Core Competencies

1.1 Acute Coronary Syndrome

© 2017 Society of Hospital Medicine

Acute coronary syndrome (ACS) encompasses a spectrum of ischemic heart disease that may include unstable angina (UA), non–ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). Coronary artery disease (CAD) is the leading cause of mortality in the United States and accounts for 1 in 6 deaths annually. Each year, approximately 635,000 Americans have ACS and 300,000 have a recurrent event.1 Of persons who experience a coronary event or myocardial infarction, approximately 34% and 15%, respectively, will die.1 More than 45% of patients with symptoms of acute myocardial infarction arrive at the hospital 4 or more hours after symptom onset, and the mortality rate increases for every 30 minutes that elapse before a patient with ACS is diagnosed and treated.2,3 A shorter time to intervention leads to improved outcomes.4,5 If the acute stage of a myocardial infarction is survived, patients have a risk of illness and mortality that is 1.5 to 15 times higher than that of the general population.1,6 Annually in the United States, the number of hospital discharges with a primary or secondary diagnosis of ACS approaches 1.2 million.1 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 use resources. In addition, hospitalists initiate secondary preventive measures and facilitate adherence to outpatient medical regimens.

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KNOWLEDGE

Hospitalists should be able to:

  • Define and differentiate UA, NSTEMI, and STEMI.
  • Describe the pathophysiologic processes and variable clinical presentations of patients with ACS.
  • Distinguish ACS from other cardiac and noncardiac conditions that may mimic this disease process.
  • Describe the use of cardiac biomarkers in the diagnosis of ACS, including timing of testing and the effects of renal disease and other conditions (such as pulmonary embolism or sepsis) on cardiac biomarker levels.
  • Describe the role of noninvasive cardiac tests in the diagnosis and management of ACS.
  • Explain indications for and risks associated with cardiac catheterization.
  • Recognize indications for early specialty consultation, which may include cardiology and cardiothoracic surgery.
  • List the major and minor risk factors predisposing patients to CAD.
  • Explain the value and use of validated risk stratification tools.
  • Explain indications for hospitalization of patients with chest pain.
  • Explain indications and contraindications for fibrinolytic therapy.
  • Explain indications, contraindications, and mechanisms of action of pharmacologic agents that are used both upstream and downstream to treat ACS.
  • Describe factors that indicate the need for early invasive interventions, including angiography, percutaneous coronary intervention, and/or coronary artery bypass grafting.
  • Describe the optimal timeframe for coronary reperfusion when indicated.
  • Identify clinical, laboratory, and imaging studies that indicate severity of disease.
  • Recognize appropriate timing and thresholds for hospital discharge, including specific measures of clinical stability for safe transition of care.

SKILLS

Hospitalists should be able to:

  • Elicit a thorough and relevant medical history with emphasis on presenting symptoms and patient risk factors for CAD.
  • Perform 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, electrocardiography, 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 fibrinolytic therapy and/or early revascularization in a timely manner, and activate appropriate teams accordingly.
  • Treat patients’ symptoms of chest pain, anxiety, and other discomfort associated with ACS.
  • Initiate immediate indicated therapies when patients display symptoms and signs of decompensation.
  • Anticipate and address factors that may complicate ACS or its management, which may include inadequate response to therapies, hemodynamic and cardiopulmonary compromise, life-threatening cardiac arrhythmias, or bleeding.
  • Assess patients with suspected ACS in a timely manner, identify the level of care required, and manage or comanage the patient with the primary requesting service.
  • Communicate with patients and families to explain the history and prognosis of their cardiac disease.
  • Communicate with patients and families to explain tests and procedures and their indications and to obtain informed consent.
  • Communicate with patients and families to explain the use and potential adverse effects of pharmacologic agents.
  • Facilitate discharge planning early during hospitalization.
  • Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transition of care.
  • Initiate secondary preventive measures before discharge, which may include smoking cessation, dietary modification, and evidence-based medical therapies.
  • Communicate to outpatient providers the notable events of the hospitalization and postdischarge needs including outpatient cardiac rehabilitation.
  • Provide and coordinate resources to ensure safe transition from the hospital to arranged follow-up care.

ATTITUDES

Hospitalists should be able to:

  • 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.
  • Follow evidence-based recommendations, 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, and/or participate in efforts to develop protocols to rapidly identify patients with ACS and minimize time to intervention.
  • Lead, coordinate, and/or participate in efforts among 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 (eg, The Joint Commission, American Heart Association, American College of Cardiology, Agency for Healthcare Research and Quality).
  • Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize resource use, which may include order sets for ACS and chest pain.
  • Lead, coordinate, and/or participate in efforts to educate staff on the importance of smoking cessation counseling and other preventive 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.

References

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