5. Secondary Care Themed Days

5.6. Day 7 Theme: Cardiovascular 2

 Introduction – Once admitted with an acute coronary syndrome a patient’s risk for further events may be stratified using their history, examination, investigation results and on-going symptoms. The patient’s secondary risk factors should be addressed and secondary prophylaxis should be instituted to improve prognosis. Patients deemed to be in a high-risk group should undergo further investigation and possible non-operative or operative intervention.

Case History: Mr Ali is a 54 year old Bangladeshi chef who walked into Newham A&E complaining of vague discomfort in his chest. He has a history of Type 2 Diabetes Mellitus and his brother had a CABG at the age of 45. As his ECG was unremarkable and Troponin I was negative, he was discharged from A&E. However, a month later, he returned with a further episode of chest discomfort.  His GP had referred him for an exercise stress test but he did not turn up as he didn’t think he could run on the treadmill because of arthritis in his knees.

 

During this placement you should observe how patients with acute coronary syndromes are investigated and treated. This includes the acute treatment of myocardial infarction and unstable angina and the subsequent work up to possible coronary artery bypass surgery. You should always bear in mind that these patients have a significant illness which may be associated with relatively acute deterioration and that post admission and operation they require a lot of rest and recuperation.

 

Learning Issues

  • What objective parameters may be used to stratify patients’ risk of further cardiac events? Who should be considered for further investigation? What may exclude a patient from further investigation?
  • What blood tests should be requested for a patient admitted with an acute coronary syndrome?
  • What are the indications and contra-indications to an exercise stress test (EST)? What reasons may stop an EST prematurely?
  • What are the major and minor risks of coronary angiography? What risks were your patients aware of?
  • What are the indications of coronary angioplasty +/- stenting and do they have any long term benefits over operative intervention?
  • What were the major problems faced by your patients post coronary artery bypass surgery? How were these dealt with by the care team and the patient?

 

Suggested Learning tasks

  • Record the conversation you have with a patient awaiting coronary angiography or CABG surgery.
  • Record the conversation you have with a patient following coronary intervention regarding the problems they may have faced post-procedure.