ehjqcco/qcx048.

27. Adamson P.D., Newby D.E., Hill C.L., et al. Comparison of International Guidelines for Assessment of Suspected Stable Angina: Insights From the PROMISE and SCOT-HEART. JACC Cardiovasc Imaging. 2018;11(9):1301-10. DOI:10.1016/j.jcmg.2018.06.021.

28. Knuuti J., Ballo H., Juarez-Orozco L.E., et al. The performance of non-invasive tests to rule-in and rule-out significant coronary artery stenosis in patients with stable angina: a meta-analysis focused on post-test disease probability. Eur Heart J. 2018;39(35):3322-30. DOI:10.1093/eurheartj/ehy267.

29. Kaski J.C., Crea F., Gersh B.J., Camici P.G. Reappraisal of Ischemic Heart Disease. Circulation. 2018;138(14):1463-80. DOI:10.1161/CIRCULATIONAHA.118.031373.

30. Knuuti J. Diagnostics in the era of reduced prevalence of coronary artery disease [cited by Oct 20, 2019]. Available from:

For citation:

Sumin A.N. A New Diagnostic Algorithm for Examining Patients with Suspected Chronic Coronary Syndrome: Questions Remain? Rational Pharmacotherapy in Cardiology. 2020;16(3):474-480. (In Russ.)

Views: 236

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 License.

ISSN 1819-6446 (Print)
ISSN 2225-3653 (Online)