Adult General Cardiology Program Curriculum
Cardiology Inpatient Service
Cardiac Rehabilitation Program
Cardiology Consultation Services and EKG Laboratories
Adult Echocardiographic Laboratories
Heart Failure / Transplant Service
Cardiac Catheterization Laboratories
- Develop skills at the bedside that can be correlated with invasive and noninvasive studies.
- Know when to order appropriate invasive and noninvasive studies.
- Understand the management of acute events, i.e. acute coronary syndromes.
- Know when and how to use cardiovascular drugs.
- Understand decision making: when to do cardiac cath, when to consider invasive procedures, when to order stress test.
- Mix of diseases: All types of cardiovascular problems – coronary disease, cardiomyopathy, valvular disease, pericardial diseases, arrhythmias, congestive heart failure.
- Procedures/CCU Management: All procedures will be entered into the Apollo computer database systems and a report will be generated for each procedure. (Swan Ganz, Intubations/respiratory parameters, cardioversion/defibrillation, pacemakers, pericardiocentesis.)
Ancillary Educational Material
Throughout the rotation, the attending cardiologist provides the cardiology fellow with important reading material (recent publications, classic journal articles, etc.) that should supplement their educational experience on the inpatient service. Time is set aside on a daily basis to make sure that service needs do not interfere with formal education. Also, educational time is provided to ensure that the fellow’s experience is not diluted by the attending focusing his/her educational efforts only at the level of the resident and students.
Goals and Objectives
- Be able to interpret electrocardiograms and realize that it is a simple, useful and non-invasive test.
- Understand and show that the EKG may enable one to arrive at a diagnosis at times without the need for more expensive procedures, thus being cost effective.
Our goal is to teach fellows the physiology and pathophysiology of cardiac conduction and arrhythmias. The molecular and genetic aspect of arrhythmias will not be directly addressed, but extensive reading of the literature is encouraged. At the end of this rotation, they should understand the theoretical concepts of all arrhythmias. They should be able to conceptually take care of cardiac patients with arrhythmias so they can be stabilized, order appropriate diagnostic tests, and initiate treatment. Investigational or experimental research projects are encouraged during this rotation. The fellow should develop a project that can be carried out in the rotation or throughout the year. This hopefully will allow them to understand clinical investigation and be able to submit and abstract or article. The fellow will be given designated research time while the attending is at outreach clinics. If the fellow is able to get an abstract accepted at a major meeting, we will cover the cost of meeting expenses.
The objective of this rotation is to give the general fellow an overview regarding concepts of arrhythmias so they can order appropriate diagnostic tests and initiate effective therapies. For the subspecialty EPS fellow the objective is to train them for the independent use of both noninvasive and interventional technologies.
Mix of Disease: Each three month rotation will have a variable mix of diseases. Therefore, it is important for the fellow to use ancillary educational material to fulfill their total knowledge of arrhythmias. Over the last ten years, the main classification of arrhythmias seen in this patient population is ventricular arrhythmias. Approximately 42% of the patients present with some form of ventricular arrhythmias with an additional 8% presenting with sudden cardiac death. Superventricular arrhythmias are seen in approximately 11% and syncope is seen in 20-25%.
The in-hospital phase of the program is carried out by the Heart Center floor nurses and the program dietician. It includes patient education, counseling by the dietitian and supervised activity.
The post discharge phases are held in the Gazes Research Institute (GRI), Room 117 (Phase II and Phase III) and the Citadel gymnasium in Deas Hall (Phase IV and the Adult Fitness program) fellow assigned. In the early phase (II), patients are monitored by telemetry as well as by visual monitoring and blood pressure recordings. After completing Phase II, telemetry monitoring is discontinued and Phase III begins. After a few months, the patients are graduated to Phase IV and have the options of attending the exercise sessions at the Citadel gymnasium at 6:30 AM or at the GRI between 4 and 6 PM or excercising on their own. Dietary counseling and education regarding atherosclerosis, symptoms of risk factors for coronary artery disease, benefits and techniques of exercise, safety precautions and stress management are carried out. The patient’s medications are reviewed. Vocation rehabilitation counseling is available.
All patients referred to the program are examined by the Medical Director and usually an exercise stress test is carried out to observe the patient’s response to exercise and to obtain data on which to base the exercise prescription. Psychological evaluation of the patient is carried out by questionnaires.
