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Acute coronary syndrome

Copyright © 2006 Society of Hospital Medicine

Acute coronary syndrome (ACS) defines a spectrum of ischemic heart disease that may include non‐ST‐segment elevation myocardial infarction (NSTEMI) and ST‐elevation myocardial infarction (STEMI). The American Heart Association (AHA) estimates that 942,000 people with ACS were discharged from acute care hospitals in 2002. This number increased to approximately 1.7 million when including secondary discharge diagnoses. According to the AHA, an estimated $142 billion will be spent on the treatment of heart disease in 2005. Hospitalists diagnose, risk stratify, and initiate early management of patients with ACS. Hospitalists provide leadership for multidisciplinary teams that optimize the quality of inpatient care, maximize opportunities for patient education, and efficiently utilize resources. In addition, hospitalists initiate secondary preventive measures, which increase compliance with outpatient medical regimens.

KNOWLEDGE

Hospitalists should be able to:

  • Define and differentiate ACS without enzyme leak, NSTEMI and STEMI.

  • Describe the variable clinical presentations of patients with unstable angina and acute myocardial infarction.

  • Distinguish ACS from other cardiac and non‐cardiac conditions that may mimic this disease process.

  • Describe how cardiac biomarkers are used in the diagnosis of ACS, including timing of testing, and the effects of renal disease and other co‐morbidities.

  • Describe the role of noninvasive cardiac tests.

  • Explain indications for and risks associated with cardiac catheterization.

  • List the major and minor risk factors predisposing patients to coronary artery disease.

  • Explain the value and use of validated risk stratification tools.

  • Explain indications for hospitalization of patients with chest pain.

  • Explain indications and contraindications for thrombolytic therapy.

  • Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat ACS.

  • Describe factors that indicate the need for early invasive interventions, including angiography, stenting and/or coronary artery bypass grafting.

  • Identify clinical, laboratory and imaging studies that indicate severity of disease.

  • Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

  • Elicit a thorough and relevant history with emphasis on presenting symptoms and patient risk factors for coronary artery disease (cad).

  • Conduct a physical examination with emphasis on the cardiovascular and pulmonary systems, and recognize clinical signs of acs and disease severity.

  • Diagnose acs through interpretation of expedited testing including history, physical examination, electrocardiogram, chest radiograph, and biomarkers.

  • Perform early risk stratification using validated risk stratification tools.

  • Synthesize results of history, physical examination, ekg, laboratory and imaging studies, and risk stratification tools to determine therapeutic options, formulate an evidence‐based treatment plan, and determine level of care required.

  • Identify patients who may benefit from thrombolytic therapy and/or early revascularization.

  • Appreciate and treat patient chest pain, anxiety and other discomfort.

  • Recognize symptoms and signs of decompensation and initiate immediate indicated therapies.

  • Anticipate and address factors that may complicate acs or its management, which may include inadequate response to therapies, cardiopulmonary compromise, or bleeding.

  • Assess patients with suspected acs in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.

ATTITUDES

Hospitalists should be able to:

  • Communicate with patients and families to explain the history and prognosis of their cardiac disease.

  • Communicate with patients and families to explain goals of care plan, discharge instructions, and management after release from the hospital.

  • Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

  • Communicate with patients and families to explain tests and procedures and their indications, and to obtain informed consent.

  • Recognize indications for early specialty consultation, which may include cardiology and cardiothoracic surgery.

  • Initiate secondary prevention measures prior to discharge, which may include smoking cessation, dietary modification, and evidence based medical therapies.

  • Employ a multidisciplinary approach, which may include nursing, nutrition, rehabilitation and social services in the care of patients with acs that begins at admission and continues through all care transitions.

  • Communicate to outpatient providers the notable events of the hospitalization and post‐discharge needs, including outpatient cardiac rehabilitation.

  • Provide and coordinate resources to patients to ensure safe transition from the hospital to arranged follow‐up care.

  • Utilize evidence based recommendations and protocols and risk stratification tools for the treatment of acs.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

  • Lead, coordinate or participate in efforts to develop protocols to rapidly identify patients with acs and minimize time to intervention.

  • Lead, coordinate or participate in efforts between institutions to develop protocols for the rapid identification and transfer of patients with acs to appropriate facilities.

  • Implement systems to ensure hospital‐wide adherence to national standards, and document those measures as specified by recognized organizations (jcaho, aha/acc, ahrq or others).

  • Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization, which may include acs and chest pain order sets.

  • Lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.

  • Integrate outcomes research, institution‐specific laboratory policies, and hospital formulary to create indicated and cost‐effective diagnostic and management strategies for patients with acs.

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