Suspicion arises not from "cholesterol 5.2" but from a symptom in a territory, an early event, a family history or a physical sign (xanthomas, a bruit, an absent pulse, a pulsatile abdominal mass). The plan is sequential, not "all methods at once".
Step 1. Clinical picture and risk factors. Characteristics of the pain/claudication/neurological episode. Smoking, BP, diabetes, family history of premature ASCVD, drugs, alcohol. Anthropometry. Examination of the skin and tendons for xanthomas, xanthelasmas, arcus cornealis. Foot pulses, auscultation of the carotids, palpation of the abdomen.
Step 2. Basic laboratory tests. Lipid profile, as in Lesson 4.1. Glucose, HbA1c. Creatinine, eGFR, urine albumin/creatinine. ALT, AST, bilirubin (both as the liver background and as a baseline before a statin). TSH. The Kazakhstan Ministry of Health protocol No. 196 adds a complete blood count and hs-CRP depending on the situation.
Step 3. The instrumental minimum that protocol No. 196 considers the main one: BP; 12-lead ECG; transthoracic echocardiography; ultrasound of the lower limb arteries and the brachiocephalic vessels / duplex of the extracranial segment. This is not "a CT for everyone". It is a search for disease in several territories and a reclassification of risk.
Step 4. Deepening by the leading territory.
- Coronary: the ESC CCS 2024 algorithm — pre-test likelihood by a risk-factor-weighted model; with low (5–15%) and moderate (15–50%) pre-test likelihood — coronary CT angiography, if available and with expertise; with high (>50%) likelihood — a functional test or invasive angiography. The Agatston calcium score in the Kazakhstan Ministry of Health protocol: 0 — no signs, low risk; 1–10 — minimal calcification, moderate; 11–100 — usually plaques with stenosis up to 50%, high; 101–400 — high or very high; >400 — very high. ESC/EAS 2025 does not recommend CAC as mass screening, but considers it as a modifier at moderate risk and "around the decision threshold" (IIa B).
- Cerebral: duplex; with symptomatic stenosis — further imaging according to the stroke protocol (not this course).
- Peripheral: ABI, duplex, with critical ischaemia — angiographic anatomy for reconstruction.
- Aorta: abdominal aortic ultrasound as the method for measuring diameter (ESVS 2024); CTA — when the treatment threshold has been reached or when rupture is suspected.
- Renal: kidney size, eGFR; renal artery stenosis is not sought "in everyone with hypertension".
Step 5. The FH branch. DLCN, cascade screening, genetics at ≥6 points.
The boundary of the lesson. The plan does not include coronary angiography "because the cholesterol is high". Invasive angiography is a tool for high event risk or high likelihood of obstructive CAD, not a tool for dyslipidaemia screening. The course does not describe contrast CT protocols at eGFR <30: that is a decision about the risk of contrast-induced nephropathy in a specific service.