TABLE OF CONTENTS

EDUCATIONAL PROGRAM……………………………………………………….. 3
      Objectives
      General Expectations
KEY CLINICAL F...
Policy to Monitor Residents and Fellows with Prior Issues of
        Concern
Duty Hour Policy
Anonymous Evaluation




   ...
CARDIOVASCULAR DISEASES FELLOWSHIP
             MANUAL
                         Educational Program
                      ...
with their mentor and provide regular progress reports.

     In addition to these rotations, a number of other conference...
When a fellow has a clinic obligation, he/she must arrange for another fellow
                 to cover any service until ...
the division and fellowship directors are required. Flexibility will be allowed for job
      interviewing but this will b...
Upon the fellows return from travel, a request for reimbursement must be submitted to
      the division administrator wit...
Key Clinical Faculty
Kul Aggarwal, MD, FACC, FACP
Associate Professor of Clinical Medicine
   Chief, Cardiovascular Medici...
Greg Flaker, MD, FACP, FACC
Brent Parker Professor of Medicine
   Program Director, Cardiovascular Disease Fellowship Prog...
Facilities and Resources
Cardiovascular Medicine trainees provide inpatient and outpatient care to University
Hospital and...
Fellows Office:
Cardiovascular Medicine Fellows will have their own desk, which will be located in
Clinical Support and Ed...
Specific Program Content

   The goals and objectives of each rotation are listed in this manual and are posted on the
   ...
Patients who present to the Emergency Room with chest pain and are thought to
          have acute myocardial infarction, ...
5. Provide appropriate supervision of residents and students in procedures such as
           insertion of central lines, ...
Patients who present with acute heart failure or shock syndromes requiring intensive care
      unit management
       Pat...
Evaluate new admissions to the CICU and to the Cardiovascular Medicine Ward
           Service. This evaluation will inclu...
Educate all members of the team including Fellows, Internal Medicine residents,
          students and nurses. Such educat...
cardiovascular follow-up.



Cardiovascular medicine fellow responsibilities for the UMC and VA Consultative Service
inclu...
In addition to skills acquired at the previous level:
     Be able to effectively function as a Cardiovascular Consultant...
clinics at UMHC and VAH provide the opportunity for ―a single continuity clinic for the entirety
of the fellowship.‖ The c...
9. Understand reimbursement policies by private insurance carriers, Medicare, Medicaid and
       other financial sources....
At UMC all Power Chart notes that are electronically signed will be FAXed to the
              referring physician by the ...
Manage smooth workflow in the echo lab
   Provide preliminary readings on studies
   Understand the indications of contras...
    Assessment of prosthetic valves
           Conducting research

            Fellows are responsible for having all e...
Components of Cardiac Rehabilitation Phases 1, 2, 3, and 4
                       Standards for certification of a cardiac...
American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR).
Guidelines for Cardiac Rehabilitation and Se...
VA NON-INVASIVE LABORATORY

GOALS and OBJECTIVES:
The goals and objectives of the VA non-invasive rotation is similar to t...
master the catheterization skills progressively over the course of 3 years and are expected to
   perform several diagnost...
EPS AND ARRHYTHMIA SERVICE
GOALS and OBJECTIVES:
The goals and objectives of the EP and Arrhythmia service is to provide s...
4. Kowey P, Naccarelli GV. Atrial Fibrillation. New York: Marcel Dekker 2005.
5. Zipes DP, Haissaguerre M. Catheter Ablati...
Relative effectiveness of the implantable cardioverter-defibrillator and antiarrhythmic drugs
    in patients with varying...
defibrillator after acute myocardial infarction. New Engl J Med 2004;351(24):2481-2488.
20. Gillis AM. Prophylactic implan...
Biventricular Pacing
1. Ellenbogen KA, Kay GN, Wilkoff BL (eds.), Device Therapy for Congestive Heart Failure
   Elsevier ...
4. Byrd CL, Wilkoff BL, Love CJ, Sellers TD, Reiser C. Clinical study of the laser sheath for
   lead extraction: the tota...
Second Year Fellows:
    Further refining research and presentation skills by acquiring the ability to present with
     ...
Nuclear Cardiology (CBNC) as well as to meet the requirements defined in 10CFR35.290 and
35.390 for becoming an authorized...
2001.
      Nuclear Medicine Self-Study Program III, Topic 5: Myocardial Perfusion Scintigraphy-
       Technical Aspects...
Monday and Tuesday:
Core Curriculum/Graphics Conferences

Core Curriculum:
Review of a major Cardiovascular Medicine topic...
5. Heart disease in pregnancy.
6. Cardiovascular rehabilitation.
7. Cardiovascular pathology including endomyocardial biop...
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
CARDIOLOGY FELLOWSHIP MANUAL
Upcoming SlideShare
Loading in …5
×

CARDIOLOGY FELLOWSHIP MANUAL

1,444 views

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
1,444
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
17
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

CARDIOLOGY FELLOWSHIP MANUAL

  1. 1. TABLE OF CONTENTS EDUCATIONAL PROGRAM……………………………………………………….. 3 Objectives General Expectations KEY CLINICAL FACULTY………………………………………………… ………8 FACILITIES AND RESOURCES………………………………….………………….10 SPECIFIC PROGRAM CONTENT………………………………..……………….…12 Rotation Components Cardiovascular Medicine Inpatient Service UMC and VA Consultative Service UMC Outpatient Clinics VA Outpatient Clinics UMC Non-Invasive Laboratory & Graphics UMC Fit for Life/Cardiac Rehab VA Non-Invasive Laboratory UMC and VA Invasive Laboratory EPS and Arrhythmia Service Research Rotations Elective Rotation Options Pediatric Cardiovascular Medicine VA Nuclear Medicine Didactic Schedule Mentoring Methods of Assessment INSTITUTIONAL POLICIES………………………………………………………43 Professional Activities Outside the Educational Program Primary verification of credentials for applicants to residency and fellowship training programs ACLS/BLS/PALS Certification Policy for Educational/Career Counseling Disciplinary Action Policy For Residents/Fellows Grievance Policy For Residents/Fellows Policy To Address Resident Concerns Institutional Vacation And Leave Policy Non-Renewal Of A Resident/Fellow Professional Assistance Policy Reduction In Size Or Closure Of A Residency Program/Fellowship Supervision Of Residents And Fellows Moonlighting - J-1 or H-1B Visa Holders Resident Work Hours And On-Call Frequency Policy 1
  2. 2. Policy to Monitor Residents and Fellows with Prior Issues of Concern Duty Hour Policy Anonymous Evaluation 2
  3. 3. CARDIOVASCULAR DISEASES FELLOWSHIP MANUAL Educational Program GOALS AND OBJECTIVES The Division of Cardiovascular Medicine offers a three-year fellowship training program in Cardiovascular Diseases. During this time our goal is to produce physicians who maintain the intellectual curiosity, the concern for patients, and the attention to detail fostered by Internal Medicine training programs. However, we want to expand knowledge in the specialty of Cardiovascular Diseases. As specialists in Cardiovascular Diseases, we strive to acquire a basic core of knowledge of cardiovascular anatomy and physiology to make an accurate diagnosis and establish an effective treatment plan in patients with a wide variety of acute and chronic cardiovascular disorders. Furthermore, we seek to provide opportunities to make new discoveries and observations and to disseminate this knowledge in oral and written formats. The first year Cardiovascular Medicine Fellow typically spends 7 months on an inpatient service - either a Coronary Intensive Care Unit rotation or a Consultative Service. Two months are usually spent in the Non-Invasive Laboratory and two months are spent in the Invasive Laboratory. One month is spent on Research. Weekly half day outpatient continuity clinics are part of the first year experience. The second and third years are spent tailoring the type of training desired by the fellow (non-invasive, invasive, or research). Weekly half day outpatient clinics are also part of the second and third year experience. At the end of three years, the Cardiovascular Medicine Fellow will spend at least 8 months in the Inpatient (CICU or consultative Service), at least 8 months in the Invasive Laboratory and at least 4 months in the Non-Invasive Laboratory. Research opportunities are available to all fellows and are dependent on the type of research chosen. Fellows may elect to take ½ day per week for the duration of the three year program for research duties. During that time they are free from clinical responsibility. Alternatively, fellows may elect to receive protected time for one month at a time for a maximum of six rotations during their three year fellowship. Fellows are provided a list of ongoing clinical and basic science projects performed by members of the Division of Cardiovascular Medicine or other University faculty members. Proposals suitable for competitive grant funding may be required from certain fellows. Publication in peer reviewed journals is also expected. Fellows will be expected to meet regularly 3
  4. 4. with their mentor and provide regular progress reports. In addition to these rotations, a number of other conferences are designed to provide didactic instruction. These include Cardiovascular Medicine Conferences at 7:30 am M- F, the Departmental M&M conference at Noon on Tuesdays, and Internal Medicine Grand Rounds at Noon on Thursdays. GENERAL EXPECTATIONS 1. Attendance and punctuality are required at all Divisional and Departmental functions. These functions include, but are not limited to rounds, fellows‘ clinics, and conferences. Except in instances involving emergent patient care, faculty will excuse fellows from other duties to ensure attendance at these functions. 2. All pages will be answered promptly. Beepers are worn from 8am - 5pm and on call. During procedures pages should be answered by other fellows or support staff. 3. Interactions with staff, patients, and colleagues are to be courteous and polite at all times. 4. If a fellow is for any reason unable to meet a clinical schedule requirement, he or she is responsible for identifying a replacement as soon as possible. This applies to consult, night, weekend, and holiday coverage, procedure and clinic appointments, and conference presentations. The fellow should report the changes in coverage to the Education Coordinator in writing. 5. Clinics are never canceled except for designated holidays and pre-approved vacation. If a fellow will be unable to attend clinic as scheduled, he or she must first obtain the approval of the Director of the fellows‘ Clinic and then arrange alternate coverage. When canceling a clinic date for anticipated vacation, notify the fellowship coordinator in writing at least four weeks in advance to the canceled clinic. The coordinator will notify the proper clinic personnel. No more than two clinic cancellations for vacation at the University Hospital and no more than two clinic cancellations for vacation at the VA Hospital. The fellowship coordinator will track vacation time and number of clinics cancelled for vacation. In the rare circumstance when one fellow is substituting for another fellow‘s duties in clinic, 24 hour notice should be given in writing to the fellowship coordinator so that the clinic can be notified of the substitutions. In the event a fellow‘s clinic needs to be overbooked, approval from that fellow must be obtained prior to overbooking. 4
