St Emlyn’s Lesson Plans
Acute coronary syndrome: initial assessment
Connect the clinical story, ECG and assay-specific troponin pathway while recognising when treatment cannot wait.
Medical Students · 45-minute session
For learners
Before: Allow about 13 minutes in total.
When we meet: We will compare an urgent reperfusion presentation with an early troponin sample, using the local pathway to explain why their next steps differ.
For facilitators
Send: the learner preparation link before teaching.
Bring: Local pathway, blank handover card and optional ECG teaching image.
Before the session
If you are attending this session, complete the core preparation below before you come. Allow about 13 minutes in total.
Core preparation
NICE NG185 STEMI early management · About 5 minutes
Read the “Initial assessment” box and follow the primary PCI and fibrinolysis branches of this one-page STEMI summary. Focus on urgent assessment and access to reperfusion; the detailed antithrombotic choices can wait for the discussion.
https://www.nice.org.uk/guidance/ng185/resources/visual-summary-stemi-pdf-8900623405
NICE CG95 acute chest-pain assessment · About 5 minutes
Read 1.2.2.1–1.2.2.7 on the ECG and 1.2.5.7 on interpreting troponin in its clinical context. The facilitator will bring the current local assay pathway for the cases; you do not need access to a hospital intranet beforehand.
https://www.nice.org.uk/guidance/cg95/chapter/recommendations
Think about (allow 3 minutes): Which clinical and ECG findings would require action before the troponin result is available?
Picture the scene
A nurse brings you an ECG from a person with ongoing chest pain. The department is busy; you need to recognise whether this needs immediate review.
By the end of the session
- Identify a presentation requiring urgent senior ECG review and a reperfusion pathway.
- Explain what cardiac troponin can and cannot establish.
- Describe why a normal ECG or a single early result may not complete an ACS assessment.
After the session
- During your next chest-pain encounter, ask your supervisor to show where symptom timing changes the local troponin pathway.
Optional further learning
You do not need to complete this before attending. The listening time is additional to the core preparation above.
Optional listening · 19 min 30 sec
St Emlyn’s Podcast: Ep 299 - Which patients with chest pain need a troponin?
Explore how symptoms and clinical judgement influence the decision to request troponin.
Search for this episode by title in MedPod Learn if you want to record your listening there.
Identify one apparently reassuring feature that cannot safely exclude MI. Explain how a credible alternative diagnosis changes your assessment. The numerical estimates concern selected suspected-ACS populations; use the current local ECG/troponin pathway. If you have heard this episode before, bring your previous reflection.
https://www.stemlynspodcast.org/e/ep-299-which-patients-with-chest-pain-need-a-troponin/
Facilitator guide
Send learners the preparation link several days before teaching. Allow about 13 minutes in total.
Before learners arrive
- Bring the current local high-sensitivity troponin algorithm, including assay name, thresholds and sampling times. If it is unavailable, teach the interpretation principles and ask learners to identify the missing information; defer any numerical rule-out exercise.
- Confirm the urgent ECG/reperfusion route and use a licensed tracing or the written descriptions supplied here.
Equipment: Local pathway, blank handover card and optional ECG teaching image.
Setup: Two groups take opposite cases, then explain why their next action differs.
If the preparation has not been completed
Use five minutes instead of “Prepare together”. Display the NICE STEMI summary and the case’s written ECG description. Give pairs two minutes to decide whether action can wait for troponin, two to review the difference between an assay reference limit and a rule-out pathway, and one to check the local sampling plan. If the local pathway is unavailable, identify the missing information; do not invent cut-offs.
Suggested session plan
- 0–5 min — Explore. Ask what makes an ECG review urgent.
- 5–10 min — Prepare together. Clarify the difference between an assay reference range and a pathway threshold.
- 10–32 min — Discuss & Apply. Spend 10 minutes on reperfusion and 12 on troponin interpretation.
- 32–40 min — Consolidate. Ask pairs to hand over the STEMI case, then explain what remains uncertain after the second patient’s first troponin result.
- 40–45 min — Reflect & Transfer. Ask learners to find a supervised chest-pain encounter in which they can check the sample timing against the local pathway.
Start the discussion
Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.
Cases and discussion
Use these cases, or invite an anonymised case from the group that addresses the same questions.
Pain with regional ST elevation
A 50-year-old has ongoing pressure-like chest pain radiating to the arm and throat. ECG shows regional anterior ST elevation with reciprocal inferior change.
Add this information as the discussion develops:
- A learner proposes waiting for the troponin result.
