Cardiology

I. ROTATION BASICS

Cardiology elective is available for PGY 1 - PGY 3's at Montefiore Hospital as a 2 or 4 week elective.

While on elective there are daily attending teaching rounds for consults seen throughout the day and structured didactics for the residents / fellows.

Moses Campus

On your first day please arrive at 9:00 am and page the cardiology fellow from the cardiology fellows office (2nd floor silver zone, next to echo lab).

II. GOALS AND OBJECTIVES

A. Overview/Goals:

The program of the cardiology consult service (discipline) is designed to provide the house officer with the knowledge and skills needed to diagnose and treat diseases of the cardiovascular system

Patients are very diverse ethnically and socioeconomically, and are representative of the neighboring Montefiore communities.

The cardiology rotation/elective consists of one block of 2 or four weeks, with a 24/7 coverage by the cardiology fellow. Internal medicine residents rotate on the service five days per week without weekend or call responsibilities for the cardiology service. The cardiology rotation/elective is available to all Internal Medicine PGY1s, PGY2s and PGY3s.

Residents work in teams under the supervision of the Cardiology fellow and the cardiology attending. The Attending physician is responsible for supervision of all patient care.

Residents are involved intensively in the daily management of all patients on the consult service. They will become very familiar with patients with acute coronary syndromes, including acute myocardial infarction and unstable angina, as well as other forms of valvular and myocardial disease, and arrhythmias and conduction disturbances. Trainees are expected to provide patient care that is compassionate, appropriate, and effective for the promotion of health, prevention of illness, treatment of disease, and care at the end of life.

Residents will gather accurate, essential information from all sources, including medical interviews, physical examination, records, and diagnostic procedures. They will make informed recommendations about preventive, diagnostic and therapeutic options and interventions that are based on clinical judgment, scientific evidence, and patient preferences. They will learn to interact appropriately with patients, families, and consultants to determine the most appropriate course of action tailored to the individual patient, and then implement that plan.

B. Level based Rotation Objectives:

PGY1:

- Patient Care: Appreciate the daily patient workload and to prioritize; recognize the significance of a patient’s cardiologic conditions; differentiate the acuity level of illness, to establish patient focused care.

- recognize basic murmurs such as mitral regurgitation and aortic stenosis.

- formulate an initial assessment incorporating the patient’s history, physical exam and incorporation the PGY1’s understanding of the patient’s underlying pathophysiology.

- Medical Knowledge: Use discussions during daily rounds; use literature and reference sources to increase knowledge base, to learn guidelines apply for patient management; acquire basic knowledge in the areas of underlying pathophysiology and the clinical aspects of cardiac disease states.

Trainees are expected to acquire in-depth knowledge of the medical conditions managed on the consult service. They are expected to be current on the established and evolving biomedical, clinical, and social sciences, and to have good clinical judgment in the application of this information to the care of acutely ill patients. It is also expected that the trainee will take an active role in teaching the other members of the consult team concerning these medical issues.

Diagnosis and management of the following conditions in considered an essential foundation for the management of patients on the consult service:

1. Non-ST elevation myocardial infarction

2. Unstable angina pectoris

3. Chest pain

4. Systemic arterial hypertension

Essential to the understanding of these disorders is an understanding of the appropriate selection and timing of diagnostic procedures such as cardiac catheterization, coronary angiography, echocardiography, stress testing and other radiologic techniques such as computed tomography and magnetic resonance imaging.

The trainee is also expected to gain understanding in optimal timing and nature of interactions with surgical and radiologic colleagues to help in the management of patients.

Trainees at the PGY 1 level will also be expected to have a basic understanding of EKGs, including being able to assess NSR and atrial fibrillation, LVH, bundle brand blocks and overt ischemic changes.

They will be expected to have a basic understanding of atherogenesis, valvular disease, and CHF.

- Professionalism: Establish trust with critically ill cardiac patients and family; to participate in teamwork. Exhibit honesty, reliability, and responsibility in patient care; demonstrate respect for patients and staff; attend conferences.

- Interpersonal and Communication Skills: Write understandable and timely notes; listen to patients and staff and communicate; work effectively as a member of the health care team.

