CURRICULUM


 Fellowship Education Program
   in Cardiovascular Diseases




University of Missouri-Columbia
      School ...
I. Major Goals/Objectives: General Considerations

               The major goal of the Curriculum in Cardiovascular Disea...
Rotations (UH and HSTMVH, minimum of 4 months), Cardiac Electrophysiology and
       Pacemaker Rotations (minimum of 2 mon...
conferences or ad hoc performance on clinical services. Information gleaned from fellows’
       performance evaluations a...
pacemaker placement of an intra-arterial catheter and management of
   patients with an intra-aortic balloon pump. They ar...
assessment in patients undergoing cardiac and non-cardiac surgery and
   the management of peri-operative and post-operati...
d. Electrocardiography

   Early in their fellowship each Fellow in Cardiovascular Disease is
   scheduled to rotate for o...
subsequent Echocardiography Laboratory rotations fellows are provided
   the opportunity to become proficient in the inter...
modalities, data acquisition and processing, and interpretation of studies.
   Additional training of up to 200 hours is o...
valvuloplasties. They are not however, expected to become proficient in
   these interventions during the three year train...
k. Cardiac and Vascular Surgery

                  Presently, experience in cardiac and vascular surgery is gained primari...
this conference is to provide the Fellows in Cardiovascular Disease
       information that has been identifies by the ACG...
cardiology clinic. Whenever possible cases focus on areas of faculty interest
       and expertise. (PC, MK).

5. Cardiac ...
electrocardiograms and electrophysiologic studies are presented at each
       conference, there is often a theme focusing...
Each senior fellow in Cardiovascular Disease is assigned to one of three
              hospital quality assurance (QA) com...
f. Be able to perform a comprehensive cardiovascular
                 history. (PC, MK, CS)

       2. Methods of Educatio...
d. Perform accurate evaluation of the jugular venous pulse.
         Identify and explain the physiologic basis for normal...
b. Clinical experience on the inpatient cardiology
                 consultation service, in the cardiology outpatient cli...
a. Describe the electrophysiologic basis for elective
                 cardioversion. (PC, MK)

              b. List the ...
e. Describe the thermodilution method for assessing cardiac
                output. (PC, MK)

             f. Identify the...
c. Describe the various modes of temporary cardiac pacing
                 and discuss the uses and comparative advantages...
a. Discuss the historical aspects of cardiac catheterization.
   (MK)

b. Describe the technical aspects of cardiac cathet...
m. Describe the clinical usefulness of obtaining
         hemodynamic information during exercise and describe
         th...
3. Methods of Evaluation

             a. Direct observation by         faculty   in   the   cardiac
                cathe...
h. Describe and use angulated views of the coronary
   arteries. (PC, MK)

i. Describe and identify the pitfalls of corona...
to mortality risk. Describe and be able to implement
          TIMI score an corrected frame count. (PC, MK)

      r. Des...
b. Participation in Cardiac Catheterization Conferences.
                 (PC, MK)

              c. Clinical correlation ...
f. Describe the treadmill protocols used in clinical practice.
   (PC, MK)

g. Describe the lead systems used in exercise ...
maximal work capacity, submaximal exercise heart rate
          response, rate-pressure product and the presence or
      ...
d. Presentation and discussion of cases at teaching rounds,
                EKG Conference, Cardiology Grand Rounds and Co...
i. Discuss    the advantages         and     limitations   of
   echocardiography. (PC, MK)

j. Be able to accurately iden...
q. Perform and interpret at least 150 comprehensive trans-
         thoracic echocardiographic/Doppler/color flow studies....
c. Performance on portions of the ABIM Subspecialty
                         Board Examination in Cardiovascular Diseases ...
a. Observation by qualified cardiology faculty in the cardiac
                catheterization laboratory and coronary care...
c. Attendance at EKG/Electrophysiology Conferences. (PC,
                  MK)

               d. Participation in industr...
h. Describe the clinical indications for, and the applications
                 of, intra-cardiac electrophysiologic mappi...
c. Describe the indications for and clinical application of
                intra-aortic balloon counterpulsation. (PC, MK...
b. List the indications for PTCA, coronary atherectomy
                 (directional and rotational), coronary stent deplo...
a. Discuss the role of exercise in cardiac rehabilitation and
   physical reconditioning including factors influencing
   ...
n. Discuss sexual aspects of cardiovascular rehabilitation.
                         (PC, MK)

              2. Methods of...
e. Describe and be able to identify the signs of cardiac
   calcification on a chest x-ray including those associated
   w...
cyst, herniation of the pericardium and congenital
                 absence of the pericardium. (PC, MK)

             l. ...
b. Describe and discuss the electrical basis for elements of
   the routine EKG including the P wave, the PR interval,
   ...
presence of conduction defects, the EKG and locale of
          infarction and non-infarction. (PC, MK)

      j. Describe...
b. Performance during EKG/Electrophysiology Conference.

              c. Performance on portions of the ABIM Subspecialty...
i. Compare and contrast the following aspects of
   myocardial perfusion image interpretation: normal,
   defect, reversib...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
CURRICULUM Fellowship Education Program in Cardiovascular ...
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CURRICULUM Fellowship Education Program in Cardiovascular ...

