Diagnosis and Management of Coronary Artery Disease: A Guide

The diagnosis and management of coronary artery disease rest on three things: picking up the disease early from often subtle symptoms, confirming it quickly with an ECG and a troponin test, and then matching each patient to the right treatment, whether lifestyle change and medicines, a stent or bypass surgery. Prevention and regular blood tests underpin all three.

That is the framework Dr. Biswarup Purkayastha, a cardiac surgeon by training and Consultant – Heart & Lung Transplant and Vascular Surgery at Artemis Hospitals, Gurugram, India, set out for general practitioners and physicians across Africa in November 2025. He built the session around a practical premise: not every health system has the same resources, so a physician has to know how to manage coronary artery disease when a catheterisation laboratory is hours away as well as when it is down the corridor. In his view, working within constraints makes a more able physician.

This guide covers the disease itself, prevention and risk stratification, the baseline blood panel, the management of stable angina, and the signals that a case has become too complex to manage locally. Two deeper articles cover the rest of the session:

• Heart attack symptoms in women, diabetics and men, and the first steps: recognition, the ECG and troponin, and the 120-minute emergency pathway.
• Left main disease and the case for bypass over a stent: the SYNTAX score, the trials, durability and total arterial revascularisation.

What coronary artery disease is

Coronary artery disease is a narrowing or blockage of the arteries that supply the heart muscle with blood. The heart has two main coronary arteries, the left and the right. The left main coronary artery is short: it divides into the left anterior descending artery, which runs down the front of the heart, and the circumflex artery, which travels around behind it. A blockage anywhere in this system starves part of the heart muscle of oxygen.

Where the blockage sits matters a great deal for treatment. Disease in the left main artery puts a large share of the heart muscle at risk at once, and Dr. Purkayastha treats it as a separate decision (see the bypass versus stent article). Disease in the right coronary artery is, in his words, extremely tricky, because it can present with nothing more than an irregular heartbeat.

Early warning signs of coronary artery disease

Coronary artery disease usually announces itself well before a heart attack. Dr. Purkayastha's list of early symptoms is deliberately broad:

• chest pain or chest tightness
• dyspnoea (shortness of breath)
• fatigue that comes on far more easily than before
• pain in the legs
• general weakness and a feeling of not being well

The practical test he gives patients is functional: if tasks they could do independently a month or two ago are now beyond them, they should see their general practitioner. These symptoms tend to appear much earlier in the course of the disease than a myocardial infarction (heart attack), which is the window in which the disease is easiest to treat.

Symptoms are not uniform. Women, particularly after menopause, often present softly and over several days, and people with diabetes may feel much less chest pain; these are the patients most easily sent home with an over-the-counter remedy. Those differences, and how to respond to a suspected heart attack, are covered in the article on heart attack symptoms and first steps.

How to prevent coronary artery disease

Prevention rests on six lifestyle levers. Dr. Purkayastha regards prevention as a very important part of the topic, and his prescription is specific:

• No smoking. In his phrase, cigarettes have no place in a patient's life.
• No alcohol. He set aside the long-running debate about red wine and the heart, citing the American Heart Association's position that no amount of alcohol protects the heart.
• A healthy diet. He describes optimal nutrition as a high-protein, high-fibre, low-fat, low-carbohydrate diet.
• Regular exercise. More than two hours a week, which he frames as about half an hour of walking or exercise on each weekday.
• A healthy weight, which he defines as a body mass index (BMI) of 20 to 25.
• Stress management, including yoga and meditation.

With the right diet, the right physical effort and well-managed stress, he believes coronary artery disease can be prevented about 80% of the time before it reaches the point of needing a stent or surgery. For people over 40, he recommends regular blood tests and a visit to the general practitioner about once every three months.

Where prevention is not enough, lifestyle change still forms the base of treatment for stable disease, alongside medicines for high cholesterol (dyslipidaemia), high blood pressure and diabetes. Only when these fail, or a heart attack occurs, does the patient move to angioplasty or bypass surgery.

Risk stratification: know each patient's numbers

Risk stratification means sorting patients with chronic disease into high, moderate and low risk, using regular blood tests and a database or electronic medical record of each patient's results. Dr. Purkayastha asks general physicians to be "on top of the game" with these patients. His reasoning is direct: the higher the risk category, the stronger the suspicion of a heart attack when symptoms appear; the stronger the suspicion, the quicker the treatment; and the quicker the treatment, the better the result.

Every diabetic patient, in his practice, needs an HbA1c (a measure of average blood sugar over about three months) every third month, and the physician should know each patient's number.

Blood tests for coronary artery disease: the baseline panel

For anyone with a high cardiovascular risk assessment score, Dr. Purkayastha uses a basic panel drawn from UK NHS guidance. Each test earns its place:

On CRP he made a point worth repeating: a raised CRP in a patient with chest symptoms can reflect a heart attack in the previous day or two. In that setting the rise can come from inflammation in damaged heart muscle rather than from an infection, although CRP is a non-specific marker and infection still has to be considered.

Troponin, a protein released into the blood when heart muscle is damaged and the key test for confirming a heart attack, is covered with the ECG in the article on heart attack diagnosis.

Stable angina treatment

Stable angina is the subset general physicians see most often. These are patients with coronary artery disease who have not had a heart attack but still have symptoms such as fatigue and chest tightness on exertion, with normal cardiac enzymes. The working diagnosis is stable coronary heart disease.

