Cardiovascular Diseases Training Program
Rotations and Educational Opportunities
Learning Objectives of Individual Rotations
The training program in cardiovascular diseases at Wake Forest School of Medicine is intended to prepare a well-rounded cardiologist skilled in the diagnosis, prevention and treatment of cardiovascular disease, from intensive care for acute cardiovascular disorders on the one extreme to ambulatory, outpatient follow-up care on the other extreme. Each trainee will receive supervised training in electrocardiography, cardiac catheterization, echocardiography, nuclear cardiology, electrophysiology, cardiovascular research, heart failure, congenital heart disease in the adult and peripheral vascular disease. The major educational objectives will be achieved via rotation on clinical and research blocks as outlined below.
Cardiology Continuity Clinic
Fellows are assigned a weekly, half-day outpatient clinic in which he/she is the primary cardiologist. One to 3 new patients and 5 to 8 return patients are seen per session. A staff cardiologist is assigned as the preceptor to whom all patients are presented for discussion and formulation of diagnostic and therapeutic plans.
Educational Purpose: To master the diagnosis, evaluation and treatment of all common cardiovascular disorders in the ambulatory setting.
Inpatient General Cardiology Service (“Fellows-PA Service”)
Each fellow will rotate through the inpatient service for 3 months as a first- and second-year fellow. The educational content of this rotation will reflect the pathology encountered in a large tertiary hospital with both referral cases and cases admitted directly from the emergency room. In the past, this pathology has included all areas necessary for core training in clinical cardiology including, but not limited to, the following: coronary artery disease; hypertension; hyperlipidemia; valvular heart disease; congenital heart disease; cardiac arrhythmias; heart failure; cardiomyopathy; involvement of the cardiovascular system by systemic disease; infective endocarditis; diseases of the great vessels and peripheral blood vessels; diseases of the pericardium; pulmonary heart disease; the interaction of pregnancy and cardiovascular disease; cardiovascular complications of chronic renal failure; traumatic heart disease; and cardiac tumors.
In addition, this rotation will serve as the major learning experience for congenital heart disease and cardiac transplantation, as well as vascular medicine. The fellow will be expected to become well-educated in the pathogenesis, pathology, risk factors, natural history, diagnosis by history, physical examination and laboratory methods, medical and surgical management, complications, and prevention of the disease processes outlined above.
Educational Purpose: Fellows will learn the diagnosis and care of a wide variety of cardiac diseases seen on a general cardiology inpatient service.
Coronary Care Unit (CCU)
The ultimate goal of the cardiac care unit (CCU) rotation is to provide the fellow with the cognitive and technical skills necessary to achieve Level 2 skills of (COCATS 2) clinical cardiology in the care of critically ill patients. Third-year fellows rotate through the CCU on a monthly basis. The fellow’s CCU rotation is driven by several parallel educational experiences: direct patient care; review of diagnostic studies; performing bedside procedures; mentoring house staff and medical students; and supplemental reading.
Educational Purpose: Third-year fellows will master the evaluation and management of cardiovascular critical care issues in the CCU. Each fellow spends a total of 3 months (not in succession) as the CCU Fellow during his/her third year.
Cardiac Catheterization Laboratory
The ultimate goal of the cardiac catheterization laboratory rotation is to provide the fellow with the technical and cognitive skills necessary to achieve Level 2 skills of (COCATS 2) invasive cardiology. Fellows interested in obtaining Level 3 (COCATS 2) skills will be required to complete an additional year of subspecialty training in Interventional Cardiology. It is also the goal of this rotation to provide the requisite skills for post-catheterization care in multiple settings including elective ambulatory care (Day Hospital), inpatient and critical care (CCU). In addition to hands-on practical experience, it is the goal of this rotation to provide a core knowledge base of myocardial, coronary, valvular, and pericardial anatomy, physiology, pathology and pathophysiology.
