Ministry of health of Kyrgyz Republic

ALGORITHM IN CHRONIC CORONARY SYNDROM

Diagnostic approach by steps Step 4 Pre-test probability
I Assessment of symptoms and  Step 3 Blood tests for
clinical examination; rule out ACS. Typical Atypical Nonanginal Breathlessness
II Presence of comorbidities and
suspected CAD
quality of life. year М W М W М W М 
W • If ACS is suspected -
III Basic examination (ECG, troponin- highly
30-39 3% 5% 4% 3% 1% 1% 0 3%
biochemical tests, chest x-ray, sensitive
echocardiography). 40-49 22% 10% 10% 6% 3% 2% 12% 3% • General blood analysis
IV Assessment of pre-test
50-59 32% 13% 17% 6% 11% 3% 20% 9% • Creatinine, GFR
probability (PTP) and clinical
likelihood (CL) of CAD 60-69 44% 16% 26% 11% 22% 6% 27% 
14% • Lipid profile
V Selection of a diagnostic test based  • GlycoHb, Fasting
70+ 52% 27% 34% 19% 24% 10 32% 12% Plasma Glucose (PGTT)
on PTP and CL, patient
characteristics, preferences, %  • thyroid function in case
availability. Note: red color PTP >15% - non-invasive testing is most indicated; yellow color - PTP from 5 of suspected goiter
VI Treatment based on symptoms to 15% - consider diagnostic testing after assessing CL, if there are factors ↑PTP - non-invasive
and risk of possible CV events.
test; blue color - PTP <5% - very low probability of coronary artery disease.
Step 3 12-lead resting
Step 3 Recommended: Step 1 Typical angina: • retrosternal pain/discomfort behind the sternum or in the neck,
jaw, shoulder or arm; • occurs during physical activity; • stopped at rest or after taking
ECG for:
-Transthoracic echocardiography at - all patients with chest
rest for all patients for: nitroglycerin for 5 minutes.
Atypical angina: the presence of 2 of the above signs. pain;
a) exclusion of other causes of
Non-angina chest pain: 0 or 1 symptom - all patients during or
angina pectoris
after an episode of angina
b) detection of violations of regional with suspected unstable
contractility Step 4 Assessment of clinical
likelihood (CL) CAD.
c) determination of LV EF
PTP based on sex, age and nature of symptoms - ST segment changes
d) determination of diastolic function
during supraventricular
-Duplex scanning of the carotid tachyarrhythmia should
arteries to detect plaque in suspected Factors that reduce Factors that increase probability of not be used as evidence
CAD without overt atherosclerotic probability of coronary artery disease of CAD
disease coronary artery • CVD risk factors (DLP, DM, AH,
-Cardiac MRI with inconclusive disease smoking, family history of CVD) Holter ECG monitoring is
echocardiography • Normal stress ECG • ECG changes at rest (Q or ST/T changes) recommended
-Chest X-ray with atypical • No coronary calcium • LV dysfunction
- for patients with chest
on CT (Agatston score • Stress ECG changes
manifestations, complaints and clinic pain and suspected
= 0)* • Coronary calcium according to CT
of CHF, suspected lung disease arrhythmia
- with vasospastic angina
Clinical likelihood of CAD - should not be used as a
Step 5 Basic diagnostic tests routine test in patients with
Non-invasive functional imaging of suspected CAD
myocardial ischemia (ECHOCG stress, Contraindications for stress tests
MRI stress, PET stress, etc.) and/or MSCT Absolute Relative
of the coronary artery are recommended at • ACS • A-V high degree blockade
the initial stage of diagnosis in • Aortic dissection in acute form • Bradyarrhythmias Step 5 ECG stress test is
symptomatic CAD, if CAD is not • Aortic stenosis • Electrolyte imbalance recommended
excluded by assessing CL. • Hemodynamically significant or • Hypertension (SBP > 200 mmHg or - to determine exercise
poorly tolerated arrhythmias DBP > 110 mmHg) tolerance, symptoms,
If MSCT shows insignificant CA damage,
• Decompensated heart failure • Hypertrophic cardiomyopathy
non-invasive functional imaging of arrhythmias, BP response
• Acute myocarditis (obstructive)
myocardial ischemia is recommended. • Acute pericarditis • Mental or physical defects and event risk in individual
Invasive CAG is recommended: • Thromboembolism of the • Moderate or severe valvular stenosis patients;
- as a baseline test for high CL and/or pulmonary artery (acute form) • LCA trunk stenosis - as an alternative test to
