Cardiology — Non-Surgical Diagnosis and Management of Heart Disease

Cardiology is the non-surgical specialty for heart and vascular disease. Patients come to a cardiologist when they need diagnosis, medical treatment and long-term monitoring — not open-heart surgery. Understanding this distinction matters: knowing which specialist to see avoids wasted appointments and unnecessary repeat investigations.

What a cardiologist does:

• Evaluates chest pain, palpitations, breathlessness and dizziness.
• Interprets ECG, echocardiography, stress tests, Holter monitoring and laboratory results.
• Plans medical treatment for hypertension, hyperlipidaemia, rhythm disorders, heart failure and stable coronary artery disease.
• Conducts risk assessment and, where appropriate, arranges referral for coronary angiography, balloon angioplasty/stenting or cardiac surgery.

What a cardiovascular surgeon does:

• Bypass surgery (coronary artery surgical revascularisation).
• Cardiac valve repair and replacement.
• Aortic aneurysm surgery, peripheral vascular procedures and varicose vein surgery.

At Nis Clinic these two specialties operate under one roof. If a surgical indication is identified during a cardiology consultation, the patient is directed to Cardiovascular Surgery on the same day — investigations are not repeated and all records remain in a single file. For patients in Northern Cyprus, this eliminates the burden of carrying documents between separate facilities.

Typical patient pathway:

1. Initial consultation: history, physical examination, blood pressure, ECG.
2. Diagnostic investigations: echocardiography, stress test, Holter monitoring and blood tests (lipid profile, troponin, NT-proBNP, thyroid function) as clinically indicated.
3. Diagnosis and treatment plan: lifestyle advice and, where necessary, initiation of medication.
4. Follow-up: review every 1–3 months according to treatment response; every 6–12 months for stable patients.

Hypertension (high blood pressure) is one of the most common reasons for a cardiology consultation. Diagnosis is not made on a single elevated reading; it requires repeated measurements using correct technique — a step that is frequently overlooked in practice.

Correct blood pressure measurement:

• Measure after sitting quietly for at least 5 minutes.
• Arm at heart level, feet flat on the floor.
• No coffee, tea, smoking or exercise in the 30 minutes before measurement.
• Take 2 readings at intervals and average them. A single reading does not confirm a diagnosis.
• The cuff must fit the arm. A small cuff on a large arm gives a falsely high reading.

Diagnostic criteria:

• Office reading ≥ 140/90 mmHg on several separate occasions.
• Home reading average ≥ 135/85 mmHg.
• 24-hour ambulatory blood pressure monitoring (ABPM): daytime average ≥ 130/80 mmHg.

ABPM is the gold standard for distinguishing white-coat hypertension (elevated only in the clinic) from masked hypertension (normal in the clinic, elevated at home). It is recommended in borderline cases before treatment is started.

When medication is started — our clinical approach:

The decision to prescribe is based not on the blood pressure reading alone, but on the overall cardiovascular risk profile. Factors we assess:

• Age, sex, smoking status, lipid profile and fasting glucose.
• Evidence of target organ damage (left ventricular hypertrophy, microalbuminuria, retinopathy).
• Coexisting diabetes, chronic kidney disease or coronary artery disease.

For patients with borderline blood pressure (130–139/85–89 mmHg) and no additional risk factors, a 3–6 month lifestyle trial is appropriate. During this period the goals are salt restriction, weight management, regular aerobic exercise and reduction of alcohol and smoking. If the response is insufficient, medication is introduced. Where risk is high or blood pressure is ≥ 160/100 mmHg, medication is planned at the first visit.

Is medication for life? This is a frequently asked question with no single answer. Some patients who lose significant weight, stop smoking and establish regular exercise are able to reduce or discontinue their medication under careful supervision. This decision is made by the doctor during regular follow-up. Stopping medication independently is dangerous.

This section is educational information and does not constitute personal medication advice. Decisions to start or stop treatment are made on an individual patient basis.

Three core diagnostic tools are used in cardiology. Each shows something different; they are frequently confused.

Electrocardiography (ECG):

Records the heart's electrical activity. It takes around 10 minutes, is painless and requires no preparation. It can show:

• Rhythm disorders (atrial fibrillation, ectopic beats, heart block).
• Acute ischaemia or myocardial infarction.
• Clues to structural change such as left ventricular hypertrophy.
• Drug effects (digoxin, antiarrhythmic agents).