  1. 1. CURRICULUM Fellowship Education Program in Cardiovascular Diseases University of Missouri-Columbia School of Medicine
  2. 2. I. Major Goals/Objectives: General Considerations The major goal of the Curriculum in Cardiovascular Disease is to provide the Fellow in Cardiovascular Disease with learning experiences that will permit him or her to enhance his or her understanding of normal cardiovascular anatomy and physiology and to become knowledgeable in the epidemiology, genetics pathology, pathophysiology, pharmacology clinic features, laboratory abnormalities, differential diagnosis, natural history, treatment, prognosis and prevention of diseases of the cardiovascular system. It is anticipated that the Fellow in Cardiovascular Disease will draw on such knowledge to become competent in the discipline of cardiovascular disease. The fellow is also expected to become familiar with the role of psychosocial factors in the clinical presentation of cardiovascular disease and to understand the economic burdens of cardiovascular disease including those associated with diagnosis, management and prevention. The fellow is afforded the opportunity to participate in scholarly activities including research and are provided with the education, tools and mentoring to become proficient in the analysis and performance of clinical, translational or basic research. The Fellow in Cardiovascular Disease is encouraged to learn to practice compassionate, efficient, cost-effective, high- quality and whenever possible, evidence-based cardiovascular medicine. The Curriculum in Cardiovascular Disease consists of four components (1) clinical experience, (2) lectures, conferences, and committee assignments, (3) the opportunity to attain competence in and/or knowledge of a variety of cardiovascular skills and procedures (including research) and (4) formal education in cardiovascular diseases. The Curriculum in Cardiovascular Disease is organized around topical and instructional objectives. Topical objectives identify subject areas about which fellows will learn and instructional objectives define what within those subject areas is to be learned. Each instructional objective addresses one or more of the core competencies mandated by the Accreditation Council for Graduate Medical Education (ACGME). These are (1) patient care (PC), (2) medical knowledge (MK), (3) inter-personal and communication skills (CS), (4) professionalism (P), (5) practice-based learning and improvement (PBLI) and (6) systems-based practice (SBP). In sections IVA, B, C, and D of this document each of the clinical and educational experiences and instructional objectives are accompanied by denotation of the core competencies that apply to that experience or objective. II. Methods of Education The fellow in Cardiovascular Disease derives knowledge of cardiovascular disease from multiple sources. These include clinical rotations, outpatient experiences, lectures and conferences, research rotations and elective rotations. Clinical rotations include the Inpatient Cardiology Service at University Hospital (UH) which consists of both coronary intensive care unit and cardiology ward experiences (minimum of 4 months), the Inpatient Cardiology Consultation Services at (UH and at the Harry S Truman Memorial Veterans Hospital (HSTMVH), minimum of 6 months), the Graphics Laboratory Rotation (1 month), Echocardiography Laboratory Rotations (UH and HSTMVH, minimum of 4 months)., Nuclear Cardiology Rotations (minimum of 2 months), Cardiac Catheterization Laboratory 2
  3. 3. Rotations (UH and HSTMVH, minimum of 4 months), Cardiac Electrophysiology and Pacemaker Rotations (minimum of 2 months including pacemaker/ICD surveillance and analysis), the Cardiac Rehabilitation experience (2 weeks). One month elective experiences are available in cardiac transplantation and advanced cardiac imaging at institutions with available cardiac transplantation programs and advanced imaging services. Each fellow maintains a half-day outpatient clinic per week throughout the three year fellowship (UH and HSTMVH). In these clinics fellows evaluate and manage new patients and then follow those who require continued care for the duration of their fellowship. All fellows are provided the opportunity to participate in scholarly activity under faculty mentorship (6-12 months). Fellows are strongly encouraged to complete at least one research project during the course of their fellowship and are also encouraged to write scholarly reviews for publication in referred journals. A variety of lectures and conferences supplement the fellow’s educational experiences gained from inpatient clinical rotations, outpatient experiences, clinical laboratory experiences, and research rotations. These include the Core Curriculum Lecture Series (weekly), Cardiology Grand Rounds (weekly), Morbidity and Mortality Conference (monthly), Journal Club (monthly), Research Conference (monthly) and Fellows Conference (monthly), EKG/Electrophysiology Conference (monthly) and Professor Rounds (bi-monthly). An extended lecture series in Nuclear Cardiology designed to satisfy certification requirements is offered every other year for interested fellows. In addition to these lecture and conferences, fellows are encouraged to attend the annual AHA or ACC Scientific Sessions or a national subspecialty conference if they are so interested. They are also encouraged to attend Internal Medicine Grand Rounds whenever possible. Fellows may avail themselves of the Cardiology Learning Center. This facility is located in the fellows office area and consists of a library of textbooks and computer programs relevant to the discipline of cardiovascular disease. Desk carrels are available for each fellow. Three computers with access to the main library are available to fellows, copies of major cardiovascular and internal medicine journal are available in the nearby Cardiology Office area. A fully equipped conference room is located next to the Cardiology Learning Center. Senior fellows are appointed to hospital quality assurance committees (ACS, CHF, Cardiac Arrest) so that they may learn the quality assurance process. III. Methods of Evaluation Each fellow receives a summary of the goals and objectives and expectations from the attending physician at the beginning of each rotation and an oral summative evaluation at the end of the rotation. In addition, each fellow receives a written evaluation (ABIM evaluation form) at the end of each rotation. Each fellow receives biannual written and oral evaluations form the Program Director which summarize evaluations from the previous 6 months. Each fellow receives a semiannual 360 degree evaluation from attendings, peers and paramedical staff who have worked with the fellow during the previous 6 months. Feedback based on these 360 degree evaluations is provided by the Program Director. Fellows also receive real-time formative evaluations from faculty relating to performance at 3
  4. 4. conferences or ad hoc performance on clinical services. Information gleaned from fellows’ performance evaluations and from the ABIM Certifying Examination in Cardiovascular Disease is evaluated by the Program Director. Changes in the curriculum are made to address deficiencies. Once per year faculty meet with all of the fellows so that they (the fellows) may critique the fellowship program. Minutes of these meetings are kept and the Program Director is charged with evaluating criticism and implementing changes in the curriculum/program. In addition, fellows evaluate faculty in writing at the end of each rotation. These evaluations are analyzed by the Division Director and Program Director who provide feedback to faculty and make changes when necessary in the exposure of faculty to fellows. IV. Specific Program Content A. Clinical Experience 1. The Fellow in Cardiovascular Diseases is provided a broad spectrum of opportunities to acquire clinical experience in and knowledge of adult cardiovascular diseases in the inpatient setting, in the outpatient setting and in the clinical laboratories. The following descriptions list the general goals and objectives of rotations in these venues and summarize the scope of cardiovascular disease and experiences encountered by fellows during various clinical rotations. Specific duties on each rotation are listed separately in the Cardiovascular Disease Fellowship Manual. a. Direct Cardiology Inpatient and Coronary Intensive Care The Fellow in Cardiovascular Disease is provided a minimum of 4 months of experience in the Coronary Intensive Care Unit. At UH this service is coupled with the Cardiology Ward service. It is a high-volume, high-turnover service. At the HSTMVH, the Coronary Intensive Care Unit rotation is a low volume service that is coupled with the Cardiology Consultation Service. During the Coronary Intensive Care Unit component the fellow in Cardiovascular Disease is afforded the opportunity to acquire knowledge and skill in the diagnosis and management of definite or suspected acute myocardial infarction and its complications, unstable angina pectoris, highly-symptomatic or life- threatening arrhythmias and conduction disturbances, acute/severe congestive heart failure, acute vascular disease, acute infective endocarditis, hemodynamically-significant pericardial effusion, hypertensive emergencies and urgencies, aortic dissection, acute pulmonary embolism, life-threatening complications of cardiac therapy, hypotension and shock. During the Coronary Intensive Care Unit component fellows are provided the opportunity to become proficient in bedside cardiac procedures including placement of a Swan-Ganz catheter, temporary pacemakers insertion, and a temporary transvenous 4
  5. 5. pacemaker placement of an intra-arterial catheter and management of patients with an intra-aortic balloon pump. They are expected to maintain proficiency in BLS and ACLS and to become familiar with Phase I Cardiac Rehabilitation. During the non-Coronary Intensive Care Unit Ward component of the rotation fellows have the opportunity to gain knowledge and experience in the evaluation of management of patients who no longer need coronary intensive care and those with severe acute and chronic coronary artery disease, hypertensive disease, valvular disease, cardiomyopathy, pericardial disease, congenital heart disease, congestive heart failure and cardiac arrhythmias that require inpatient care and/or monitoring, but not intensive care. Fellows are expected to become proficient in the use of cardiovascular drugs and in the judicious use of diagnostic tests and non-pharmacologic therapeutic modalities. Fellows are provided the opportunity to learn to deal with psychosocial and ethical considerations and to practice evidence-based, cost-effective cardiology in a highly- professional, compassionate manner. They are also expected to integrate their knowledge of general internal medicine into the management of cardiovascular disease. Finally, they are expected to learn to work within hospital systems (including with paramedical personnel) and use external medical systems to enhance patient care. They are expected to internalize feed back from attendings, colleagues and paramedical personnel to improve their practice of inpatient cardiology. (PC, MK, CS, P, SBP, PBLI). b. Inpatient Cardiology Consultation The Fellow in Cardiovascular Diseases is provided a minimum of 6 months of full-time experience on the Inpatient Cardiology Consultation Services. Inpatient Cardiology Consultation Services are present at UH and at the HSTMVH. The only difference in these services is that the HSTMVH Inpatient Cardiology Consultation Service is coupled with the low-volume HSTMVH Coronary Intensive Care Unit Service. During inpatient cardiology consultation experiences the Fellow in Cardiovascular Diseases is afforded the opportunity to acquire knowledge of cardiovascular anatomy, physiology, pharmacology, pathology, molecular biology, genetics and metabolism. The fellow is provided the opportunity to learn to evaluate and manage acute and chronic coronary artery disease, hypertension and hypertensive cardiovascular disease, cardiomyopathies, acute and chronic valvular disease, acute and chronic pericardial disease, adult congenital heart disease, peripheral vascular disease, pulmonary heart disease, acute and chronic congestive heart failure, cardiac arrhythmias and conduction disturbances, cardiovascular risk factors, complications of cardiovascular therapy, and cardiac complications of non-cardiovascular therapy. Fellows are expected to become proficient in pre-operative risk 5
