Cardiology Curriculum Project

Introduction

In an effort to provide a meaningful and useful exposure to Cardiovascular Medicine, the Cardiology Section has developed the following curriculum for this rotation.

Please note that this is an ongoing and evolving project and that your input and feedback are appreciated. Also please note that the implementation of this curriculum will take some time as certain aspects require resources which may not yet be in place.

It is our intent that the knowledge covered by this curriculum be a floor of knowledge that every practicing internist should know. We encourage your reaching beyond the confines of this curriculum at every opportunity, and will be happy to assist you in that endeavor if possible.

Your evaluation and performance on this rotation will, in part, be based on your acquisition of the knowledge and skills as listed here. Again, because this is a project in evolution, not all of the resources that we intend to provide to help you meet these goals are yet in place. Accordingly, those areas in italics are not yet implemented, and you should not expect the rotation to include those activities in a formal way, nor should you expect to be evaluated on those topics specifically. These areas are included, however, to illicit your feedback and suggestions for implementation.

Thank you in advance and please pass any suggestions (in writing if possible) to your attending physician or Dr. Barry K. Rayburn, the curriculum project coordinator.

Cardiology Curriculum Project

Core Competencies by Area

Knowledge Areas by Topic

Coronary Artery Disease

Epidemiology of coronary artery disease

Identify the risk factors for the development of coronary artery disease

Appropriate management of modifiable risk factors

Recognition, evaluation and management of angina and unstable angina

Recognition, evaluation and management of acute myocardial infarction

Recognition and management of post infarction complications

Appropriate post infarction risk stratification

Appropriate post infarction home care

Basic understanding of indications and use of non-invasive and invasive diagnostic tests

Basic understanding of use of interventional techniques

Understanding of the indications for revascularization

Congestive Heart Failure and Pericardial Diseases

Epidemiology of CHF

Causes of CHF

Recognition, evaluation and management of chronic CHF

Evaluation and management of acute decompensation

Management of cardiogenic shock

Management of hypertrophic cardiomyopathy

Recognition, diagnosis and treatment of pericarditis

Arrhythmias

Application of ACLS

Recognition, evaluation and management of atrial fibrillation

Evaluation and management of common bradyarrhythmias

Indications for temporary and permanent pacing

Evaluation and management of common tachyarrhythmias

Indications and utility of electrophysiolgic testing and intervention

Basic understanding of use of antiarrhythmic therapy

Cardiac evaluation of syncope

Valvular Heart Disease

Common causes / clinical settings of valvular heart disease in general population

Physical diagnosis and diagnostic testing in valvular heart disease

Natural history of aortic stenosis, mitral regurgitation, aortic regurgitation and mitral stenosis

Appropriate use of antibiotic prophylaxis in valvular heart disease

Indications for surgical intervention in valvular heart disease

Recognition and management of endocarditis

Congenital Heart Disease

Recognition, evaluation and management of natural survivors - bicuspid aortic valve, ASD and mitral valve prolapse

Physical diagnosis and diagnostic testing for common congenital heart disease in the adult

