Kansas City VA Inpatient Cardiology RotationRevised 12/2006

The Residency Review Committee requires that the resident and attending have a face-to-face meeting at the beginning of the rotation to review the learning objectives.

Educational Purpose for Rotation:Cardiac disease is the most-represented subject area on the ABIM examination,

and it encompasses the most often encountered diagnoses in the general practice of Internal Medicine. Residents are required to complete at least one inpatient cardiology rotation at the Kansas City VA because of the experience it offers in the care of acute cardiac illness outside a tertiary care center. The rotation provides experience in initial diagnosis and treatment of acute coronary syndromes and other cardiac conditions, including stress testing and cardiac catheterization. Competency in systems-based practice is enhanced by experience in transferring patients requiring coronary artery bypass procedures or emergent therapeutic cardiac catheterization.

Teaching Methods:

1. Each patient the residents admit is discussed in detail with the Coronary Care Unit attending.

2. The CCU attending makes daily patient management rounds with the house staff.

3. Diagnostic, invasive and non-invasive tests and procedures are reviewed daily with the CCU attending.

4. Hemodynamic data from cardiac catheterization and echocardiography is reviewed with the CCU attending.

5. Directly supervised procedures - House staff have the opportunity to learn procedures under the direct supervision of the CCU attending. Central venous lines and arterial lines will be done in the presence of the attending until the resident has documented satisfactory competency in these procedures. Residents may have the opportunity to participate in the placement of Swan-Ganz catheters under supervision of an attending cardiologist or cardiology fellow.

6. Residents will have the opportunity to be present during non-invasive and invasive testing that their patients will undergo. These include cardiac catheterization, non-invasive testing such as echocardiograms and nuclear cardiology with exercise and pharmacologic stress, and insertion of pacemakers and implantable cardioverter defibrillators.

Clinical Experience and Level of Resident Supervision:

Resident and Intern rotations in the CCU are one month in duration. While on the CCU rotation, house staff will work closely with the cardiology attending. Generally rounds during the week-days begin at 9:00 am and the house staff receives admissions until 4:00 P.M. House staff will cover cardiology patients both in the ICU and on the general medicine floors. They will also assist in the supervision and education of 4th year medical students who are taking a cardiology elective. The senior resident on the cardiology service does not take call during this month. The intern will take call approximately every 5th night. This service has just two house officers, the senior resident and the intern, coordination needs to take place on clinic days and on weekends to insure adequate cross coverage. The senior resident should be overseeing the management of all the patients on the cardiology service. Both senior residents and interns are supervised by the attending physician on the service, including discussion of each new admission and daily management plans. Cardiology fellows are available to residents for questions and assistance with procedures as well.

Competency-Based Educational Goals and Objectives by Level of Training and Evaluation Methods:

Medical Knowledge:PGY-1:

Expand clinically applicable knowledge base of the basic and clinical sciences underlying the care of patients with chest pain and acute cardiac disease

Access and critically evaluate current medical information and scientific evidence relevant to acute cardiac care

Understand indications for aggressive anticoagulant and antiplatelet therapy as well as the mechanisms of action of the various agents

Understand the physiologic and pathophysiologic principals of invasive hemodynamic monitoring including indications

PGY-2: All of the above, and: Be aware of indications, contraindications and risks of commonly used cardiac

medications and procedures Demonstrate knowledge of epidemiologic and social-behavioral sciences. Apply the basic, clinical, epidemiologic and social behavioral science knowledge

to the care of the patient Successfully complete required Internet-based training modules. Show progress in board preparation indicative of successfully passing the board

exam.

PGY-3: All of the above, and: Demonstrate an investigatory and analytic approach to clinical situations Demonstrate familiarity with the attached learning objectives for board

preparation

Evaluation Methods: Attending evaluation, Internet-based training module, chart-stimulated recall

Patient Care:PGY-1:

Effectively evaluate and manage patients with acute cardiac illness; particularly acute coronary syndromes, acute myocardial infarction, congestive heart failure, pulmonary edema and acute valvular heart disease

Effectively evaluate and manage patients who have undergone interventional procedures

Effectively manage patients with undiagnosed chest pain, including the appropriate use of diagnostic testing

Learn to insert central venous lines and arterial lines with proper technique, under senior resident supervision

Recognize limits in clinical experience and know when to ask for help. Elicit common findings on physical examination. Recognizes deterioration in clinical condition and takes appropriate initial

diagnostic and therapeutic steps.

