Lesson Plan – Acute Coronary Syndrome

Learning Objective

To learn about the pathophysiology, clinical presentation, investigation and treatment of Acute Coronary Syndrome (ACS)

Intended Learners – ED SHOs

Curriculum – CAP7

Task 1 – Knowledge

Read this comprehensive blog post from RCEM Learning. Focus particularly on the clinical assessment. Likelihood ratios are an excellent way of knowing how good a test is (when applied to a pretest probability). The higher the number the more likely a positive test is true and vice versa.

Task 2 – Podcast

We use High Sensitivity Troponin as a test to “rule out” ACS as a diagnosis. Listen to St Emlyn’s Rick Body on this podcast explain what troponin is and how we can use it in the ED.

Task 3 – “Face to Face”

This part of the teaching session should be lead by an experienced clinican. The cases provided are merely examples and if possible the learners should be encouraged to discuss patients they have seen in their clinical practice.

Case 1 – A patient with chest pain

A 50 year old man presents to the ED with sudden onset chest pain. The paramedics tells you he smokes 20 cigarettes a day and is on treatment for high blood pressure. The pain radiates into his right arm and up into his throat.

1, What other questions would you ask in the first few minutes of your clinical assessment?

2, An ECG is performed. What does it show?

3, What treatment would you give and what needs to happen next?

Case 2 – A patient with chest pain

A 35 year old man presents with an intermittant history of central chest pain. It does not radiate and can come on at any time. He smokes occasionally and does not use drugs. His mother and father are still alive and both have high blood pressure.

1, What other questions would you ask in the first few minutes of your clinical assessment?

2, What does his ECG show?

3, What test(s) would you do next?

Task 4 – Summary

In this session we have learned about the clinical assessment of the patient with acute coronary syndrome and the use of troponin to rule out a cardiac cause for chest pain.

Consider these questions based on your learning today

1, Which of these features of the history have the highest likelihood ratio, ie if present is most likely to suggest the patient has cardiac cause for their chest pain?

a, Pain radiating down the left arm
b, Pain radiating down the right arm
c, Pain described as a “pressure”
d, Associated with nausea and vomiting

Perhaps rather surprisingly the answer is (b) – pain radiating down the right arm. All of these features can be associated with ACS, but in the paper quoted the LR+ for right arm is 4.7.

2, Which of these statements about high sensitivity troponin is correct?

a, A negative hs-cTn means the patient cannot have ACS
b, Troponin is only released by cardiac muscle
c, The change in troponin between two measurements is important
d, Troponin is useless in patients with renal failure

The correct answer is (c). All muscle will release troponin if damaged, but it is the cardiac troponin that we are measuring in the diagnosis of ACS. Although often rasied in patients with renal faiulre (due to accumulation) the troponin will still go up in these patients if they have myocardial damage. Troponin will take some time to rise after myocardial damage, and “unstable angina” has often been considered a “troponin negative” state.

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