Preoperative Evaluation for Noncardiac Surgery

Recognition and Management of Important Cardiovascular Emergencies

Aortic dissection

Acute pulmonary embolus

Cardiac tamponade

Hypertensive emergencies

Acute complications of cardiac therapy

Cardiac Pharmacology

Anticoagulation, both short and long term

Drug interactions

Practical Skills

Physical diagnosis of common cardiac abnormalities

Interpretation of ECG's and rhythm strips in common cardiac disease states

Indications, performance and use of invasive hemodynamic monitoring

Indications, performance and use of temporary pacing

Running a code

Attitudes and Behavioral Skills

Use of consultation in cardiovascular medicine

Application of preventive strategies for CAD in everyday practice

Housestaff Curriculum Project

Cardiology - CCU Rotation

I. Goals of the Rotation

The CCU rotation provides houseofficers with exposure to the recognition, evaluation and management of acute cardiovascular disorders in a critical care setting. This is a clinically busy rotation where the patient's care is directly supervised by a cardiology fellow as well as a member of the cardiology faculty in conjunction with the housestaff. By the end of the rotation, houseofficers at each level are expected to be able to demonstrate competence in the emergent management of common cardiovascular problems including coronary artery disease, decompensated heart failure and potentially dangerous arrhythmias. In addition, upper level house officers are expected to gain an understanding of the broader issues surrounding the long term management of these patients including risk factor modification, the subtleties of post infarction risk stratification and the use of various invasive and non-invasive diagnostic and therapeutic modalities.

II. Specific Learning Objectives

Knowledge Areas:

Objectives	Learners	Methods
Coronary Artery Disease Discuss the evaluation of chest pain Recognize and begin appropriate therapy for acute MI, including indication and use of thrombolytic therapy and anticoagulation Discuss post infarct complications and their management Understand and compare different strategies for post infarct risk stratification, including supporting data Demonstrate a basic understanding of interventional techniques	R1 R1-R3 R1-R3 R2-R3 R2-R3	Daily rounds, didactic talk Daily rounds, didactic talk, reading list Didactic talk, possibly rounds Daily rounds, case conference, reading list Day in cath lab, review of cine films and didactic talk
Congestive Heart Failure Perform acute management of decompensated CHF and cardiogenic shock, including use of hemodynamic monitoring and inotropic support Discuss choice and use of vasoactive agents Discuss use of mechanical support in CHF	R1-R3 R2-R3 R2-R3	Daily rounds, didactic talk Didactic talk, case conference Didactic talk, reading list
Arrhythmias Competently manage a code under direct supervision Differentiate wide complex tachycardias and demonstrate correct acute management Appropriately manage symptomatic bradyarrhythmias, including use of temporary pacing	R2-R3 R1-R3 R1-R3	Patient care and follow-up discussion Daily rounds, didactic talk Daily rounds, didactic talk

Practical / Skills Areas:

Objectives	Learners	Methods
Residents will increase their ability to interpret ECG's and rhythm strips	R1-R3	Daily rounds, case conferences with ECG's
Discuss indications for invasive hemodynamic monitoring, perform insertion of Swan-Ganz catheter using proper technique and demonstrate correct interpretation of results	R1-R3	Patient care, case conference
Discuss indications for temporary pacing with both external (Zoll) and internal devices, show correct use of temporary pacing equipment	R2-R3	Patient care, discussions with fellow, reading list
Demonstrate a practical understanding of ACLS principles by running a code under supervision	R2-R3	Patient care, discussion with fellow/attending
Demonstrate knowledge and recognition of physical findings of cardiovascular disease in this setting	R1-R3	Patient care, demonstration by fellow

Attitudes / Lifelong Learning Behaviors:

Objectives	Learners	Methods
Demonstrate use of preventive strategies in routine practice (both secondary prevention in patients with CAD and primary in those without)	R1-R3	Daily rounds

III. Logistics of Rotation

The CCU rotation is a busy clinical service in a critical care setting. Patients admitted to the CCU have a variety of acute cardiovascular problems varying in severity from immediately life threatening to currently stable patients with a potential risk for serious morbidity. Patients cared for by the CCU team will be admitted directly to the CCU. The team may follow patients onto the floor as well, but no patients should be admitted to the floor directly. The cardiology fellow in the CCU is responsible for supervising the care of all patients on the service and for serving as a liaison between the housestaff and various attendings with patients in the CCU but who are not the CCU teaching attending. The CCU teaching attending will be a cardiology faculty member who will have a substantial number of patients during the month and will serve as a principal teacher and resource for both the fellow and the housestaff. Coordination of didactic talks and case conferences will be the responsibility of the CCU fellow. Housestaff are expected to participate in the educational programs provided during the month. The nature of a critical care unit necessitates some flexibility in scheduling, and therefore a rigid schedule of talks and conferences is unrealistic. During the month, time will be arranged for each upper level houseofficer to spend a day in the catheterization laboratory beginning after work rounds. Ideally, this will be a day on which patients from the CCU are having a procedure performed.

