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Coronary heart disease: diagnosis
Medical expert of the article
Last reviewed: 04.07.2025
A reliable diagnosis of coronary heart disease based on questioning, anamnesis and physical examination is possible only in patients with classic angina pectoris or with a documented history of myocardial infarction with Q wave (post-infarction cardiosclerosis). In all other cases, for example, with atypical pain syndrome, the diagnosis of coronary heart disease is less reliable and is of a presumptive nature. Confirmation by additional instrumental research methods is necessary.
The nature of the pain in the chest can be used to assess the likelihood of coronary heart disease.
- "Classic" angina pectoris - the probability of coronary heart disease is 80-95%.
- Atypical pain syndrome (not all the signs of typical angina pectoris are present, for example, there is no clear connection with physical activity) - the probability of coronary heart disease is about 50%.
- Clearly non-anginal pain (cardialgia), no signs of angina pectoris - the probability of coronary heart disease is 15-20%.
These figures are calculated for men. The probability of coronary heart disease is much lower for women. For example, for men over 30 years old with typical angina pectoris, the probability of coronary heart disease is approximately 90%, while for women aged 40-50 years - only 50-60% (no more than for men with atypical pain syndrome).
Typical angina of effort in patients without ischemic heart disease (without coronary artery disease) can be observed in patients with aortic stenosis, hypertrophic cardiomyopathy, arterial hypertension (with left ventricular hypertrophy), heart failure. In these cases, there is "ischemia and angina without ischemic heart disease".
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Instrumental methods for diagnosing coronary heart disease
ECG recording at rest.
ECG recording during an attack of angina pectoris.
Long-term ECG monitoring.
Load tests:
- physical activity,
- atrial electrical stimulation. Pharmacological tests:
- with dipyridamole (curantil),
- with isoproterenol (isadrin),
- with dobutamine,
- with adenosine.
Radionuclide methods for diagnosing coronary heart disease
Echocardiography.
Coronary angiography.
Signs of ischemia during functional tests are detected using ECG, echocardiography and radionuclide methods.
ECG recording during an attack of angina pectoris
When providing emergency care, ECG recording during an attack of angina is of primary importance. If there are no changes on the ECG during an attack, this does not exclude the presence of myocardial ischemia, but the probability of ischemia in these cases is low (even if the cause of pain is ischemia, the prognosis for such patients is more favorable than for patients with ECG changes during attacks). The appearance of any ECG changes during or after an attack increases the probability of myocardial ischemia. The most specific are changes in the ST segment.
ST segment depression is a reflection of subendocardial myocardial ischemia, ST segment elevation is a sign of transmural ischemia (most often due to spasm or thrombosis of the coronary artery). Let us recall that signs of ischemia can be observed in patients who do not have coronary artery disease, for example, with left ventricular hypertrophy. When persistent ST segment elevation is registered, "acute coronary syndrome with ST segment elevation" is diagnosed, and in the case of a protracted attack of angina with any changes on the ECG (except for ST segment elevation) or even without ECG changes, "acute coronary syndrome without ST segment elevation" is diagnosed.
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Formulation of the diagnosis of ischemic heart disease
After the abbreviation IHD, it is necessary to indicate specific manifestations of myocardial ischemia: angina pectoris, myocardial infarction, postinfarction cardiosclerosis, acute coronary syndrome or painless myocardial ischemia. After this, complications of IHD are indicated, for example, heart rhythm disturbances or heart failure. It is unacceptable to use the term "atherosclerotic cardiosclerosis" instead of manifestations of myocardial ischemia, since there are no clinical criteria for this term. It is also impossible to indicate heart rhythm disturbances as the only manifestation of IHD immediately after the abbreviation IHD. In this case, it is unclear on what basis IHD was diagnosed if there are no signs of myocardial ischemia.