  5. 5. When a fellow has a clinic obligation, he/she must arrange for another fellow to cover any service until his/her clinic obligation is complete. The clinic obligation has priority over all other responsibilities that might conflict with clinic. All fellow‘s clinic notes must be done electronically (Power Note) using the Cardiovascular Medicine IM Clinic Note. This note should be used for all patients, including consults in clinic. (Use the Chest Pain Clinic Notes for the chest pain follow-up patients from the ED.) All notes need to be completed the same day as the clinic visit and forwarded to the attending for clinic within 24 hours. 6. The Cardiovascular Medicine faculty attending is ultimately responsible for the performance of all cardiovascular procedures, including their prompt termination when he or she deems it necessary. The amount of time and degree of independence allotted a fellow for the safe and efficacious completion of a procedure will be determined solely by the faculty attending on a case-by-case basis. 7. Fellows who perform procedures on patients have the responsibility to acquaint the patient with the steps involved in procedure preparation and performance, inform the patient of associated risks and obtain the patient‘s signature on a consent form. The physician obtaining consent must date, time, and sign each form. It is desirable that fellows who perform a given procedure also obtain informed consent. 8. Fellows performing consultations, procedures, and clinic follow-up visits on patients at University of Missouri affiliate hospitals must provide prompt follow-up to referring physicians and to the patient‘s primary physician. Obviously, this is extremely important to continuity of care and preservation of referral relationships. 9. At the end of each rotation, each fellow will be evaluated by the Cardiovascular Medicine attending and/or attending faculty from other departments with whom we work closely, such as pediatrics, nuclear medicine and surgery. The standard American Board of Internal Medicine evaluation form is used for this purpose and is submitted electronically through New Innovations. Fellows are evaluated by other health care providers (360 degree evaluations). Fellows will evaluate attendings at the end of each rotation using a similar format. In addition, every six months, fellows will evaluate individual rotations. The results of these evaluations are reviewed by the faculty and fellows at least yearly. 10. Requests for vacation time should be made through the fellowship coordinator during the first week of the year or earlier. (Twenty working days of vacation are permitted annually. These days may not be carried over into the following year). Approvals from 5
  6. 6. the division and fellowship directors are required. Flexibility will be allowed for job interviewing but this will be considered vacation leave. Fellows should notify the educational coordinator at least two weeks in advance of absence, please note time requirements above for clinic cancellations. It is appropriate to notify your faculty attending in advance of your absence. 11. It is the responsibility of the fellow to notify the education coordinator in the event they are sick. Ten working days of sick leave are provided per year. (These days may not be carried over into the following year.) Use of sick leave is permitted for personal or family illness and/or doctor's appointments. The fellow is responsible for finding coverage of their service which should be given to the fellowship coordinator in writing (note time requirement for clinic cancellations). Maternity/Paternity leave is considered as sick leave. Fellows are eligible for FMLA (Family and Medical Leave Act) as outlined in the University Policy. 12. It is the fellow‘s responsibility to complete a Notification of Absence form (obtained from the fellowship office) 2 weeks prior to any absence from the University. This form will indicate appropriate coverage and must be signed and approved by Program Director prior to departure. This policy will be strictly enforced and disciplinary action will be taken in the event of non-compliance. 13. All fellows are encouraged to attend either the American Heart Association or the American College of Cardiology annual scientific sessions during their training program. Fellows will be provided with $1,500 of travel funds to attend one AHA or ACC scientific meeting during their fellowship. Chief Fellow(s) may attend one additional meeting with the approval of the fellowship director. Third year fellows may travel for one board review course or specialty course review at their own expense, upon approval from the fellowship director. This travel is not considered vacation; however, additional courses, which may be requested, will be considered vacation. Fellows submitting an abstract for consideration need to first discuss travel funding with their faculty mentor. If division funds are requested the fellow must have his/her abstract reviewed by the Program Director and Division Director prior to submission. Funding must be approved before the abstract is submitted. The division will cover travel expenses for fellows presenting abstracts at ACC or AHA annual scientific sessions with the prior approval of the Program Director and Division Director. Funds for subsidizing travel to meetings must be arranged via the Division Administrator at least 30 days prior to the meeting. In no case will the division cover expenses greater than $1,500 per meeting. If fellows obtain unrestricted travel grants from industry, the funds may be used only to attend major meetings such as AHA, ACC, and Heart Rhythm Society. 6
  7. 7. Upon the fellows return from travel, a request for reimbursement must be submitted to the division administrator within 30 days. Documentation in the form of receipts must accompany all reimbursement requests for meals, taxi fare, parking, etc. All travel must comply with the Department of Internal Medicine‘s and University of Missouri Travel Guidelines. These policies are available on the departmental intranet. 14. Fellows should not apply to attend a meeting (or submit an abstract to a meeting) unless they have first discussed with their mentor a funding of their travel, if the abstract is accepted. In most cases, it will be the responsibility of the mentor to fund the trainees travel expenses. 15. Each day there are two fellows on call for MU & VA, one for the consults and CCU, and one for the emergency echocardiograms and cardiac catheterizations. Fellows are on call approximately 5-7 days in a month. Although the call is taken from home, the fellows come to the hospital as required. Communication with the attending physician on call is encouraged. 16. Fellows are expected to keep all licensure current. This would include state license, ACLS, BLS, staff health requirements and VISA if applicable. Should any licensure or mandatory testing become delinquent, it is the responsibility of the fellow to renew in an expedited manner. If licensure is not kept current, the fellow employment contract will be considered null and void. 7
  8. 8. Key Clinical Faculty Kul Aggarwal, MD, FACC, FACP Associate Professor of Clinical Medicine Chief, Cardiovascular Medicine Section, Harry S Truman Memorial Veterans Hospital Director, Cardiac Catheterization Laboratories, Harry S Truman Memorial Veterans Hospital Martin Alpert, MD Professor of Internal Medicine Director of Clinical Cardiovascular Medicine Dmitri Baklanov, MD, PhD Assistant Professor of Medicine Anand Chockalingam, MD Assistant Professor of Clinical Medicine Kevin C. Dellsperger, MD, PhD Marie L. Vorbeck Chair Professor and Chairman, Department of Internal Medicine Professor, Department of Medical Pharmacology and Physiology Thomas P. Dresser, MD, PhD Associate Professor of Clinical Medicine Chief, Nuclear Medicine Section, Harry S Truman Veterans Hospital Director, Nuclear Cardiovascular Medicine Training Program Director, Clinical Support Service Line, Harry S Truman Veterans Hospital Mary Dohrmann, MD, FACC Associate Professor of Clinical Medicine Director, Cardiovascular Medicine Clinic Director, Cardiac Rehabilitation William P. Fay, MD, FACC, FAHA J.W. and Lois Winifred Stafford Distinguished Chair in Diabetes and Cardiovascular Research Professor of Internal Medicine, Pharmacology & Physiology Director, Division of Cardiovascular Medicine 8
  9. 9. Greg Flaker, MD, FACP, FACC Brent Parker Professor of Medicine Program Director, Cardiovascular Disease Fellowship Program Director, Division of Cardiovascular Medicine Research Director, Electrophysiology Laboratory, University of Missouri Saravanan Kuppuswamy, MD Assistant Professor of Clinical Medicine Leonard Politte, MD Professor of Medicine Hongmin Sun, PhD Assistant Professor of Medicine Richard Weachter, MD Assistant Professor of Clinical Medicine Richard Webel, MD Associate Professor of Clinical Medicine Director, Cardiac Catheterization Laboratory Jainbo Wu, PhD Research Assistant Professor Gong-Yuan Xie, MD, FACC Professor of Medicine Director, Non-Invasive Cardiovascular Medicine & Adult Echocardiography Cuiha Zhang, MD, PhD Associate Professor of Internal Medicine Associate Professor of Medical Pharmacology and Physiology Associate Professor of Nutritional Sciences 9
  10. 10. Facilities and Resources Cardiovascular Medicine trainees provide inpatient and outpatient care to University Hospital and Clinics and Harry S Truman Memorial Veterans' Hospital and consult service coverage to Columbia Regional Hospital. University Hospital and Clinics: Mid-Missouri‘s leading cardiovascular referral center, University Hospital, admits more than 1,000 Cardiovascular Medicine patients each year and supports more than 10,000 invasive and non-invasive procedures. The 400 bed hospital is equipped with state-of- the-art cardiac catheterization facilities providing a wide range of diagnostic and therapeutic modalities such as coronary angiography, angioplasty, and endomyocardial biopsy, electrophysiology and hemodynamic studies and placement of coronary stents. Non-invasive capabilities include Doppler, transesophageal and stress echocardiography, ambulatory ECG monitoring and exercise testing, nuclear cardiac imaging and stress / cardiopulmonary exercise testing. Harry S Truman Veterans Hospital: The Harry S Truman VA Hospital is a 97 bed hospital immediately adjacent to the University Hospital. The hospital has a progressive Intensive Care Unit, modern cardiac catheterization facilities and updated non-invasive laboratories to provide up to date cardiovascular care to veterans from the Midwest. In 2006, University of Missouri cardiologists performed over 700 invasive cardiovascular procedures at the HSTVAMC. Fellows rotating thru the VA hospital have the following resources available to them: 1. Computer terminals at the VA hospital in the Echo reading room (Room A107) and the Cath lab room next to reviewing room (Room B131) to look up online resources. 2. Online access to MU as well as VA. VA library facilities are available thru the Main Page of the VA on every computer. The web address for the library facilities are: vaww.columbia-mo.med.va.gov/library. They can get online access to several textbooks and journals 3. VA library. The VA library is situated in the main inpatient building and has the following hours: staffed Monday to Friday from 8am to 430pm Afterhours access is available at all times by contacting the VA Police on the first floor. Columbia Regional Hospital: Columbia Regional Hospital serves Mid-Missouri as a 219-bed full service acute care facility offering state-of-the-art diagnostic and medical treatment. In 2006, University of Missouri cardiologists performed over 500 invasive cardiovascular procedures at CRH. 10
