Exercise ECG

Role of stress tests in instrumental diagnostics

When managing cardiology patients, it is strongly recommended to consider specialized diagnostic procedures. This category primarily includes electrocardiography (ECG) and echocardiography (stress echocardiography), performed under physical exertion.

In addition to classical exercise tests, specialists may also consider alternative or complementary diagnostic tools as part of a comprehensive evaluation. These include cardiac magnetic resonance imaging (MRI), transesophageal echocardiography, and 24-hour ECG monitoring.

According to strict quality-of-care criteria for specialized medical care in adult patients with stable ischemic heart disease (IHD), basic instrumental diagnostics must include recording an electrocardiogram. This is a primary and indispensable step. As for echocardiography (as well as bicycle ergometry or coronary angiography in appropriate cases), its performance is strictly regulated: it is prescribed in situations where significant data are completely or partially missing after the completion of the primary health care stage.

Stratification of cardiovascular risk

A key stage in the management of patients with stable IHD is risk stratification. The physician must assess the probability of developing severe cardiovascular events. The main method used to objectively address this task is recognized as the non-invasive imaging stress test.

It is important to emphasize that the choice of diagnostic approach is always based on the evidence base. Cardiology utilizes levels of recommendation consensus and levels of evidentiary validity. For example, performing echocardiography is strictly regulated in various pathologies:

• In the presence of symptoms of aortic regurgitation (AR), echocardiography has a class I B recommendation.
• In chronic aortic regurgitation, the level of evidence is higher: class I B recommendation.
• To assess the aortic root in bicuspid aortic valve (BAV), class I B is also applied.
• For congenital anomalies of the aortic valve, level I B is used.

Antianginal and antithrombotic therapy

Following exercise testing and risk stratification, the list of mandatory therapeutic measures includes prescribing pharmacotherapy. Assessment of the quality of medical care implies monitoring the prescription of drugs to relieve angina attacks. Antianginal therapy should include combination therapy, selected in accordance with the approved algorithm. The main condition is the absence of medical contraindications.

Antithrombotic therapy aims to prevent life-threatening events:

1. Standard approach: Prescription of a single antiplatelet agent (acetylsalicylic acid or clopidogrel is used).
2. At high ischemic risk: The quality standard is the prescription of combination antithrombotic therapy.

This decision is made strictly based on clinical indications and in the absolute absence of contraindications in the patient.

Prognosis-modifying therapy for comorbidities

A comprehensive assessment of the condition helps identify the need for prognosis-modifying therapy. This treatment aims to correct comorbid conditions in stable IHD. The prescription of medications depends on the clinical situation and the absence of contraindications.

ACE inhibitors (ACEi) or angiotensin II receptor blockers (ARBs) are mandatory components of treatment in the presence of the following conditions:

• Reduction of left ventricular ejection fraction (LVEF) $\le$ 40%;
• Clinically overt heart failure;
• Arterial hypertension (AH);
• Chronic kidney disease (CKD);
• Diabetes mellitus.

Beta-blockers, in turn, form the basis of treatment for patients in whom stable IHD occurs against the background of:

• Arterial hypertension (AH);
• Chronic heart failure (CHF);
• Cardiac arrhythmias.

Strict adherence to these prescriptions is a crucial criterion for the quality of care.

Class and exam questions

What else to study on this topic

• Algorithms of combination antianginal therapy in stable IHD.
• Assessment of the aortic root in bicuspid aortic valve (BAV).
• Levels of recommendation consensus for congenital aortic valve anomalies.
• Choice between acetylsalicylic acid and clopidogrel in standard therapy.
• Indications for bicycle ergometry and cardiac MRI when primary diagnostic data are insufficient.

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.