IV. Required Educational Resources

A series of didactic talks will be presented during the month addressing the points noted in the curriculum outline above. The topics to be covered will be standardized, but the actual presentations will be arranged by the fellow in the CCU. Additionally, education of housestaff in the CCU will continue with daily discussions focusing on individualization of pertinent medical issues involving patients currently in the unit. This may necessitate that work rounds be somewhat longer than may be customary on other services. A formal reading list will be established and copies of classic or important articles provided to each resident at the beginning of the rotation with the expectation that they will be read during the month. Time will be provided for the R2-R3 level residents to spend time in the catheterization laboratory to observe the diagnostic and therapeutic techniques available. Finally, case conferences, using clinical examples from the CCU will be held to highlight decision making subtleties in the areas outlined.

Housestaff Curriculum Project

Cardiology - A Service Rotation

I. Goals of the Rotation

The Cardiology "A Service" is the flagship rotation for the section. It is an active clinical service with patients demonstrating a variety of cardiovascular problems. The goals of this rotation are to expose the houseofficer to a wide range of common cardiovascular diseases in a setting that allows for learning and discussion of the pathophysiology, evaluation and management of the various disorders. Additionally, this rotation should serve as an introduction for those houseofficers considering a career in cardiovascular medicine. As more patient care is moved into the clinics, a wide variety of routine management issues never appear in the inpatient setting. Accordingly, this rotation will give upper level residents an opportunity to work in continuity with one of the cardiology faculty by participating in a weekly WFUP Cardiology Outpatient Clinic during their month on the service. By the end of this rotation, it is expected that residents will be able to recognize, correctly evaluate and initiate management for common cardiovascular disorders seen in the practice of medicine. They should also gain some insight into the unique skills and services provided by subspecialists in cardiovascular medicine, thus enabling them to better utilize consultants. Finally, they should develop an understanding of the role of preventive cardiology strategies in everyday patient care and the means for keeping up to date in this rapidly changing field.

II. Specific Learning Objectives

Knowledge Areas:

Objectives	Learners	Methods
Coronary Artery Disease Discuss the epidemiology of CAD Perform appropriate evaluation of chest pain in patients with known CAD as well as previously undiagnosed patients Appropriately identify and manage modifiable risk factors in all patients Recognize, evaluate and initiate therapy for angina and unstable angina, including use of noninvasive and invasive testing Understand and employ appropriate post infarct counseling for patients in activity restrictions, rehab goals, life style changes	R1-R3 R1 R1-R3 R1-R3 R1-R3	Reading list Reading list, patient care, upper level residents Patient care, reading list, cardiology clinics Patient care, reading list, clinics, didactic talk Didactic talk, reading list, clinics
Congestive Heart Failure Discuss the causes and epidemiology of CHF Appropriately evaluate and initiate therapy for new onset CHF Appropriately evaluate and manage decompensation in chronic CHF Discuss results of large CHF treatment trials and their practical application	R1-R3 R1-R3 R1-R3 R2-R3	Didactic talk, reading list Didactic talk, reading list, clinics, patient care Didactic talk, reading list, clinics, patient care Reading list
Arrhythmias Recognize, evaluate and appropriately treat atrial fibrillation alone and in conjunction with other cardiac diseases Discuss evaluation of bradyarrhythmias and indications for permanent pacing Appropriately evaluate the patient with syncope, emphasizing those of cardiovascular origin Discuss common antiarrhythmic agents and their appropriate use and precautions	R1-R3 R1-R3 R1-R3 R2-R3	Reading list, patient care, clinics, didactic talk Reading list, patient care Reading list, patient care, didactic talk Reading list, discussions with faculty
Valvular Heart Disease Identify common valvular abnormalities in clinical practice and their risk factors Recognize and evaluate patients with common valvular abnormalities Know the indications for and choice of antibiotic prophylaxis in valvular heart disease Understand the indications for surgical intervention for common valvular abnormalities	R1-R3 R1-R3 R2-R3 R1-R3	Didactic talk, patient care Didactic talk, patient care Reading list Didactic talk
Congenital Heart Disease Identify the common "natural survivors" to adulthood and discuss their presentation and therapy	R2-R3	Clinics, reading list
Preoperative Evaluation for Noncardiac Surg. Discuss the principles of "pre-op" evaluation	R2-R3	Clinics, reading list