PGY-2: All of the above, and: Elicit subtle findings on physical examination Obtain a precise, logical and efficient history Interpret results of procedures properly Beable to manage multiple problems at once Make informed decisions about diagnosis and therapy after analyzing clinical

data. Develop and carry out management plans. Consider patient preferences when making medical decisions. Triage patients to appropriate location Insert central venous lines and arterial lines independently and with proper

technique

PGY-3: All of the above, and: Reasons well in ambiguous situations Spends time appropriate to the complexity of the problem Teach other residents how to insert central venous lines and arterial lines with

proper technique

Evaluation Methods: Attending evaluation

Professionalism:PGY-1:

Establish trust with patients and staff Be honest, reliable, cooperative and accept responsibility Show regard for opinions and skills of colleagues

Demonstrate respect, compassion and integrity. Demonstrate sensitivity to patient culture, gender, age, preferences and

disabilities. Acknowledge errors and work to minimize them.

PGY-2: All of the above, and: Display initiative and leadership Be able to delegate responsibility to others Demonstrate commitment to ethical principles pertaining to the provision or

withholding of care, patient confidentiality, informed consent and business practices.

PGY-3: All of the above, and: Demonstrate commitment to on-going professional development.

Evaluation Methods: Attending evaluation, with incorporation of feedback from care coordinator, floor nurses, and other care team members

Systems-Based Practice:PGY-1:

Understand and utilize the multidisciplinary resources necessary to care optimally for acutely ill cardiac patients

Collaborate with other members of the health care team to assure comprehensive coronary care

PGY-2: All of the above, and: Apply knowledge of how to partner with health care providers to assess,

coordinate and improve patient care Use systematic approaches to reduce errors. Participate in developing ways to improve systems of practice and health

management. Demonstrate ability to adapt to change

PGY-3: All of the above, and: Understand how individual practices affect other health care professionals,

organizations and society. Demonstrate knowledge of types of medical practice and delivery systems. Use evidence-based, cost-conscious strategies in the care of patients with chest

pain and other acute cardiac disease

Evaluation Methods: Attending evaluation

Practice-Based Learning and Improvement:PGY-1:

Identify and acknowledge gaps in personal knowledge and skills in the care of acute cardiac patients

Develop real-time strategies for filling knowledge gaps that will benefit patients in the coronary care unit

PGY-2: All of the above, and: Understand limitations of knowledge Show willingness to learn from mistakes Be self motivated to acquire knowledge Be able to access and apply multiple sources of information to practice evidence-

based care of the cardiac patient Accept feedback and develop self-improvement plans.

PGY-3: All of the above, and: Undertake self-evaluation with insight and initiative. Facilitate the learning of students and other health care professionals.

Evaluation Methods: Attending evaluation

Interpersonal and Communication Skills:PGY-1:

Communicate effectively with patients and families in a stressful critical care environment

Communicate effectively with physician colleagues and members of other health care professions to assure timely, comprehensive patient care

Communicate effectively with colleagues when signing out patients or turning over care to another service

Write pertinent and organized notes Use effective listening, narrative and non-verbal skills to elicit and provide

information. Create and sustain therapeutic and ethically sound relationships with patients

and families.PGY-2: All of the above, and:

Provide education and counseling to patients, families and colleagues.

PGY-3: All of the above, and: Work effectively as a leader of the health care team.

Evaluation Methods: Attending evaluation

References1. Braunwald, E. Heart Disease, 6th Edition. Philadelphia, W.B.Saunders Company.

2002

2. Murphy JG. Mayo Clinic Cardiology Review, 2nd Edition. Philadelphia, Lippincott, Williams and Wilkins. 2000.

3. Baim DS, Grossman W. Grossman's Cardiac Catheterization, Angiography, and Intervention, 6th Edition. Philadelphia, Lippincott, Williams and Wilkins. 2000.

