Cardiologist: heart and vascular diseases

A cardiologist is a physician specializing in the diagnosis, treatment, and prevention of cardiovascular diseases, including coronary heart disease, hypertension, heart failure, arrhythmias, cardiovascular complications of diabetes, and valvular heart disease. Their expertise includes clinical assessment, interpretation of imaging studies, prescribing medications, and coordinating invasive procedures with cardiac surgeons and interventional radiologists. [1]

A cardiologist's work focuses on restoring and preserving cardiac function, reducing the risk of heart attack and stroke, and improving exercise tolerance and quality of life. The approach is multidisciplinary: the cardiologist collaborates with an endocrinologist, nephrologist, pulmonologist, therapist, and physiotherapist during rehabilitation after events and surgery. [2]

Modern cardiology relies on clinical guidelines regularly updated by specialized societies. The latest major documents from the European Society of Cardiology contain specific diagnostic and treatment algorithms for acute coronary syndrome, chronic ischemic heart disease, heart failure, and hypertension. Implementation of these guidelines improves the safety and effectiveness of treatment. [3]

In addition to treating existing conditions, a cardiologist performs screening and risk factor management, including monitoring blood pressure, lipid levels, glycemia, weight, physical activity, and smoking cessation. Preventive measures reduce the incidence of severe cardiovascular events and improve the prognosis in the population. [4]

When to see a cardiologist

Immediate consultation is indicated for acute symptoms: severe or prolonged chest pain, shortness of breath at rest, sudden loss of consciousness, markedly increased or decreased heart rate, acute swelling, or symptoms of heart failure. In such cases, urgent evaluation and possibly hospitalization are required. [5]

A routine visit is advisable for persistent or progressive dyspnea with exertion, persistent angina with minimal exertion, paroxysmal palpitations, asymptomatic hypertension with high blood pressure readings, high-risk lipid profile abnormalities, and a family history of risk factors. Early assessment allows for the initiation of interventions that prevent heart attack and reduce mortality. [6]

Patients with confirmed coronary artery disease require regular follow-up visits to assess the effectiveness of therapy, adherence, and the need for revascularization. Patients with heart failure require frequent monitoring to optimize drug therapy and prevent decompensation. [7]

Consultation is also indicated before planned major surgery in patients at risk for cardiovascular complications, in the case of progressive diabetes with organ damage, and before prescribing therapies affecting the cardiovascular system. In these scenarios, the cardiologist assesses the objective risk and recommends preventive measures. [8]

Initial appointment: what does a cardiologist evaluate?

The initial examination includes a history and complaint collection, risk factor assessment, physical examination, resting blood pressure measurement, heart rate assessment, and clinical assessment of peripheral edema. Information on exercise tolerance, tobacco dependence, medications, and comorbidities is important. The initial interview and examination guide the selection of further tests. [9]

Required simple tests during the appointment include a resting electrocardiogram and basic laboratory tests: complete blood count, biochemistry, creatinine to assess renal function, glucose, lipids, and inflammation risk markers as indicated. These data help quickly identify the cause of complaints and the risk of complications. [10]

Echocardiography, stress testing, and Holter monitoring are used to assess ischemia and cardiac function if arrhythmia is suspected. In most clinical cases, a combination of clinical assessment and basic instrumental testing allows for the development of a diagnostic and treatment plan. [11]

At the initial appointment, treatment goals, prognosis, and the need for immediate intervention are also discussed. If the risk is high, urgent follow-up examination or hospitalization in the cardiology department for advanced diagnostics is prescribed. [12]

Basic diagnostic methods

Electrocardiography remains a rapid and accessible test for detecting ischemia, worrisome arrhythmias, chamber strain, and electrolyte changes. A resting ECG is mandatory if there is any suspicion of an acute coronary event. [13]

Echocardiography provides a visual assessment of the heart's structure and left ventricular function, helps identify contractility disorders, valve pathologies, and assess pulmonary artery pressure. An echocardiogram is necessary when heart failure is suspected and when monitoring valve disease. [14]

Functional stress testing and scintigraphy are used to stratify the risk of ischemia in patients with suspected stable coronary artery disease. Coronary computed tomography with contrast allows noninvasive exclusion of significant coronary disease in patients with low-to-intermediate pretest risk. [15]

Invasive coronary angiography remains the standard of diagnosis and treatment for acute coronary syndrome and proven ischemia with a high pre-test risk. The decision for revascularization (percutaneous coronary intervention or coronary artery bypass grafting ) is made in a multidisciplinary manner, taking into account the anatomy and clinical presentation. [16]