Practical / Skill Areas:

Objectives	Learners	Methods
Physical diagnosis of common cardiovascular conditions	R1-R3	Patient care, clinics, faculty one-on-one sessions
Interpretation of ECG's / rhythm strips	R1-R3	Didactic sessions, case conferences, ECG teaching file

Attitudinal / Lifelong Learning Behaviors:

Objectives	Learners	Methods
Apply principles of CAD prevention in routine practice	R1-R3	Patient care, clinics
Establish foundation for keeping up to date with changing standards of care and applying new findings in practice	R2-R3	Each upper level resident will be responsible for scanning the recent literature in an assigned topic for the specific purpose of updating the reading list for the rotation

III. Logistics of Rotation

The "A Service" rotation is centered around the care of inpatients with cardiovascular diseases. The activities of daily care of the patients and discussion of patient care issues with attending physicians will provide a large amount of the educational material during the rotation. In order to extend and supplement this experience, there will be conferences given on a scheduled basis by the attendings covering certain topics and related to cases if possible. The housestaff are expected to attend and participate in these conferences. A reading list will be established by the section with copies of the articles on reserve in the library for reading or copying. Each upper level resident will be assigned a specific topic / area at the beginning of the month and will be expected to review the recent literature and update the reading list in that topic. These updates will be reviewed with a faculty member. Upper level residents will also be paired with one of the faculty at the beginning of the month and will participate in at least one half-day clinic session with that faculty member each week of the rotation. This continuity should allow the resident sufficient time to be able to be an active participant in the clinic rather than just an observer.

IV. Required Educational Resources

It is expected that the residents will read many or all of the references on the reading list during the month. In order to facilitate this, we will make copies of the articles available in the library. The residents can either read them there, or more likely make copies for their own files. Alternatively, these references could be provided for each houseofficer depending on the availability of funds for copying and collating into binders. The faculty members who will participate in having residents in one of their clinic sessions during the entire month will need to have adequate room space in the clinic to allow for teaching to occur without jeopardizing service to our patients by slowing the progress of the clinic.

Housestaff Curriculum Project

Cardiology - Arrhythmia Service

I. Goals of Rotation

The arrhythmia service provides in depth exposure to a group of patients bound together by the common phenomenon of some electrical disturbance of the heart. Fortunately, such phenomena rarely happen in total isolation, and these patients usually have an additional underlying cardiac diagnosis such as coronary artery disease or congestive heart failure. In addition, some of the rhythm disturbances themselves are quite common in the general practice of internal medicine such as atrial fibrillation and bradyarrhythmias in the elderly. It is expected that residents on the arrhythmia service will learn a great deal about the management of common rhythm disturbances, but also will increase their foundation of knowledge in cardiovascular diseases overall. Residents should also be able to markedly improve their skills in the interpretation of ECG's, particularly with regards to rhythm disturbances.