4. Topol EJ. Textbook of Interventional Cardiology, Third Edition. Philadelphia, W.B. Saunders Company. 1999.

5. Zipes DP, Jalife J. Clinical Electrophysiology: From the Cell to the Bedside. Philadelphia, WB Saunders Company. 1995.

6. Feigenbaum H. Echocardiography, Lea and Febiger, Malvern PA.

7. Marriot HJ. Practical Electrocardiography. Williams & Wilkins, Baltimore MD.

8. Cho TC. Third Edition, WB Saunders Company 1991

9. Wayman AE. Second Edition. Lea and Febiger, Malvern PA 1992

10.www.uptodate.com

Learning Objectives for Board Preparation

Item 1. Recognize the best strategy for drug implementation at discharge in a patient who is hospitalized because of decompensated congestive heart failure.

Item 2. Recognize the optimal medical management for non-ST-segment elevation acute coronary syndrome.

Item 3. Recognize the clinical presentation of paroxysmal supraventricular tachycardia.

Item 4. Understand the indications for surgical intervention in patients who have chronic severe mitral regurgitation.

Item 5. Understand appropriate secondary prevention for patients who have coronary artery disease.

Item 6. Recognize an acute aortic dissection.

Item 7. Recognize the clinical presentation of acute pericarditis.

Item 8. Recognize the prevalence of peripheral artery disease in patients who have cardiovascular risk factors or other manifestations of cardiovascular disease.

Item 9. Recognize diastolic dysfunction as a cause of heart failure symptoms.

Item 10. Recognize the physiologic murmur that is related to pregnancy.

Item 11. Understand the physiologic exercise training effect that occurs as a result of an exercise training program.

Item 12. Recognize the appropriate therapy for premature atrial contractions.

Item 13. Understand the pharmacologic treatment of chronic coronary artery disease.

Item 14. Recognize an innocent murmur and understand the indications for additional testing.

Item 15. Recognize that low molecular weight heparin may require dose adjustment in renal insufficiency.

Item 16. Recognize the side effects of angiotensin-converting enzyme inhibitors in patients who have heart failure as a result of left ventricular systolic dysfunction and understand the treatment options.

Item 17. Recognize the physical findings of patent ductus arteriosus.

Item 18. Recognize the treatment options for the prevention of diabetes.

Item 19. Recognize the appropriate management of a pregnant patient who has mitral valve stenosis.

Item 20. Recognize the clinical presentation and evaluation of constrictive pericarditis.

Item 21. Recognize the electrocardiographic features of preexcitation (Wolff-Parkinson-White) conduction.

Item 22. Understand the natural history of aortic stenosis and the nature and timing of intervention for aortic stenosis.

Item 23. Understand the appropriate diagnostic tests in patients who have symptomatic congestive heart failure as a result of systolic left ventricular dysfunction.

Item 24. Understand the risk of cognitive defects after coronary artery bypass surgery.

Item 25. Understand and apply an exercise prescription to a patient who takes cardioactive medications that may affect heart rate.

Item 26. Recognize the role of aggressive management of risk factors in patients who have peripheral arterial disease.

Item 27. Identify a patient who is at high risk for rupture of a thoracic aortic aneurysm.

Item 28. Assess and modify the risk of coronary artery disease in a healthy elderly woman.

Item 29. Determine the appropriate treatment for a pregnant patient who has mitral stenosis and sinus rhythm.

Item 30. Recognize that anemia is a secondary cause of acute coronary syndrome.

Item 31. Recognize the treatment options for atrial fibrillation.

Item 32. Recognize and understand the treatment of anthracycline cardiomyopathy.

Item 33. Manage triggers of recurrent pericarditis.

Item 34. Know the appropriate management of the patient who has Marfan Syndrome.

Item 35. Assess the risk of coronary artery disease in a healthy obese woman.

Item 36. Understand the factors that determine myocardial oxygen supply and demand.

Item 37. Recognize peripartum cardiomyopathy.

Item 38. Understand the benefit of an aldosterone antagonist in treating systolic dysfunction heart failure.

Item 39. Understand the various degrees of conduction abnormalities and heart block.

Item 40. Select the appropriate management for your high risk patient with elevated troponin levels with acute coronary syndrome.