  11. 11. Fellows Office: Cardiovascular Medicine Fellows will have their own desk, which will be located in Clinical Support and Education Building CE305. An Education Coordinator is provided to assist Cardiovascular Medicine Fellows in a variety of clerical needs. Office support is available to the fellows in preparation for speaking engagements such as lectures, conferences, and research presentations. Fellows have access to the Otto Lottes Health Sciences Center Library. In addition, the Division of Cardiovascular Medicine provides the Cardiovascular Medicine Fellows with a variety of resources including computer access, a variety of software, and Internet access. The Division has resource books and journals involving invasive and non-invasive information. Current Board Review tapes and books are also accessible. 11
  12. 12. Specific Program Content The goals and objectives of each rotation are listed in this manual and are posted on the Division website. Selected tests or important references from the medical literature which are recommended reading for each rotation are listed at the end of each section. CARDIOVASCULAR INPATIENT SERVICE GOALS and OBJECTIVES: 1. To learn to recognize and treat all aspects of cardiovascular disease in patients who present to the inpatient Cardiovascular Medicine service. 2. To learn the appropriate use and relative value of various diagnostic tests used in the evaluation of these patients. 3. To develop a basic knowledge of cardiovascular anatomy, physiology, and recent literature/guidelines and apply it to each patient in a logical and efficient way to achieve a good, cost-effective, and evidence-based plan of care. 4. To enhance the internal medicine knowledge base especially as it relates to cardiovascular disorders and the interplay of other medical problems with the cardiovascular disease being treated. 5. To maintain the highest degree of empathy possible with patients who are often frightened and anxious, by maintaining good communication with them, their families, and with other health care providers. 6. To maintain an inquisitiveness about patient care that fosters self-motivated learning and searching after answers that may not be obvious. 7. To understand the role of drugs used in acute and chronic cardiovascular diseases, such as vasoactive, inotropic, antithrombotic, lipid-lowering, antiarrhythmic drugs. 8. To learn the indications for and technique of invasive monitoring in the care of cardiovascular patients, such as PA catheter insertion and use, IABP use and troubleshooting, temporary pacing, arterial lines, ultrafiltration catheters, etc. At the University Hospital this service is usually composed of Cardiovascular Medicine attending physicians (2/month), a Cardiovascular Medicine Fellow, Medical Residents and Medical Students. In addition, nurses, dieticians, social workers, and other health care professionals make rounds on a daily basis in a 16 bed integrated CICU with cardiovascular medicine and thoracic surgery patients. At the Harry S Truman VA Hospital, this service is usually composed of a Cardiovascular Medicine attending physician and a Cardiovascular Medicine Fellow. They are directly responsible for patients admitted in CICU. For patients on the floor, they provide consultative services. Patients in the Cardiovascular Medicine Inpatient Rotation include: 12
  13. 13. Patients who present to the Emergency Room with chest pain and are thought to have acute myocardial infarction, intermediate coronary syndrome or unstable angina. Patients who are hemodynamically unstable and need intensive monitoring and/or Swan Ganz catheterization or other invasive procedures for management. Patients who present with acute heart failure or shock syndromes requiring intensive care unit management. Patients with symptomatic brady or tachyarrhythmias who are unstable or at risk of instability who need intravenous antiarrhythmics or are in need of temporary pacemakers. Patients who have undergone an interventional procedure including post operative procedures and require short-term intensive monitoring. Patients who have predominantly cardiovascular problems who require mechanical ventilation. Any other patients, who upon determination of the Cardiovascular Medicine team, need CICU care for management of hypertensive, valvular, pericardial, cerebrovascular or congenital heart disease. Patients with heart disease of pregnancy, cardiac transplant patients, and patients with pulmonary heart disease including pulmonary embolism may be evaluated in the CICU. In order to provide one 24-hour period per week free from patient care responsibilities, VA CCU-Consult fellow and MU CICU fellow will share the weekend responsibilities for rounds on the above services. Specifically, one person will make morning rounds with staff in both CCUs on Saturday and other person on Sunday. This will give both fellows 24 hour period free of direct patient care responsibilities. Sometimes VA and MU may not have concurrent holidays. In case of holiday at VA ONLY, the VA CCU-Consult fellow will cover the service including consults till 12 noon and subsequently on call person will take over. For holiday in MU ONLY, the MU-CCU fellow will make CCU rounds as usual and on call will do the consults from 8:00 am (as on weekends). For UMC and VA Cardiovascular Medicine inpatient services, the Cardiovascular Medicine Fellow will: 1. Evaluate all new patients admitted to CICU and Cardiovascular Medicine wards. 2. Write an admission note for all CICU patients, discuss all admissions with the resident and medical student on service, to develop an appropriate differential diagnosis, proposed work-up plan, and initiate therapy. 3. Conduct daily ‗work‘ rounds with residents, students, nursing and other health care personnel in CICU, to include ethical, cost-containment, social issues as well as medical and discharge planning issues, and triage for transfer out of CICU at the earliest time each morning. 4. Provide teaching for residents and students. 13
  14. 14. 5. Provide appropriate supervision of residents and students in procedures such as insertion of central lines, PA catheters, temporary pacemakers, arterial lines, and thoracentesis and pericardiocentesis. Preferably, these will be done with the CICU attending present as well. 6. Provide appropriate triage support for the residents in deciding transfers to and out of CICU, as well as discharge planning, including discharge medications. 7. Ensure efficient patient flow. 8. Maintain effective, day-by-day communication with patients, their families, and with nursing personnel, with respect to medical care, diagnosis, medical testing, and prognosis, especially with critically ill patients. 9. Communicate with referring physicians at the time of referral, significant in-hospital events, and at discharge. 10. Provide basic and advanced cardiac life support. 11. Evaluate admissions in the ER with attention to triage for appropriate placement in CICU, step-down, or telemetry. 12. Personally review chest x-rays, EKG‘s, telemetry rhythm strips, coronary angiograms, echocardiograms, myocardial perfusion scans, and stress tests on patients assigned to them. 13. Maintain the highest level of professionalism, ethics, and of medical care for each patient without regard for social, religious, ethnic, or gender differences. 14. Wash hands before and after each patient contact. 15. Ensure communication with any physicians consulted, with expressed appreciation and due regard for recommendations given, in the best interest of the patient. 16. Maintain open communication with the CICU attending, who will be available for daily attending rounds, procedures, and at other times deemed necessary for good patient care. 17. CICU admission notes are to include at minimum a brief history of present illness, documentation of pertinent cardiovascular physical exam findings, an interpretation of the admission EKG, and brief assessment and plan. This is forwarded in the electronic medical record to the attending physician for his or her signature. 18. Daily review of resident progress notes for accuracy in documentation of the ongoing plans and reassessment as new information becomes available. 19. CICU fellows will care for all patients on the cardiovascular medicine inpatient service, but in general will not be required to carry a load of more than 12 patients at one time. If this occurs, he/she may notify the attending physician, who may redistribute the number of patients supervised by that fellow. 20. Enroll patients in research projects 21. Present patient information at M&M conference or other conferences Patient who may be in CICU: Patients who present to the emergency department with chest pain and are thought to have acute myocardial infarction or acute coronary syndrome. 14
  15. 15. Patients who present with acute heart failure or shock syndromes requiring intensive care unit management Patients who are hemodynamically unstable and need intensive monitoring or invasive procedures for management. Patients with symptomatic brady or tachyarrhythmias who are unstable or at risk of instability who need intravenous antiarrhythmics or are in need of temporary pacemakers. Patients who have undergone an interventional procedure including post operative procedures and require short-term intensive monitoring. Patients who have predominantly cardiovascular problems who require mechanical ventilation. Any other patients, who upon determination of the Cardiovascular Medicine team, need CICU care for management of hypertensive, valvular, pericardial, cerebrovascular or congenital heart disease. Patients with heart disease of pregnancy, cardiac transplant patients, and patients with pulmonary heart disease including pulmonary embolism may be evaluated in the CICU. The level of service and the degree of supervision provided will depend on the experience of the trainee. In general, First Year Fellows:  History and physical examination of the cardiovascular patient  Developing a differential diagnosis  ―Work-up‖ and management plan formulation  Understanding the ethical, legal and cost-containment issues involved in patient care  Right heart cardiac catheterization including indications, placement of Swan Ganz catheters, hemodynamic monitoring and interpretation of data  Gaining proficiency in the interpretation of EKGs  Assess patients who are candidates for cardiac transplantation  Teaching of Students and Residents Second Year Fellows: In addition to skills acquired at the previous level:  Leading discussions on multi-disciplinary rounds  Understanding the ethical, legal and cost-containment issues involved in patient care  Insertion of temporary transvenous pacemakers  Insertion of and management of intra-aortic balloon counterpulsation devices Third Year Fellows: In addition to skills acquired at the previous level:  Management of complex cardiovascular problems  Gaining further understanding of the interplay of various disciplines such as Critical Care, Pulmonary Medicine, Nephrology and Cardiothoracic Surgery in the care of the patient Understanding the ethical, legal and cost-containment issues involved in patient care For these UMC and VA Cardiovascular Medicine Inpatient Services, the Resident will: 15