  6. 6. assessment in patients undergoing cardiac and non-cardiac surgery and the management of peri-operative and post-operative cardiac complications of cardiac and non-cardiac surgery. Fellows are provided the opportunity to learn to use cardiovascular tests in an efficient, yet thorough and cost-effective manner. Fellows are expected to learn to provide evidence-based cardiovascular advice whenever possible and are encouraged to engage in verbal communication with requesting physicians on a frequent basis to enhance understanding. They are expected to be personable and humane in their interactions with patients. Fellows will have the opportunity to learn how to co-manage patients when necessary and when and how to terminate consultations. (PC, MK, CS, P, SBP). c. Outpatient Cardiology Experiences Each Fellow in Cardiovascular Disease maintains an outpatient cardiology clinic one-half day per week throughout their fellowship. Half of these take place at UH and half at the HSTMVH. At their HSTMVH clinic, fellows also work with an electrophysiologist to learn to interrogate, trouble-shoot and reprogram pacemakers and implantable cardioverter defibrillators (ICD’s). Fellows are typically scheduled to see 1-2 new patients and 7-8 return patients per clinic. Fellows are encouraged to return patients to their primary care physician when cardiovascular problems become stable or resolve, but are permitted to co-manage patients indefinitely when appropriate. In Cardiology Clinic fellows learn to evaluate and manage patients with chronic coronary artery disease, hypertension and hypertensive cardiovascular disease, cardiomyopathies, valvular heart disease, pericardial disease, adult congenital heart disease, congestive heart failure, non-life threatening cardiac arrhythmias and conduction disturbances, cardiovascular risk factors and long-term sequelae to acute cardiovascular problems. They are expected to learn to expeditiously and effectively provide pre- operative cardiovascular risk assessment and recommendations and to manage patients following cardiac surgery who have been discharged from the hospital. Fellows are provided the opportunity to learn to use cardiovascular drugs in the outpatient and to understand their diverse effect. Conversely, they also learn to recognize cardiovascular effects of non-cardiac drugs. Fellows are expected to learn to use diagnostic tests judiciously and to practice in an evidence-based, cost-effective manner. They are expected to create and maintain a compassionate relationship with patients and to communicate with referring physicians and staff in an effective collegial manner. Fellows are taught to utilize hospital and community medical and social systems to enhance patient care and to constantly evaluate their effectiveness as clinicians. (PC, MK, CS, P, PBLI, SBP). 6
  7. 7. d. Electrocardiography Early in their fellowship each Fellow in Cardiovascular Disease is scheduled to rotate for one month in the Electrocardiography Laboratory (Graphics Rotation). The main goal during this rotation is to become proficient in the interpretation of resting electrocardiograms, ambulatory electrocardiograms, event monitor electrocardiograms, signal-averaged electrocardiograms and stress electrocardiograms. Under faculty supervision fellows are taught to determine rate, rhythm and axis on the scalar electrocardiogram. They are also taught to identify left and right ventricular hypertrophy, left and right atrial enlargement, intraventricular conduction block, fascicular and bifascicular block, signs of myocardial ischemia and infarction, signs of pericarditis and signs of drug, metabolic and electrolyte disturbances and miscellaneous repolarization abnormalities on the electrocardiogram. Fellows are taught to recognize common cardiac arrhythmias and conduction disturbance on scalar ambulatory and event monitor electrocardiogram and are taught to interpret signal-averaged electrocardiograms. They are provided the opportunity to perform treadmill exercise tests and to interpret the symptom, hemodynamic and electrocardiographic responses during such tests. By the end of the one month rotation fellows are expected to interpret a sufficient number of electrocardiograms and perform a sufficient number of treadmill exercise tests to become proficient based on ACGME criteria. Additional opportunities exist for electrocardiogram interpretation and treadmill exercise testing on Cardiology Inpatient Service rotations, on the Cardiology Consultation rotations, in the cardiology clinics and on the Electrophysiology/Pacemaker Service rotations and on the HSTMVH Non-invasive Cardiology rotations. (PC, MK, PBLI). e. Echocardiography and Cardiac Doppler Fellows in Cardiovascular Disease are provided a minimum of 5 months of experience in the Echocardiography Laboratories (UH and HSTMVH). During the initial month in the Echocardiography Laboratory fellows are required to learn the basic principles of cardiac ultrasound and to be able to perform a complete transthoracic echocardiographic and cardiac Doppler study. They are taught to identify normal echocardiographic and cardiac Doppler patterns, to begin to recognize and interpret abnormal transthoracic echocardiograms and Doppler (pulse wave, continuous wave, tissue) images. Fellows are expected to learn the indications for cardiac ultrasound procedures and to understand the value, limitations and potential complications of the procedures. All of this is conducted under faculty supervision. During 7
  8. 8. subsequent Echocardiography Laboratory rotations fellows are provided the opportunity to become proficient in the interpretation of abnormal transthoracic echocardiographic and Doppler (pulse wave, continuous wave, tissue) studies and in the performance and interpretation of stress echocardiogram (exercise, dobutamine), contrast echocardiograms (saline bubble) and transesophageal echocardiograms. Fellows have the opportunity to participate in intra-operative echocardiography. Fellows perform and interpret a sufficient number of transthoracic echocardiograms/Doppler studies, stress echocardiograms and transesophageal echocardiograms by the end of their fellowship to meet or exceed the ACGME threshold for proficiency. (PC, MK, PBLI) f. Nuclear Cardiology Nuclear Cardiology training is provided to the Fellow in Cardiovascular Disease in 3 tiers. The first tier must be completed by all fellows and consist of a 2 month experience in the HSTMVH Nuclear Cardiology Laboratory. Under the direction of the laboratory director fellows acquire basic knowledge of radiation safety, use of radiopharmaceuticals and acquisition and processing of nuclear medicine images. Fellows are expected to learn the indications for, value and limitations of cardiac nuclear medicine studies and are provided the opportunity to interpret myocardial perfusion images using sestamibi collected in association with exercise or pharmacologic stress (dobutamine, adenosine). Under faculty supervision fellows are taught to recognize normal radionuclide images and abnormal images, and are encourage to correlate these images with coronary angiographic anatomy when available. Fellows are also provided the opportunity to interpret myocardial viability studies using thallium-201. In addition, fellows are taught to interpret normal and abnormal radionuclide ventriculograms (MUGA, first pass). The aforementioned training serves as an introduction to cardiac nuclear medicine. To become proficient in cardiac nuclear medicine, fellows must complete tiers 2 and 3. Tier 2 consists of completion of nuclear cardiology training modules that are designed to meet requirements for certification eligibility and licensure in nuclear cardiology. This program consists of assigned reading from nuclear cardiology textbooks, web- based reading and quizzes, classroom lectures and examinations. Tier 3 provides advanced nuclear cardiology training over a 4-6 month period. This training provides the fellow with qualifications to become an authorized user of radiopharmaceuticals as defined by the Nuclear Regulatory Commission. A total of 700 hours of training is required. A minimum of 500 hours is spent in supervised work. A minimum of 300 cases are interpreted under the supervision of a licensed preceptor, 100 of which must be correlated with coronary angiograph. The fellow is expected to become proficient in the selection of appropriate diagnostic 8
  9. 9. modalities, data acquisition and processing, and interpretation of studies. Additional training of up to 200 hours is obtained via lecture, reading, electronic media and examinations. Areas covered included radiation physics, radiation biology, instrumentation, radiopharmaceuticals (handling, preparation, daring, injection) and radiation tapes. Hot lab requirements are completed in the HSTMVH Nuclear Medicine suite. Tiers 2 and 3 are elective, but are selected by most fellows. g. Advanced Cardiac Imaging At present, there is no advanced cardiac imaging rotation. MRI and PET scanning of the heart are currently available, but are little-utilized. With the acquisition of a 64 slice CT scanner early in 2008, we anticipate a sufficient number of cases to provide case-based training which will be supplemented by lectures, selected reading and web-based programs (already available). Advanced cardiac imaging training will initially be integrated into nuclear cardiology rotations. The major goal of this rotation will be to provide the fellow with an introduction to the physics, acquisition, indications, interpretation and clinical application of advanced cardiac imaging and images. (PC, MK). h. Cardiovascular Catheterization The Fellow in Cardiovascular Disease is provided a minimum of four months of experience in the cardiac catheterization laboratories. Most fellows choose to take additional rotations in the cardiac catheterization laboratory. The main goal of Cardiac Catheterization Laboratory rotations is to acquire sufficient knowledge and experience to become proficient in the performance and interpretations of diagnostic cardiac catheterizations. During the first year fellows are provided the opportunity to learn normal and abnormal cardiac hemodynamics, ventricular function and coronary anatomy. They also are expected to become proficient in gaining intravenous and intra-arterial access to the vascular system, right heart catheterization and temporary transvenous pacemaker placement. During the latter portion of the first year and during the second and third years fellows are provided to opportunity to become proficient in left heart catheterization, combined right and left heart catheterizations, coronary angiography, aortography, and pulmonary angiography. In addition, the fellow is afforded the opportunity to become proficient in myocardial biopsy, intra-aortic balloon placement and maintenance and pericardiocentesis. The Fellow in Cardiovascular Disease is exposed to percutaneous coronary interventions including balloon angioplasty, coronary stent deployment (following angioplasty and primary) and rotational atherectomy. They are also exposed to and assist on peripheral arterial interventions and 9