angina symptoms on therapy and/or low • Acute pulmonary infarction • Systemic disease confirm/exclude CAD when
levels of exercise. It is necessary to • Tachyarrhythmias non-invasive imaging
determine the functional assessment of the methods are not available;
degree of stenosis - to confirm its - in the treatment of patients
hemodynamic significance (FFR ≤ 0.8, Determining the high risk of events in CCS to control symptoms and
iwFR ≤ 0.89) before revascularization if Clinical and primary instrumental assessment myocardial ischemia;
the stenosis is <90%. CAD PTP >15% + factors that increase PTP; - not recommended for
- in patients with doubtful results of non- Symptoms + LV EF<35%; diagnostic purposes in
invasive diagnostic methods. ECG stress test: ST-segment depression with exercise in patients with depressed ST
MSCT of the coronary arteries can be combination with symptoms (angina pectoris or shortness of at 1 mm and > on resting
considered as an alternative to ICA in case breath), life-threatening arrhythmias and inadequate BP response; ECG or on digoxin
of doubtful results of non-invasive Non-invasive functional imaging of myocardial ischemia
diagnostic methods. SPECT (single photon emission CT) / PET: Area of ischemia
Abbreviations: MRI - magnetic
MSCT of the coronary artery is not ≥10% of the myocardium of the left ventricle; resonance imaging, MSCT –
recommended for extensive coronary Stress echocardiography: ≥ 3 of 16 segments of stress-induced multispiral computer tomography,
calcification, arrhythmias, severe obesity. hypokinesia or akinesia; ECG – electrocardiography, ICA -
invasive coronary angiography,
MRI: ≥ 2 of 16 segments with perfusion defects on stress test or ≥ PET- positron emission tomography,
Abbreviations: CCS-chronic coronary syndrome, 3 dysfunctional segments on dobutamine test. GFR - glomerular filtration rate,
CAD- coronary artery disease, ACS-acute coronary Invasive imaging of myocardial ischemia EF- ejection fraction, RF- risk
syndrome, CHF-chronic heart failure, PTP-pretest MSCT-CA/invasive coronary angiography: 3rd vascular lesion of factors, DM-diabetes mellitus, BP-
probability, CL-clinical likelihood, CV-cardio- blood pressure, DLP-dyslipidemia,
vascular, LCA-left coronary artery, ACA - anterior
the CA with proximal stenoses; LCA trunk lesion or proximal RA OGTT-oral glucose tolerance test,
descending artery, FFR - functional flow reserve, lesion
iwFR - instantaneous wave-free ration Invasive functional testing: FFR1 ≤ 0.8, MFR ≤ 0.89.
 Step 5 Reducing cardiovascular
Step 5 Lifestyle change. Step 5 Stepwise anti-ischemic therapy risk
Education Steps Standard High heart Low heart LV dys- Low blood Lipid-lowering therapy:
 To give up smoking. Therapy rate (> 80 rate (< 50 function or pressure - statins are recommended for all
Avoid passive smoking. bpm) bpm) CHF patients with CCS; target LDL not
 A diet high in vegetables, 1 BB or BB or non- DHP-CCB BB Low dose BB or reached → add ezetimibe; target
fruits and whole grains.
CCB DHP-CCB non-DHP-CCB not achieved → add PCSK9
2 BB + DHP- BB + non- LAN + LAN / + IVB, RNZ or inhibitor.
Limit saturated fat to < CCB DHP-CCB IVB TMD
10% of total intake, The target level for CCS (very
3 + 2nd line + IVB DHP-CCB + 2nd line high risk) is ↓LDL by at least 50%
alcohol < 100 g/week or drug + LAN drug
<15 g/day. of the baseline and / or less than
4 + IVB,
 Moderate physical activity RNZ or 1.4 mmol / l (less than 55 mg / dl).
30-60 minutes at least 5 TMD At the second vascular event
days a week. Maintain a 2nd line drugs: LAN, RNZ, TMD, IVB within two years - < 1.0 mmol / l
BMI < 25 kg/m2. Not recommended combinations: DHP-CCB with non-DHP-CCB, BB with non- (less than 40 mg / dl).
DHP-CCB, non-DHP-CCB with ivabradine (unless HR>80) ACE inhibitors (or ARB2) are
recommended for CCS with CHF,
hypertension, diabetes, very high
Antiplatelet therapy for CCS in sinus rhythm High risk of ischemic events: multifocal coronary artery risk of CVD.
Aspirin 75-100 mg/d is recommended for disease + one of: DM; recurrent MI; APA; CKD with eGFR Other drugs: BB - with LV
previous myocardial infarction or myocardial 15–59 ml/min/1.73m2.