  16. 16. Evaluate new admissions to the CICU and to the Cardiovascular Medicine Ward Service. This evaluation will include a comprehensive history, physical examination, diagnosis and an assessment and plan. The plan can be formulated with the help of the Cardiovascular Fellow. Such evaluation will be documented in the chart of the patient. Responsible for writing the admission orders for the patient at the time of admission, and at the time of transfer from the floor to the CICU or from CICU to the ward. Additionally, it will be the resident‘s responsibility to write all subsequent orders for all patients under his/her care. Responsible for dictating discharge and death summaries in a timely fashion on all patients under his/her care. Will coordinate his/her plans for scheduling days off with his/her co-residents on the rotation and with the fellow. Closely monitor progress of all patients and promptly bring to the attention of the fellow any significant change in the condition of any patient under his/her care. Notify and coordinate with the fellow any invasive procedures such as central venous line insertion, right heart catheterization, pleural fluid paracentesis, arterial line insertions, etc., that a patient may need and ensure that the fellow is present during the procedure. Attend daily rounds with the Cardiovascular Fellow and with the service attending. The resident will present all cases to the attending. Examine all patients assigned to him/her at least once a day and more frequently if clinical circumstances warrant and write a progress note in the patient‘s medical record documenting such examination together with an assessment and any changes in plan. Responsible for checking all laboratory results such as blood tests, ECG‘s, and x-rays on his/her patients and acting appropriately upon such results. Supervise student activities as related to patient care. Provide teaching to medical students. For the UMC and VA Cardiovascular Medicine Inpatient Services the Attending will: Communicate the goals, objectives, expectations and define the teaching structure to all members of the team including fellows, residents, students and support staff. Conduct rounds daily at which time each assigned patient is personally interviewed and examined. Be personally responsible for the conduct of special procedures (e.g., cardioversion, Swan Ganz catheter, etc.). Review patient‘s clinical data and formulate a plan with the house staff for the management of each patient. Be available at all times to advise the fellow and the residents on issues related to the care of all patients on the Cardiovascular Medicine Service. In case the attending anticipates being unavailable for any period of time, then to make arrangements with an alternate attending to be available for such support and to notify the team about such coverage. 16
  17. 17. Educate all members of the team including Fellows, Internal Medicine residents, students and nurses. Such education will be in the form of formal teaching rounds and will incorporate clinical discussions in addition to addressing legal, ethical and cost- containment issues. Education in bedside manner, elicitation of history and physical examination will also be carried out. Communicate with the patient regularly and with families especially in the case of critically ill patients. Be a team leader and role model for all members of the team. Provide effective feedback and evaluation of fellows, residents and medical students on the rotation. Provide references for further reading. (Appendix A) Support and encourage scholarly activities and research projects. Discuss individually at the end of the rotations strengths, weaknesses and suggestions for improvement. Be responsive to any special difficulties that fellows or residents may be experiencing and make efforts to relieve such difficulties. Provide a list of texts or key articles for reading during the rotation. UMC AND VA CONSULTATIVE SERVICE GOALS and OBJECTIVES: The goals and objectives of the Cardiovascular Medicine Consultation rotation are to provide expert consultation to inpatients or outpatients with cardiac problems. During this rotation an emphasis will be placed on 1) understanding the pathophysiology of a wide variety of cardiac conditions and different treatment options, 2) provide effective therapy for cardiac conditions, and 3) provide continued follow-up and advice to physicians of other services concerning cardiac patients. The UMC Consultative service is usually composed of the Cardiovascular Medicine Attending Physician, a Cardiovascular Fellow, Medical Residents, and Medical Students. Rounds are conducted at mutually agreeable times. In general, rounds are performed at least daily except Sundays. A list of patients is generated and, to ensure continuity, checked out to the faculty or fellow on call on a daily basis, informing the person on call about important details of each patient. The VA Consultative Service includes the Attending physician and Cardiovascular Medicine Fellow assigned to the VA Inpatient Service. Patients evaluated by the Cardiovascular Medicine Consultation Service include: Patients in the Emergency Room, Outpatient Clinics or Inpatient Services who have heart failure, chest pain, cardiac arrhythmias, hypertensive, pericardial disease, valvular, cerebrovascular or congenital heart disease. Patients who require cardiovascular medicine evaluation prior to surgery. Patients who are admitted to the hospital for non-cardiac causes, but who require 17
  18. 18. cardiovascular follow-up. Cardiovascular medicine fellow responsibilities for the UMC and VA Consultative Service include: Provide a prompt written evaluation and treatment plan on patients referred for consultation from 8 am to 5 pm Monday - Friday. The ―on call‖ cardiovascular medicine fellow provides this service during evenings and weekends. At UMC the clinic note should be dictated on the date of the clinic visit and reviewed for corrections in Power Chart within 48 hours, then forwarded to the appropriate attending for final signature. Discuss the plan with the assigned cardiovascular medicine attending. The dictation should include a summary of this discussion. Communicate by written or oral form to the referring and primary care physician. At UMC all Power Chart notes that are electronically signed will be FAXed to the referring physician by the division secretary after final signature by the attending. Discuss evaluation with attending, residents, and students during scheduled consult rounds. Evaluate patients for potential admission to the Cardiovascular Medicine Service or arrange appropriate outpatient follow-up and testing. Provide teaching to residents and students. Communicate to physicians the results of the cardiovascular medicine evaluation including test results and plans for further follow-up. Interpret ECGs, chest x-rays, stress tests, ambulatory monitors, and other selected graphic material on a daily basis. The level of service and the degree of supervision provided will depend on the experience of the trainee. In general, First Year Fellows:  Assessment of patients referred for cardiovascular consult focusing on clinical skills required in the assessment of such patients  Formulate a differential diagnosis and a management recommendation for such patients  Acquire an understanding of the peri-operative assessment of patients undergoing non- cardiac surgery Second Year Fellows: In addition to skills acquired at the previous level:  Be able to effectively render assessment and recommendations on peri-operative cardiovascular care of the patient undergoing non-cardiac surgery  Be able to effectively render assessment and recommendations on peri-operative cardiovascular care of the patient undergoing cardiac surgery especially in the areas of arrhythmia management, hemodynamics and myocardial ischemia and infarction Third Year Fellows: 18
  19. 19. In addition to skills acquired at the previous level:  Be able to effectively function as a Cardiovascular Consultant  Participate in the teaching of members of disciplines other than Cardiovascular Medicine Cardiovascular Medicine Attending responsibilities for the UMC and VA Consultative Services include: Communicate the goals, objectives, expectations and define the teaching structure to all members of the team including fellows, residents, and students. Conduct rounds M-F at which time each assigned patient is personally interviewed and examined. Review patient‘s clinical data and the written plan with the Cardiovascular Medicine Fellow. Be available M-F 8am - 5 pm to advise the fellow and the residents on issues related to the care of all patients on the Cardiovascular Medicine Consult Service. After hours and on weekends an ―on call‖ attending will be available for such support. Educate all members of the team including Fellows, Internal Medicine residents, students and nurses. Such education will be in the form of formal teaching rounds and will incorporate clinical discussions in addition to addressing legal, ethical and cost- containment issues. Education in bedside manner, elicitation of history and physical examination will also be carried out. Communicate with the primary care team regularly. Be a team leader and role model for all members of the team. Provide effective feedback and evaluation of fellows, residents and medical students on the rotation. Provide references for further reading. (Appendix B) Support and encourage scholarly activities and research projects. Discuss individually at the end of the rotations strengths, weaknesses and suggestions for improvement. Be responsive to any special difficulties that fellows or residents may be experiencing and make efforts to relieve such difficulties. Faculty will provide a list of key references pertinent to the patient population. UMC OUTPATIENT CLINICS GOALS and OBJECTIVES: The goals and objectives of the outpatient rotation is to develop an appreciation of the pathophysiologic mechanisms of disease, to develop an understanding of the use of diagnostic testing, to observe the response of therapy over longitudinal follow-up of patients with cardiovascular disorders over the 3-year training program with faculty supervision. In compliance with ACGME requirements for program curriculum section V, subsection F, item 1, 2 and 3, titled ―Ambulatory Medicine‖, the goal of the Cardiovascular Medicine Division is to provide the facility, faculty, support personnel, patients and supporting services for the fellows to become competent in evaluating, treating and follow-up care in an outpatient setting in a longitudinal manner over a three year period of their training. The Cardiovascular Medicine 19
  20. 20. clinics at UMHC and VAH provide the opportunity for ―a single continuity clinic for the entirety of the fellowship.‖ The clinic scheduling template is designed to meet the ACGME goal of ―four to eight patients during each ½ day session.‖ The full range of patients with cardiovascular disease is available for the fellow to evaluate under the supervision of an attending physician at each clinic. Volumes of patient: given the ACGME goal of 4 – 8 patients per clinic, the projected volume per fellow (based on 48 weeks of clinic, UMHC/VAH combined) is 192 minimum, 384 maximum. The Cardiovascular Medicine Fellowship Coordinator currently tracks the patient volumes at UMHC/VAH. Types of patients: no surveillance currently exists for tracking the types of patients seen by the fellows, although this is easily obtainable. It is recommended that a spread sheet for each fellow track ICD-9 codes used at the clinic visits. Periodic review would help assess the variety of each fellow‘s clinic experience. Oversight: an attending supervises every clinic and evaluates every patient with the fellow in clinic. Recommended reading: it is recommended that the fellows are familiar with the published ACC/AHA guidelines for management of cardiovascular diseases. Additionally, Braunwald‘s Heart Disease: A Textbook of Cardiovascular Medicine is an important companion text for in-depth reading. This requires the Fellows to gain an understanding and skills in: 1. Office organization including the function of receptionist, scheduling, nursing support, record keeping, dictation, billing procedures and other business aspects of the office. 2. Knowledge of the services available and how to access them such as obtaining consults from other services, laboratory, radiology, rehabilitation, social services, etc. 3. Understand the patient‘s ability to receive medical care as to travel, financial constraints, family support, and other personal issues affecting receiving appropriate care. 4. Improve communication skills with the patient and their family in understanding their illness and the rational the recommended care carefully explaining any side effects or complications that might occur and the seriousness of the complication as to risk-benefit. 5. Improve skills in time management. 6. Prompt documentation of medical data and communicating this to appropriate people. 7. Develop a thorough understanding of the ICD-9 code and its importance to the patient and third party carriers. 8. Understand the Resource-Based Relative Value Scale as it applies to services rendered. 20