- Practice Based Learning and Improvement: Recognize limitations of knowledge; use literature to improve your practice patterns; to accept feedback and change behavior; ask for help when needed; learn from the outcomes of cardiac patients to improve outcomes in the future.

- System Based Practice: Advocate for cardiac patients; accept and try to apply necessary devised guidelines; to develop understanding about the health care systems/structure and how it relates to patients requiring cardiac procedures.

PGY2:

- Patient Care: Prioritize daily tasks recognize the relative significance

of a given cardiac patient’s list of cardiac conditions; begin to recognize the acuity levels of illness; recall the indications, contraindications and risks of cardiac procedures; work with all providers to provide patient focused care.

In addition to the above, they will be expected to recognize additional murmurs such as tricuspid regurgitation, VSDs and aortic regurgitation and they will be expected to increase their ability to recognize JVP

Trainees at the PGY 2 level will be expected to formulate an assessment and initial plan incorporating the patient’s history, physical exam and incorporation the PGY-2’s understanding of the patient’s underlying pathophysiology.

- Medical Knowledge: Use literature and reference sources to increase knowledge base in cardiology; demonstrate basic knowledge in the areas of underlying pathophysiology and the clinical aspects of cardiac disease states; apply knowledge in the treatment of patients.

In addition to the above, diagnosis and management of the following additional conditions in considered an essential foundation for the management of patients on the consult service for the PGY 2:

Acutely or chronically decompensated left ventricular dysfunction

All forms of cardiomyopathy, including dilated, ischemic, and restrictive

All forms of pericardial disease, including acute pericarditis, cardiac tamponade, chronic pericarditis

Valvular heart disease

Acute or chronic pulmonary embolism

Infective endocarditis

The trainee is also expected to gain understanding in optimal timing and nature of interactions with surgical and radiologic colleagues to help in the management of patients.

In addition to the above trainees at the PGY 2 level will be expected to have a more advanced understanding of EKGs, including being able to assess SVTs, AV blocks, and subtle ischemic changes.

- Professionalism: Establish trust with patients and staff; exhibit honesty, reliability and responsibility in patient care; demonstrate respect for patients and staff; work to fulfill the needs of patients; accept assignments graciously; attend conferences.

- Interpersonal and Communication Skills: Write understandable and timely notes and consultation reports; improve ability to listen to patients and staff and communicate verbally and nonverbally in a productive manner; work effectively as a member of the health care team.

- Practice Based Learning and Improvement: Recognize limitations of knowledge; use references and literature to improve practice patterns; accept feedback and change behavior; ask for help when needed.

- System Based Practice: Be an advocate for cardiac patients; apply necessary devised guidelines; to develop understanding about the health care systems/structure and how it relates to patients requiring cardiac procedures.

PGY3:

- Patient Care: Prioritize the daily work load or cardiac patients and supervise the junior house staff appropriately; recognize the relative significance of a given patients list of cardiac conditions; recognize the acuity levels of illness; fully understand the indications, contraindications and risks of common and uncommon procedures; discuss risks/benefits native of patient’s with specialists.

In addition to the above, they will be expected to recognize additional murmurs/sounds such as mitral stenosis, hypertrophic cardiomyopathy, mitral valve prolapse, utilizing S2 to identify bundle branch and to increase their ability to recognize JVP

Trainees at the PGY 3 level will be expected to formulate an assessment and detailed plan incorporating the patient’s history, physical exam and incorporation the PGY3’s understanding of the patient’s underlying pathophysiology.

- Medical Knowledge: Use literature and reference sources to increase knowledge base and share knowledge with junior house staff; demonstrate sophisticated knowledge in the areas of underlying pathophysiology an the clinical aspects of simple and complicated disease states; apply knowledge in the treatment of patients.

In addition to the above, diagnosis and management of the following additional conditions in considered an essential foundation for the management of patients on the consult service for the PGY 3:

Pulmonary hypertension

Atrial and ventricular tachy- and bradyarrhythmias

A basic understanding of common adult congenital heart disease diagnoses such as ASD, VSD and tetralogy of fallot

The trainee is also expected to gain understanding in optimal timing and nature of interactions with surgical and radiologic colleagues to help in the management of patients.