Moderate risk of ischemic events: at least one of:
dysfunction or systolic CHF; - for
revascularization; without MI or a long time with a previous MI
multivascular/diffuse CAD, DM requiring drug therapy,
revascularization, but with confirmed CAD on recurrent MI, APA, CHF, or CKD with GFR 15–59 with a rise in ST
imaging tests, may be considered; mL/min/1.73 m2 Myocardial revascularization in CCS
Clopidogrel 75 mg/d is recommended for High risk of bleeding: history of intracerebral hemorrhage or - is an adjunct to optimal medical
aspirin intolerance; preferred for APA, IS, TIA IS, and / or other intracranial pathology; recent GI bleeding;
therapy (OMT)
history. other GI pathology with a risk of bleeding; liver failure;
hemorrhagic diathesis or coagulopathy; "deep" old age or - indicated for stenosis > 90% or FFR ≤
Adding a second antiplatelet agent to aspirin
"weakness"; CKD with eGFR < 15 ml/min/1.73 m2. 0.8 (iwFR ≤ 0.89 or LV EF < 35% due to
for long-term therapy:
Risk of stent thrombosis (risk factors): stenting of the LCA ischemic cardiomyopathy; large
-should be considered for ↑ risk of ischemic
trunk, proximal AAD, or the last remaining open artery; ischemic area >10% LV
events and no ↑ risk of bleeding; suboptimal stent deployment; stent length >60 mm; DM; - decide on revascularization if the
-m.b. considered at moderate risk of ischemic CKD; bifurcation stenting with two stents; treatment of expected benefit outweighs its potential
events and without ↑ risk of bleeding. chronic total occlusion; previous stent thrombosis on risk
adequate antithrombotic therapy
Antiplatelet therapy for CCS with sinus Recommendations on the type of
rhythm after PCI revascularization depending on the
Aspirin 75–100 mg daily is recommended Antithrombotic therapy for CCS with AF severity of the lesion
after PCI (indications for DOACs) and PCI Lesion bypass PCI
Clopidogrel 75 mg is recommended after Aspirin and clopidogrel are given before PCI 1-vascular lesion
loading (600 mg) with aspirin daily after PCI - If there are no contraindications to DOACs, it is Without proximal IIb C IC
(any stent) for 6 months; if ↑ risk of bleeding - recommended to give preference to NOACs stenosis of the ADA
3 months, if very ↑ risk of bleeding -1 month. (apixaban 5 mg 2 times, dabigatran 150 mg 2 times, With proximal stenosis I A IA
endoxaban 60 mg 1 time or rivaroxaban 20 mg 1 of the ADA
Prasugrel or ticagrelor as initial therapy - at ↑
time) over VKA in combination with antiplatelet 2-vascular lesion
risk of stent thrombosis, complex main trunk
LCA, multivessel stenting, aspirin intolerance. drugs (if ↑ risk of bleeding - rivaroxaban 15 mg Without proximal IIb C IC
daily, or dabigatran 110 mg twice for long-term stenosis of the ADA
therapy). With proximal stenosis I B IC
Antithrombotic therapy for CCS with AF of the ADA
- After uncomplicated PCI:
(indications for oral a/coagulants) The defeat of the LCA trunk
• if the risk of bleeding outweighs the risk of stent SYNTAX (0-22) IA IA
- NOACs should be preferred over VKA; thrombosis, consider stopping aspirin early (≤ 1
- long-term DOACs therapy (NOACs or VKA, SYNTAX (23-32) IA IIa A
week) and continuing dual therapy with DOACs and SYNTAX >33 IA III B
time in the therapeutic range > 70%): clopidogrel; 3-vessel lesion without DM
• recommended for AF and CHA2DS2-VASc • if the risk of stent thrombosis outweighs the risk of SYNTAX (0-22) IA IA
≥ 2 in men and ≥ 3 in women; bleeding, consider triple therapy with aspirin, SYNTAX (>22) IA III A
•should be considered in AF and CHA2DS2- clopidogrel, and DOACs for ≥ 1 month total duration 3-vessel lesion with DM
VASc 1 in men and 2 in women. (≤ 6 months); SYNTAX (0-22) IA IIb A
- Aspirin 75-100 mg daily (or clopidogrel 75 - with indications for VKA - together with aspirin SYNTAX (>22) IA III A
mg daily) may be considered in addition to and / or clopidogrel, the dose of VKA is determined
DOACs in AF, history of myocardial by the INR 2-2.5, the time in the therapeutic range>
infarction, high risk of ischemic events With refractory angina, enhanced external
70%. counterpulsation, spinal cord stimulation,
without high risk of bleeding.
reducer for narrowing the coronary sinus are
considered.
Use of proton pump
inhibitors - at ↑ risk of DAPT options with aspirin 75–100 mg for ↑ or moderate risk of ischemic events and no high risk of bleeding
GI bleeding and A drug Dose Indications Peculiarities
therapy with aspirin, Clopidogrel 75 mg
DAPT, DOACs Prasugrel 10 mg/s or 5 mg/s (weight < 60 kg or > 75 years) age > 75 years
Rivaroxaban 2.5 mg 2 times a day 1 year after MI or multivessel coronary artery GFR 15-29
Ticagrelor 60 mg 2 times a day one year after MI with adequate DAPT

Abbreviations: BB - β-blockers, CCB - calcium channel blockers, non-DHP CCB - non-dihydropyridine calcium channel blockers, LAN - long-acting nitrates, IVB-ivabradine, RNZ-
ranolazine, TMD-trimetazidine, APA- arterial peripheral atherosclerosis, IS- ischemic stroke, TIA-transient ischemic attack, MI-myocardial infarction, PCI- Percutaneous coronary
intervention, CA-coronary artery, CABG- coronary artery bypass graft, AF - atrial fibrillation, DOACs - direct-acting oral anticoagulants, NOACs -new oral anticoagulants, VKA-
vitamin K antagonists , DAPT-dual antiplatelet therapy, INR-international normalized ratio, CKD-chronic kidney disease, OMT-optimal medical therapy, BMI-body mass index, GI
- gastrointestinal, LDL-low-density lipoprotein, ARB - angiotensin receptor blockers, ACE- angiotensin converting enzime