Item 41. Understand the application of resistance training as part of a program of endurance training in a patient who has modifiable cardiovascular risk factors.

Item 42. Identify the appropriate management of a patient who has a ventricular septal defect.

Item 43. Recognize the role of medical management of claudication in patients who have peripheral arterial disease.

Item 44. Recognize the importance of prescribing an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker to treat hypertension in a patient with diabetes.

Item 45. Understand the long-term pharmacotherapeutic strategies for patients who have stable congestive heart failure as a result of left ventricular systolic dysfunction.

Item 46. Understand the volume overload that is associated with atrial septal defect in a pregnant patient.

Item 47. Understand the application of coronary artery bypass graft surgery in patients who have coronary artery disease.

Item 48. Recognize the clinical presentation and initial management of hypertrophic cardiomyopathy.

Item 49. Recognize the appropriate diagnostic evaluation of palpitation.

Item 50. Treat a patient who has rheumatic mitral stenosis.

Item 51. Recognize the embolic potential of aortic atheroma.

Item 52. Understand the role of anticoagulation in patients who have heart failure with paroxysmal atrial fibrillation.

Item 53. Recognize the role of primary angioplasty in the management of cardiogenic shock.

Item 54. Recognize the role of revascularization therapy for claudication in patients who have peripheral arterial disease.

Item 55. Recognize the clinical correlates associated with atrial fibrillation.

Item 56. Recognize the increased vascular risk that is associated with mild chronic renal disease.

Item 57. Understand the risk of repeated pregnancies in a patient who has peripartum cardiomyopathy.

Item 58. Know the management of a patient who has Eisenmenger's syndrome and secondary erythrocytosis.

Item 59. Understand the significance of electron beam computed tomography coronary calcium scores.

Item 60. Understand the role of ACE inhibitors in patients at high risk for cardiovascular morbidity and mortality.

Item 61. Recognize the appropriate evaluation of premature ventricular contractions following myocardial infarction.

Item 62. Understand the assessment for risk of sudden death in a patient with hypertrophic cardiomyopathy.

Item 63. Recognize the clinical presentation of aortic dissection.

Item 64. Understand the indications for treatment with a permanent pacemaker.

Item 65. Recognize the appropriate therapy for acute severe aortic regurgitation.

Item 66. Recognize the role of cardiac glycosides in treatment of patients who have symptomatic (stage C) congestive heart failure.

Item 67. Identify the best management of a patient at delivery.

Item 68. Identify the optimal therapeutic approach for a patient who has a low HDL cholesterol level in the absence of elevated total and LDL cholesterol levels.

Item 69. Know the indications for closure of an atrial septal defect.

Item 70. Understand the use of cardiac stress testing after coronary bypass graft surgery.

Item 71. Understand the indications for endomyocardial biopsy in a patient with congestive heart failure.

Item 72. Recognize the appropriate options in treating a patient with a late presentation of ST segment elevation acute myocardial infarction.

Item 73. Understand and apply an exercise prescription in a high-risk patient who has cardiovascular disease.

Item 74. Understand the prognostic issues associated with uncomplicated mitral valve prolapse.

Item 75. Diagnose congenital complete heart block.

Item 76. Understand the role of metabolic exercise testing in determining the severity of disease and the prognosis of a patient who has congestive heart failure.

Item 77. Understand when to order a cardiac imaging stress test.

Item 78. Know the indications for surgery for an abdominal aortic aneurysm.

Item 79. Recognize the mechanism of myocardial infarction due to mitral stenosis.

Item 80. Recognize the factors that are associated with cardiac arrest.

Item 81. Recognize that echocardiography is the most important test in the initial evaluation of a patient with heart failure.

Item 82. Recognize when pregnancy is contraindicated in a patient who has Marfan Syndrome.

Item 83. Recognize the optimal blood pressure in a patient with diabetes.

Item 84. Understand the mechanism of failure of a bioprosthetic valve.

Item 85. Recognize a patient for whom an angiotensin-converting enzyme inhibitor should be prescribed in acute myocardial infarction.

Item 86. Recognize the role of antiarrhythmic agents in secondary prevention of cardiac arrest.

Item 87. Understand that β-blockers are indicated in patients who have asymptomatic left ventricular dysfunction.