  10. 10. valvuloplasties. They are not however, expected to become proficient in these interventions during the three year training period. All cardiac catheterizations performed by fellows are supervised by experienced invasive/interventional cardiologists. It is anticipated that all Fellows in Cardiovascular Disease will perform a sufficient number of invasive procedures to meet COCATS 3 guidelines for proficiency. (PC, MK, CS). i. Cardiac Electrophysiology and Permanent Pacemaker Implantation Each fellow in Cardiovascular Diseases is provided a minimum of two months of experience in the Cardiac Electrophysiology Laboratories (UH, HSTMVH) separate from Cardiac Catheterization Laboratory rotations. Fellows in Cardiovascular Disease are provided instruction in the fundamentals of cardiac electrophysiology and are afforded the opportunity to become proficient in the performance and interpretation of head-up tilt tests and cardiac conduction studies. They acquire substantial exposure to programmed electrical stimulation, intracardiac mapping and radiofrequency ablation of the AV node, slow pathways, atrial flutter pathways, accessory pathways and automatic foci, but do not become proficient in these procedures during the three year training period. Fellows gain experience in permanent pacemaker (single or dual chamber) implantation and ICD implantation during their Cardiac Electrophysiology Laboratory rotations but not perform enough implantations to be considered proficient in these procedures according to ACC/AHA guidelines. Experience in pacemaker/ICD follow up, surveillance and trouble-shooting is gained primarily in monthly (HSTMVH) pacemaker/ICD follow-up clinics throughout the fellowship. The fellow is afforded the opportunity to gain experience in temporary pacemaker placement as well during cardiac catheterization and coronary intensive care rotations. (PC, MK, CS). j. Cardiac Rehabilitation Experience in phase I cardiac rehabilitation is gained during Coronary Intensive Care Unit rotations. Fellows in Cardiovascular Diseases are introduced to phases II and III during their Electrocardiography rotation. They spend four half – days during that month rotating in Fit-For-Life, the cardiac rehabilitation program at UH. They are expected to learn the design and structure of a cardiac rehabilitation program, to understand its effect of cardiac morbidity, mortality and cardiovascular risk factors and to be able to write an exercise prescription based on clinical information. (PC, MK, SBP). 10
  11. 11. k. Cardiac and Vascular Surgery Presently, experience in cardiac and vascular surgery is gained primarily on the Inpatient Cardiology Service and via the Inpatient Cardiology Consultation Services. Cardiac surgery patients are transferred to the Inpatient Cardiology Service 2-3 after surgery. Fellows gain experience in the late post-operative care of their patients. Vascular surgery patients are initially seen in consultation in the Cardiology Clinics or in via the Inpatient Cardiology Consultation Service. We are presently considering a one month elective rotation that would permit the Fellow in Cardiovascular Disease to observe and participate in pre-operative, intra- operative, and early post-operative care of cardiac and vascular surgery patients, and to gain exposure to non-invasive and invasive vascular studies. We hope to initiate this rotation in July of 2008. (PC, MK, SBP). l. Vascular Medicine We are in the process of designing a one month rotation in vascular medicine that will afford the fellow the opportunity to gain experience in the vascular surgery clinic and in the non-invasive vascular laboratory. We anticipate initiating this rotation in early 2009 (PC, MK). m. Advanced Cardiac Imaging In early 2009 we will initiate a one month rotation in advanced cardiac imaging wherein the fellow will gain exposure to CT angiography, cardiac MRI and cardiac PET scanning. (PC, MK). n. Other Elective Rotations As previously noted, we hope to initiate an advanced imaging elective within the next year. Currently, fellows may elect a one month rotation at an institution with an active advanced cardiac imaging program. Also, previously-described was the elective component of the Nuclear Cardiology experience. Fellows may elect a one month rotation in advanced heart failure management and cardiac transplantation at an institution with an active heart transplantation program. (PC, MK, SBP). B. Lectures, Conferences, and Committees 1. Core Curriculum Lecture Series This series consists of 72 weekly or biweekly lectures presented by Cardiology faculty to Fellows in Cardiovascular Diseases. The purpose of 11
  12. 12. this conference is to provide the Fellows in Cardiovascular Disease information that has been identifies by the ACGME as essential to the understanding of the principles and practice of cardiology. Each lecture is one hour in duration and is presented in a didactic or case-based manner. The lecture series is designed to be completed over an 18 month period. Each lecture is presented twice during the three year fellowship to ensure that all fellows have the opportunity to attend >80% of the lectures. The Core Curriculum Lecture Series includes, but is not limited to topics identified by the ACGME as essential areas of knowledge for the fellow in Cardiovascular Disease. Core Curriculum Lectures are listed in a separate document. (PC, MK). 2. Fellows Conference This monthly lecture series is presented by Fellows in Cardiovascular Disease. The purpose of this conference is to provide the fellow the opportunity to perform a detailed literature search on a specific topic and organize the material for the purpose of presenting it in a coherent and stimulating manner. The lectures may be presented in a didactic or case- based format. Although fellows may select a core topic to present, they usually select more focused topics. Three recent fellows conference consisted of lectures on patent foramen ovale, aspirin and clopidogrel resistance and left main coronary artery disease. Fellows Conference Lectures are characterized by a rigorous review of the literature on the topic selected. Discussions stimulated during Fellows conference are invariably spirited, vibrant and informative. (PC, MK). 3. Cardiology Grand Rounds This weekly conference consists of one hour lectures that focus on recent advances in cardiovascular disease and/or state of the art lectures. During a typically month 2-3 lectures will be presented by a distinguished scientists from other institutions, one lecture will be presented by one of the Division of Cardiology faculty and one lecture will be presented by faculty from other divisions or department in the medical school. Presentations may focus on clinical cardiology, clinical research translational research or basic research. (PC, MK, SBP). 4. Professor Rounds The purpose of this bimonthly conference is to provide a format wherein Fellows of Cardiovascular Disease can present cases to a single Cardiology faculty attending and participate in a faculty-led discussion of the cases at the fellow level. Cases are drawn from the inpatient services or from 12
  13. 13. cardiology clinic. Whenever possible cases focus on areas of faculty interest and expertise. (PC, MK). 5. Cardiac Catheterization Conference This case-based conference takes place 3-4 weeks per month. Attendance consists of Division of Cardiology faculty and fellows and faculty from the Division of Cardiothoracic Surgery. Fellows select and present an average of 4-6 cases per conference. All cases are selected for there teaching value. This format also facilitates discussions with cardiac surgeons about complex or high risk cases. One conference per month is oriented toward correlation of coronary angiographic findings with imaging studies. Each conference 1- 2 fellows prepare a brief (10 minutes) mini-literature review on a topic germane to a case presented during the conference. Discussions are typically brisk, and informative, and not infrequently have therapeutic implications for patients discussed. (PC, MK, PBLI). 6. Echocardiography Conference This case-based conference occurs 3-4 weeks per month. Fellows on the Echocardiography rotations present 3-4 cases per conference which focuses on diverse aspects of echocardiographic/Doppler diagnosis. Cases are selected for teaching value and may consist of any of the echocardiographic/ Doppler modalities. A core curriculum of echocardiography topics to be presented by noninvasive cardiology faculty is scheduled to be integrated into Echocardiography Conference in 2008. (PC, MK). 7. Nuclear Cardiology Conference This conference occurs monthly and consists of a series of lectures focusing on the technical aspects of nuclear cardiology as well as general principles of interpretation of myocardial perfusion cases and, radionuclide ventriculography. This didactic and case-based lecture series is required for all Fellows in Cardiovascular Disease. It is supplemented by web-based presentations. The live lecture and web-based presentations serve as the didactic basis for preparation for certification in Nuclear Cardiology. (PC, MK, SBP). 8. Electrocardiography/Electrophysiology Conference Electrocardiography/Electrophysiology conference occurs once per month. It is a case-based conference. Electrocardiograms and electrophysiology studies together with clinical information are presented by faculty or senior fellows. Fellows are asked to interpret the graphics and discuss the electrophysiological basis for the findings. Although a variety of 13
  14. 14. electrocardiograms and electrophysiologic studies are presented at each conference, there is often a theme focusing on a specific topic are within each conference (eg, fascicular block, pacemaker ECG’s, pre-excitation, etc.). This highly-interactive conference invariably engender active discussion and debate. (PC, MK, PBLI). 9. Morbidity and Mortality Conference This monthly conference is presented by fellows rotating on the Inpatient Cardiology Service or Inpatient Consultation Service. Patients selected for presentation are drawn from cases in which a patient died or suffered a non- fatal unanticipated complication. Attending physicians involved in these cases are required to be present. When appropriate, pathologists, radiologists and surgeons involved in the case are invited to attend. These conferences are typically characterized by frank discussions of the management strategies that were used as well as alterative strategies that might have altered outcomes. (PC, MK, PBLI, SBP). 10. Journal Club The purpose of this monthly conference is to teach the Fellow in Cardiovascular Disease to critically analyze research articles form the recent literature. Each fellow is assigned one Journal Club per year and typically presents two to three articles. Fellows are expected to summarize the purpose and hypothesis the study, to present the methods (including statistical methods) and results in detail and to summarize the authors’ conclusions. The fellow then provides a detailed critique of all aspects of the study, citing strengths and weaknesses and identifying alternative methodologies that might have been more suitable. Fellows are strongly encouraged to review selected articles with a faculty member prior to presentation. Articles to be presented are typically selected form the major clinical cardiology or internal medicine journals. (PC, MK). 11. Research Conference The purpose of this monthly conference is to allow the Fellow in Cardiovascular Disease to present research hypotheses or work in progress for discussion by other fellows and faculty. Fellow research is always mentored, either by a faculty member of the Division of Cardiology or a faculty member of another Department within the medical school. Discussions at this conference are typically vibrant and not infrequently lead to suggestions that strengthen proposed research or research in progress. (PC, MK). 12. Quality Assurance Committees 14
  15. 15. Each senior fellow in Cardiovascular Disease is assigned to one of three hospital quality assurance (QA) committees for the duration of his or her third year. These include: (1) the ACS QA Committee, the Heart Failure QA Committee and the Cardiac Arrest QA Committee. The purpose of waiting until the third year is to facilitate meaningful involvement based on clinical experience. The one year assignment allows the fellow to observe the handling of quality issues in the aforementioned areas over an extended period of time, thus facilitating the ability to identify quality issues and their root causes. The fellows then learn how to design an action plan based on root cause analysis and to evaluate the results of the action plan. We are in the process of designing a divisional quality assurance initiative which will provide fellows the opportunity to assess quality issues within their own practices. (PC, MK, PBLI, SBP). C. Technical and Other Skills 1. The program will provide sufficient experience for the cardiology resident to acquire expertise in the performance and interpretation of a broad spectrum of skills and procedures. a. Cardiology History 1. Goals and Objectives a. Characterize the role of the cardiovascular history in diagnosis. (PC, MK, CS) b. Describe the importance of the cardiovascular history. (PC, MK, CS) c. Describe the pathogenesis and clinical significance of the following cardinal symptoms of cardiovascular disease: chest pain/discomfort, dyspnea (including paroxysmal nocturnal dyspnea and orthopnea), cyanosis, syncope/pre- syncope, palpitations, edema, cough, hemoptysis and fatigue. (PC, MK) d. Describe and apply the New York Heart Association Classification for cardiac disease. (PC, MK, CS) e. Describe the Canadian Cardiovascular Society Criteria for Cardiac Disability. (PC, MK, CS) 15
  16. 16. f. Be able to perform a comprehensive cardiovascular history. (PC, MK, CS) 2. Methods of Education a. Utilization of textbooks, journal articles, audiovisual modules and computer programs relevant to the cardiac history. (PC, MK) b. Interviewing and presenting patients during rotations on the cardiology consultation service, in the cardiology outpatient clinic, on the coronary care unit service and in the cardiac catheterization and echocardiography laboratories. (PC, MK, CS) c. Attendance at Cardiology Grand Rounds and core lecture series. (MK) 3. Methods of Evaluation a. Direct observation of the cardiology resident by cardiology faculty. b. Evaluation of verbal and written diagnostic evaluations by cardiology faculty. b. Cardiovascular Physical Examination 1. Goals and Objectives a. Identify and explain the pathogenesis and clinical significance of non-cardiovascular physical examination findings associated with cardiovascular disease (general appearance, head and face, eyes, skin and mucous membranes, extremities, thorax and abdomen). (PC, MK) b. Describe and perform accurate blood pressure measurements. (PC, MK) c. Perform accurate evaluation of arterial pulses. Describe the characteristics of normal and abnormal arterial pulses and describe their physiologic basis. (PC, MK) 16
  17. 17. d. Perform accurate evaluation of the jugular venous pulse. Identify and explain the physiologic basis for normal and abnormal jugular venous pulsations. (PC, MK) e. Identify and describe the physiologic and pathophysiologic basis of normal and abnormal percordial movements based on inspection and palpitation. (PC, MK) f. Identify and describe the physiologic basis for normal heart sounds (S1, S2, physiologic S3). (PC, MK) g. Identify the various abnormalities of S1 and describe their pathophysiologic basis. (PC, MK) h. Identify and describe the pathogenesis of the ejection click, mid-systolic click, opening snap, pericardial knock and precordial rubs. (PC, MK) i. Provide a differential diagnosis of systolic, diastolic and continuous heart murmurs. (PC, MK) j. Identify and describe the physiologic or pathophysiologic basis for systolic ejection and regurgitant heart murmurs. (PC, MK) k. Identify and describe the pathophysiologic basis of diastolic and continuous heart murmurs. (PC, MK) l. Provide a differential diagnosis, identify and describe the physiologic or pathophysiologic basis for non-cardiac murmurs. (PC, MK) m. List and describe the influence of physical maneuvers on heart sounds and murmurs. (PC, MK) n. List and describe the influence of pharmacologic interventions on heart sounds and murmurs. (MK, PC) 2. Methods of Education a. Utilization of textbooks, journal articles, audio-visual modules and computer programs relevant to the cardiovascular examination. (PC, MK) 17
  18. 18. b. Clinical experience on the inpatient cardiology consultation service, in the cardiology outpatient clinic, on the coronary care unit rotation and to a more limited extent on the cardiology catheterization and echocardiography laboratory rotations. (PC, MK) 3. Methods of Evaluation a. Direct observation by cardiology faculty on the afore- mentioned rotations. b. Clinical correlation with echocardiographic and cardiac catheterization findings. c. Performance on sections of the ABIM Subspecialty Board Examination in Cardiovascular Diseases dealing with the normal and abnormal cardiovascular examination. c. Cardiopulmonary Resuscitation and Advanced Cardiac Life Support 1. Goals and Objectives a. To become proficient in basic life support and advanced cardiac life support. (PC, MK) 2. Methods of Education a. American Heart Association Provider Course and Syllabus on Basic life support and Advanced Cardiac Life Support. (PC, MK) 3. Methods of Evaluation a. Successful passage of the American Heart Association Provider Course on basic life support and advanced cardiac life support prior to or on entering into the training program. b. Personal observation by cardiology faculty in various clinical situations. d. Elective Cardioversion 1. Goals and Objectives 18
  19. 19. a. Describe the electrophysiologic basis for elective cardioversion. (PC, MK) b. List the indications for elective cardioversion. (PC, MK) c. Describe the methods available to achieve elective cardioversion. (PC, MK) d. Describe preparations for elective cardioversion. (PC, MK) e. Describe in detail how to achieve/perform elective medical and electro-cardioversion. (PC, MK) f. Describe post-cardioversion management. (PC, MK). 2. Methods of Education a. Utilization of textbooks, pertinent journal articles, audiovisual modules and computer programs relating to cardioversion. (PC, MK) b. Perform 10 elective medical or electro-cardioversions under the direct supervision of cardiology faculty and at least 20 cardioversions independently after discussion with cardiology faculty. (PC, MK, CS) e. Bedside Right Heart Catheterization 1. Goals and Objective a. Describe the indications for bedside right heart catheterization. (PC, MK) b. Describe the anatomic and hemodynamic basis for bedside right heart catheterization. (MK) c. Perform 25 bedside right heart catheterizations prior to or during the cardiology residency. (PC, MK) d. Identify the key pressure wave forms detected during bedside right heart catheterization. (PC, MK) 19
  20. 20. e. Describe the thermodilution method for assessing cardiac output. (PC, MK) f. Identify the potential complications of bedside right heart catheterization. (PC, MK) 2. Methods of Education a. Utilization of textbooks, journal articles, audiovisual modules and computer programs pertinent to bedside right heart catheterization. (PC, MK) b. Observation of 5 bedside right heart catheterizations. (PC, MK) c. Performance of 10 bedside right heart catheterization under faculty supervision. (PC, MK) d. Performance of 25 bedside right heart catheterizations prior to or during the cardiology fellowship. (PC, MK) e. Interpretation of the results of at least 25 bedside right heart catheterizations prior to or during the cardiology fellowship. (PC, MK) 3. Methods of Evaluation a. Direct observation of 10 cases by a member of the Cardiology faculty or equivalent. b. Presentation of hemodynamic data and use of these data in the clinical context in 25 cases. f. Insertion and Management of a Temporary Cardiac Pacemaker 1. Goals and Objectives a. List and discuss the indications for temporary cardiac pacing including temporary pacing during acute myocardial infarction and after cardiac surgery. (PC, MK) b. Describe the various accesses for temporary cardiac pacing. (PC, MK) 20
  21. 21. c. Describe the various modes of temporary cardiac pacing and discuss the uses and comparative advantages of each. (PC, MK) d. Perform at least 20 insertions of a temporary cardiac pacemaker. (PC, MK) e. Describe how to maintain a temporary cardiac pacemaker. (PC, MK) f. Discuss the potential complications of temporary cardiac pacing. (PC, MK) g. Become proficient in the use of external temporary cardiac pacing. (PC, MK) 2. Methods of Education a. Utilization of textbooks, journal articles, audiovisual modules and computer programs relevant to temporary cardiac pacing. (PC, MK) b. Justify insertion of 20 temporary pacemaker insertions to a faculty cardiologist. (PC, MK) c. Performance of 20 temporary pacemaker insertions (10 under the direct supervision of a faculty cardiologist) in the cardiac catheterization laboratory, coronary care unit or emergency department. (PC, MK) d. Attempt external cardiac pacing in at least 5 patients. 3. Methods of Evaluation a. Direct supervision by a faculty cardiologist (10 cases). b. Discussion of indication for and efficacy of temporary cardiac pacing during rounds on the cardiology consultation service or coronary care unit rotation, on call, or in the cardiac catheterization laboratory with a faculty cardiologist (30 cases). g. Right and Left Heart Catheterization 1. Goals and Objectives 21
  22. 22. a. Discuss the historical aspects of cardiac catheterization. (MK) b. Describe the technical aspects of cardiac catheterization, including cardiac catheterization facility requirements, radiology equipment requirements, and radiation safety requirements. (MK) c. Describe the brachial and radial approach to access including catheter selection. (PC, MK) d. Describe the femoral approach to access including catheter selection. (PC, MK) e. Describe the trans-septal catheterization technique, including catheter selection. (PC, MK) f. Describe the theoretical considerations relating to measurement of intravascular and intracardiac pressures including systems for pressure measurement, fluid-filled catheter systems and manometer-tipped catheter systems. (MK) g. Correctly identify normal pressure waveforms and abnormal pressure wave forms. (PC, MK) h. Describe the theoretical and practical aspects of cardiac output measurement, including the Fick, indicator dilution and angiographic methods. (PC, MK) i. Discuss the theoretical aspects of intracardiac shunt measurements. Accurately quantify intracardiac shunts in 5 patients. (PC, MK) j. Discuss the theoretical basis for calculation of regurgitant flow. Be able to calculate regurgitant flow. (PC, MK) k. Describe the anatomic and physiologic basis for coronary blood flow. (PC, MK) l. Describe the theoretical basis for measurement of vascular resistance. Accurately calculate systemic vascular, total pulmonary, pulmonary vascular and coronary vascular resistance. (PC, MK) 22
  23. 23. m. Describe the clinical usefulness of obtaining hemodynamic information during exercise and describe the protocols used to carry out this technique. (PC, MK) n. List the indications for cardiac catheterization. (PC, MK) o. List the contraindications to cardiac catheterization. (PC, MK) p. Describe the principles used to design cardiac catheterization protocols. Design a proto-typical cardiac catheterization protocol. (PC, MK) q. Describe how to prepare and pre-medicate cardiac catheterization patients. (PC, MK) r. Describe the complications of cardiac catheterization, discuss the risk factors that predispose to complications and describe their management. (PC, MK) s. Perform at least 100 (level I) and preferably 300 (level II) left right heart catheterizations. (PC, MK) t. Describe the indications for, techniques of and complications of myocardial biopsy. Perform 10 myocardial biopsies. (PC, MK) 2. Educational Methods a. Utilization of textbooks, pertinent journal articles, audio- visual modules and computer programs relating to cardiac catheterization. (PC, MK) b. Experience in the cardiac catheterization laboratory under the supervision of qualified cardiology faculty. Performance of at least 150 – 300 left right heart catheterizations. (PC, MK) c. Attendance at Cardiac Catheterization Conference. (PC) d. Evaluation and management of prospective cardiac catheterization candidates while rotating on the cardiology consultation service, coronary care unit service and in the cardiology outpatient clinic. (PC, MK) 23
  24. 24. 3. Methods of Evaluation a. Direct observation by faculty in the cardiac catheterization laboratory. b. Monthly ABIM evaluations by individual faculty. c. Performance on sections of the ABIM Subspecialty Board Examination in Cardiovascular Diseases dealing with cardiac catheterization. h. Coronary Angiography, Left Venticulography, Aortography and Pulmonary Angiography 1. Goals and Objectives a. Describe the Judkins technique including a discussion of the equipment required and catheterization technique. (PC, MK) b. Describe the Sones technique. (MK) c. Describe an Amplatz and multipurpose catheter techniques including discussion of equipment required and catheterization technique. (PC, MK) d. Perform at least 100 and preferably 300 coronary angiograms. Utilize the Judkins technique in at least 100, the Sones technique in at least 25, the Amplatz technique in at least 10 and the multipurpose catheter in at least 15 cases. (PC, MK) e. Discuss the technical features of coronary angiography. Describe the cinéangiographic equipment needed, drugs used during coronary angiography, and the potential electrocardiographic and hemodynamic changes that may occur during coronary angiography. (MK) f. Describe and identify normal coronary anatomy and its variations on coronary angiograms. (PC, MK) g. Describe and use standard angiographic views of the coronary arteries. (PC, MK) 24
  25. 25. h. Describe and use angulated views of the coronary arteries. (PC, MK) i. Describe and identify the pitfalls of coronary angiography in reference to each of the major coronary arteries and their branches, including early bifurcation of the left coronary artery, catheter-induced spasm and flow artifacts. (PC, MK) j. Compare and contrast eccentric stenosis, unrecognized occlusions at branches, superimposition of branches, myocardial bridging and recanalization. (PC, MK) k. Describe the complications of coronary angiography. (PC, MK) l. Recognize congenital abnormalities of the coronary arteries on coronary angiograms, including coronary artery fistulae, the spectrum of anomalous origins of coronary arteries, congenital coronary stenosis, sinus of Valvalva aneurysms and fistulae and single coronary artery. (PC, MK) m. Discuss the effect of stenosis on coronary blood flow. (MK) n. Describe the angiographic appearance of coronary artery collaterals. Recognize coronary artery collaterals on the coronary angiogram. (PC, MK) o. Characterize angiographic appearance of coronary artery spasm. Recognize coronary artery spasm on the coronary angiogram. (PC, MK) p. Describe the angiographic appearance of coronary artery stenosis. Recognize concentric lesions, types I and II eccentric lesions and lesions with over hanging ledges and multiple irregularities on coronary angiogram. Recognize the arteriographic appearance of coronary artery thrombus. (PC, MK) q. Discuss the use of coronary angiography in patients with coronary artery disease including the patient with myocardial infarction. Discuss the usefulness of the coronary jeopardy score. Relate the severity of stenosis 25
  26. 26. to mortality risk. Describe and be able to implement TIMI score an corrected frame count. (PC, MK) r. Describe the techniques used for coronary bypass angiography. Be able to recognize the appearance of patent bypass grafts. Be able to recognize the spectrum of angiographic abnormalities of bypass grafts. Perform bypass graft angiography. (PC, MK) s. Discuss theoretical basis of digital and quantitative coronary angiography. Describe the equipment required for these techniques. Interpret coronary angiograms utilizing these techniques. (PC, MK) t. List the technical requirements and standard views for contrast left ventriculography. Perform left ventriculography. Recognize the normal left ventriculogram. (PC, MK) u. Characterize and be able to recognize the various abnormalities of ventricular wall motion seen on contrast left ventriculography including hypokinesia, akinesia, dyskinesia, and dysyneresis. Describe techniques used to determine reversibility of abnormal left ventricular wall motion during left ventriculography. Describe the potential complications of left ventriculography and their treatment. (PC, MK) v. Describe the technical requirements for aortic angiography and pulmonary angiography. Discuss views necessary to obtain interpretable aortograms and pulmonary angiograms. Perform proximal aortography and pulmonary angiography. Describe the complications of these techniques and their management. Recognize the features and normal and abnormal proximal aortograms and pulmonary angiograms. (PC, MK) 2. Methods of Education a. Practical experience in the cardiac catheterization laboratory. Performance of a minimum of 100 and preferably 300, coronary angiograms and a sufficient number of aortograms to attain proficiency. (PC, MK) 26
  27. 27. b. Participation in Cardiac Catheterization Conferences. (PC, MK) c. Clinical correlation during cardiology consultation and coronary care unit rotations and in the cardiology outpatient clinics. (PC, MK) d. Utilization of textbooks, journal articles, audiovisual modules and computer programs relevant to coronary angiography, left ventriculography, proximal aortography and pulmonary angiography. (PC, MK) 3. Methods of Evaluation a. Direct observation by a qualified cardiology faculty. b. Presentations and discussions at Cardiac Catheterization Conference. c. Performance on sections of the ABIM Subspecialty Board Examination in Cardiovascular Diseases dealing with coronary angiography. i. Exercise Stress Testing 1. Goals and Objectives a. Discuss exercise physiology as it applies to exercise stress testing. Discuss the relevance of patient position and the significance of anaerobic threshold. Define the metabolic equivalent as it applies to exercise stress testing. (PC, MK) b. Describe the pathophysiology of the myocardial ischemic exercise response. (MK) c. Describe static exercise protocols used in clinical practice. (PC, MK) d. Describe arm ergometry protocols used in clinical practice. (PC, MK) e. Describe bicycle ergometry protocols used in clinical practice. (PC, MK) 27
  28. 28. f. Describe the treadmill protocols used in clinical practice. (PC, MK) g. Describe the lead systems used in exercise stress testing. Discuss the electrocardiographic and electrophysiologic basis for these lead systems. (MK) h. Compare and contrast normal and abnormal ST segment depression. Describe the mechanism of ST segment displacement. (PC, MK) i. Quantify ischemic ST depression and describe ischemic T wave abnormalities observed during exercise stress testing. (PC, MK) j. Describe the use of computer-assisted ECG analysis in exercise stress testing. (PC, MK) k. List the indications and contraindications for exercise stress testing. (PC, MK) l. Describe the techniques used to prepare the patient for exercise stress testing. (PC, MK) m. List the causes of a false positive stress electrocardiogram. (PC, MK) n. Describe the correlation of exercise test results with coronary angiography including the relationship between the severity of the ischemic electrocardiographic response and the severity of coronary artery disease. (PC, MK) o. Discuss the use of Bayesian theory and multivariate analysis in the interpretation of exercise stress tests. (MK) p. Discuss the significance of upsloping ST segments, ST elevation and other electorcardiographic markers and ST/beat rate measurements in exercise stress testing. (PC, MK) q. Discuss the significance of non-electrocardiographic observations in stress testing, including blood pressure response, post-exercise systolic blood pressure ratios, 28
  29. 29. maximal work capacity, submaximal exercise heart rate response, rate-pressure product and the presence or absence of chest discomfort. (PC, MK) r. Discuss the use of exercise stress testing in evaluating prognosis in asymptomatic patients, patients with atypical chest discomfort, those with stable angina pectoris and unstable angina pectoris, those with silent myocardial ischemia and following myocardial infarction. (PC, MK) s. Describe the usefulness of exercise stress testing in the evaluation of cardiac arrhythmias and conduction disturbances, including ventricular arrhythmias, supra- ventricular arrhythmias, atrial fibrillation, the sick sinus syndrome, AV block, left and right bundle branch block and the Wolff-Parkinson-White Syndrome. (PC, MK) t. Discuss the value and limitations of exercise stress testing in men, women, hypertensive patients with congestive heart failure, patients on various drugs that affect repolarization, post-coronary bypass patients, cardiac transplant patients, patients with valvular heart disease, patients with cardiac pacemakers. (PC, MK) u. Characterize the safety and risks of exercise stress testing. (PC, MK) v. List the indications for terminating an exercise stress test. (PC, MK) w. Perform and interpret at least 50 exercise stress tests. (PC, MK) 2. Methods of Education a. Performance and interpretation of exercise stress tests in the inpatient and outpatient settings. (PC, MK) b. Review of interpretations with faculty cardiologists. (PC, MK) c. Utilization of textbooks, journal articles, audiovisual modules and computer programs relating to stress testing. (PC, MK) 29
  30. 30. d. Presentation and discussion of cases at teaching rounds, EKG Conference, Cardiology Grand Rounds and Core Curriculum Conference. (PC, MK). 3. Methods of Evaluation a. Observation of the performance of 10 exercise stress tests by cardiology faculty and the interpretation of 50 exercise stress tests by cardiology faculty. b. Performance on sections of the ABIM Subspecialty Board examination in Cardiovascular Diseases pertaining to exercise stress testing. j. Echocardiography 1. Goals and Objectives a. Describe the fundamental principles of ultrasound imaging as they apply to echocardiography. Distinguish among A-mode, B-mode and M-mode presentations. (MK) b. Describe the technique of M-mode echocardiography including the standard views. (MK) c. Describe the technique of two-dimensional echocardiography including the standard views. (MK) d. Describe in general the technique of three-dimensional echocardiography. (MK) e. Describe the technique of Doppler echocardiography including color flow Doppler, pulse Doppler, continuous wave Doppler, and tissue Doppler. (MK) f. Describe the technique of transesophageal echocardiography including the standard views. (MK) g. Describe the technique of saline contrast echocardiography including the standard views. (MK) h. Describe the techniques of stress echocardiography using treadmill exercise and pharmacologic stress. (MK) 30
