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And is the accuracy also affecting it?
I doubt it. Each time I got the rating was already during the level the same way I got bronze/silver/gold, meaning that you just have to beat some certain (undisclosed) point threshold. How you do it is irrelevant as long as you attain it.
I'm guessing the Slayer Medal might be a sort of achievement where you need to have already earned the gold medal AND need to kill an undisclosed number of demons with a 32x multiplier (maybe that's why it's called SLAYER medal). My second guess is that maybe throughout the whole run, if you are able to not let your multiplier hit 1x then maybe that might also give you the slayer medal near the end. Those are my guesses, if I find out something new I'll be posting here again.