Item 88. Identify a patient who is at risk for aortic coarctation.

Item 89. Manage a vagal reaction in a setting of acute myocardial infarction.

Item 90. Recognize primary (severe) pulmonary hypertension in a pregnant patient.

Item 91. Understand the role of a diuresis in a patient with decompensated congestive heart failure.

Item 92. Recognize the clinical presentation of right ventricular myocardial infarction.

Item 93. Manage acute atrial fibrillation associated with hemodynamic compromise.

Item 94. Manage angiotensin-converting enzyme inhibition in a patient who has renal dysfunction and severe heart failure.

Item 95. Understand when to order exercise electrocardiography.

Item 96. Identify the absolute contraindications for administration of thrombolytic agents.

Item 97. Recognize the higher risk of mortality associated with pulmonary hypertension in a pregnant patient.

Item 98. Understand the potential for nonsteroidal anti-inflammatory drugs to exacerbate or cause heart failure.

Item 99. Understand the long-term anticoagulation regiments that are recommended for patients who have mechanical prosthetic valves.

Item 100. Recognize acute ventricular septal defect after myocardial infarction.

Item 101. Recognize the mortality benefits associated with implantable cardioverter defibrillators.

Item 102. Identify alcohol as a cause of left ventricular systolic heart failure.

Item 103. Understand the complications associated with anticoagulation therapy during pregnancy.

Item 104. Manage angina or silent ischemia after a successful thrombolysis for acute myocardial infarction.

Item 105. Recognize manifestations of congenital long QT syndrome.

Item 106. Recognize the drug interaction between amiodarone and digoxin.

Item 107. Treat dislipidemia in a patients with diabetes mellitus.

Item 108. Manage a low risk patient hospitalized with unstable angina.

Item 109. Diagnose tachycardia-mediated cardiomyopathy.

Item 110. Recognize the appropriate evaluation of syncope.

Item 111. Recognize the ATP III guidelines for initiation of cholesterol-lowering drug therapy at a variety of target levels.

Item 112. Understand the role of resynchronization therapy in a patient who has refractory congestive heart failure.

Item 113. Recognize if appropriate medical management of patient with subacute stent thrombosis.

Item 114. Recognize the risk of cardiovascular events in a patient with peripheral arterial disease.

Item 115. Evaluate a patient with aortic stenosis with concomitant cardiomyopathy.

I. .Angina Pectoris (Objectives 1,2,3) (Questions 1, 6, 12, 14, 25, 26, 37, 48, 71, 96, and 109)

1) Pathophysiology2) Presentation/clinical features3) ECG/Laboratory testing4) Chest pain pathways5) Risk stratification - indications for stress testing6) Medical therapy7) Indications for cardiac catheterization8) Indications for revascularization9) Non-atherosclerotic causes by angina (Hyperthroidism, cocaine, anemia, etc.)

II. Acute Coronary Syndrome (Objectives 4,5,6) (Questions 3, 16, 31, 41, 54, 73, 80, 86, 90, 93, 97, 101, 105, and 114)

1) Pathophysiology2) Clinical features – history3) EKG changes – STE vs. Non-STE4) Rapid cardiac markers5) Management

Medical therapyReperfusion therapy

6) ComplicationsArrythymiasHemodynamic abnormalities - hypotension/CHF/shock/ RV infarction

Surgical complications7) Post Infarct Care

Medical therapyCardiac rehabRisk stratificationCardiac Rehab

Rhythm disturbances - Bradyarrhythmias, supraventricular and ventricular arrhythymias

III. Risk Factor for Coronary Atherosclerosis (Objectives 7,8,9) (Questions 19, 29, 36, 42, 45, 57, 60, 69, 74, 84, 108, and 112)

1) Hyperlipidemia types

2) NCEP guidelines3) Treatment strategies for Hyperlipidemia4) Diabetic5) Hyperhomocysteinemia 6) Diabetes mellitus7) Obesity/metabolic syndromes8) Hypertension9) Sleep apnea10) Renal disease

IV. Congestive Heart Failure (Objectives 10,11,12) (Questions 2, 10, 17, 24, 33, 38, 39, 46, 58, 61, 67, 72, 77, 82, 88, 92, 95, 99, 103, 110, and 113)

