CARDIOLOGY

ACUTE CORONARY SYNDROME

Introduction

5 min

Introduce yourself and the group

Provide rationale for the session and relevance to clinical practice

Outline learning objectives:

Appreciate the spectrum of ACS regarding ECG and biochemical patterns
Interpret acute ECG changes and understand the clinical relevance of coronary vascular supply
Interpret biochemical testing for cardiac injury and strain
Consider the differential diagnosis in chest pain +/- breathlessness
Understand basic management of ACS and the role of primary PCI

Explain structure of session

Total time:

60 min

Number of students:

1-5

Grade of students:

3rd to 5th year medical students

Created by:

Dr Alex Henson

Uploaded:

16th September 2019

Last updated:

16th September 2019

Resources needed for this session:

Prescription chart, pen, paper, access to guidelines

Students can scan the QR code opposite to view all investigation results on their phone as you work through the session.

Resources linked to this session:

None

Activity 1: History Taking Skills

10 min

Ask the student(s) to take a history from a patient presenting with chest pain, considering their family history, past medical history and social history. Observe if time allows.

Activity 2: Case-Based Discussion

10 min

Ask the student(s) to present the key findings of the history and suggest a few reasonable differential diagnoses, including their rationale. Some points for discussion:

What initial investigations would you request and what are you assessing for?
What is the role of an ECG and troponin measurement?

Discuss with the students the spectrum of ACS and stable, unstable angina, non-STEMI and STEMI are categorised clinically. You may want to prompt students to construct the diagram opposite.

Activity 3: ECG Interpretation

10 min

Allow the students to view the patient's ECG. If none is available, or the ECG is non-diagnostic, consider using some of the examples below. Use the following prompts to facilitate discussion:

What is the abnormality shown (described in basic terms e.g. ST depression in leads II, III and AVF)?
Which coronary artery supplies the territory outlined by the ECG changes?
Assuming a positive troponin rise, which classification of ACS would this fall into?

Students can scan the QR codes to view the ECGs on their phones if required.

Example 1

Example 2

Example 3

Example 4a

Example 4b

Activity 4: Biochemistry of ACS

2 min

Discuss the use of the troponin test with learners including timings, pitfalls and interpretation alongside other conditions.

Activity 5: Initial Management

5 min

Ask student(s) to find the local ACS management protocol. Consider the patient they have just seen. Discuss:

Is this patient suitable for primary PCI? If not, who is suitable for primary PCI?
What is the initial medical management?
What factors influence your initial choice of antiplatelet therapy?

Ask the student(s) to find a drug chart and prescribe appropriate initial treatment. The QR code opposite links to the BNF if needed.

Activity 7: Follow Up and Further Management

5 min

Ask the student(s) to consider the scenario that the patient they have seen has undergone a coronary angiogram confirming coronary artery disease and a stent has been placed. The patient is now almost ready to be discharged. Consider: