Ischaemic Heart Disease and Acute Coronary Syndromes — WACS Viva & Clinical Scenarios (Cardiovascular Medicine)

Exam-style ischaemic heart disease and acute coronary syndromes viva scenarios with examiner probes and model answers for Internal Medicine candidates.

Scenarios covered

• SCENARIO 1: A 54-year-old male with a 10-year history of type 2 diabetes mellitus presents to the emergency department with severe, crushing retrosternal chest pain of 90 minutes duration, radiating to the left arm and jaw, accompanied by diaphoresis and nausea. Blood pressure is 100/60 mmHg, heart rate is 105 beats per minute, and oxygen saturation is 96% on room air. The 12-lead electrocardiogram demonstrates 3 mm ST-segment elevation in leads V1 through V4 with reciprocal ST-segment depression in leads II, III, and aVF. The nearest percutaneous coronary intervention facility is 3.5 hours away. Outline
• SCENARIO 2: A 62-year-old female presents to the cardiology outpatient clinic with exertional chest tightness that reliably occurs after walking 200 metres on flat ground or climbing one flight of stairs, relieved within 5 minutes of rest. Her resting 12-lead electrocardiogram is normal, and baseline blood pressure is 135/85 mmHg. Detail the diagnostic algorithm to confirm obstructive coronary artery disease, outline the clinical utility of pre-test probability models, and describe the initial disease-modifying and anti-anginal medical regimen.
• SCENARIO 3: On day 4 post-inferior wall myocardial infarction, a 68-year-old female suddenly develops acute respiratory distress, severe hypotension (blood pressure 75/40 mmHg), and oliguria. Physical examination reveals cold, clammy extremities, bilateral diffuse pulmonary crackles, and a new, harsh pansystolic murmur loudest at the apex with radiation to the axilla. Describe the differential diagnosis, immediate bed-side diagnostic investigations, hemodynamic stabilization measures, and definitive management.
• SCENARIO 4: A 58-year-old male presents with accelerating episodes of chest discomfort occurring at rest over the preceding 48 hours. Serial high-sensitivity cardiac troponin I levels are significantly elevated above the 99th percentile with a rising and falling delta pattern. The electrocardiogram reveals 1.5 mm horizontal ST-segment depression in leads V4 to V6 and inverted T waves in leads I and aVL. Explain the pathophysiology distinguishing unstable angina from non-ST elevation myocardial infarction, apply validated clinical risk scores (TIMI/GRACE) to determine the timing of invasive coronary angiog
• SCENARIO 5: A 49-year-old commercial driver is recovering following an uncomplicated anterior myocardial infarction treated with successful primary percutaneous coronary intervention and drug-eluting stent placement to the left anterior descending artery. Detail the comprehensive secondary prevention regimen, including antiplatelet duration, lipid-lowering targets, neurohormonal blockade, lifestyle interventions, and the specific counseling required regarding return to work and driving regulations.