Bedside Teaching

Teaching Acute Coronary Syndrome Management in the Clinical Setting

The following teaching pearls are used by SHM’s ACS Advisory Board members to teach ACS management to residents and students. Submit your own to: acs@hospitalmedicine.org.

“Teaching about stress testing in patients admitted for ACS is an excellent opportunity to discuss the different uses of stress testing, particularly the difference between using it for diagnosis and prognosis. Depending on the level(s) of learners, this conversation can be used to address several different learning objectives including:  Risk-stratification methods in patients admitted with ACS, pre-test probabilities and likelihood ratios, treatment and testing thresholds, the role of conservative versus invasive management in differing populations of patients with ACS, and even the use of guidelines in clinical care.  The low risk chest pains are such a common reason for admission and often are thought of as having little educational value by the housestaff.  By being prepared to discuss several different aspects of the evidences and rationale that form the foundation for a very protocol driven approach to patient care, you can use these simple cases as excellent teaching opportunities.”

Chad Whelan, MD
Associate Professor of Medicine
University of Chicago
Chicago, IL

“I always remind my residents and students that not all patients with chest pain and elevated troponins have a diagnosis of NSTEMI.  I reinforce that 90% of diagnostic medicine is still in the history and physical examination and to always listen to the patient’s story before assuming any diagnosis based on test results.  Patients with pulmonary embolism, pericarditis/myocarditis, and vasospasm can all have chest pain and elevated troponins and these clinical entities must always be considered in this patient population.”

Mohammad Salameh, MD
Associate Program Director, Internal Medicine
Director of Academic Hospitalist and Inpatient Services
St. Joseph Mercy Hospital
Ypsilanti, MI

“I also remind my students and residents that: Not all patients with Acute Coronary Syndrome present with chest pain. Some patients present with atypical symptoms like dyspnea alone, nausea and/or vomiting, palpitations, syncope, or cardiac arrest. EKG may or may not show diagnostic changes in these patients. Therefore it is important not to ignore atypical symptoms in an appropriate clinical setting.” 

Yousaf Ali, MD, MS
Assistant Professor of Medicine
Hospital Medicine Division
Department of Medicine
University of Rochester Medical Center
Rochester, NY

“I always teach the residents to ignore a high CK-MB in the setting of a normal total CK and a negative troponin.”

Larry Appel
Assistant Professor of Medicine
Mercer University School of Medicine
Savannah, GA