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Coronary Artery Disease — Written Clinical Reasoning
DCE long-case preparation: structured written reasoning for acute coronary syndrome management, including problem-list synthesis, investigation interpretation, risk stratification, and integrated secondary prevention planning.
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FRACP DCEMRCP Part 2
Prompt
DCE long-case preparation: structured written reasoning for acute coronary syndrome management, including problem-list synthesis, investigation interpretation, risk stratification, and integrated secondary prevention planning.
SAQ 1 — Integrated Management of NSTEMI (20 marks, 30 minutes)
Prompt: Outline your immediate and integrated management plan for this patient, including acute pharmacotherapy, reperfusion strategy, secondary prevention, and comorbidity optimisation. Justify each decision with reference to evidence and risk stratification. [1]
Model Answer
Problem list (4 marks):
- High-risk non-ST-elevation myocardial infarction (NSTEMI) — GRACE 165, dynamic ST depression, troponin rise/fall
- Type 2 diabetes (HbA1c 72 mmol/mol) — under-optimised, high cardiovascular risk
- Hyperlipidaemia — on sub-target statin dose (atorvastatin 40mg, not high-intensity)
- Ongoing tobacco dependence (40 pack-years)
- Hypertension (BP 150/90 on amlodipine)
- Likely multivessel coronary disease — will require heart team assessment (diabetic) [1]
Immediate management — acute pharmacotherapy (6 marks): [1]
| Intervention | Dose / detail | Rationale |
|---|---|---|
| Aspirin | 300 mg loading (chewed, non-enteric), then 75–100 mg daily | Irreversible COX-1 platelet inhibition; foundational antiplatelet |
| Ticagrelor | 180 mg loading, then 90 mg BD | PLATO: 16% RRR vs clopidogrel in CV death/MI/stroke with mortality benefit. Preferred P2Y12 inhibitor for invasive-strategy ACS [1] |
| Anticoagulation | Unfractionated heparin (or enoxaparin) | Prevents further thrombus propagation pending angiography |
| High-intensity statin | Atorvastatin 80 mg immediately | Target LDL below 1.4 mmol/L post-ACS |
| GTN | Sublingual for ongoing chest pain | Venodilator reduces preload and myocardial oxygen demand |
| Oxygen | Only if SpO₂ below 90% | Routine oxygen in non-hypoxic MI may worsen outcomes |
Reperfusion strategy (3 marks):
- This patient is high-risk NSTE-ACS (GRACE >140, troponin rise/fall, dynamic ST depression). He is NOT very-high-risk (no haemodynamic compromise, refractory angina, cardiac arrest, mechanical complications, or acute heart failure).
- Indication: coronary angiography within 24 hours, with PCI to the culprit lesion if indicated.
- If angiography reveals multivessel disease (likely given diabetes and extensive risk factors), involve the heart team for CABG vs PCI decision. As a diabetic with potential complex disease, CABG may be favoured (SYNTAX and FREEDOM evidence) [6].
Secondary prevention plan (4 marks): [1]
| Therapy | Detail |
|---|---|
| Antiplatelet | Aspirin lifelong + ticagrelor for 12 months (post-ACS DAPT) |
| Statin | Atorvastatin 80 mg; target LDL below 1.4; add ezetimibe if not at target; consider PCSK9 inhibitor (evolocumab) if still above target (FOURIER) [4] |
| ACE inhibitor | Add ramipril or perindopril (post-MI with diabetes; stop amlodipine or add ACEi for BP control) |
| Beta-blocker | Bisoprolol or metoprolol (post-MI; also an anti-anginal and anti-hypertensive) |
| SGLT2 inhibitor | Empagliflozin or dapagliflozin (diabetes + post-ACS; reduces CV death and HF hospitalisation) |
| Smoking cessation | Offer varenicline or NRT; refer to cessation programme |
Comorbidity optimisation (2 marks):
- Diabetes: SGLT2 inhibitor addresses both glycaemic control and cardiovascular protection. Consider GLP-1 receptor agonist (semaglutide) for additional CV benefit and weight management. Continue metformin; review gliclazide (hypoglycaemia risk if adding SGLT2i).
- Blood pressure: Target below 130/80. ACE inhibitor + beta-blocker will help; titrate as outpatient.
- Renal function: Monitor with ACEi initiation and contrast exposure; acceptable creatinine rise up to 30%. [1]
Communication and follow-up (1 mark):
- Cardiac rehabilitation referral for structured exercise and education.
- Medication adherence counselling — explain that the 12-month DAPT is essential to prevent stent thrombosis.
- Advance care planning discussion appropriate at follow-up if LV dysfunction is confirmed.
- GP follow-up for cardiovascular risk factor optimisation. [1]
References5ShowHide
- [1]Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes N Engl J Med, 2009.PMID 19717846
- [2]Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation N Engl J Med, 2001.PMID 11519503
- [3]Wiviott SD, Braunwald E, McCabe CH, et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes N Engl J Med, 2007.PMID 17982182
- [4]Sabatine MS, Giugliano RP, Keech AC, et al. Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease N Engl J Med, 2017.PMID 28304224
- [6]Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease N Engl J Med, 2009.PMID 19228612