Educational Purpose: Each fellow will spend 7 months on this rotation during the fellowship. The fellow receives training in all aspects of invasive cardiology, including right and left heart catheterization, ventriculography, coronary angiography, endomyocardial biopsy, pericardiocentesis, peripheral angiography, placement of an intraaortic balloon pump, and percutaneous coronary interventional techniques. The training is not designed to provide for independent performance of coronary interventional procedures. The rotation is designed to provide the fellow with comprehensive training in the fundamentals of cardiovascular physiology, analysis of hemodynamic recordings, and the interpretation of angiographic images. Indications, risks, and benefits of each interventional procedure are discussed. All fellows will receive formal training in radiation physics, radiation safety, fluoroscopy, and radiologic anatomy. It is expected that the fellows will have performed 500 to 700 catheterizations during the fellowship. For each patient scheduled to have catheterization, the fellow is responsible for performing a history and physical examination, reviewing the past medical history, and appropriately documenting the procedure’s indications and risks in the chart before the procedure. After reviewing the results with the supervising staff cardiologist, the fellow is responsible for preparing the final report, including a description of the hemodynamic and angiographic results. The fellows present data obtained during catheterization for selected patients at the Clinical Cardiology Conference and Interventional Conference.
Echocardiography/Noninvasive Laboratory
Each fellow will spend 6 to 8 months in the echocardiography lab. This rotation provides intense exposure to the performance and interpretation of TTE, Doppler echocardiography, TEE and stress echocardiography (SE). Each fellow must know the general principles, indications, limitations, risks and benefits of all echocardiographic procedures. During the orientation/Phase I (first 2 to 6 weeks), each fellow spends substantial time with the hands-on performance of TTE and basic TEE, working with a skilled registered sonographer. During the Phase II rotation (second 2 months), the fellow spends increasing amounts of time with more advanced procedures, such as TEE, SE and strain rate imaging. Daily reading sessions emphasize the relationship of cardiac anatomy and physiologic to the echocardiographic examination. During the Phase III rotation (last 2 or more months), the fellow is expected to have developed the skills expected of an independent echocardiographer.
Educational Purpose: Each fellow will master the understanding and performance of transthoracic (TTE), transesophageal and stress echocardiography in a system of graduated responsibility as he/she rotates through the echocardiography laboratory in each of the 2 clinical fellowship years. Rotations occur at Wake Forest Unversity Baptist Medical Center, which allows for a diverse patient population that enhances training in the common and uncommon adult cardiovascular diseases. It is expected that the fellows will have personally performed approximately 50 and interpreted 300 to 600 transthoracic examinations under supervision during this period. Fellows are also expected to perform under supervision transesophageal echocardiograms (TEE) with at least 25 esophageal intubations and 50-100 TEE examinations, as well as supervise and interpret more than 150 stress echocardiography studies. Exposure to emerging technologies such as contrast echocardiography (>75), tissue Doppler imaging, strain and strain rate imaging, and 3-D echocardiography will be expected. Fellows may also perform under supervision echo-directed pericardiocentesis.
Nuclear Cardiology/MRI
Hands-on supervised experience will be provided in a minimum of 35 patients: 25 patients with myocardial perfusion scintigraphy and 10 patients with radionuclide ventriculograms. Such experience includes pretest patient evaluation, radiopharmaceutical preparation (including experience with relevant radionuclide generators), performance of the study, administration of the dosage, calibration and setup of the gamma camera, setup of the imaging computer, processing the data for display, interpretation of the studies and generating clinical reports. In addition, the training program for Level 2 training provides experience in computer methods for analysis. This includes perfusion and functional data derived from technetium agents and ejection fraction and regional wall motion measurements from radionuclide ventriculographic studies.
Educational Purpose: Training in nuclear cardiology provides an understanding of the indications for specific nuclear cardiology tests, the safe use of radionuclides, basics of instrumentation and image processing, methods of quality control, image interpretation, integration of risk factors, clinical symptoms and stress testing and the appropriate application of the resultant diagnostic information for clinical management. Didactic, clinical case experience and hands-on training hours require documentation in a logbook and having the trainee’s name appear on the clinical report or other specific record. The hours are monitored and verified by the nuclear cardiology training preceptor. A copy of the logbook is kept in the fellow’s file.