  21. 21. 9. Understand reimbursement policies by private insurance carriers, Medicare, Medicaid and other financial sources. 10. Skills in appropriate follow-up care coordinated with the care given by the referring physician and patient‘s ability to receive care. Develop skills communicating with referring physicians. Clinics are designed to provide 4-8 patients during each ½ day session. Monday or Wednesday afternoons from 1:00 pm to 5:00 pm in Medicine Specialty Clinic. An annual clinic schedule has been made. The Fellow will be assigned to this clinic every other week, alternating with the VA Outpatient Clinic. ―Special‖ appointments may be arranged on a per patient basis by arrangement with the clinic staff. Such appointments are usually made for tenuous patients needing earlier than two week follow-up or for outpatients being seen by the consult fellow. The fellow must pre-arrange an attending for these special appointments. VA OUTPATIENT CLINICS GOALS and OBJECTIVES: This continuity clinic allows longitudinal follow-up of patients with cardiovascular disorders over the 3-year training program with faculty supervision. Tuesday and Thursday afternoons from 1:00 pm to 4:00 pm in Cardiovascular Medicine Clinic on the first floor. An annual clinic schedule has been made. Any additional changes need to be addressed to the supervising clinic attending. In the event of a cancellation, there must be a 30 day in advance notice. The Fellow will be assigned to this continuity clinic every other week, alternating with the UMC clinic. VA Pacemaker, ICD Clinic Monday mornings from 9:00 am to 11:00 am in room A101. Cardiovascular Medicine Fellow responsibilities for the UMC and VA Outpatient Services include: Make every effort to be on time for scheduled appointments. In case of an emergency, notify the clinic attending of an absence and your substitute for the clinic. Provide a written evaluation, including a diagnostic plan and treatment strategy. At UMC the clinic note should be dictated on the date of the clinic visit and reviewed for corrections in Power Chart within 48 hours, then forwarded to the appropriate attending for final signature. Discuss the plan with the assigned Cardiovascular Medicine attending. The dictation should include a summary of this discussion. Communicate by written or oral form to the referring and primary care physician. 21
  22. 22. At UMC all Power Chart notes that are electronically signed will be FAXed to the referring physician by the division secretary after final signature by the attending. Personally review diagnostic studies including ECGs, chest x-rays, stress tests, echocardiograms, ambulatory monitors and cardiac catheterization studies. Office organization including the function of receptionist, scheduling, nursing support, record keeping, dictation, billing procedures and other business aspects of the office. Knowledge of the services available and how to access them such as obtaining consults from other services, laboratory, radiology, rehabilitation, social services, etc. Cardiovascular Medicine Attending responsibilities for the Outpatient Services include: Make every effort to provide timely consultation with the Cardiovascular Medicine Fellow. Review the patent‘s clinical data and laboratory studies and formulate a treatment plan with the Cardiovascular Medicine Fellow on each patient. Review written evaluations and letters to referring physicians and primary care physicians. Provide quarterly performance evaluations of each fellow to the division director. Recommended reading for Outpatient Clinic Rotation: It is recommended that the fellows are familiar with the published ACC/AHA guidelines for management of cardiovascular diseases. Additionally, Braunwald‘s Heart Disease: A Textbook of Cardiovascular Medicine is an important companion text for in-depth reading. UMC ECHO LABORATORY GOALS and OBJECTIVES: The goals and objectives of the UMC and VA echo services are to gain an understanding of the diagnostic capabilities of echocardiography and Doppler. Specific goals include: Gain understanding on instrumentation and controls on echo machines Able to acquire 2-D and Doppler images and store and retrieve them Able to carry out a comprehensive echocardiographic evaluation of a patient Understand the indications of echocardiography especially in context of ACC/AHA and ASE guidelines Interpret 2-D and Doppler echo and be able to identify structural and hemodynamic abnormalities Understand the indications and complications of TEE Interpret and perform TEE 22
  23. 23. Manage smooth workflow in the echo lab Provide preliminary readings on studies Understand the indications of contrast Understand the principles and application of contrast echo Understand tissue Doppler and its application ( Strain and strain rate imaging) Actively participate in Treadmill Stress testing with echocardiography including selection of digitized image looped immediately post exercise Pharmacologic stress testing with echocardiography including selection of digitized image loops immediately post exercise TEE guided cardioversion Understand advanced echo: (a) AV optimization (b) Research applications Be fluent in presentation of case based echocardiography in formal presentations Formulate Research projects, echo related Carry out research projects In the Echo rotation fellows perform and interpret multidimensional echocardiography. Studies are performed between 8:30 am to 5:00 pm. Emergency procedures are provided through the ―on call‖ Cardiovascular Medicine fellow and attending. Studies are interpreted in conjunction with the Non-Invasive Cardiovascular Medicine attending or the Nuclear Medicine attending. Cardiovascular Medicine fellows are strongly encouraged to attend conferences in Nuclear Medicine during this rotation. With adequate numbers, certification for licensure to perform nuclear studies is available. The University echocardiographic laboratory is fully ICAEL accredited and is a fully digital lab. At the end of the required rotations, level II certification in echocardiography will be achieved. Responsibilities of the Cardiovascular Medicine Fellow in the Echo Rotation include: If the VA Echo Fellow is on vacation, then the fellow assigned to MU Echo Block rotation will cover. First Year Fellow:  Understanding the basic principles of 2-D, M-Mode and Doppler echocardiography  Performing and interpreting 2-D, M-Mode and Doppler studies  Performing and interpreting head up tilt studies. Second Year Fellow: In addition to skills acquired at the previous level:  Performance and interpretation of transesophageal echocardiograms  Performance and interpretation of dobutamine and exercise stress echocardiograms  Performing and interpreting urgent echocardiographic studies while on call  Performing and interpreting head up tilt studies. Third Year Fellow: In addition to skills acquired at the previous level:  Performance and interpretation of intra-operative transesophageal echocardiograms  Performing and interpreting head up tilt studies 23
  24. 24.  Assessment of prosthetic valves  Conducting research Fellows are responsible for having all echo studies preliminarily read by the end of the day whenever possible and placed in the Enconcert system under preliminary reports. If the echo attending cannot be present to overread studies by 6:00 pm the fellows may leave if they wish, leaving the lab set up in and in orderly fashion so that attending can read efficiently. However, they should check the finalized reports the next day in the system to see what differences there were in interpretation. At a time that is suitable to the staff attending, the fellow can go over those corrections he/she does not clearly understand. At the end of the block all fellows should be prepared to perform a transthoracic 2D, M mode, doppler, and color flow echocardiographic study (TEE and stress echoes of any type-DSE, etc. are already performed always under the staff supervision) which will be reviewed and critiqued by the staff physician. The attending also has the prerogative to make up a brief written test which the fellow will be required to take if the staff so desires. The fellows need to attend all educational conferences set out by the division and may expect to be responsible for presenting at echo conferences interesting studies for educational QA purposes. In addition, it should be noted that if a fellow wishes to attend the 7:30 am conference rather than perform the intra-operative study all he/she needs to do is simply let the attending know and that will not be a problem. This is also true for the noon Department of Medicine lectures that occur on Tuesdays and Thursdays. If a fellow would prefer to perform a study during the 7:30 am - 8:30 am period they may call the Cardiovascular Medicine Fellowship office and let the secretary know and this will be an excused absence, followed-up with an e-mail to the fellowship coordinator. Each individual staff echo attending on rotation may supplement the Echo Fellow‘s instruction as deemed appropriate as long as it is within reason. (Appendix C) UMC Fit for Life/Cardiac Rehabilitation Goals and Objectives: The purpose of the rotation is to provide the fellow with instruction and clinical experience in cardiovascular rehabilitation. At the end of the rotation the fellow will be knowledgeable in the following areas: Acquire knowledge about prevention and rehabilitation of cardiovascular disease, including coronary disease, valvular disease, congestive heart failure, peripheral vascular disease 24
