MCT

Hello, and welcome to Cardiology.

The Medicine Cardiology Teaching (MCT) team is a medicine service in which patients with primarily cardiac issues (i.e. heart failure, NSTEMI/angina, Afib, etc) are admitted. A dedicated cardiology attending staffs the service and also covers the CCU. While the patient turn-over is high on MCT, most patients have fewer, more focused problems (ACS, heart failure, etc.). You will become familiar with managing ACS, decompensated heart failure, and many other inpatient cardiology issues and will learn discharge pathways specific to these problems. 

During your MCT rotation, you are excused from morning report but are expected to attend noon conference and grand rounds.

Specifics

• Workroom location: East Tower, UB6528, Code: 28455#

• Patient locations: The majority will be located on unit 66 (East Tower) and will be med-surg level, but they may be located on any floor in the East tower. IMC patients admitted to the service will be located on Unit 76 (CCU boarders).

• Off days: Interns take one weekend off per week, senior residents take one weekday off per week, preferably coordinated around continuity clinic days.  

• Team cap: 18 patients. Daily admission cap: None. 

• Admitting times: 7am to 5pm on weekdays, 7am to 3pm on weekend days or holidays.

  • 5-7pm weekday or 3-7pm weekend admissions: Provided that the team has signed out to the CCU, appropriate MCT admissions can be admitted by the resident AOD or handed off to the night AOD to count toward the 7pm-7am holding note cap of 4 patients.

• H2H/ Direct admissions: On the rare chance that there is an H2H or direct admission that reaches 66/76 before 5:00PM, it is the MCT team responsibility to admit the patient. If the admission (H2H or direct admission) comes in between 5:00-7PM the Cardiology Fellow should be informed and the CCU Resident/Fellow should lay eyes, place admission orders, and assign the admission based on the CCU fellow protocol. The AOD should be made aware for accounting purposes as this admission will count towards the maximum of 4 overnight holding notes. 

• Holding notes: Up to 4 from 5pm (or 3pm on weekends/holidays) to 7am

Where do we receive our MCT admissions from?

Usually, the MCT patient panel is either admitted from the ED, downgraded from CCU, or accepted as an H2H (hospital to hospital transfer). 

For H2H admissions, make sure that a release of information for IMAGES (not just radiographic reports) has been obtained In order to compare new studies to previous studies. If you find the images are missing from the patient's transfer records, you can call the transfer center to obtain the missing images without a release of information form if within 24 hours of H2H acceptance. This is particularly important to prevent exposure to unnecessary invasive procedures, compare new TTE's to previous, etc. The CDs with the images can be brought to the Cath Lab or Heart Station (both on the second floor) to load.

How do rounds work on MCT?

Rounds typically begin at at 8:00 am in the CCU. You should be ready to round at 8:00 am (your pre-rounds should include reviewing the chart for overnights events, follow up on medications and make sure patient received all of his/her medications, physical examination and Tele review). Depending on the attending on service, you may run the list prior to the attending rounding on CCU patients and then perform MCT rounds following this. Some attendings are also interventionalists and will work rounds around procedures. In general, it will be important for the senior to communicate with the attendings prior to their taking over the service regarding when you should be expected to round.

Presentations:

• Generally, mention the following during your presentations: 

  • 1- Reason of admission 

  • 2- What are we doing as an inpatient 

  • 3- What is our endpoint that once we reach we can discharge the patient.

• Have a hard copy of the summary of all ECHOs, MPS, and Caths for the patients, as well hard copies of all the ECGs since admission with a baseline old ECG if in our records. Your Resident should get access to McKesson (most do because they want to go into Cardiology), but this does not mean that you cannot get access. Simply call IT to have it installed on any computer or to gain access. 

• Electrolyte goals: K always correct to 4 (may be tricky as lots of the patients have poor kidneys, try to avoid IV replacement to reduce the amount of volume you are putting in these patients), Mag correct to 2 (please dont attempt to replace Mag less than 1.8 via PO mag as it will cause diarrhea and more mag loss), Phos correct to 4 as well. 

• Medications: Make sure to have all your cardiac medications written down. Prior to discharge, always check with case manager/social worker that patients can afford their medications (Bumex and Ticagrelor are expensive; you don’t want a bounce because patients couldn't afford Bumex or in-stent stenosis if patients couldn't afford Ticagrelor). 

• Telemetry: as part of pre-rounds please check telemetry to ensure no events and print out any events if they occur. This is especially important if the patient is being discharged. 

Most Common Cases on MCT:

• Heart failure: whenever you admit a patient with heart failure you will need to know the following: 

  • Ischemic vs non-ischemic cardiomyopathy

  • Systolic vs diastolic

  • Presence of any valvular disease

  • Whether or not there are recent changes in EF

  • Dry weight, weight on admission and daily weights

  • Daily I/Os. ALWAYS MAKE SURE THAT CHANGES IN WEIGHT CORRELATES WITH I/Os.

  • Medications (all HF patients should be on ACEi/ARB, metoprolol(Toprol XL is better than Lopressor yet more expensive - KEEP THAT IN MIND) or Coreg. 

• Acute coronary syndrome (ACS): 

  • Trop T and CK-MB Q6-8 hours for 3 occurrences

    • If a good story with no ECG changes and negative cardiac markers, repeat ECG in an hour as electrical changes lags behind ischemia for 30 min to an hour

  • Patients will need to be on hep gtt for 48 hours post ACS. 

  • Post catheterization, please examine site of cath to eval for complications including hematomas or aneurysms

  • Medications: All ACS patients should be on DAPT (dual anti platelet therapy: ASA + Plavix/Ticagrelor), BB, ACEi/ARB, and high dose statin. 

  • Whenever you are admitting a patient with chest pain, make sure to calculate the TIMI score and GRACE score.