- The patient becomes clammy and more hypotensive while the team is arranging review.
Ask the group:
- What needs to happen immediately?
- Which information belongs in the call to the senior/cardiology team?
- How does deterioration change the setting and monitoring?
Discussion notes
Points to draw out:
- Obtain immediate senior review and activate the local reperfusion route when the clinical and ECG assessment indicates STEMI; do not wait for troponin.
- NICE recommends a 300 mg aspirin loading dose for acute STEMI unless clear allergy; administration belongs within the supervised clinical plan.
- Assess and treat ABC problems, pain and complications while arranging definitive care. Oxygen is for hypoxaemia or other indicated resuscitation, not automatically for every chest pain.
- Record onset, ongoing symptoms, ECG findings, observations, allergies and relevant bleeding or medication history.
Common misconceptions:
- Thinking an apparently well patient can wait because the department is busy.
- Giving a full ACS drug bundle without considering contraindications or competing diagnoses.
For a more experienced group: Add abrupt maximal-onset pain with a neurological deficit and ask why aortic disease changes the urgent senior discussion.
A normal ECG and an early sample
A 35-year-old has intermittent central chest discomfort. The resting ECG is normal. Symptoms began recently and the first high-sensitivity troponin is below the laboratory’s reference threshold.
Add this information as the discussion develops:
- Use the local pathway supplied by the facilitator to check the assay and sampling-time requirements. If it is unavailable, list what must be known before a rule-out decision; do not choose a numerical cut-off.
- Contrast with an elevated troponin in someone with sepsis and no clear ischaemic history.
Ask the group:
- Is ‘below the reference range’ the same as meeting a rule-out threshold?
- What does a change between samples contribute?
- Does every raised cardiac troponin mean an acute coronary occlusion?
Discussion notes
Points to draw out:
- Interpret the assay, symptoms, timing and ECG together. Use the locally validated serial or single-sample pathway; avoid universal thresholds.
- A normal ECG does not exclude ACS. Myocardial injury has several causes; diagnosing MI needs the clinical context and evidence of ischaemia.
- Even when MI is excluded, explain the working diagnosis, uncertainty and return advice rather than saying all cardiac or serious causes have been ruled out.
Common misconceptions:
- Calling every result ‘negative’ without checking the actual algorithm.
- Explaining chronic elevation in kidney disease only as failure of clearance.
For a more experienced group: Ask how persistent concerning symptoms alter a reassuring biochemical pathway.
Important clinical points
- Urgent reperfusion assessment must not wait for a troponin result.
- A normal resting ECG cannot exclude ACS.
- The student must escalate concerning clinical features even if an automated ECG interpretation or laboratory flag appears reassuring.
Closing the session
Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.
- Give an immediate-action handover for the first case.
- Explain why the second case cannot be discharged on the word ‘negative’ alone.
- Describe what you would tell someone after MI has been excluded.
Key teaching points:
- Act promptly on clinical and ECG findings that need urgent reperfusion assessment.
- Interpret troponin as a marker of myocardial injury within the clinical context.
- After excluding MI, explain the remaining assessment and return advice.
Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.
Adapting the discussion
Uncertainty and local practice
Troponin pathways use assay-specific thresholds and sampling times. Apply the local pathway and seek review when clinical concern persists.
If the discussion drifts
Which decision does this ECG or result support now, and what remains unresolved?
For a more experienced group
Distinguish acute myocardial injury, type 1 MI and supply-demand ischaemia without using terminology as a substitute for a patient plan.
A 30-minute version
30 minutes: opening 3, local pathway 5, cases 15, consolidation 5, reflection 2.
Evidence and guidance
- NICE NG185 — Acute coronary syndromes and initial treatment.https://www.nice.org.uk/guidance/ng185/chapter/Recommendations
- NICE CG95 — Acute chest-pain assessment and test interpretation.https://www.nice.org.uk/guidance/cg95/chapter/recommendations
Suggested curriculum links
GMC Outcomes for graduates / MLA 2026: Acute coronary syndrome; ECG and investigation interpretation
Students connect a clinical assessment with appropriate urgent and supervised action.
Check these links against the learner’s stage and programme. Attendance at a teaching session does not establish competence.
Clinical review: awaiting clinician sign-off
The references have been checked during editing. A named clinician has not yet signed off the revised lesson collection. Use current local guidance when preparing to teach; editorial updates do not constitute clinical approval.
First published 2020-09-22 · Iain Beardsell.