  25. 25. Components of Cardiac Rehabilitation Phases 1, 2, 3, and 4 Standards for certification of a cardiac rehabilitation and secondary prevention program by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) Standards for certification for Chest Pain Center Documentation requirements for CMS and AACVPR Reimbursement requirements for CMS Role of the medical director in cardiac rehabilitation program, including staff relations, program development, and safety considerations Setting Fit for Life is located in GL-20 of the University of Missouri Health Care. Fit for Life offers the following programs: Cardiac rehabilitation (post-MI, post-CABG, post-PCI, post-valvular surgery) Heart failure rehabilitation Pulmonary rehabilitation Peripheral Artery Disease Rehabilitation Bariatric Rehabilitation Stayfit Wellness Freedom from Smoking Rotation Basic: All fellows in Cardiovascular Medicine will rotate through Fit for Life ½ day per week during their MU Non-Invasive Lab (non-Echo) rotation. Elective: Fellows may elect an additional month rotation in Fit for Life. An individual program of study will be coordinated with the supervisor and medical director of Fit for Life at least one month in advance of this elective. Responsibilities The fellow will meet with the supervisor and/or medical director of Fit for Life at the start of their MU Non-Invasive Lab (non-Echo) rotation to coordinate the ½ day per week commitment to Fit for Life. During the rotation the fellow will participate in the following: New patient intake (including pre-test, 6-minute walk test, screening examination, and planning rehabilitation program) Inpatient rehabilitation consultation rounds Exercise with patients in phase 2 and 3 rehabilitation Patient education programs (e.g., smoking cessation counselling) Read the recommended chapters provided in the Fit for Life resource library Recommended reading 25
  26. 26. American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs, 4th ed. Champaign: Human Kinetics, 2004. Chp. 1 – Integration of Cardiac Rehabilitation and Secondary Prevention Chp. 2 – Cardiac Rehabilitation Cointinuum of Care Chp. 3 – Emergence of Nutrition and Plant-based Diets in the Treatment and Prevention of Cardiovascular Disease Chp. 4 – Cardiac Rehabilitation in the Inpatient and Transitional Settings Chp. 8 – Modifiable Cardiovascular Disease Risk Factors Chp. 9 – Special Considerations Chp. 10 – Administrative Considerations American College of Sports Medicine. Resource Manual for Guidelines for Exercise Teating and Prescription, 5th ed. Leonard A. Kaminsky et al, editors. Philadelphia: Lippincott Williams & Wilkins, 2005. Chp. 3 – Exercise Physiology Chp. 4 – Physiologic Effects of Aging and Deconditioning Chp. 9 – Relationship of nutrition to Chronic Diseases Chp. 22 – Cardiopulmonary Adaptations to Exercise Chp. 27 – Applied Exercise Programming Chp. 31 – Exercise Training in Patients in Cardiovascular Disease Chp. 41 – Factors Associated with Regular Physical Activity Participation Chp. 42 – Behavioral Strategies to Enhance Physical Activity Participation Chp. 45 – Exercise Program Professionals and Related Staff Chp. 46 – Health and Fitness Program Development and Operation Chp. 47 – Clinical Exercise Program Development and Operations Chp. 48 – Financial Considerations Chp. 49 – Policies and Procedures for Program Safety and Compliance Chp. 50 – Legal Considerations American College of Sports Medicine. Guidelines for Exercise Testing and Prescription, 7th ed. Mitchell H. Whaley et al, editors. Philadelphia: Lippincott Williams & Wilkins, 2005. Chp. 2 – Preparticipation Health Screening and Risk Stratification Section III – Exercise Prescription 1. Chp. 7 – General Principles of Exercise Prescription 2. Chp. 8 – Exercise Prescription Modifications for Cardiac Patients 3. Chp. 9 – Other Clinical Conditions Influencing Exercise Prescription 4. Chp. 10 – Exercise Testing and Prescription for Children and Elderly People 26
  27. 27. VA NON-INVASIVE LABORATORY GOALS and OBJECTIVES: The goals and objectives of the VA non-invasive rotation is similar to the UMC Echo and Graphics rotation.  The Cardiovascular Medicine fellow will perform/interpret echocardiogram, tilt tests. If VA echo fellow is on vacation, echo fellow from the University Hospital will cover his responsibilities. VA Treadmills are covered by VA Nuclear Fellow. If there is no VA Nuclear fellow for a particular rotation, the default coverage for treadmills VA Echo fellow, followed by VA CCU/consult fellow. EKGs, Holter, Event Monitors at VA are the responsibility of VA CCU/Consult Fellow.  The Echo Fellow at MU/VA should take note of next day‘s first start OR TEEs, inform the responsible attending, and review the indication for TEE and previous noninvasive/invasive studies pertinent to that patient. UMC AND VA INVASIVE LABORATORY GOALS and OBJECTIVES: The goals and objectives of training in the invasive laboratory include:  Hemodynamic assessment – recording of pressures in the cardiac chambers and the vascular tree.  Determination of cardiac function, evaluation of shunts, and valvular disease.  Angiography to evaluate the presence of vascular obstruction or other abnormalities, contractile function the left ventricle, and valvular lesions.  Therapeutic procedures such as pericardiocentesis, intraaortic balloon pumping, endomyocardial biopsies, and temporary transvenous pacemaker insertion. Fellows will receive training in right and left heart catheterization, coronary angiography, interventional Cardiovascular Medicine, endocardial biopsy, pericardiocentesis, and intra- aortic balloon couterpulsation. Procedures are scheduled from 8:30 am to 4:00 pm. Emergency procedures are arranged by the "on call" Cardiovascular Medicine fellow and attending. Responsibilities of Cardiovascular Medicine Fellow on Invasive Lab Rotation are: During cardiac catheterization rotations the fellow is expected to be present in the catheterization laboratory for the entire work day, unless assigned to clinic, and report to the Charge Person in the cath lab regarding the case assignment and other functions (exposure to X-ray and other equipment operation, QA and troubleshooting, as well as the catheter inventory management is included in the cath lab experience). The fellows are expected to know the patients and perform a relevant cardiovascular physical exam, including their vascular access sites prior to the admission of the patient to the laboratory, and be physically present with the assigned patient the entire time the patient is in the room. The fellows will 27
  28. 28. master the catheterization skills progressively over the course of 3 years and are expected to perform several diagnostic catheterizations with the attending present but not scrubbed during their last rotation. Fellows will interpret studies, generate a report in conjunction with the attending physician, and arrange appropriate follow-up. Fellows will generate a discharge summary for outpatients undergoing catheterization studies. In taking part in these UMC and VA rotations, the fellow will be able to meet minimum performance and interpretation guidelines including: The level of service provided is dependent upon the experience of the trainee. In general, First Year Fellow:  Learning vascular access  Achieving hemostasis, sheath removal  Setting up pressure manifolds or Acist device  Learning basic hand washing techniques, gowning and gloving  Maintaining sterility in cardiac catheterization lab  Performing diagnostic coronary angiography and left ventriculography  Performing and interpreting right heart catheterization  Understanding basics of interventional Cardiovascular Medicine especially indications for interventional procedures and selection of patients for surgical referral  Hemodynamics and valve area calculations  Assessment of severity of lesion stenosis  Interpretation of coronary and peripheral angiograms Second and Third Year Fellows: In addition to skills acquired at the previous level:  Assisting in percutaneous transluminal coronary angioplasties  Assisting in intra-coronary stent placements  Insertion and care of intra-aortic balloon counterpulsation devices  Perform endomyocardial biopsies  Take calls for emergent cardiac catheterization laboratory procedures  Assisting in other interventional procedures such as rotablations, directional coronary atherectomies, laser angioplasties, and thrombectomy  Assisting in balloon valvuloplasties  Taking call for emergent call cardiac catheterization laboratory procedures  Learning techniques of lesion assessments including ―setting up‖ angiographic views, analyzing lesions with quantitative coronary angiography  Planning interventional strategies  Assisting in intra-coronary doppler flow studies and pressure wire measurements  Assisting in the performance and interpretation of intravascular and intracrdiac ultrasound studies  Assisting in the performance of peripheral interventional procedures, PFO and ASD closures 28
  29. 29. EPS AND ARRHYTHMIA SERVICE GOALS and OBJECTIVES: The goals and objectives of the EP and Arrhythmia service is to provide special instruction in the diagnosis and treatment of patients with cardiac arrhythmias. An emphasis will be on understanding the pathophysiologic mechanisms of disease, the usefulness of specialized diagnostic and therapeutic procedures, and an appreciation of the long term challenges faced in follow-up of patients with cardiac arrhythmias. One fellow is assigned to EP rotation and is responsible for EP procedures at UMC and VA. EP studies at VA are scheduled on Fridays. If EP fellow is occupied with procedures at UMC, the Cath Lab fellow in VA will cover for him. Selected references are enclosed (Appendix D). Responsibilities of Cardiovascular Medicine Fellow on EP rotation include: ICU Clinic Care of EP patients Communication with Dr. Greg Flaker and Dr. Rich Weachter when need identified and the night before a scheduled procedure Assigned to cath lab for all EP procedures First Year Fellow:  Understanding basics of EPS through didactics  Follow-up of patients with permanent pacemakers/ICD‘s Second and Third Year Fellows: In addition to skills acquired at the previous level: 1. Follow-up of patients with permanent pacemakers/ICD‘s 2. Basic electrophysiologic studies including vascular access, positioning of catheters, evaluation of Sinus node recovery time, programmed stimulation and mapping techniques 3. Implantation and follow-up of permanent pacemakers 4. Assisting in the follow-up of ICDs 5. Assisting in radiofrequency ablation procedures 6. Assisting in implantation of ICDs Recommended Reading for EP rotation: EP Textbooks 1. Ellenbogen KA, Kay GN, Wilkoff BL. Clinical Cardiac Pacing and Defibrillation. 2 ed. Philadelphia: W.B. Saunders, 2000 2. Hayes DL, Lloyd MA, Friedman RA. Cardiac Pacing and Defibrillation: A Clinical Approach. Mount Kisco, NY: Futura, 2000. 3. Josephson M. Clinical cardiac electrophysiology techniques and interpretations. 3rd edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2002. 29
  30. 30. 4. Kowey P, Naccarelli GV. Atrial Fibrillation. New York: Marcel Dekker 2005. 5. Zipes DP, Haissaguerre M. Catheter Ablation of Arrhytmias. 2 ed. New York: Futura 2002. 6. Fogoros R. Electrophysiologic testing. 3rd edition. Malden, MA: Blackwell Science, 1999. Other Books 1. Ellenbogen, KA, and Wood,MA. Cardiac Pacing and ICDs, third edition. Malden MA: Blackwell Science, Inc. 2. Barold SS, Stroobandt RX, Sinnaeve AF, Cardiac Pacemakers Step by Step: An Illustrated Guide. Mount Kisco, NY: Futura, 2004. 3. Grubb BP and Olshansky B. Syncope: Mechanisms and Management. 2nd Edition. Malden, MA: Blackwell Publishing 2005. Defibrillation 1. Kadish A, Dyer A, Daubert JP, Quigg R, Estes NA, Anderson KP, Calkins H, Hoch D, Goldberger J, Shalaby A, Sanders WE, Schaechter A, Levine JH. Defibrillators in Non- Ischemic Cardiomyopathy Treatment Evaluation (DEFINITE) Investigators. Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy. New England Journal of Medicine. 350(21):2151-8, 2004. 2. Bristow MR. Saxon LA. Boehmer J. Krueger S. Kass DA. De Marco T. Carson P. DiCarlo L. DeMets D. White BG. DeVries DW. Feldman AM. Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) Investigators. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. New England Journal of Medicine. 350(21):2140-50, 2004. 3. Wathen MS, Sweeney MO, DeGroot PJ, Stark AJ, Koehler JL, Chisner MB, Machado C, Adkisson WO. PainFREE Investigators. Shock reduction using antitachycardia pacing for spontaneous rapid ventricular tachycardia in patients with coronary artery disease. Circulation. 104(7):796-801, 2001. 4. Moss AJ, Hall WJ, Cannom DS, Daubert JP, Higgins SL, Klein H, Levine, JH, Saksena S, Waldo AL, Wilber D, Brown MW, Heo M. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators. New England Journal of Medicine 1996; 335(26):1933-1940. 5. Moss AJ, Zareba W, Hall WJ, Klein H, Wilber DJ, Cannom DS, Daubert JP, Higgins SL. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. New England Journal of Medicine 2002; 346(12): 877-883. 6. A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. The Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators. New England Journal of Medicine 1997; 337(22): 1576- 1583. 7. Causes of death in the Antiarrhythmics Versus Implantable Defibrillators (AVID) Trial. Journal of the American College of Cardiovascular Medicine 1999; 34(5): 1552-1559. 8. Domanski MJ, Saksena S, Epstein AE, Hallstrom AP, Brodsky MA, Kim S, Lancaster S. 30