An ECG is a snapshot in time. If symptoms are absent during the recording, the result may appear normal. This is why it is sometimes insufficient on its own.

Echocardiography (echo):

Ultrasound assessment of the heart's structure and function. Where an ECG shows "electrical" activity, an echo shows "mechanical" function. It takes approximately 15–30 minutes and is painless. It can show:

• Chamber dimensions and wall thickness.
• Valve structure and function (regurgitation, stenosis).
• Left ventricular ejection fraction (EF): the key indicator for heart failure assessment.
• Pericardial effusion, masses and congenital abnormalities.

Echo is a standard investigation for palpitations, a cardiac murmur, suspected heart failure and follow-up after myocardial infarction.

Stress (treadmill) test:

Continuous ECG recording while the patient exercises on a treadmill at progressively increasing workloads. Duration is 6–15 minutes depending on the patient's exercise capacity. Indications:

• Suspected exertional chest pain (stable angina).
• A patient with a coronary risk profile whose symptom-limited capacity is unclear.
• Monitoring treatment response in known coronary disease.
• Assessing whether a rhythm disorder is provoked by exercise.

A patient with a normal resting ECG may demonstrate ischaemia on exercise. A negative stress test does not definitively exclude coronary disease but is a reassuring indicator of low risk. Stress testing is not performed in suspected acute myocardial infarction, uncontrolled hypertension or severe valvular stenosis.

Decision framework: An ECG is typically performed at the first visit. If there are palpitations, a murmur or breathlessness, an echo is added. If chest pain is provoked by exertion, a stress test is planned. These three investigations are not a fixed sequence; they are tools selected according to the presenting symptom.

Palpitations, the sensation of the heart "skipping a beat" and brief episodes of dizziness are among the most common reasons for attending a cardiology clinic. These symptoms may represent a benign ectopic beat arising from anxiety, or a significant arrhythmia. The investigation that makes the distinction is usually not an ECG but a 24–48 hour Holter monitor.

What is a Holter monitor:

Electrodes attached to the skin and a small recording device provide continuous ECG recording for 24–72 hours. The patient continues normal daily activities and avoids contact with water. Any symptomatic episodes are noted in a diary. The recording is then analysed.

What a Holter monitor can detect:

• Atrial fibrillation (AF): the paroxysmal (intermittent) form in particular is rarely captured on a standard ECG.
• Frequency and character of ectopic beats.
• Episodes of ventricular tachycardia.
• Sinus pauses and atrioventricular blocks.
• Rhythm changes at specific times of day, during exertion or during sleep.

Atrial fibrillation (AF) — why it matters:

AF is characterised by irregular, rapid activation of the atria. It is not immediately life-threatening in itself, but it increases the risk of stroke by approximately five times on average; turbulent blood flow within the atria promotes clot formation. If a clot dislodges and travels to the brain, it can cause an ischaemic stroke.

AF management has two components:

1. Rate and rhythm control: Beta-blockers, antiarrhythmic drugs or, in selected patients, electrical cardioversion.
2. Anticoagulation: Anticlotting medication. Risk is stratified using the CHA₂DS₂-VASc score. Factors such as age, hypertension, diabetes, heart failure and prior stroke contribute to the score. A score of ≥ 2 in men or ≥ 3 in women is the typical threshold for anticoagulation. Anticoagulation-free monitoring may be appropriate in young, low-risk patients with isolated AF.

These decisions are individual. Not every patient with an AF diagnosis receives the same treatment. Bleeding risk, renal function and patient preference are all taken into account.

When to attend the emergency department:

• Palpitations with syncope (loss of consciousness).
• Palpitations with chest pain and breathlessness.
• Rapid, irregular palpitations lasting several hours that do not resolve spontaneously.

Brief, self-terminating palpitations are generally not an emergency, but if they recur they should be assessed in a cardiology clinic.

Coronary artery disease (CAD) results from atherosclerotic narrowing or occlusion of the arteries supplying the heart. The clinical spectrum is broad: from entirely silent disease through stable angina (exertional chest pain), acute coronary syndrome (unstable angina) and acute myocardial infarction.

Cardiology manages the medical side of this spectrum.

