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IM2.1-24 | Acute Myocardial Infarction and Ischemic Heart Disease — Assignment

CLINICAL SCENARIO

You are a final-year MBBS student attached to the medical ward. A 58-year-old male, Mr Suresh Kumar, a bus driver from a semi-urban background, is admitted with a 3-hour history of crushing central chest pain radiating to the left arm. He is a chronic smoker (30 pack-years), hypertensive on amlodipine 5 mg, and has a family history of premature coronary artery disease (elder brother died at age 52 of a heart attack). His ECG on arrival shows 3–4 mm ST elevation in leads V1–V5, and his first troponin I is 6.8 ng/mL. He is haemodynamically stable: BP 130/80, HR 88/min, SpO2 97% on room air. Your task is to produce a structured clinical analysis and evidence-based management plan for this patient, followed by a brief patient counselling note.

Instructions

Write your structured case analysis in the five sections above. Use precise clinical language in Sections 1–4 (drug names, doses, ECG criteria, guideline targets). Section 5 should shift to plain, empathic patient-facing language. Do not copy SDL or textbook text verbatim — demonstrate your own clinical reasoning. Cite the specific guideline figures where relevant (e.g., STEMI ECG criteria, D2B time, LDL target). Word limit: 1,200–1,600 words.

Length: 1,200–1,600 words across all sections

What to Submit

Section 1: History Structure and ACS Classification

Guidance: Using the history provided and the additional elements you would elicit, present a structured ACS-focused history across the following 6 domains: (i) pain character, onset, radiation, and duration; (ii) associated symptoms (diaphoresis, dyspnoea, nausea, presyncope); (iii) cardiovascular risk factor profile (complete Framingham and INTERHEART risk factor inventory); (iv) relevant past history, medications, and allergies; (v) family history with exact relationship and age at event; (vi) social and occupational history relevant to prognosis and rehabilitation. Then classify his ACS type (STEMI/NSTEMI/UA) with explicit reference to ECG criteria and troponin findings. Approximately 300 words.

Section 2: ECG Interpretation and Infarct Localisation

Guidance: Provide a systematic ECG interpretation for the ECG described (ST elevation V1–V5). Include: rate, rhythm, axis, intervals (PR, QRS, QTc), and a description of the ST and T-wave changes. State the STEMI diagnostic criteria met (mm of ST elevation, leads involved). Localise the infarct territory and identify the most likely culprit coronary artery. Identify whether any additional ECG features should be looked for (RV involvement leads, posterior leads V7–V9). State which ECG findings would alter the management (e.g., new LBBB, de Winter pattern, aVR elevation pattern). Approximately 250 words.

Section 3: Acute Management Plan

Guidance: Write a timed, prioritised acute management plan covering: (a) First 10 minutes: immediate interventions, monitoring, IV access, oxygen indications; (b) Pharmacotherapy: list each drug by generic name, dose, route, and indication — include antiplatelet agents, anticoagulation, analgesia/antiemetic, and any contraindications relevant to this patient; (c) Reperfusion strategy: state whether this patient should receive primary PCI or fibrinolysis (justify with time targets), give the specific agent, dose, and co-treatment if fibrinolysis is chosen; (d) CCU admission criteria for this patient. State any drug explicitly contraindicated in this presentation and why. Approximately 400 words.

Section 4: Secondary Prevention and Discharge Planning

Guidance: Assuming successful primary PCI with a drug-eluting stent placed in the LAD, and a discharge LVEF of 38%: construct the complete discharge medication bundle with drug, dose, and duration for each agent. State the LDL-C target and the plan if target is not achieved at 6 weeks on atorvastatin 80 mg. Include referral to cardiac rehabilitation (type, setting, timing). List at least 3 lifestyle modifications with specific, actionable advice. Note any monitoring required at 4–6 weeks (bloods, echo, clinic). Approximately 300 words.

Section 5: Patient Counselling Note

Guidance: Write a brief (150–200 word) counselling note as if speaking to Mr Suresh Kumar using plain language he can understand. Explain: (a) what happened to his heart (avoid jargon — use simple analogies); (b) why all his medications are needed and the risk of stopping them; (c) the most important lifestyle change he can make (smoking cessation — give a specific, empathic recommendation); (d) what to watch for and when to return to hospital urgently. Use a tone that acknowledges his fear and validates his concerns, while motivating adherence. The note should be written in the second person (addressing the patient directly).

Grading Rubric — ACS Case Analysis and Management Plan Rubric

Criterion	Points	Full-marks descriptor
Clinical History and ACS Classification (Section 1): Structures the history to capture all ACS-relevant domains; correctly classifies the presentation as STEMI, NSTEMI, or UA with appropriate justification using ECG and troponin findings.	20 pts	All 6 history domains covered (pain character, onset, radiation, severity, associated symptoms, risk factors and medication history); classification correct with explicit reference to ECG and troponin criteria; distinction from key differentials explained.
ECG Interpretation and Localisation (Section 2): Correctly interprets the ECG systematically; identifies STEMI/NSTEMI ECG criteria; localises the infarct territory and names the likely culprit vessel; identifies any additional features (RV infarction, posterior MI, arrhythmia).	25 pts	Systematic ECG interpretation (rate, rhythm, axis, intervals, ST-T changes); correct STEMI criteria stated (≥2 mm elevation in V2–V3 or ≥1 mm elsewhere); culprit vessel named with lead-territory reasoning; at least one additional ECG feature identified if present.
Acute Management Plan (Section 3): Constructs a time-sensitive, evidence-based acute management plan with correct pharmacotherapy, anticoagulation, and reperfusion strategy appropriately chosen for the ACS type and available resources.	25 pts	Correct initial pharmacotherapy (aspirin + P2Y12 + anticoagulant) with doses stated; correct reperfusion strategy and timing (primary PCI ≤90 min D2B, or fibrinolysis if PCI unavailable in ≤120 min); correct CCU indications stated; no contradictory orders (e.g., nitrates in RV infarction).
Secondary Prevention and Discharge Planning (Section 4): Constructs a complete discharge medication bundle with correct drugs, doses, and durations; sets evidence-based LDL-C target; addresses cardiac rehabilitation and lifestyle counselling.	20 pts	Complete discharge bundle (aspirin + P2Y12 for 12 months + high-intensity statin + ACE inhibitor or ARB + beta-blocker ± MRA if LVEF ≤35%); LDL target <1.8 mmol/L stated with escalation plan; cardiac rehabilitation referral; at least 3 lifestyle counselling points.
Patient Counselling Reflection (Section 5): Writes a structured patient counselling note demonstrating empathic communication, plain-language explanation of the diagnosis and need for medication adherence, and sensitivity to patient concerns.	10 pts	Counselling note is empathic, uses plain language, addresses diagnosis explanation + medication adherence + lifestyle change; acknowledges patient's emotional response; no medical jargon without explanation.

PEER REVIEW

Review your peer's ACS case analysis using the rubric provided. For each section, assign a score and write one specific comment explaining your assessment — do not simply restate the rubric descriptor. Key checks: (1) Section 2 — are the STEMI criteria stated precisely (mm threshold, specific leads)? (2) Section 3 — is the P2Y12 agent choice correct for the reperfusion strategy? If thrombolysis was chosen, has the student avoided ticagrelor? (3) Section 4 — is the LDL-C target specified as <1.8 mmol/L? Is cardiac rehabilitation mentioned with timing? (4) Section 5 — does the note acknowledge the patient's emotional state, or is it merely a translated medication list? Complete your review within 72 hours of receiving the submission.