  31. 31. Relative effectiveness of the implantable cardioverter-defibrillator and antiarrhythmic drugs in patients with varying degrees of left ventricular dysfunction who have survived malignant ventricular arrhythmias. AVID Investigators. Antiarrhythmics Versus Implantable Defibrillators. Journal of the American College of Cardiovascular Medicine 1999; 34(4): 1090-1095. 9. Schron EB, Exner DV, Yao Q, Jenkins LS, Steinberg JS, Cook JR, Kutalek SP, Friedman PL, Bubien RS, Page RL, Powell J. Quality of life in the antiarrhythmics versus implantable defibrillators trial: impact of therapy and influence of adverse symptoms and defibrillator shocks. Circulation 2002; 105(5): 589-594. 10. Larsen G, Hallstrom A, McAnulty J, Pinski S, Olarte A, Sullivan S, Brodsky M, Powell J. Cost-effectiveness of the implantable cardioverter-defibrillator versus antiarrhythmic drugs in survivors of serious ventricular tachyarrhythmias: results of the Antiarrhythmics Versus Implantable. Circulation 2002; 105(17): 2049-2057. 11. Lee KL, Hafley G, Fisher JD, Gold MR, Prystowsky EN, Talajic M, Josephson ME, Packer DL, Buxton AE, Multicenter Unsustained Tachycardia Trial Investigators. Effect of implantable defibrillators on arrhythmic events and mortality in the multicenter unsustained tachycardia trial. Circulation 2002; 106(2): 233-238. 12. Buxton AE, Lee KL, DiCarlo L, Echt DS, Fisher JD, Greer GS, Josephson ME, Packer D, Prystowsky EN, Talajic M. Nonsustained ventricular tachycardia in coronary artery disease: relation to inducible sustained ventricular tachycardia. MUSTT Investigators. Annals of Internal Medicine 1996; 125(1): 35-39. 13. Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, Hafley G. A randomized study of the prevention of sudden death in patients with coronary artery disease. New England Journal of Medicine 1999; 341(25): 1882-1890. 14. Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, Hafley G. A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators. New England Journal of Medicine 1999; 341(25): 1882-1890. 15. Buxton AE, Lee KL, DiCarlo L, Gold MR, Greer GS, Prystowsky EN, O'Toole MF, Tang A, Fisher JD, Coromilas J, Talajic M, Hafley G. Electrophysiologic testing to identify patients with coronary artery disease who are at risk for sudden death. Multicenter Unsustained Tachycardia Trial Investigators. New England Journal of Medicine 2000; 342(26): 1937- 1945. 16. Maron BJ, Shen WK, Link MS, Epstein AE, Almquist AK, Daubert JP, Bardy GH, Favale S, Rea RF, Boriani G, Estes NA, III, Spirito P. Efficacy of implantable cardioverter- defibrillators for the prevention of sudden death in patients with hypertrophic cardiomyopathy. New England Journal of Medicine 2000; 342(6): 365-373. 17. Gardy GH, Lee KL, Mark DB, Poole JE, et al. Amiodarone or an implantable cardioverter— defibrillator for congestive heart failure. New Engl J Med 2005;352(3):225-237. 18. Solomon Sd, Zelenkofske S, McMurray JJV, Finn PV, et al. Sudden death in patients with myocardial infarction and left ventricular dysfunction, heart failure, or both. New Engl J Med 2005;352(25):2581-2640. 19. Hohnloser SH, Kuck KH, Roberts RS, et al. Prophylactic use of an implantable cardioverter- 31
  32. 32. defibrillator after acute myocardial infarction. New Engl J Med 2004;351(24):2481-2488. 20. Gillis AM. Prophylactic implantable cardioverter-defibrillators after myocardial infarction – not for everyone. New Engl J Med 2004(24):2540-2542. 21. Kadish A, Dyer A, Daubert JP, Quigg R, et al. Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy. New Engl J Med 2004;350(21):2151- 2158. Pacing 1. Gregoratos G, Abrams J, Epstein AE, Freedman RA, Hayes DL, Hlatky MA, Kerber RE, Naccarelli GV, Schoenfeld MH, Silka MJ, Winters SL, Gibbons RJ, Antman EM, Alpert JS, Gregoratos G, Hiratzka LF, Faxon DP, Jacobs AK, Fuster V, Smith SC, Jr., Committee M, Task FM. ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices: Summary Article: A Report of the American College of Cardiovascular Medicine/American Heart Association Task Force on Practice Guidelines (ACC/AHA/NASPE Committee to Update the 1998 Pacemaker Guidelines). Circulation 2002; 106(16): 2145-2161. 2. Ellenbogen KA. Cardiac Pacing. Cardiovascular Medicine Clinics 18, 1-239. 2000. 3. Josephson ME, Maloney JD, Barold SS, Flowers NC, Goldschlager NF, Hayes DL et al. Guidelines for training in adult cardiovascular medicine. Core Cardiovascular Medicine Training Symposium (COCATS). Task Force 6: training in specialized electrophysiology, cardiac pacing and arrhythmia management. Journal of the American College of Cardiovascular Medicine 1995; 25(l): 23-26. 4. Connolly SJ, Sheldon R, Roberts RS, Gent M. The North American Vasovagal Pacemaker Study (VPS). A randomized trial of permanent cardiac pacing for the prevention of vasovagal syncope. Journal of the American College of Cardiovascular Medicine 1999; 33(1): 16-20. 5. Sutton R. Guidelines for pacemaker follow up. Report of a British Pacing and Electrophysiology Group (BPEG). Heart 1996; 76(5): 458-460. 6. Connolly SJ, Kerr CR, Gent M, Roberts RS, Yusuf S, Gillis AM, Sami MH, Talajic M, Tang AS, Klein GJ, Lau C, Newman DM. Effects of physiologic pacing versus ventricular pacing on the risk of stroke and death due to cardiovascular causes. Canadian Trial of Physiologic Pacing Investigators. New England Journal of Medicine 2000; 342(19): 1385-1391. 7. Lamas GA, Lee KL, Sweeney MO, Silverman R, Leon A, Yee R, Marinchak RA, Flaker G. Ventricular pacing or dual-chamber pacing for sinus-node dysfunction. New England Journal of Medicine 2002; 346(24): 1854-1862. 8. Goldschlager N, Epstein A, Friedman P, Gang E, Krol R, Olshansky B, North American Society of Pacing and Electrophysiology (NASPE) Practice Guideline Committee. Environmental and drug effects on patients with pacemakers and implantable cardioverter/defibrillators: a practical guide to patient treatment. Archives of Internal Medicine. 161(5):649-55, 2001. 9. Lamas GA. Ellenbogen KA. Evidence base for pacemaker mode selection: from physiology to randomized trials. Circulation. 109(4):443-51, 2004. 10. The DAVID Trial Investigators. Dual-chamber pacing or ventricular backup in patients with an implantable defibrillator. JAMA 2002;288(24):3115-3123. 32
  33. 33. Biventricular Pacing 1. Ellenbogen KA, Kay GN, Wilkoff BL (eds.), Device Therapy for Congestive Heart Failure Elsevier Science, Philadelphia, Pennsylvania, 2004. 2. Abraham WT, Fisher WG, Smith AL, Delurgio DB, Leon AR, Loh E, Kocovic DZ, Packer M. Cardiac resynchronization in chronic heart failure. New England Journal of Medicine 2002; 346(24): 1845-1853. 3. Cazeau S, Leclercq C, Lavergne T, Walker S, Varma C, Linde C, Garrigue S, Kappenberger L, Haywood GA, Santini M, Bailleul C, Daubert JC, Multisite Stimulation iC. Effects of multisite biventricular pacing in patients with heart failure and intraventricular conduction delay. New England Journal of Medicine 2001; 344(12): 873-880. 4. Kuhlkamp V, The I. Initial experience with an implantable cardioverter-defibrillator incorporating cardiac resynchronization therapy. Journal of the American College of Cardiovascular Medicine 2002; 39(5): 790-797. 5. Lozano I, Bocchiardo M, Achtelik M, Gaita F, Trappe HJ, Daoud E, Hummel J, Duby C. Impact of biventricular pacing on mortality in a randomized crossover study of patients with heart failure and ventricular arrhythmias. Pacing & Clinical Electrophysiology 2000; 23(11 Pt 2): 1711-1712. 6. Saxon LA, De Marco T, Schafer J, Chatterjee K, Kumar UN, Foster E, VIGOR C. Effects of long-term biventricular stimulation for resynchronization on echocardiographic measures of remodeling. Circulation 2002; 105(11): 1304-1310. 7. Stellbrink C, Breithardt OA, Franke A, Sack S, Bakker P, Auricchio A, Pochet T, Salo R. Impact of cardiac resynchronization therapy using hemodynamically optimized pacing on left ventricular remodeling in patients with congestive heart failure and ventricular conduction disturbances. Journal of the American College of Cardiovascular Medicine 2001; 38(7): 1957-1965. 8. Bradley DJ, Bradley EA, Baughman KL, Berger RD, et al. Cardiac resynchronization and death from progressive heart failure: A Meta-analysis of randomized controlled trials. JAMA 2003;289(6):730-740. 9. Cleland JGF, Daubert JC, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. New Engl J Med 2005;352:Cleland1-Cleland 11. Lead Extraction 1. Love CJ, Wilkoff BL, Byrd CL, Belott P, Brinker J, Fearnot NE, Friedman RA, Furman S, Goode LB, Hayes DL, Kawanishi DT, Parsonnet V, Reiser C, Van AR. Recommendations for Extraction of Chronically Implanted Transvenous Pacing and Defibrillator Leads: Indications, Facilities, Training. Pacing and Clinical Electrophysiology 2000;(23). 2. Wilkoff BL, Byrd CL, Love CJ, Hayes DL, Sellers TD, Schaerf R, Parsonnet V, Epstein LM. Pacemaker lead extraction with the laser sheath: results of the pacing lead extraction with the excimer sheath (PLEXES) trial. Journal of the American College of Cardiovascular Medicine 1999; 33(6): 1671-1676. 3. Kay GN, Brinker JA, Kawanishi DT, Love CJ, Lloyd MA, Reeves RC, Pioger G, Overland MK, Ensign LG, Grunkemeier GL. The Risks of Spontaneous Injury and Extraction of an Active Fixation Pacemaker Lead: Report of the Accufix Multicenter Clinical Study and World-Wide Registry. Circulation 1999; 100: 2344-2352. 33
  34. 34. 4. Byrd CL, Wilkoff BL, Love CJ, Sellers TD, Reiser C. Clinical study of the laser sheath for lead extraction: the total experience in the United States. PACE 2002; 25(5): 804-808. Syncope 1. Stickberger SA, Benson DW, Biaggioni I, Callans DJ, et al. AHA/ACCF Scientific Statement on the Evaluation of Syncope: From the American Heart Association Councils on Clinical Cardiovascular Medicine, Cardiovascular Nursing, Cardiovascular Disease in the Y oung, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiovascular Medicine foundation: In Collaboration with the Heart Rhythm Society: Endorsed by the American Autonomic Society. Circ 2006;113:316-327. 2. Soteriades ES, Evans JC, Larson MG, Chen MH, et al. Incidence and prognosis of syncope. New Engl J Med 2002;347(12):878-885. 3. Manolis AS, Linzer M, Salen D, Estes NAM. Syncope: current diagnostic evaluation and management. Ann Int Med 1990;112(11):850-863. 4. Grubb, BP. Neurocardiogenic Syncope. New Engl J Med 2005;352(10):1004-1010. 5. Kapoor WN. Syncope. New Engl J Med 2000;343(25):1856-1862. RESEARCH ROTATIONS GOALS and OBJECTIVES: The goals and objectives of the Research rotation is to discover new knowledge and to translate this knowledge into the practice of Cardiovascular Medicine. Research rotations are required. Cardiovascular Medicine fellows are encouraged to take part in clinical trials. Duties include review and understanding of research protocols, recruitment of patients into studies, and follow-up of patients within protocol guidelines. In addition, blocks of 1-3 months of research time are available with selected members of the Cardiovascular Medicine and University Faculty. Fellows should meet regularly with their mentors regarding their progress in research. The amount of research is dependent upon the experience of the trainee. In general, First Year Fellows:  Researching topics of presentation with the help of assigned mentors  Presentation of researched topics in Conference formats  Critically analyzing journal articles of relevance to Cardiovascular Diseases and presenting such analyses in the form of Journal Club presentations  Preparing and presenting topics/case reports/ research studies of importance to Internal Medicine at the regional and National meetings of the American College of Physicians and other organizations in Internal Medicine  Attending the National Annual Scientific Sessions of the American Heart Association/ American College of Cardiovascular Medicine  Identifying areas of potential research, including participation in clinical trials 34