The program is certified jointly by the South Carolina Medical Association and the South Carolina Chapter of the American Heart Association, and recertified every three years. The safety of patients is assured by the fact that a nurse and exercise director, who is trained in Advanced Cardiac Life Support, are at the exercise location in the Gazes Research Institute and that a designated physician is within five minutes walking distance of this site. The cardiology fellow assigned to the program is the designated physician and will be available for this purpose during the hours of program operations currently 7:00 AM to Noon and 4 to 6 PM on Monday, Wednesday and Friday. This will require that the physician be on campus by 7 AM.
To familiarize the cardiology fellow with the concepts of cardiac rehabilitation, its benefits and the structure and operation of a formal program.
To have the cardiology fellow become knowledgeable in:
- The evidence for benefit from a formal cardiac rehabilitation program
- Patient assessment and risk stratification
- The response of the cardiovascular system to exercise
- Prescribing an exercise program and the value of different types of exercise
- Problems related to special categories of patients, for example: cardiac transplantation patients, the elderly or handicapped
- Risk factors for coronary artery disease and appropriate management for those which can be modified
- The psychological aspects of coronary events and psychological assessment of patients.
- Safety issues
- The structures of a formal cardiac rehabilitation program including the staff, space and equipment required and the details of the education component
- The finances of a program in general terms
- The criteria for certification of cardiac rehabilitation programs in South Carolina
During a three month rotation period, the cardiology fellow will enhance his/her clinical skills and knowledge in the area of consultative cardiology. The fellow will additionally achieve advanced skills in the interpretation of twelve-lead EKG’s and twenty-four hour Holter recordings.
- The fellow will demonstrate the ability to respond appropriately and accurately to cardiology consultation requests, together with an ability to supervise the work of residents and medical students assigned to a consultation team.
- The fellow will demonstrate familiarity with all regularly encountered twelve-lead EKG patterns; an understanding of physiologic mechanisms for arrhythmias and an ability to recognize all arrhythmias regularly encountered on twelve-lead EKG’s and twenty-four hour Holter recordings. The fellow will also demonstrate an advanced ability to recognize normal EKG variants.
Mix of Diseases – Diseases frequently encountered include coronary artery disease, cardiomyopathy, congestive heart failure, hypertensive cardiovascular disease, valvular heart disease, arrhythmias and peripheral vascular disease. Less frequently, the fellow will participate in the management of patients with pericardial disease, pulmonary heart disease, endocarditis and cardiac manifestations of connective tissue disease.
The objective of this rotation is to provide the cardiology fellow with an education experience that provides instruction in all aspects of ultrasound utilized in assessing cardiovascular anatomy and function. The training in echocardiography will be integrated closely with the educational experience in clinical cardiology to include physical diagnosis, cardiovascular catheterization and intervention, surgery, and pathology.
The adult echocardiography laboratory at the Medical University Hospital performs 5000-6000 echocardiographic studies, 150-200 transesophageal studies and 700-800 stress echocardiograms per year. The fellow will receive exposure to the entire spectrum of acquired and congenital heart disease in adult patients of all ages, gender, and race. Extensive experience will be gained not only in coronary artery disease, but also valvular, pericardial, myocardial, surgical and post surgical cardiac cases and congenital diseases of the heart.
In the past decade, many advances have been made in the care of patients with coronary artery disease and primary valvular disease. This has allowed patients with these diseases to live longer placing them at risk for the subsequent development of congestive heart failure. The incidence and prevalence of congestive heart failure has been steadily increasing over the past decade with heart failure now constituting the number one cardiovascular discharge diagnosis. Whereas patients with mild to moderate congestive heart failure may be adequately cared for by family practitioners and general internists, the patient with advanced congestive heart failure often presents with life-threatening complications requiring a higher level of expertise.
Despite major advances in the treatment of congestive heart failure over the past five to ten years, the prognosis from this disease remains poor. During this same period, cardiac transplantation has become an accepted alternative to the conventional medical armamentarium. Most patients that undergo cardiac transplantation are referred to the Transplant Center by cardiologists and although the Transplant Center generally assumes a primary care role for these patients postoperatively, the community cardiologist continues to have a role in the initial evaluation of postoperative problems after transplant patients return to their home community.