1) Definition2) Causes of systolic heart failure3) Causes of diastolic heart failure4) Presenting symptoms and clinical features5) Medical therapy 6) Indications for evaluation of ventricular contractility and exercise capacity7) Indications for hemodynamic monitoring8) Hemodynamic profiles of CHF/cardiogenic shock9) Indications for resynchronization therapy and transplantation

V. Valvular Heart Disease (Objectives 13, 14, 18) (Questions 5, 15, 18, 20, 23, 30, 51, 66, 68, 75, 85, 91, 98, 100, 104, and 116)

1. Physical findings and clinical presentation ofAortic stenosisAortic regurgitationMitral stenosisMitral regurgitationTricuspid/pulmonary valve disease

2. Indications for intervention3. Medical therapy4. Infective endocarditis5. Prosthetic valve management including warfarin anticoagulation

VII. Hypertrophic Cardiomyopathy (Objective 14) (Questions 49 and 63)

1. Presenting symptoms2. Physical findings3. Non invasive imaging4. Invasive testing5. Indications for invasive therapy

6. Indications for electrophysiologic therapy7. Genetic aspects/family counseling

VIII. Supraventricular arrhythmias (Objective 15) (Questions 4, 13, 32, 50, 53, 56, and 94)

1. Atrial fibrillation / flutter - etiologies, rate control versus rhythm control, indications for anticoagulation 2. SVT mechanisms, medical therapy, and indiacations or eletrophysiologic testing

IX. Ventricular Arrhythmias/Sudden Death (Objective 16) (Question 62, 81, 87, 102, 106, 107

1. Etiologies including long QT syndromes2. Presentation3. Emergent care of patient with lethal ventricular arrhythmia4. Indications for electrophysiologic testing5. Indications for ICD implantation6. Chronic care of patient with ICD

X. Syncope and Bradyarrthymias (Objective 16) (Questions 40, 65, 76, and 111)

1. Etiologies and presenting clinical features 2. Evaluation - Holter monitoring, event recorder, electrophysiologic testing 3. Indications for pacemaker implantation 4. Care of the patient with a permanent pacemaker

XI. Pericardial Disease (Objective 17) (Questions 8, 21, 34, and 115)

1. Etiologies of pericardial disease1) Tamponade clinical features and intervention2) Pericarditis presenting symptoms and physical findings3) Neoplastic heart disease4) Autoimmune heart disease 5) Restrictive cardiomyopathy vs. constrictive pericarditis

XII Aortic Disease (Objective 19) (Questions 7, 9, 27, 28, 44, 52, 55, 64, and 79)1. Etiology2. Acute aortic dissection presentation, evaluation and treatment options3. Aortic aneurysm evaluation and indication for surgery4. Peripheral vascular disease5. Presenting features, evaluation, and indication for surgical vs. medical therapy

XIII. ECG Interpretation (Objective 20) (Question 22)

1. LBBB/RBBB2. LAFB/LPFB3. LVH/RVH4. RAE/LAE5. STEMI/NONSTEMI6. Pericarditis7. Atrial fibrillation/flutter8. SVT9. Ventricular arrhythmias versus aberrancy

XIV. Congental Heart Disease in Adults (Objective 21) (Questions 35, 43, 47, 59, 70, 83, and 89)

1. Physical findings and management of common shunt lesions such as ASD, VAD, and PDA.

2. Presentation and management of aortic coarctation3. Management of complications of cyanotic congenital heart disease such as polycythemia 4. Etiology, physical findings and management of pulmonary hypertension

XV. Cardiac Issues in Pregnancy (Objective 22) (Questions 11, 91, and 98)

1. Cardiac physical findings in normal pregnancy 2. Management of valvular heart disease, congenital heart disease, and pulmonary hypertension in pregnancy.

Review of Goals and Objectives with Resident

Resident statement:The above goals and objectives were reviewed with me at the beginning of my rotation, and I understand the expectations for the rotation and how I will be evaluated.

Resident Signature: ____________________________________________________

Printed Name: ________________________________________________________

Date: ________________________________________________________________

Staff Signature: ______________________________________________________