  31. 31. i. Discuss the advantages and limitations of echocardiography. (PC, MK) j. Be able to accurately identify cardiac structures on the normal M-mode, two-dimensional, transesophageal, contrast, stress and Doppler echocardiogram. Accurately perform standard echocardiographic measurements on a normal echocardiogram. (PC, MK) k. Describe the role of echocardiography and cardiac Doppler techniques in the assessment of cardiac performance. Include assessment of left ventricular systolic and diastolic function and cardiac output. l. Discuss how Doppler echocardiography is used to obtain hemodynamic information. (PC, MK) m. Describe the physiologic basis for the use of Doppler echocardiography to measure pressure gradients. Describe the formula used to measure pressure gradients. Measure pressure gradients across the four cardiac valves. (PC, MK) n. Discuss the application of Doppler echocardiography to the assessment of intracardiac pressures. Apply these methods in clinical practice (e.g. right ventricle systolic pressure). (PC, MK) o. Describe the measurement of valve areas using two- dimensional Doppler echocardiography. Measure aortic and mitral valve areas using these techniques. (PC, MK) p. Discuss the use of M-mode, two-dimensional transesophageal, stress, contrast, intra-operative and Doppler echocardiography in the evaluation of acquired heart diseases including valvular heart disease, infective endocarditis, congenital heart disease in adults, ischemic heart disease, cardiomyopathies, pericardial disease, cardiac tumors and thrombi and diseases of the aorta. Identify the full spectrum of the cardiovascular disease encompassed by these disorders using M-mode, two- dimensional, Doppler, transesophageal, stress, contrast and intra-operative echocardiography. (PC, MK) 31
  32. 32. q. Perform and interpret at least 150 comprehensive trans- thoracic echocardiographic/Doppler/color flow studies. Perform and interpret at least 100 transesophageal echocardiograms. Perform and interpret at least 10 intra- operative echocardiograms. (PC, MK) 2. Methods of Education a. Performance of at least 150 transthoracic echo- cardiograms and cardiac Doppler studies under the super- vision of qualified echocardiography technicians. (PC, MK) b. Interpretation of at least 150 transthoracic echocardiograms and cardiac Doppler studies under the supervision of a faculty cardiologist. (PC, MK) c. Performance and interpretation of 100 transesophageal echocardiograms under the supervision of a faculty cardiologist. (PC, MK) d. Performance and interpretation of at least 100 stress echocardiograms under the supervision of a faculty cardiologist. (PC, MK) e. Performance of 10 intra-operative echocardiograms and cardiac Doppler studies under the supervision of a faculty cardiologist. (PC, MK) f. Utilization of textbooks, journal articles, audiovisual modules and computer programs related to echocardiography. (PC, MK) g. Attendance at Echocardiography Conference and Cardiology Grand Rounds. (PC, MK) h. Attendance at regional and national conferences with sections devoted to echocardiography. (PC, MK) 3. Methods of Evaluation a. Direct faculty observation. b. Observation by echocardiography technicians. 32
  33. 33. c. Performance on portions of the ABIM Subspecialty Board Examination in Cardiovascular Diseases relating to echocardiography. 2. Acquire experience in the performance and (where applicable) the interpretation of the following procedures: a. Pericardiocentesis 1. Goals and Objectives a. List the indications for pericardiocentesis. (PC, MK) b. Describe the equipment required for pericardiocentesis. (PC, MK) c. Describe the various techniques used to perform pericardiocentesis. (PC, MK) d. Discuss the role of echocardiography in association with pericardiocentesis. Describe the technique of concurrent cardiac catheterization and pericardiocentesis. (PC, MK) e. Perform at least 5 pericardiocenteses. (PC, MK) f. List the routine laboratory tests performed on pericardial fluid following pericardiocentesis. (PC, MK) g. Describe the risks and complications of pericardiocentesis. (PC, MK) 2. Methods of Education a. Utilization of textbooks, journal articles and audiovisual modules and computer programs relating to pericardiocentesis. (PC, MK) b. Performance of at least 5 pericardiocenteses under faculty supervision after observing 1 procedure. (PC, MK) 3. Methods of Evaluation 33
  34. 34. a. Observation by qualified cardiology faculty in the cardiac catheterization laboratory and coronary care unit. b. Pacemaker Followup and Surveillance 1. Goals and Objectives a. Describe the equipment necessary to perform permanent pacemaker follow-up and surveillance. (MK) b. Describe the technique of transtelephonic pacemaker surveillance. (MK) c. Describe the optimal frequencies of pacemaker surveillance after permanent pacemaker implantation. (MK) d. Describe the use of the magnet in pacemaker surveillance. (MK) e. List the pacemaker parameters that can be routinely assessed during transtelephonic checks or office visits. Describe how these variables are measured during evaluation. (PC, MK) f. Describe the role of telemetry in pacemaker followup. (MK) g. Describe the role of long-term electrocardiographic monitoring in pacemaker followup. (PC, MK) h. Perform pacemaker followup, trouble-shooting or surveillance on at least 50 permanent pacemaker patients. (PC, MK) 2. Methods of Education a. Utilization of textbooks, journal articles, audiovisual modules and computer programs relating to pacemaker followup, trouble-shooting and surveillance. (PC, MK) b. Participation in Pacemaker Followup Clinic. Reprogram or trouble-shoot at least 50 permanent pacemakers. (PC, MK) 34
  35. 35. c. Attendance at EKG/Electrophysiology Conferences. (PC, MK) d. Participation in industry-sponsored meetings related to pacemaker implantations and/or followup. (PC, MK) 3. Methods of Evaluation a. Direct observation by qualified cardiology faculty. b. Performance on portions of ABIM Subspecialty Board Examination in Cardiovascular Diseases relating to pace- maker followup. c. Feedback from computer-based training programs. c. Intra-cardiac Electrophysiologic Studies 1. Goals and Objectives a. Describe the electrophysiologic basis for His bundle studies, sinus node function studies and programmed electrical stimulation. (MK) b. Describe the equipment required to perform the aforementioned studies. (MK) c. Describe the technique of His bundle electrography. Describe the intervals that are measured. (PC, MK) d. Describe how to perform sinus node function tests including the sinus node recovery time and the sinoatrial conduction time. (PC, MK) e. Describe how to perform programmed ventricular and atrial stimulation studies for assessment of tachycardia. (PC, MK) f. Describe the role of intra-cardiac electrophysiologic testing inpatients with unexplained syncope and in those with palpitations. (PC, MK) g. Describe the potential risks and complications of intra- cardiac electrophysiologic studies. (PC, MK) 35
  36. 36. h. Describe the clinical indications for, and the applications of, intra-cardiac electrophysiologic mapping. (PC, MK) i. Assist in the performance and interpretation of 10 – 15 intracardiac electrophysiologic studies. (PC, MK) j. Describe the indications for and techniques for performing ablations for paroxymal supraventricular tachycardia, atrial flutter, atrial fibrillation and ventricular tachycardia. 2. Methods of Education a. Utilization of textbooks, journal articles, audiovisual modules and computer programs related to intra-cardiac electrophysiology. (PC, MK) b. Assist in the performance and interpretation of 10 – 15 intra-cardiac electrophysiologic studies under faculty supervision in the Cardiac Electrophysiology Laboratory. (PC, MK) c. Attendance at EKG/Electrophysiology and Core Curriculum Conferences. (PC, MK) d. Attendance at national cardiac meetings with sections devoted to cardiac electrophysiology. (PC, MK) 3. Methods of Evaluation a. Personal supervision by qualified faculty cardiologists. b. Performance on portions of the ABIM Subspecialty Board Examination in Cardiovascular Diseases relating to performance of intra-cardiac electrophysiology tests. d. Intra-aortic Balloon Counterpulsation 1. Goals and Objectives a. Discuss the physiologic rationale for intra-aortic balloon counterpulsation. (MK) b. Describe the equipment required for intra-aortic balloon counterpulsation. (MK) 36
  37. 37. c. Describe the indications for and clinical application of intra-aortic balloon counterpulsation. (PC, MK) d. Discuss the various hemodynamic effects of intra-aortic balloon counterpulsation. (PC, MK) e. Perform intra-aortic balloon insertion and maintain counterpulsation on at least 5 patients. (PC, MK) f. Discuss the risks and complications of intra-aortic balloon counterpulsation. (PC, MK) 2. Methods of Education a. Perform intra-aortic balloon counterpulsation in the Cardiac Catheterization Laboratory and maintain counter-pulsation in the intensive care unit on at least 5 patients. (PC, MK) b. Utilization of textbooks, journal articles, audiovisual modules and computer programs relating to intra-aortic balloon counterpulsation. (PC, MK) c. Attendance at national meetings with sections devoted to intra-aortic balloon counterpulsation. (PC, MK) d. Attendance at Cardiac Catheterization Conference. (PC, MK) 3. Methods of Evaluation a. Direct observation by qualified faculty and technicians in the cardiac catheterization laboratory, in the coronary care unit and in the operating room. e. Percutaneous Transluminal Coronary Angioplasty (PTCA), Coronary Atherectomy, Coronary Stent (Bare metal and Drug-eluting) Deployment And Valvuloplasty 1. Goals and Objectives a. Describe the historical development of PTCA, coronary atherectomy, coronary stent deployment and valvulopasty. (MK) 37
  38. 38. b. List the indications for PTCA, coronary atherectomy (directional and rotational), coronary stent deployment and valvuloplasty. (PC, MK) c. Describe the procedures of PTCA, coronary atherectomy, coronary stent deployment and valvuloplasty. (PC, MK) d. Describe the potential complications of PTCA, coronary atherectomy, and coronary stent deployment, and valvuloplasty. (PC, MK) e. Observe the performance of PTCA, thrombectomy, coronary atherectomy, coronary stent deployment and valvuloplasty. (PC, MK) 2. Methods of Education a. Experience gained in the Cardiac Catheterization Laboratory. Assistance in the performance of interventional techniques. (PC, MK) b. Attendance at Cardiac Catheterization Conference and Cardiology Grand Rounds. (PC, MK) c. Utilization of textbooks, journal articles, and audiovisual modules and computer programs dealing with interventional procedures. (PC, MK) d. Attendance at regional and national meetings with sections devoted to interventional procedures. (PC, MK) 3. Methods of Evaluation a. Assistance on interventional procedures under faculty supervision in the cardiac catheterization laboratory. b. Performance on sections of the ABIM Subspecialty Board Examination in Cardiovascular Diseases relating to interventional procedures. f. Cardiovascular Rehabilitation 1. Goals and Objectives 38
  39. 39. a. Discuss the role of exercise in cardiac rehabilitation and physical reconditioning including factors influencing physical capacity, iatrogenic and physiologic factors, left ventricular dysfunction, myocardial ischemia, concommitant diseases and drugs. (PC, MK) b. Discuss the effects of exercise training in cardiac rehabilitation including the roles of skeletal muscle and myocardial performance and the effect on morbidity and mortality. (PC, MK) c. Describe the eligibility requirements for cardiovascular rehabilitation. (PC, MK) d. Discuss the role of exercise testing in cardiovascular rehabilitation. (PC, MK) e. Describe how to formulate an individualized exercise prescription. (PC, MK) f. Describe the components of exercise sessions. (PC, MK) g. State how to advance the exercise prescription. (PC, MK) h. Describe special considerations in patients with myocardial ischemia, heart failure and cardiac arrhythmias. (PC, MK) i. Characterize the risks of exercise training. Discuss the role of patient selection and surveillance and the safety of the personal program. (PC, MK) j. Describe the components of secondary prevention of coronary artery disease. (PC, MK) k. Discuss the psychosocial benefit of cardiovascular rehabilitation. (PC, MK) l. Discuss the role of vocational rehabilitation in cardiovascular rehabilitation. (PC, MK, SBP) m. Describe phases I, II, and III in cardiovascular rehabilitation programs. (PC, MK) 39