Table 1. Clinical methods and their purpose

Method	What does it show?	When is it prescribed?
Resting electrocardiogram	Ischemia, arrhythmia, signs of hypertrophy	Any acute chest pain, arrhythmia
Echocardiography	Ejection fraction, valves, hemodynamics	Dyspnea, suspected heart failure, valve pathology
Holter monitoring	Paroxysms of arrhythmia	Intermittent heartbeats, fainting, palpitations
Load test	The degree of ischemia during physical exertion	Suspected stable coronary artery disease
Coronary CT	Coronary artery calcium, coronary anatomy	Low-moderate pre-test risk of coronary heart disease
Invasive coronary angiography	Degree of stenosis, possibility of PCI	Acute coronary syndrome, high probability of coronary heart disease

Treatment and management strategy

Treatment is based on a combination of non-pharmacological measures and proven pharmacotherapy. Non-pharmacological measures include smoking cessation, regular physical activity, weight loss in overweight patients, a diet low in salt and saturated fat, and glycemic control in diabetes. These interventions reduce the risk of heart attack and stroke. [17]

Drug therapy is tailored to the specific disease: for arterial hypertension – antihypertensive classes; for stable coronary heart disease – antiplatelet agents, a statin, a beta-blocker if indicated, and a renin-angiotensin system inhibitor. The secondary prevention strategy is based on current international recommendations. [18]

In chronic heart failure, the standard is early optimization of the "four drugs," which have been shown to reduce mortality and hospitalizations: a renin-angiotensin system inhibitor or receptor inhibitor, an SGLT2 inhibitor, a beta-blocker, and mineralocorticoid antagonists, depending on the indication and tolerability. This improves prognosis and quality of life. [19]

In emergency situations (acute myocardial infarction), the priority is to restore coronary perfusion as quickly as possible through reperfusion: percutaneous coronary intervention if possible, or thrombolytic therapy if immediate access to interventional cardiology is not available. Antiplatelet agents and anticoagulants are also administered according to protocols. [20]

Table 2. Pharmacotherapeutic groups and their role

Group	Examples	Who is it prescribed to?	The goal of therapy
Angiotensin-converting enzyme inhibitors	Ramipril, enalapril	Arterial hypertension, heart failure	Lowering blood pressure, cardiac remodeling
Beta blockers	Bisoprolol, metoprolol	IHD, heart failure, tachycardia	Reduction in heart rate, protective effect
Statins	Atorvastatin, rosuvastatin	High risk or CHF after a heart attack	Lowering cholesterol, preventing myocardial infarction
SGLT2 inhibitors	Dapagliflozin, empagliflozin	Heart failure independent of diabetes	Reduction in hospitalizations and mortality
Antiplatelet agents	Aspirin, clopidogrel	After revascularization, with ischemic heart disease	Prevention of thrombotic events

Arterial hypertension

New European guidelines for 2024 have clarified the definition of high blood pressure and simplified classification. Target blood pressure levels depend on age and comorbidities, and treatment is based on an early combination of two drugs when the initial level is significantly above the target. Monitoring blood pressure at home remains a key element of management. [21]

In younger patients and those with high risk levels, lower blood pressure goals are recommended, while in older patients and those with high levels of side effects, more individualized goals are chosen. Treatment is always accompanied by lifestyle modification. [22]

Arterial hypertension often coexists with other risk factors. A comprehensive approach assesses overall cardiovascular risk (SCORE2 and SCORE2-OP in the European scale) and determines the need for early aggressive therapy in patients with a high cumulative risk. [23]

Monitoring the effectiveness of therapy involves regular visits, home blood pressure measurements, and laboratory monitoring of renal function and electrolytes after initiation and titration of medications. This reduces the risk of complications and improves treatment adherence. [24]

Table 3. Target blood pressure levels

Age/condition	Target systolic pressure
Age <65 years	<130 mmHg as tolerated
Age 65-79 years	<140 mmHg, aim for <130 if tolerated
Age ≥80 years	Individualized, goal usually <150 mmHg with careful reduction
Patients at high risk of vascular complications	Target values reduce the baseline risk, individually

Heart failure: what you need to know

Current guidelines emphasize early optimization of drug therapy in patients with heart failure with reduced ejection fraction. Combinations of four main drug classes influence mortality and hospitalization rates and should be initiated and titrated rapidly if tolerated. [25]

Echocardiography is important in diagnosis to assess ejection fraction and natriuretic peptide markers to confirm or exclude heart failure. This helps differentiate cardiac and non-cardiac dyspnea and determine treatment strategies. [26]

Rehabilitation after decompensation includes educational programs, weight and diet management, adapted physical activity, and influenza and pneumococcal vaccinations as indicated. This reduces the risk of rehospitalization and improves quality of life. [27]

In refractory heart failure, the following devices are discussed: implantation of a cardioverter-defibrillator in patients with a high risk of ventricular arrhythmia and cardiac resynchronization therapy in patients with asynchrony of contraction. The decision is made taking into account the patient's prognosis and goals. [28]