II. Specific Learning Objectives

Knowledge Areas:

Objectives	Learners	Methods
Recognize, evaluate and manage common supraventricular arrhythmias including atrial fibrillation and flutter	R1-R3	Patient care, didactic talks, reading list
Recognize, evaluate and manage complex ventricular ectopy and ventricular tachyarrhythmias	R1-R3	Patient care, didactic talks, reading list
Understand, identify and manage bradyarrhythmias and conduction blocks including indications for permanent and temporary pacing	R1-R3	Patient care, didactic talks, reading list
Recognize the role arrhythmias play in the natural history of other cardiovascular illnesses (esp. CAD and CHF)	R1-R3	Patient care, discussions with faculty
Discuss use of electrophysiologic testing and interventions in the management of patients with arrhythmias	R1-R3	Case discussions with faculty, didactic talk
Understand the uses, general properties, side effects, toxicities and general precautions needed for the use of the Class I- IV antiarrhythmics.	R1-R3	Patient care, case discussions with faculty, reading list and didactic talks

Skills Areas:

Objectives	Learners	Methods
Interpretation of ECG's and rhythm strips	R1-R3	Daily review of strips with faculty / fellow

Attitudes / Lifelong Learning Behaviors:

Objectives	Learners	Methods
Identify appropriate use of consultation with arrhythmia specialists	R1-R3	Discussion with faculty
Become comfortable with interactions among drugs in overall care of the patient	R1-R3	Patient care, case reviews

III. Logistics of Rotation

The arrhythmia service is a standard inpatient service tied closely to an active clinic and consultation service. There is an attending physician responsible for the care of all the patients on the service at any one time which provides for a great deal of direct interaction between the housestaff and the faculty. Didactic talks and case driven discussions are held periodically throughout the rotation and are arranged by the attending with the houseofficers.

IV. Required Educational Resources

The section will develop a reading list of pertinent articles for the housestaff on the rotation. Clinical material for the review of ECG's and rhythm strips is abundant on the service and can be supplemented as needed by studies from the attending's files. Ideally, a teaching file of select ECG's and rhythm strips would be available to ensure coverage of important topics regardless of clinical material.

Housestaff Curriculum Project

Cardiology - General and Arrhythmia Consult Services

I. Goals of Rotation

The consultation services of the cardiology section provide residents with the opportunity to see the effective use of subspecialists as consultants to other physicians. It is expected that residents rotating on these services will gain insight into the effects of cardiovascular disorders on patients with a wide variety of other medical conditions. Additionally, the very important skills of preoperative assessment of the patient undergoing noncardiac surgery and management of cardiac complications following noncardiac surgery are emphasized. These rotations are particularly useful for residents considering a career in cardiovascular medicine who want more exposure to the subspecialty to help them with their decision and for residents planning a career in general internal medicine where preoperative evaluation is a common reason for consultation with an internist.

II. Specific Learning Objectives

Knowledge Areas:

Objectives	Learners	Methods
Understand and apply the principles of preoperative assessment of patients for noncardiac surgery	R2-R3	Daily rounds with attending, reading list
Apply risk factor modification strategies for primary and secondary prevention	R2-R3	Daily rounds with attending
Learn appropriate use of consultation and appropriate response to request for consultation	R2-R3	Daily rounds with attending

Skills Areas:

Objectives	Learners	Methods
Correctly interpret ECG's in a variety of clinical settings	R2-R3	Discussion with fellow / attending
Gain a basic understanding of the interpretation of diagnostic testing of the cardiovascular system including stress tests and echocardiograms	R2-R3	Review of studies with fellow / attending on a case specific basis
Physical diagnosis of common cardiovascular conditions	R2-R3	Case review with fellow / attending

Attitudes / Lifelong Learning Behavior:

Objectives	Learners	Methods
Apply principles of preventive cardiology in everyday practice	R2-R3	Daily patient care
Learn appropriate consultant behaviors and relationships with other services	R2-R3	Daily patient care

III. Logistics of Rotation

The consult services operate via a central phone number. The call is then routed to the fellow on the appropriate service who in turn will distribute the consults among the members of the team. It is expected that each resident on the consult service will perform at least one new consult daily and provide follow-up information on existing consults that they saw primarily. Generally the small team size allows for daily one on one interaction between the resident and the attending and fellow. This direct interaction provides for an excellent opportunity for case driven in-depth discussions often unavailable on busy inpatient services.

IV. Required Educational Resources

The major resources required for these rotations are consults which are generally plentiful.