The Core Competencies in Hospital Medicine—Clinical Conditions 2023 Update

Acute Coronary Syndrome Acute Kidney Injury Acute Pancreatitis Alcohol Withdrawal Asthma Cardiac Arrhythmia Chronic Obstructive Pulmonary Disease Community-Acquired Pneumonia Decompensated Cirrhosis Delirium and Dementia Diabetes Mellitus Gastrointestinal Bleed Heart Failure Hypertension in Hospitalized Patients Hyponatremia Nosocomial Pneumonia (previously titled Hospital-Acquired Pneumonia) Opioid and Other Substance Use Disorders Pain Management Perioperative Medicine Sepsis Skin and Soft Tissue Infections Stroke Syncope Urinary Tract Infection Venous Thromboembolism Acute coronary syndrome (ACS) encompasses a spectrum of ischemic heart disease that may include unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). Heart disease, including coronary artery disease (CAD), is the leading cause of mortality in the United States.1 Urgent evaluation and treatment is critical for improving outcomes.2 Hospitalists diagnose, risk stratify, and initiate early management of patients with ACS. Hospitalists provide leadership for multidisciplinary teams that optimize the quality of inpatient care, maximize opportunities for patient education, and efficiently use resources. In addition, hospitalists initiate secondary preventive measures and facilitate adherence to outpatient medical regimens. Define and differentiate UA, NSTEMI, and STEMI. Describe the pathophysiologic processes and variable clinical presentations of patients with ACS. Distinguish ACS from other cardiac and noncardiac conditions that may mimic this disease process. Describe the use of cardiac biomarkers in the diagnosis of ACS, including timing of testing and the effects of renal disease and other conditions (such as pulmonary embolism or sepsis) on cardiac biomarker levels. Describe the role, diagnostic accuracy, and limitations of noninvasive cardiac tests in the diagnosis and management of ACS. Explain indications for and risks associated with cardiac catheterization. Describe the indications for early specialty consultation, which may include cardiology and cardiothoracic surgery. List the major and minor risk factors predisposing patients to CAD. Explain the value and use of validated risk stratification tools including evidence-based indications for hospitalization of patients with chest pain. Explain indications and contraindications for fibrinolytic therapy. Explain indications, contraindications, and mechanisms of action of pharmacologic agents that are used pre- and postrevascularization. Describe factors that indicate the need for early invasive interventions such as angiography, percutaneous coronary intervention, and coronary artery bypass grafting. Describe the optimal timeframe for coronary reperfusion when indicated. Identify clinical, laboratory, and imaging studies that indicate the severity of acute events and inform the expected prognosis. Describe appropriate timing and thresholds for hospital discharge, including specific measures of clinical stability for safe transition of care. Elicit a thorough and relevant medical history with emphasis on presenting symptoms and patient risk factors for CAD. Perform a physical examination with emphasis on the cardiovascular and pulmonary systems and recognize clinical signs of ACS and disease severity. Diagnose ACS through interpretation of expedited testing including history, physical examination, electrocardiogram, chest radiograph, and biomarkers. Use risk stratification tools to determine appropriate site of testing and treatment for patients presenting with chest pain and communicate recommendations to patients and families. Synthesize results of history, physical examination, electrocardiography, laboratory and imaging studies, and risk stratification tools to determine therapeutic options and formulate an evidence-based treatment plan. Identify patients who may benefit from fibrinolytic therapy and/or early revascularization in a timely manner, and activate appropriate teams accordingly. Treat patients' symptoms of chest pain, anxiety, and other discomfort associated with ACS. Initiate immediate indicated therapies when patients display symptoms and signs of decompensation. Anticipate and address factors that may complicate ACS or its management, which may include inadequate response to therapies, hemodynamic and cardiopulmonary compromise, life-threatening cardiac arrhythmias, or bleeding. Assess patients with suspected ACS in a timely manner, identify the level of care required, and manage or comanage the patient with the primary requesting service. 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