Table 4. The basic “four” drugs for heart failure with proven effect

Class of drugs	Examples	Role in therapy
Angiotensin receptor inhibitors	Sacubitril/valsartan	Reduction of mortality in CHF with low fraction
SGLT2 inhibitors	Dapagliflozin, empagliflozin	Reduction in hospitalizations, positive effect in CHF
Beta blockers	Bisoprolol, carvedilol	Reducing mortality, controlling heart rate
Mineralocorticoid antagonists	Spironolactone, eplerenone	Reduction in mortality under certain criteria

Acute coronary syndrome

When acute myocardial infarction is suspected, the first priority is rapid triage and confirmation of the diagnosis using serial electrocardiograms and high-sensitivity troponin levels. Emergency reperfusion minimizes infarct size and improves outcomes. [29]

If ST-segment elevation infarction is detected, the priority is immediate percutaneous coronary intervention if it is available quickly; if access is not possible, pharmacological reperfusion is used. For unstable angina and non-ST-segment elevation infarction, the decision on invasive strategy is made by a multidisciplinary team based on risk. [30]

Thrombo- and anticoagulant therapy, as well as early antiplatelet therapy, are standard in the first hours of management; then, the secondary prevention regimen includes a statin, renin-angiotensin system inhibitors, and a beta-blocker as indicated. Attention is paid to the balance between bleeding and thrombotic risk. [31]

Post-infarction rehabilitation is essential for restoring function, reducing the risk of recurrence, and improving quality of life. Programs include risk factor management, physical training, and psychological support. [32]

Table 5. Algorithm for primary care in case of suspected acute coronary syndrome

Step	Action
1	Immediate ECG and troponin analysis
2	In case of ST-elevation - urgent revascularization (PCI) if possible
3	Antiplatelet and anticoagulant therapy according to the protocol
4	Evaluation of indications for long-term dual antiplatelet therapy
5	Rehabilitation and secondary prevention plan

Interventional and surgical options; devices

Percutaneous coronary intervention is the standard of care for infarction and is often used for symptomatic ischemia. The decision to use stenting or conservative management is made after assessing the anatomy and clinical presentation. [33]

Coronary artery bypass grafting is indicated for multivessel disease, large proximal stenoses of the left coronary artery, and complex anatomy, where surgical reconstruction provides better long-term results. The decision is made by a team of interventional cardiologists and cardiac surgeons. [34]

Implantable devices are important for arrhythmias and refractory heart failure: modes range from single- and dual-chamber pacemakers to cardioverter-defibrillators and cardiac resynchronization therapy systems. Indications are determined by the severity of symptoms, ejection fraction, and history of arrhythmias. [35]

Minimally invasive technologies and new techniques, including transcatheter valve replacement and technologies for the treatment of structural heart disease, are expanding treatment options for patients with high surgical risk. The choice of approach and method depends on the assessment of a multidisciplinary team. [36]

Table 6. Indications for devices and main interventions

Method	Main indications
PCI (stenting)	Acute infarction, symptomatic ischemia with suitable anatomy
CABG	Multivessel disease, stenosis of the left coronary artery
Cardioverter-defibrillator	Ejection fraction ≤35% after therapy optimization or life-threatening atrial fibrillation
Resynchronization therapy	Low ejection fraction with symptoms in dyssynchrony
Transcatheter valve replacement	High surgical risk in aortic stenosis

How to choose a cardiology center and prepare for your visit

When choosing a center, consider its required specialization: ECG monitoring, echocardiography, stress diagnostics, coronary angiography, and emergency revascularization. Multidisciplinary conferences improve the quality of decision-making in complex cases. [37]

Before a scheduled examination, it is helpful to have a list of current medications, previous test results, a symptom diary, and exercise tolerance data. For a scheduled coronary angiography, it is important to follow the preoperative regimen and discuss with your cardiologist the need to temporarily discontinue certain medications. [38]

The SCORE2 system and other validated scales are used for risk assessment and decision-making; their use helps to objectively guide the decision to initiate intensive therapy in patients with subclinical atherosclerosis. Discussion of treatment goals and potential side effects is a mandatory part of the routine consultation. [39]

After hospital discharge or when starting a new treatment regimen, scheduled visits are important for drug titration, monitoring of kidney function and electrolytes, and assessing adherence. Good communication with the center reduces the risk of readmissions. [40]

Codes and documentation

In international practice, ICD-10 and ICD-11 codes are used to formalize diagnoses: ischemic heart disease and myocardial infarction, arterial hypertension, heart failure, rhythm disorders, and valve diseases have their own categories. Correct coding facilitates statistics and access to targeted treatment programs. [41]

In registries and clinical protocols, the priority is the use of standardized terminology and accurate documentation of laboratory and instrumental data for subsequent audit and treatment quality. This is important for assessing the effectiveness of therapy and participation in clinical trials. [42]

When issuing sick leave, referrals, or insurance claims, the cardiologist provides a structured report with the clinical picture, examination results, and treatment plan. This facilitates communication with other specialists and the patient. [43]