Diagnosis and Management of Coronary Artery Disease

Coronary artery disease begins with a blockage in one of the heart's two main arteries, the left and the right coronary systems that supply blood to the heart muscle itself. Left untreated, that blockage progresses from silent narrowing to angina to a heart attack, and the interval between those stages is where most of the difference in outcome gets decided. In a masterclass built specifically around variable-resource clinical settings, Dr. Biswarup Purkayastha, Consultant in Heart and Lung Transplant and Vascular Surgery at Artemis Hospitals, Gurgaon, walked general practitioners across Africa through the full arc of coronary artery disease: how to recognize it before it becomes an emergency, how to manage the emergency itself when a catheterization lab is not within reach, how to confirm the diagnosis with a minimum viable set of tests, and how to decide between stenting and bypass surgery once a patient reaches a specialist.

Recognize the disease before it becomes an emergency

Chest pain is the headline symptom, but Purkayastha's list of early warning signs is broader: breathlessness, unusual fatigue, pain in the legs, a generalized sense of not feeling well, and unexplained weakness. Any one of these, on its own, is reason enough for a patient to see a general practitioner, because these symptoms typically surface well before a full myocardial infarction. Presentation also differs by sex. Women tend to describe a classical jaw pain, shortness of breath, back ache and extreme fatigue, sometimes with nausea and vomiting. Men more often report sweating and a heartburn-like sensation that gets mistaken for reflux disease. Purkayastha's rule of thumb: if heartburn persists more than half an hour after the standard over-the-counter antacid, the patient needs a general practitioner immediately, not another dose of antacid.

The first 120 minutes matter more than the eventual procedure

When a patient is actively having a heart attack, the single most useful early intervention, according to Purkayastha, is aspirin: 300 mg total, whether as three 100 mg tablets or two 150 mg tablets, taken as soon as symptoms are recognized. That dose buys time to reach care. The next decision point is a 120-minute window. If a percutaneous coronary intervention (PCI) facility is reachable within 120 minutes, the patient should go straight to primary angioplasty, which Purkayastha describes as having a materially better chance of resolving the infarction than any medical-only pathway. If PCI is not reachable in that window, the fallback is fibrinolysis, typically streptokinase at 1.5 million units infused over one hour, alongside dual antiplatelet therapy. Purkayastha is direct about the tradeoff: the medical pathway carries a higher bleeding risk than primary PCI, but for a patient without cath lab access, it remains the better option over no treatment at all.

Confirming the diagnosis without over-testing

A working diagnosis of myocardial infarction rests on three things together: symptoms, an ECG, and a positive cardiac enzyme. ST-elevation and ST-depression are the two patterns to know on the ECG, corresponding to STEMI and NSTEMI respectively. For enzyme testing, Purkayastha highlighted a point-of-care troponin T kit, manufactured by Roche and sold under the Tropy brand internationally, that returns a result from a blood sample with two lines indicating a positive test. None of these three pieces of evidence, alone, is sufficient; the diagnosis is made when symptoms, ECG changes and enzyme positivity align.

For patients with a high cardiovascular risk score, Purkayastha referenced the UK's NHS guidance on a baseline blood panel: full blood count (to catch anemia or a clotting anomaly), creatinine (kidney function, which affects drug choice), liver function tests (historically used as an infarction marker before troponin), a clotting profile including INR (to guide anticoagulant choice), HbA1c every three months for diabetics, and BNP and CRP as inflammatory markers, with a BNP above 1000 flagging heart failure risk and an elevated CRP after a recent infarction reflecting inflammation rather than infection.

Choosing between stenting and bypass surgery

Once a patient reaches a specialist, the central decision is stenting versus coronary artery bypass grafting (CABG). Purkayastha's clearest rule concerns the left main coronary artery: disease here is, in his words, scientifically accepted as better served by CABG than by PCI, a conclusion he traces to four randomized trials, SYNTAX, NOBLE, PRE-COMBAT and EXCEL, of which SYNTAX and PRE-COMBAT specifically followed patients for roughly a decade and favored bypass for long-term, disease-free survival. The SYNTAX score, calculated from angiographic findings and available as a downloadable scoring sheet, further stratifies patients: below 22 favors PCI, 23 to 32 and above 32 both favor CABG.

Beyond the left main, Purkayastha's criteria favoring bypass include diabetes, reduced ejection fraction, multivessel disease, and any pathology in the ascending aorta; criteria favoring stenting include advanced age, frailty, reduced life expectancy, restricted mobility, and poor-quality graft conduits. His summary rule for younger patients: anyone with more than ten years of life expectancy should generally receive a bypass rather than a stent, because a stent is a time-limited stopgap while a well-performed bypass offers disease-free survival in excess of ten to twenty years.

Total arterial revascularization

Purkayastha's own operative practice favors total arterial revascularization, replacing an artery with an artery rather than harvesting a leg vein, in roughly 60 to 70 percent of his coronary bypass cases. He cited outcomes data from close to 4,000 patients treated between 2011 and 2018, in which CABG patients showed roughly half the mortality of PCI patients (13 percent versus 26 percent) and roughly half the rate of major adverse cardiovascular and cerebrovascular events.

Managing stable angina

Not every patient presents as an emergency. Patients with stable coronary heart disease, normal enzymes and no acute events are started on antiplatelet therapy (aspirin with clopidogrel), a statin, and lifestyle changes, with the goal of delaying progression until specialist referral is warranted. Purkayastha referenced trial evidence indicating that patients with obstructive coronary disease generally do better with active intervention (CABG or PCI) than on optimal medical therapy alone over the long term, even though medical therapy alone can hold many patients stable through the first six to twelve months.

Prevention and ongoing risk stratification

On prevention, Purkayastha's checklist is unambiguous: no smoking, no alcohol (he cited the American Heart Association's position that no amount of alcohol is protective for the heart), regular stress management, a BMI in the 20 to 25 range, and structured exercise. He asked general practitioners to institutionalize this: maintain a record for every chronic disease patient, order regular blood work, and use it to stratify patients into high, moderate and low risk categories, since risk stratification is what allows a practitioner to know which patients need closer surveillance before an event occurs.

The sections that follow take each of these areas in turn: symptom recognition, sex-specific and diabetic presentation, the emergency response protocol, diagnostic testing, the stenting-versus-bypass decision, total arterial grafting, stable angina management, prevention, and a set of real cases worked through directly with practitioners on the call.