The goal of the Heart Failure/Transplant Service rotation is to educate the cardiology fellow in the diagnostic and prognostic modalities available for the patient initially presenting with congestive heart failure and to allow the cardiology fellow to develop expertise in the treatment of congestive heart failure including the use of conventional medications and more aggressive modalities such as intravenous inotropes, intraaortic balloon counter pulsation and left ventricular assist devices. A further goal is to educate the fellow, in a more general way, in the care of the postoperative heart transplant patient specifically exposing the fellow to the management of postoperative hemodynamics, routine clinical follow-up and the myriad of complications that can occur in the immunosuppressed patient.
- The cardiology fellow will become knowledgeable in methods of diagnosis and evaluation of the patient with new onset congestive heart failure.
- The cardiology fellow will be become proficient in the management of congestive heart failure exacerbations in hospitalized patients. (It is assumed that the cardiology fellow will follow patients with chronic stable congestive heart failure in his longitundinal clinic.)
- The cardiology fellow will gain expertise in the more advanced methods of stabilizing patients in profound congestive heart failure such as the use of intravenous inotropes and vasodilators, intra-aortic balloon counter pulsation and left ventricular assist devices.
- The cardiology fellow will become knowledgeable in the methods of appropriate referral and evaluation for cardiac transplantation.
- The cardiology fellow will gain knowledge and proficiency in the routine care of postoperative cardiac transplant patients including:
a. the use of immunosuppressants
b. routine surveillance methods for rejection and graft vasculopathy
c. diversity and complexity of postoperative complications
The intensity of labor on the nuclear medicine rotation is not as great as some other cardiology rotations, therefore it is a time to enjoy the procedures from the standpoint of getting a clinical research protocol performed.
Goals and Objectives
- Obtain an understanding of the role of radionuclide diagnostic tests in evaluating the patient with cardiovascular diseases
- Obtain an understanding of radionuclide imaging from the standpoint of the type of disease processes evaluated, and understanding of the technology available and how it meets the diagnostic needs of the patient in this particular circumstance, and an understanding of radionuclides from the standpoint of nuclear physics, radiation, biology, radio pharmacy and radiation safety.
- An understanding of the role and where nuclear cardiology fits in, in the care of the patient.
- Obtain the necessary credentials to satisfy the Nuclear Regulatory Commission standards which are acceptable for licensure for the handling of radionuclides at the state level.
- Obtain experience in exercise and pharmacological stress testing.
Cardiac Catheterizaiton Laboratories
This is one of the “core rotations” essential to the education of the cardiology fellow. The responsibilities of the cardiology fellow vary somewhat, depending on the nature of the case (diagnostic cardiac catheterization vs. interventional procedure) and whether the patient is an in-patient (in which case the cardiology fellow will have primary responsibility for the precatheterization work-up and, in concert with the attending, arranging disposition for the patient.)
- The fellow should understand the indication for the diagnostic and/or therapeutic procedure. The fellow must know the technical aspects of the procedure and the potential complications of the procedure, in order to obtain informed consent from the patient. The fellow should learn how to achieve informed consent, without unduly alarming the patient, and to document in the patient’s chart that informed consent has been received for the procedure.
- The fellow will learn to interpret hemodynamic and angiographic data produced during the catheterization procedure.
- The fellow will integrate data generated within the cardiac catheterization procedure with non-invasive data to produce a correct and cost effective patient management decision.
- The initial three-month rotation emphasizes proper patient selection and procedural techniques for patients undergoing a wide variety of potential procedures.
- Other activities expected of the first year cardiology fellow include temporary cardiac pacing under fluoroscopic guidance, pericardiocentesis, and Intra-Aortic balloon insertion.
- Safety is emphasized. This includes knowledge of how to avoid contrast toxicity, unnecessary and radiation exposure and contaminated blood products.
- Proper record keeping is essential. The fellow should be able to express his/her interpretation of
cardiac catheterization data in a form appropriate for the permanent medical record and for transmission of this data to other physicians, nurses and health care professionals.
- Presentation at formal cardiac catheterization conferences requires that the cardiology fellow incorporate published data into their decision making process and have a thorough understanding, through presentation to colleagues, of complex cases.