Stable angina — approach:

Chest pain brought on by exertion and relieved by rest is the typical presentation. Diagnosis involves:

• History (the most informative step).
• ECG (frequently normal at rest).
• Stress test or pharmacological stress test.
• Imaging: coronary CT angiography (non-invasive), myocardial perfusion scintigraphy.
• Coronary angiography (catheterisation) in high-risk patients or when non-invasive tests are insufficient.

The pillars of medical treatment:

• Antiplatelet therapy: Aspirin or, in selected patients, clopidogrel; prevents clot formation.
• Statin: Lowers LDL cholesterol and stabilises plaque. Target LDL in established CAD: < 70 mg/dL.
• Beta-blocker: Reduces angina and slows heart rate.
• Nitrates: Sublingual for acute episodes; long-acting formulations for chronic management.
• ACE inhibitor / ARB: Particularly where hypertension, heart failure or diabetes coexist.

Non-pharmacological measures: stopping smoking (the single most effective intervention), regular aerobic exercise, a Mediterranean-style diet and weight management.

When is angiography performed, and when is surgical referral made:

The decision to proceed to coronary angiography is guided by response to medical therapy, symptom severity and the ischaemic burden demonstrated on non-invasive testing. Angiography yields one of three outcomes:

1. Insignificant narrowing (< 50%): Continue medical therapy and follow up.
2. Significant single- or two-vessel disease: Percutaneous coronary intervention (PCI) — balloon angioplasty and stenting performed in the catheterisation laboratory.
3. Multi-vessel disease, left main coronary stenosis, or coexisting valve disease: Referral for coronary artery bypass grafting (CABG).

Surgical referrals at Nis Clinic are made to Cardiovascular Surgery in the same building. All investigations (echo, angiography DICOM, blood results) are transferred as a standard package. The patient does not have to start from the beginning at the surgical consultation.

Acute chest pain warning: New-onset chest pain that does not settle with rest, lasts more than 20 minutes and is accompanied by sweating or nausea is a medical emergency. Do not wait for a clinic appointment — attend the nearest emergency department (emergency number in Northern Cyprus: 112).

Heart failure is a chronic condition in which the heart cannot pump blood adequately. The term is often misunderstood — it does not mean the heart is about to stop. In the early stages, good medication management allows patients to lead active lives for many years.

Diagnostic components:

• Clinical features: reduced exercise tolerance, breathlessness, ankle swelling, nocturnal breathlessness.
• Echocardiography: ejection fraction (EF) determines the classification.
  • EF < 40%: heart failure with reduced ejection fraction (HFrEF).
  • EF 40–49%: heart failure with mildly reduced ejection fraction (HFmrEF).
  • EF ≥ 50%: heart failure with preserved ejection fraction (HFpEF).
• NT-proBNP blood test: an elevated value supports the diagnosis of heart failure.

Medication optimisation:

In HFrEF, four evidence-based drug classes (ACEi/ARB/ARNI, beta-blocker, MR antagonist, SGLT2 inhibitor) have been shown to extend survival significantly over the past decade. All are introduced at low doses and uptitrated gradually as tolerated. Dose adjustment is the most critical element of long-term cardiology follow-up.

Key message for patients: reducing or stopping medication independently leads to deterioration. All dosage questions should be discussed with the treating doctor.

Valvular disease follow-up:

Conditions such as aortic stenosis and mitral regurgitation typically progress slowly over years. During this period, monitoring is the cardiologist's responsibility: echocardiography once or twice a year, symptom review and medication adjustment. Surgical intervention is considered when specific thresholds are reached:

• Aortic stenosis: Onset of symptoms (exertional syncope, chest pain, breathlessness) or valve area < 1.0 cm² with high transvalvular gradient.
• Mitral regurgitation: Symptoms with severe regurgitation, or the onset of deterioration in left ventricular function.
• Aortic regurgitation: Left ventricular dilatation beyond a defined threshold.

When a surgical decision is reached, the patient is referred to Cardiovascular Surgery. In selected patients with aortic valve disease, TAVI (transcatheter aortic valve implantation) may be an option; this decision is made jointly by cardiology and cardiovascular surgery in a multidisciplinary meeting.

Follow-up intervals in practice: For stable known valvular disease, echo and examination every 6–12 months may be sufficient. In progressive disease, 3–6 month intervals are preferred. The schedule is individual for each patient.