  40. 40. n. Discuss sexual aspects of cardiovascular rehabilitation. (PC, MK) 2. Methods of Education a. Participation in Fit for Life during Graphics rotation and Cardiology Inpatient rotations. (PC, MK). b. Utilization of textbooks, journal, and computer programs relating to cardiac rehabilitation. (PC, MK). c. Attendance at regional and national meetings with sections devoted to cardiac rehabilitation. (PC, MK). 3. Methods of Evaluation a. Performance on the ABIM Certifying Examination in Cardiovascular Disease. b. Observation on Fit for Life rotation. 3. The program must provide sufficient experience for fellows to acquire skill in the interpretation of: a. Chest X-rays 1. Goals and Objectives a. Describe and be able to identify normal cardiac anatomy on the chest x-ray in the frontal (posterior-anterior), lateral and right and left anterior oblique views. (PC, MK) b. Discuss the methods used to assess cardiac size on a chest x-ray. (PC, MK) c. Describe and be able to identify normal pulmonary vascular anatomy on a chest x-ray. (PC, MK) d. Describe and be able to identify the signs of increased pulmonary blood flow on a chest x-ray, including those associated with pulmonary arterial hypertension, pulmonary venous hypertension, decreased pulmonary vasculature, asymmetric blood flow and pulmonary edema. (PC, MK) 40
  41. 41. e. Describe and be able to identify the signs of cardiac calcification on a chest x-ray including those associated with pericardial calcification, valvular calcification, calcification of the great vessels and tumor calcification. (PC, MK) f. Describe and be able to identify the signs of valvular heart disease on a chest X-ray including those associated with aortic stenosis, aortic regurgitation, mitral stenosis, mitral regurgitation, pulmonic stenosis, pulmonic regurgitation and tricuspid regurgitation. (PC, MK) g. Describe and be able to identify the signs of ischemic heart disease on a chest X-ray including pulmonary edema, Dressler’s syndrome, left ventricular aneurysm, papillary muscle rupture and ventricular septal rupture. (PC, MK) h. Describe and be able to identify the signs of cardiomyopathies on chest x-ray including those associated with dilated cardiomyopathy, hypertrophic cardiomyopathy and restrictive cardiomyopathy. (PC, MK) i. Describe and be able to identify post-operative signs on a chest x-ray including the signs of the early and late normal post-operative file, the signs associated with late complication after cardiac surgery, the signs of various prosthetic heart valves, specific signs associated with a coronary artery bypass and the signs associated with cardiac transplantation. (PC, MK) j. Describe and be able to identify the signs of congenital heart disease in the adult on a chest x-ray including those of congenital bicuspid aortic valve, coarctation of the aorta, atrial septal defects, patent ductus arteriosus, ventricular septal defects, congenital pulmonic stenosis, transposition of the great arteries, Tetralogy of Fallot, and the Ebstein’s anomaly. (PC, MK) k. Describe and be able to identify the signs of a normal pericardium on a chest x-ray as well as the signs of pericardial abnormalities including pericardial effusion, pericardial constriction, pericardial tumor, pericardial 41
  42. 42. cyst, herniation of the pericardium and congenital absence of the pericardium. (PC, MK) l. Describe and discuss the use of fluoroscopy in defining the cardiac structures. Describe specific cardiac abnormalities that can be identified on fluoroscopy and discuss their signs. (PC, MK) 2. Methods of Education a. Utilization of text books, journal articles, and audiovisual modules and computer programs related to cardiovascular aspects of chest x-ray diagnosis. (PC, MK) b. Clinical experience gained from rotations on the Cardiology Consultation Services, in the Cardiology Clinic, on the Coronary Intensive Care unit, on the Cardiac Catheterization Rotation and in the Core Curriculum lecture series. (PC, MK) 3. Methods of Evaluation a. Direct observation by cardiology faculty on the aforementioned rotations. b. Performance on sections of the ABIM Subspecialty Board Examination in Cardiovascular Diseases relating to chest x-ray diagnosis. b. The Resting Electrocardiogram (EKG) 1. Goals and Objectives a. Describe the theoretical electrical basis for electrocardiography. Discuss the concepts of depolarization and repolarization as they apply to electrocardiogaphy. Discuss the effect of boundary of depolarization on the polarity of the records of the potential. Describe the sequence of normal cardiac activation. Describe the ventricular gradient and the theoretical basis of surface leads as it applies to electrocardiography. Discuss the theoretical basis for unipolar and bipolar leads and their positions. (MK) 42
  43. 43. b. Describe and discuss the electrical basis for elements of the routine EKG including the P wave, the PR interval, the QRS complex, the ST segment, the T wave, the U wave and the QT interval. (MK) c. Be able to calculate P wave, QRS and T wave axes. (MK) d. Describe the EKG criteria for and be able to recognize left atrial enlargement, right atrial enlargement, biatrial enlargement, altered atrial depolarization and atrial infarction. (MK) e. Describe the EKG criteria for left ventricular, right ventricular and biventricular hypertrophy and be able to recognize those abnormalities on the EKG. (PC, MK) f. Describe and be able to recognize the EKG patterns typically associated with acute cor pulmonale and chronic cor pulmonale. (PC, MK) g. Describe the EKG criteria for non-specific intraventricular conduction defects, left bundle branch block, right bundle branch block, left anterior fascicular block, bifasciular block and bilateral bundle branch block. Be able to recognize these abnormalities on EKG. (PC, MK) h. Describe the criteria for and be able to recognize the various forms of aberrant conduction on the EKG including pre-excitation, Ashman’s phenomenon, acceleration-dependent aberrancy, deceleration- dependent aberrancy, concealed conduction, aberrancy associated with myocardial depression and post- extrasystolic aberration. Describe the criteria for and be able to recognize the Wolff-Parkinson-White syndrome. (PC, MK) i. Describe the criteria for and be able to recognize signs of myocardial ischemia, injury and infarction on the EKG. Describe the criteria for and be able to recognize the initial ECG in myocardial infarction, the classical patterns of evolution, subtle atypical and non-specific patterns of infarction, old infarction, infarction in the 43
  44. 44. presence of conduction defects, the EKG and locale of infarction and non-infarction. (PC, MK) j. Describe the criteria for and differential diagnosis of and be able to recognize the full spectrum of ST segment and T wave abnormalities (including rate-related T-wave changes, T-wave alternans, notched or bifid T-waves and non-specific ST and T wave changes), U wave abnormalities, QT interval abnormalities electrical alternans, and the Osborn wave. (PC, MK) k. Describe the criteria for and be able to recognize the signs of hyperkalemia, hypokalemia, hypercalcemia, hypocalcemia and hypomagnesemia on the EKG. (PC, MK) l. Describe the specific electrocardiographic signs of digitalis toxicity. (PC, MK) m. Describe the criteria for and be able to recognize the full spectrum of cardiac arrhythmias on the EKG (discussed later in the section on cardiac arrhythmias). (PC, MK) n. Interpret at least 3000 EKGs, at least 1500 under faculty supervision. (PC, MK) 2. Methods of Education a. Utilization of textbooks, journal articles, audiovisual modules and computer programs relevant to EKG interpretation. (PC, MK) b. Attendance at EKG/Electrophysiology Conference. c. Daily interpretations of EKG under faculty supervision when on the Cardiology Consultation Services, in the Cardiology Clinic, on the Inpatient Cardiology Services and on the Graphics rotation. (PC, MK) d. Attendance at board review courses and other national courses dealing with EKG interpretation. (PC, MK) 3. Methods of Evaluation a. Faculty observation during daily EKG interpretation. 44
  45. 45. b. Performance during EKG/Electrophysiology Conference. c. Performance on portions of the ABIM Subspecialty Board Examination in Cardiovascular Diseases relevant to EKG interpretation. c. Radionuclide Studies of Myocardial Perfusion and Cardiac Performance. 1. Goals and Objective a. Describe the instrumentation required for radionuclide evaluation of myocardial perfusion and cardiac performance including the gamma camera, collimation equipment, and computing instrumentation. (MK) b. Describe and discuss the radiopharmaceuticals available for myocardial perfusion imaging with emphasis on thallium-201 and Tc-Sestamibi. (MK) c. Discuss the technical considerations in myocardial perfusion imaging including those relating to the gamma camera, collimation, energy window, computer acquisition and imaging protocols. (MK) d. Describe patient imaging techniques in myocardial perfusion studies including adequate count density, patient position and the zoom factor. (MK) e. Describe, discuss, compare and contrast planar and SPECT imaging in the assessment of myocardial perfusion. (MK) f. Describe and be able to recognize the characteristics of myocardial perfusion images. (PC, MK) g. Describe and be able to recognize normal variations in the thallium 201 image, the normal Tc-Sestamibi image, normal Tc-Teboroxime images, and normal SPECT images. (PC, MK) h. Describe and be able to identify typical artifacts of myocardial perfusion imaging. (PC, MK) 45
  46. 46. i. Compare and contrast the following aspects of myocardial perfusion image interpretation: normal, defect, reversible defect, fixed defect, reverse redistribution thallium-201, lung uptake and transient left ventricular dilation. (PC, MK) j. Be able to quantify thallium-201 planar images. (PC, MK) k. Describe myocardial thallium-201 kinetics. (MK) l. Discuss computer processing and analysis in myocardial perfusion imaging. (MK) m. Discuss the use of tomography computer processing and analysis in myocardial perfusion imaging. (MK) n. Discuss the clinical application of myocardial perfusion imaging in myocardial infarction including those relating to detection, patient triage, thrombolytic therapy, prognosis, unstable angina and detection of old myocardial infarction. (PC, MK) o. Discuss the clinical application of myocardial perfusion imaging in patients with chronic coronary artery disease including those relating to physical exercise, pharmacological vasodilatation (dipyridamole, adenosine), dobutamine stress, assessment of myocardial vi-ability, detection of high-risk coronary artery disease, thallium-201 imaging and prognosis, tomographic thallium-201 stress imaging, perfusion imaging for pre- operative screening, Tc-Sestamibi stress imaging, Tc- Teboroxime imaging, patient selection, myocardial perfusion imaging in left bundle branch block and thallium-201 stress imaging in the non-coronary artery disease. (PC, MK) p. Describe and discuss the instrumentation, radiopharmaceuticals and protocols used for infarct imaging including Tc pyrophosphate imaging, Indium- 111 leukocyte imaging, and Indium-111 antimyosin imaging. Describe the clinical applications of these agents. Be able to recognize normal and abnormal images derived from infarct imaging. (PC, MK) 46

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