General Cardiology Consults
Each fellow will spend 3 months on the consultation service during the first and second years of their fellowship. This is consistent with the core cardiology training in adult cardiovascular medicine (COCATS) to revise recommendations published in 2002. The ultimate goal of the cardiac consultation service is to provide the fellow with training and the technical and cognitive skills which are required to achieve independence in clinical assessment and appropriate management of patients whose primary problem is non-cardiac but in whom cardiac issues have been identified. The goal of the rotation also is to provide the fellow with an adequate knowledge base to further extend their ability to manage inpatients with multiple problems. The rotation provides a reinforcement of the core knowledge base of anatomy, physiology, pharmacology, pathology and pathophysiology of cardiovascular disease.
Educational Purpose: This rotation is designed to provide the fellow with comprehensive training in assessment of patient’s symptomatology, physical examination findings, selection and interpretation of appropriate tests and development of rational management strategies for inpatients. They will be exposed to the management of cardiovascular problems which are encountered in the setting of non-cardiac disease as well as cardiac disease. For example, patients undergoing perioperative assessment from a cardiac perspective who are undergoing non-cardiac surgery, patients with cardiac symptoms who are on non-cardiological services, patients with cardiac arrhythmias who are under the care of non-cardiologist, etc.
Arrhythmia Consult/Electrophysiology
First- and second-year cardiology fellows will spend 2 to 4 months in Clinical Electrophysiology on the Arrhythmia Consult Service. The educational goals for this rotation include, but are not limited to, the following: recognize basic cardiac arrhythmias and causes – utilization of ECG, arrhythmia monitors, continuous recordings, implantable recorders; initial management of cardiac arrhythmias – learn pharmacology of anti-arrhythmic drugs with emphasis on appropriate dosing and follow-up; understand indications for temporary and permanent pacing – introduction to pacemaker device evaluation and trouble-shooting; understand indications and function of Implantable Cardiac Defibrillators (ICDs) – introduction to ICD device evaluation and trouble-shooting; understand concepts of biventricular pacing for management of CHF; risk assessment of sudden cardiac death – use of Holter monitor, signal-averaged ECG, T-wave alternans; evaluation of the patient with syncope; understand principles and techniques of electrophysiologic testing; and understand non-pharmacologic methods of arrhythmia management including indications for and results of catheter and surgical ablation.
Educational Purpose: Provide the fellow with Level 2 training in ECG interpretation with a clinical experience involving the evaluation and treatment of heart rhythm disorders. Special emphasis is placed on the use of the electrocardiogram for diagnosis of arrhythmias and the use of continuous ECG recordings via loop recorder, tape, or hospital monitor for diagnosis. Fellows will see hospitalized patients with arrhythmias in consultation and follow the patient through the evaluation and treatment of their rhythm problems. Fellows will receive formal instruction (Thursday noon Fellows Conference and Friday 7:30 EP Conference) regarding the indications and limitations for invasive electrophysiologic evaluation for diagnosis of arrhythmias. Fellows will be instructed in methods of venous access, right heart catheterization, and intra-cardiac recording and stimulation. Provide the fellow Level 1 training in Electrophysiology and Arrhythmia Management. Fellows will learn the indications for and limitations of electrophysiologic studies, the appropriate use of pharmacologic and non-pharmacologic treatments of arrhythmias, the proper and appropriate use of anti-arrhythmic drugs including drug interactions, toxicities, and pro-arrhythmic potential. Fellows will participate in the evaluation and programming of pacemakers and defibrillators in patients hospitalized on other services and seen in consultation by the Arrhythmia group. Provide the fellow with Level 1 training in Cardiac Pacing and Defibrillation. Fellows will participate in the post-operative wound care and management of Device patients on the Arrhythmia Consult Service.