  35. 35. Second Year Fellows:  Further refining research and presentation skills by acquiring the ability to present with clarity, complex topics and controversial topics in Internal Medicine and Cardiovascular Medicine in Conference format  Participating in ongoing clinical and basic science research protocols of the Division of Cardiovascular Medicine  Attending the National Annual Scientific Sessions of the American Heart Association/ American College of Cardiovascular Medicine Third Year Fellows:  Attending the National Annual Scientific Sessions of the American Heart Association/ American College of Cardiovascular Medicine  Preparing and submitting for publication manuscripts on original research conducted  Formulate research plans for a future career in Cardiovascular Medicine Fellows need to notify the fellowship coordinator 1 week prior to research rotation in writing regarding who they will be working with. ELECTIVE ROTATION OPTIONS PEDIATRIC CARDIOLOGY Elective rotations are available in conjunctive with pediatric cardiologists. This experience will provide exposure to congenital heart disease and other pediatric conditions. The rotation includes outpatient clinics and participation in invasive and non-invasive studies. VA NUCLEAR MEDICINE ROTATION This is an elective rotation. The fellow may actually be on a research rotation while on this block, too. This block will have coverage only 6 to 8 rotations (out of 13) per year. Treadmills/CPX treadmills will routinely begin at 10:00am. During this rotation, interpretation of nuclear studies including myocardial perfusion imaging, pharmacologic stress testing, first pass and gated radionuclide angiography will be performed. A basic knowledge of radiation safety, use of radiopharmaceuticals, and acquisition and processing of nuclear medicine images is gained. NUCLEAR CARDIOLOGY TRAINING The purpose of the Nuclear Cardiology Training Modules is to give training to Fellows in Cardiovascular Medicine to meet the requirements for licensure in Nuclear Cardiology. This training is intended to be a component toward eligibility to take the Certification Examination in 35
  36. 36. Nuclear Cardiology (CBNC) as well as to meet the requirements defined in 10CFR35.290 and 35.390 for becoming an authorized user of radiopharmaceuticals. Each of the modules is 1-3 hours in length and consists of the following types of learning: a) reading from selected texts, b) WEB-based reading and homework problems, c) classroom lectures, and d) exams. The schedule for examinations is as follows: a) for every 3 hours of learning a 20 minute exam is given, b) for every 15 hours of learning a 1 hour exam is given, and c) for every 45 hours of learning a 90 minute exam is given. A passing score of 80% is required. ADVANCED NUCLEAR CARDIOLOGY TRAINING-LEVEL 2 (4-6 MONTHS). This training will give the trainee the qualifications to become an authorized user of radiopharmaceuticals as defined by the Nuclear Regulatory Commission (NRC) in CFR 35.290 or 35.390. A total of 700 hours is required. A minimum of 500 hours is spent in the Nuclear Medicine Clinic in supervised clinical work. A minimum of 300 cases in nuclear cardiology are interpreted under supervision of a preceptor, and a minimum of 100 of these cases have correlations with coronary angiogram data. The trainee will become competent in all aspects of performing myocardial perfusion imaging: patient management, data acquisition/processing, and interpretation. Additional training of up to 200 hours is obtained through a series of lectures, readings, and electronic media (Web-based; learning CD‘s), and examinations. The areas of training include radiation physics, radiation biology, instrumentation, radiopharmaceuticals (handling, preparation, dosing, patient injection), and radiation safety Nuclear Cardiology Learning Objectives Clinical training in Nuclear Cardiology involves working under a physician preceptor and mastery of the following areas: 1) Evaluating consultation requests for cardiac studies and choosing the proper diagnostic procedure. 2) Selecting the proper imaging protocol and supervising the procedure. 3) Understand the procedure for formulation of radiopharmaceutical from Mo-99/Tc-99m eluant, and the proper dose preparation using the dose calibrator. 4) Safe handling of radiopharmaceutical and proper technique for injecting patients. 5) Using proper protocol (treadmill, adenosine, or dobutamine) for inducing increased coronary flow for Myocardial Perfusion Imaging. 6) Acquiring images with gamma camera and processing data. 7) Interpreting images in order to evaluate myocardial perfusion. 8) Recognition of artifacts that affect perfusion images. 9) Preparation of final reports. 10) Correlation of findings from myocardial perfusion images and cardiac catheterization. Recommended Reading for Nuclear Cardiology Rotation:  Basic Science of Nuclear Medicine, CD-ROM, 22 lessons, Society of Nuclear Medicine, 36
  37. 37. 2001.  Nuclear Medicine Self-Study Program III, Topic 5: Myocardial Perfusion Scintigraphy- Technical Aspects; Topic 6: Myocardial Perfusion Scintigraphy-Clinical Aspects, Society of Nuclear Medicine, 2001, Editor: Elias Botvinick M.D.  Iskandrian AE and Verani MS, Nuclear Cardiac Imaging, Principles and Applications, 3rd edition, 2003, Oxford University Press, 511p.  DePuey EG, Garcia EV, and Berman DS editors, Cardiac SPECT Imaging, 2nd edition, 2001, Lippincott Williams and Wilkins, 349p. DIDACTIC SCHEDULE The important education mission of the Division of Cardiovascular Medicine is additionally achieved through our daily morning conferences. CARDIOVASCULAR MEDICINE CONFERENCES Cardiovascular Medicine Conferences are held daily from 7:30am to 8:30am in the Clinical Support & Education Building (CE313) Conference Room. A variety of topics are covered and attendance is mandatory given that these sessions form an integral component of the training experience and upon which board eligibility is based. The Division requires at least 67% attendance to conferences to be board eligible. Service assignment determines which fellow has primary responsibility for the conference. The conference material must be planned in concert with the responsible faculty member identified. This includes the availability of handouts, projectors, and slides, and the coordination with contributing departments or divisions. Fellows typically are responsible for 5-6 major conference per year. Conferences will be held in the Clinical Support & Education Building (CE313) Conference Room. The fellows attendance at the Conferences will be recorded by their signing the Attendance List. This is necessary for documenting the educational experience provided by the Division and for recommending board eligibility. The success of the fellow‘s conference will be graded by the faculty in Cardiovascular Medicine using the attached document. This document will be used to determine the trainees‘ level of performance and again relates to the Divisions‘ recommending board eligibility. 37
  38. 38. Monday and Tuesday: Core Curriculum/Graphics Conferences Core Curriculum: Review of a major Cardiovascular Medicine topic by faculty or fellow. Early in the academic year a general review occurs. Later in the year more focused topics are presented. Topics included include: cardiocirculatory physiology and metabloism cardiovascular pharmacology heart failure myocardial infarction and coronary artery disease valvular heart disease pericardial disease hypertension lipid abnormalities congenital heart disease Cardiovascular risk factors heart disease in pregnancy principles of cardiovascular rehabilitation cardiovascular pathology peripheral and cerebral vascular disease biostatistics cardiac trauma cardiovascular epidemiology pulmonary vascular disease newer imaging techniques, such as magnetic resonance imaging, fast computerized tomography, positron emission tomography ethical issues in clinical practice Cardiovascular Medicine as it relates to other subspecialties such as thoracic surgery, nephrology, pulmonary and critical care, etc cardiovascular diseases in the elderly molecular biology of the cardiovascular system cardiac transplantation Specific Objectives: 1. Understanding cardio-circulatory physiology, cardiovascular pharmacology. 2. Understanding the basic principles of management of common cardiovascular problems such as acute myocardial infarction, angina pectoris, valvular heart disease, cardiomyopathies, and congenital heart disease especially in the adult, congestive heart failure, pericardial disease, endocarditis, and cardiac arrhythmias. 3. Developing an understanding of preventive Cardiovascular Medicine. 4. Discussion of lipid abnormalities, their diagnosis and management. 38
  39. 39. 5. Heart disease in pregnancy. 6. Cardiovascular rehabilitation. 7. Cardiovascular pathology including endomyocardial biopsies. 8. Biostatistics. 9. Ethical issues in clinical practice and in research. 10. Cardiovascular Medicine as it relates to other specialties, e.g. pulmonary and critical care, nephrology, thoracic surgery. 11. Understanding the principles of effective consultation to other services and in particular peri-operative cardiovascular assessment for non-cardiac surgery. 12. Understanding the indications, contraindications, timing and complications of cardiothoracic surgical procedures. Graphics: Review of selected ECG's, echos, or stress tests other suitable patient material by faculty or fellow. Specific Objectives: 1. Understanding the basic principles involved in electrocardiography, signal averaged electrocardiography, stress testing, echocardiography including stress and transesophageal echocardiography, cardiopulmonary exercise testing, nuclear imaging, 2. Understanding cardiac arrhythmias, basics of pacemaker indications, implantation, follow-up and troubleshooting. 3. Understanding the basics of anti-tachycardia device and drug therapy. 4. Understanding implantation of and follow up of patients with implanted ICDs. 5. Understanding of application of nuclear medicine as it applies to cardiovascular disease. Indications and interpretation of Radionuclide stress tests, radionuclide ventriculograms. 6. Principles of intra-operative transesophageal echocardiographic evaluation and monitoring. Wednesday: Peer Review Conference with Cardiothoracic Surgery Challenging cases involving both services are presented by fellows or residents. Specific Objectives: 1. Present clinical cases of relevance to Cardiovascular Medicine to Cardiothoracic surgery. 2. Basic principles of right and left cardiac catheterization, hemodynamics, assessment of 39

×