Dr. Purkayastha's approach to these patients has three parts:

1. Antiplatelet therapy. He starts aspirin together with clopidogrel. For long-term stable disease, guidelines generally recommend a single antiplatelet drug, low-dose aspirin, and reserve dual antiplatelet therapy for the months after a heart attack or a stent.
2. Lifestyle change, with exercise and diet aimed at lowering cholesterol.
3. Guideline-directed medical therapy (GDMT), the full set of evidence-based medicines for the condition, used consistently.

Done well, this slows the disease enough to allow time for a specialist referral.

On how long medical therapy alone can hold, his view is firm. Patients on optimal medical therapy without a stent or bypass do reasonably well in the short term, perhaps the first six months to a year, but in his assessment it is not a long-term fix: most will eventually need either stenting or surgery. Large randomised trials in stable coronary disease, the biggest of them published in 2020, found that for many stable patients an initial strategy of optimal medical therapy did not raise the risk of death or heart attack compared with early intervention, while revascularisation gave better relief of angina. Among stable patients with obstructive disease, he noted that for women, who tend to be somewhat frailer than men, stenting is often the better intervention.

He closed the point with a principle rather than a protocol: treatment cannot be the same recipe for everyone. Each patient is assessed in detail, classified as stable angina or an evolving heart attack, and then offered a treatment or sent to an expert.

When to refer for a coronary angiogram

A case needs specialist referral when the workup shows it. General practitioners across the region often face one decision above all: is this case simple enough to manage locally, or complex enough to refer, possibly abroad? Dr. Purkayastha's answer is that the workup decides.

The markers to watch are troponin and creatine kinase. A referral for an angiogram is warranted when:

• the cardiac enzymes are very high, or keep rising
• symptoms are worsening, or have not returned to normal, despite conservative treatment (antiplatelet drugs, or thrombolysis where angioplasty is not available); ongoing chest pain or failed thrombolysis calls for immediate transfer, and guidelines advise an angiogram within 2 to 24 hours even after successful thrombolysis

The right coronary artery trap

Right coronary artery disease can present as a cardiac arrhythmia rather than chest pain, and physicians end up treating the ECG instead of the blocked artery. The right coronary artery supplies the heart's natural pacemaker and conduction tissue in most people, which is why a slow or irregular rhythm can be its only sign. Dr. Purkayastha's rule: anyone over 40 with cardiovascular risk factors and an arrhythmia that is not easily explained should have a coronary angiogram or be referred to a specialist.

A young man with two years of chest pain

One case from the session shows the principle. A man in his late thirties had two years of exertional chest pain with breathlessness and weakness, relieved by rest or nitroglycerine. His ECGs, echocardiograms, blood tests and 24-hour Holter monitoring were essentially unremarkable, apart from borderline bradycardia (a slow heart rate) on one ECG. He did not smoke or drink, but his mother had died of heart disease.

Dr. Purkayastha suspected right coronary artery disease, which can be hard to detect on blood tests or even on CT. His recommendations:

• an invasive coronary angiogram, which he called cardinal, whether the patient is treated locally or abroad
• until then, dual antiplatelet therapy with clopidogrel 75 mg and aspirin 150 mg once daily
• a high-intensity statin, atorvastatin 40 to 80 mg or rosuvastatin 20 to 40 mg once daily, to stabilise the coronary plaque
• cardiac enzymes checked during the next episode of chest pain

A note on definitions applies here. Neither unstable angina nor a non-ST elevation myocardial infarction (NSTEMI) requires an ECG change. The difference is troponin: chest pain with a rise in troponin is an NSTEMI, while unstable angina is defined by ischaemic symptoms without a troponin rise.

Once the angiogram is done, a lesion that can be fixed with a stent should be stented; otherwise a surgical specialist should interpret the angiogram and decide between bypass, stenting or medicines alone.

Kidney failure and HIV

Two further groups need particular care. For an older diabetic patient on long-term haemodialysis who presents with an NSTEMI, Dr. Purkayastha's practice is to restart a single antiplatelet drug (aspirin), give unfractionated heparin, typically for up to 48 hours or until angiography, rather than low molecular weight heparin, which accumulates when the kidneys fail, and plan coronary angiography once symptoms settle. Current guidelines favour an invasive strategy within 24 hours for most high-risk NSTEMI patients, with the timing individualised in advanced kidney disease. For a frail, older patient of this kind, he considers a stent at times a very good way to buy time.

For people living with HIV who have angina, the standard is the same as for anyone else: coronary angiography under universal precautions. Hospitals accredited by the Joint Commission International (JCI) have protocols to isolate and treat these patients safely. In Dr. Purkayastha's words, their disease is stentable and operable, and patients living with HIV must not be denied treatment.

Managing coronary artery disease: stent, bypass or both

When medicines are no longer enough, the choice is between percutaneous coronary intervention (PCI, angioplasty with a stent) and coronary artery bypass grafting (CABG). Dr. Purkayastha sees a clear role for both. Left main disease, complex disease and younger patients generally do better with bypass surgery, ideally using arteries rather than leg veins as grafts. Frail and older patients, those who need a short hospital stay and patients in the middle of an acute heart attack often do better with a stent. The full reasoning, the SYNTAX score thresholds and the trial evidence are in the article on left main disease and bypass versus stenting. Indicative costs are on the CABG cost page and the angioplasty with stent cost page.

He made one further point on referrals: the local workup comes first. For the young man above, he asked for a CT coronary angiogram at the nearest facility and the report shared with his team, rather than the patient travelling straight away.

Dr. Purkayastha's separate masterclass on heart failure and coronary artery disease in the African population covers the burden of the disease across the continent and modern heart failure drugs. The questions doctors raised in this session, including pectoral muscle spasm, risk scores and an aortic case, are on the Live Discussion page. More on the specialty is on the cardiology and cardiac surgery hubs.