In addition to the above trainees at the PGY 3 level will be expected to have a more advanced understanding of EKGs, including being able to assess fascicular blocks and RVH.

- Professionalism: Establish trust with patients and staff; exhibit honesty, reliability and responsibility in patient care; demonstrate respect for patients and staff and junior house staff who you are supervising; work with team to fulfill the needs of patients; lead health care team in patient care; understand limitations and ask supervisors for help when indicated; accept assignments graciously; attend conferences.

- Interpersonal and CommunicationSkills: Write understandable and legible notes and consultation reports; improve ability to listen to patients and staff and communicate verbally and nonverbally in a productive manner; work effectively as a member of the health care team, and be an example for your junior house officers.

- Practice Based Learning and Improvement: Understand limitations of knowledge; use references and literature to improve practice patterns; accept feedback and change behavior; ask for help when needed; learn from the outcomes of cardiac patients under your care and alter practice patterns to improve outcomes in the future; aid junior house staff in evaluating their practice patterns.

- System Based Practice: Advocate for patients; develop a sophisticated understanding about the health care system/structure and develop mechanisms to utilize ancillary services to benefit patients.

III. AREAS COVERED DURING CARDIOLOGY ROTATION

1) Principles, Physiology and Basic Sciences: Atherogenesis, thrombosis, hemodynamics, valvular heart disease, neurohormonal influence and modulation, myocardial strain and wall stress, ion channels, lipid biology

2) Practical skills unique to (Discipline): Detailed cardiac history and physical exam. A detailed understanding of the EKG. Ability to identify, treat and communicate about persons with acute and chronic cardiac disease. Review of TTEs, TEEs, stress tests, cardiac catheterization, cardiac CT and cardiac MRI as applicable.

3) Approach to presenting complaints/problems: As per usual history and physical exam with increased urgency as patient pathology requires.

4) Specific Diagnosis in (Discipline)

Non-ST elevation myocardial infarction

Unstable angina pectoris

Chest pain

Systemic arterial hypertension

Acutely or chronically decompensated left ventricular dysfunction

All forms of cardiomyopathy, including dilated, ischemic, and restrictive

All forms of pericardial disease, including acute pericarditis, cardiac tamponade, chronic pericarditis

Valvular heart disease

Acute or chronic pulmonary embolism

Infective endocarditis

Pulmonary hypertension

Atrial and ventricular tachy- and bradyarrhythmias

Common types of adult congenital heart disease such as ASD, VSD and tetralogy of fallot.

5) Treatment Modalities: lectures, real time teaching on rounds, independent reading guided by the fellow and attending

6) Technical Skills: n/a

7) Emergencies: To be seen in conjunction with the cardiology fellow and may include, acute myocardial infarction, acute PE, acute decompensated heart failure, hypertensive urgency and hypotension

IV. SCHEDULE OF ACTIVITIES

1) Afternoon rounds with the cardiology attending. These rounds include teaching

sessions by the attending or the cardiology fellow. Distribution of literature.

2) Division Grand Rounds – weekly, if applicable

3) Cardiology lectures: daily

4) Medical Grand Rounds – weekly

V. METHODS OF TEACHING COMPETENCY ASSESSMENT

The house officers are evaluated continuously during their weeks on the cardiology consult service rotation. Importantly, there is continuous feedback to the house officers. The final evaluation is done through www.new-innov.com and the results are discussed in a meeting with the house officers. They are evaluated in terms of their overall clinical competence with the following categories:, medical knowledge, clinical skills, humanistic qualities, professionalism, and teamwork.

VI. REFERENCES

1) The Only EKG Book You’ll Ever Need. Malcolm S. Thaler. J.B. Lippincott Co.

2) Unstable Angina/Non-ST-Segment Elevation Myocardial Infarction: Guidelines for the Management of Patients With J Am Coll Cardiol 2011;57:e215-367

3) Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: Guidelines for: 2011 Update doi:10.1016/j.jacc.2011.10.824

4) www.acc.org for relevant clinical statements