Acute Coronary Syndromes

ACUTE CORONARY SYNDROMES

Knowledge

Students should be able to define and describe:

the pathogenesis, signs and symptoms, clinical course, therapeutic options, and complications of unstable angina (USA), non-ST elevation (non-STE) and ST elevation (STE) myocardial infarction (MI).

the factors that may provoke or exacerbate ischemic chest pain by:

increasing myocardial oxygen demand

tachycardia or tachyarrhythmia

hypertension

increased wall stress (aortic stenosis, cardiomyopathy)

hyperthyroidism

decreasing myocardial oxygen supply

anemia, hypoxemia

the risk factors for the development of coronary heart disease

age and gender

family history of premature CAD

personal history of peripheral vascular or cerebrovascular disease

smoking

lipid abnormalities

diabetes mellitus

hypertension

obesity

sedentary lifestyle

cocaine use

estrogen use

chronic inflammation

the primary and secondary prevention of ischemic heart disease through the reduction of cardiovascular risk factors (e.g., controlling hypertension and hyperlipidemia, avoiding tobacco, and aspirin prophylaxis).

Skills

Students should demonstrate specific skills, including:

History-Taking Skills: Students should be able to obtain, document, and orally present a medical history that identifies and suggests the diagnosis of an acute coronary syndrome, including:

location, radiation and intensity of pain

duration of symptoms

associated symptoms – dyspnea, diaphoresis, nausea, lightheadedness

identification of cardiac risk factors

family history of coronary artery disease

tobacco use

hypertension

diabetes mellitus

dyslipidemia

precipitating factors

exertion, eating, stress

relieving factors

rest, nitroglycerine

Physical Exam Skills: Students should be able to perform an examination that suggests acute MI or ischemia, including accurate recognition of:

hypotension

anxiety

diaphoresis

pallor

dyspnea

pulmonary edema

crackles, rhonchi, wheezes, decreased breath sounds

abnormal heart sounds

S3, S4, murmurs, pericardial friction rub

When a heart murmur is present, students should be able to:

Identify timing

systolic vs. diastolic; holosystolic vs. ejection

Describe pitch, location and pattern of radiation

left ventricular failure, right ventricular failure

jugular venous distention

peripheral cyanosis and edema

carotid, abdominal and femoral bruits

Differential Diagnosis: Students should be able to generate a differential diagnosis of acute coronary syndrome by recognizing the specific history and physical exam findings that differentiate cardiac (stable/unstable/Prinzmetal’s angina, acute MI, dissecting aortic aneurysm, pericarditis) from non-cardiac causes of chest pain (musculoskeletal, gastrointestinal, pulmonary embolus, pneumonia)

Laboratory Interpretation: Students should be able to define the indications for and independently interpret:

12-lead electrocardiogram

chest x-ray

cardiac biomarkers indicative of myocardial necrosis

LDH and CK isoenzymes

troponins

myoglobin

Students should be able to define the indications for, and interpret with consultation the results of the following diagnostic tests and procedures:

echocardiogram – transthoracic and transesophageal

exercise stress test

stress thallium myocardial perfusion scan

dobutamine stress echocardiography

cardiac catheterization

helical CT scan

ventilation/perfusion (V/Q) lung scan

pulmonary angiography

Communication Skills: Students should be able to:

educate patients about reducing treatable cardiovascular risks through behavior modification and cardiac rehabilitation.

Management Skills: Students should be able to develop an appropriate evaluation and treatment plan for patients with acute coronary syndromes that includes:

identifying the indications, contraindications, mechanisms of action, adverse reactions and relative costs of the following medications:

anti-platelet agents (aspirin, clopidogrel)

nitroglycerine and long-acting nitrates

beta blockers

angiotensin converting enzyme inhibitors and receptor blockers

antithrombin therapy (unfractionated heparin, LMWH, warfarin)

glycoprotein IIb/IIIa inhibitors

lipid lowering agents

identifying the indications, contraindications, complications, long-term outcomes and relative costs associated with the following treatments:

thrombolytic therapy

percutaneous coronary intervention (with or without stenting)

coronary artery bypass graft surgery (CABG)

determining when to consult a cardiologist or other specialist in the management of patients with chest pain

Attitudes and Professional Behaviors

Students should be able to:

understand the emotional impact of a diagnosis of coronary artery disease and its’ potential effect of lifestyle (work performance, sexual function)

recognize the importance on early detection and modification of risk factors that contribute the development of atherosclerosis

Resources

Clerkship Seminar, “Acute Coronary Syndromes,” T. DeMartini, MD

Clerkship Seminar, “Basic EKG Interpretation,” S. Frank, MD

Clerkship Seminar, “Chest Radiograph Interpretation,” K.Kraudel, MD

Clinical Management Conference, A. Varney, MD

Clerkship Weekly Articles:

Week 1: “Unstable Angina Pectoris”, Yeghiazarians Y., Braunstein J., Askari A., and Stone P., NEJM, Jan. 2000, Vol. 342, No. 2, pp. 101-114

Week 2: “Evaluation of the Patient with Acute Chest Pain,” Lee T., Goldman L., NEJM, Apr. 2000, Vol 342, No. 16, pp. 1187-1195

Internal Medicine Clerkship Guide, Paauw, et al, Mosby 2003, pp. 23-26, 22-81, and 215-224

ACC/AHA Pocket Guideline: Management of Patients with ST Elevation Myocardial Infarction, July 2004

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