SIU School of Medicine

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Department of Internal Medicine

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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