CURRICULUM Fellowship Education Program in Cardiovascular ...

CURRICULUM

Fellowship Education Program

in Cardiovascular Diseases

University of Missouri-Columbia

School of Medicine

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I. Major Goals/Objectives: General Considerations

The major goal of the Curriculum in Cardiovascular Disease is to provide the

Fellow in Cardiovascular Disease with learning experiences that will permit him or her to

enhance his or her understanding of normal cardiovascular anatomy and physiology and to

become knowledgeable in the epidemiology, genetics pathology, pathophysiology,

pharmacology clinic features, laboratory abnormalities, differential diagnosis, natural

history, treatment, prognosis and prevention of diseases of the cardiovascular system. It is

anticipated that the Fellow in Cardiovascular Disease will draw on such knowledge to

become competent in the discipline of cardiovascular disease. The fellow is also expected to

become familiar with the role of psychosocial factors in the clinical presentation of

cardiovascular disease and to understand the economic burdens of cardiovascular disease

including those associated with diagnosis, management and prevention. The fellow is

afforded the opportunity to participate in scholarly activities including research and are

provided with the education, tools and mentoring to become proficient in the analysis and

performance of clinical, translational or basic research. The Fellow in Cardiovascular

Disease is encouraged to learn to practice compassionate, efficient, cost-effective, high-

quality and whenever possible, evidence-based cardiovascular medicine.

The Curriculum in Cardiovascular Disease consists of four components (1) clinical

experience, (2) lectures, conferences, and committee assignments, (3) the opportunity to

attain competence in and/or knowledge of a variety of cardiovascular skills and procedures

(including research) and (4) formal education in cardiovascular diseases. The Curriculum in

Cardiovascular Disease is organized around topical and instructional objectives. Topical

objectives identify subject areas about which fellows will learn and instructional objectives

define what within those subject areas is to be learned. Each instructional objective

addresses one or more of the core competencies mandated by the Accreditation Council for

Graduate Medical Education (ACGME). These are (1) patient care (PC), (2) medical

knowledge (MK), (3) inter-personal and communication skills (CS), (4) professionalism

(P), (5) practice-based learning and improvement (PBLI) and (6) systems-based practice

(SBP). In sections IVA, B, C, and D of this document each of the clinical and educational

experiences and instructional objectives are accompanied by denotation of the core

competencies that apply to that experience or objective.

II. Methods of Education

The fellow in Cardiovascular Disease derives knowledge of cardiovascular disease

from multiple sources. These include clinical rotations, outpatient experiences, lectures and

conferences, research rotations and elective rotations. Clinical rotations include the Inpatient

Cardiology Service at University Hospital (UH) which consists of both coronary intensive

care unit and cardiology ward experiences (minimum of 4 months), the Inpatient Cardiology

Consultation Services at (UH and at the Harry S Truman Memorial Veterans Hospital

(HSTMVH), minimum of 6 months), the Graphics Laboratory Rotation (1 month),

Echocardiography Laboratory Rotations (UH and HSTMVH, minimum of 4 months).,

Nuclear Cardiology Rotations (minimum of 2 months), Cardiac Catheterization Laboratory

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Rotations (UH and HSTMVH, minimum of 4 months), Cardiac Electrophysiology and

Pacemaker Rotations (minimum of 2 months including pacemaker/ICD surveillance and

analysis), the Cardiac Rehabilitation experience (2 weeks). One month elective experiences

are available in cardiac transplantation and advanced cardiac imaging at institutions with

available cardiac transplantation programs and advanced imaging services.

Each fellow maintains a half-day outpatient clinic per week throughout the three

year fellowship (UH and HSTMVH). In these clinics fellows evaluate and manage new

patients and then follow those who require continued care for the duration of their

fellowship.

All fellows are provided the opportunity to participate in scholarly activity under

faculty mentorship (6-12 months). Fellows are strongly encouraged to complete at least one

research project during the course of their fellowship and are also encouraged to write

scholarly reviews for publication in referred journals.

A variety of lectures and conferences supplement the fellow’s educational

experiences gained from inpatient clinical rotations, outpatient experiences, clinical

laboratory experiences, and research rotations. These include the Core Curriculum Lecture

Series (weekly), Cardiology Grand Rounds (weekly), Morbidity and Mortality Conference

(monthly), Journal Club (monthly), Research Conference (monthly) and Fellows

Conference (monthly), EKG/Electrophysiology Conference (monthly) and Professor

Rounds (bi-monthly). An extended lecture series in Nuclear Cardiology designed to satisfy

certification requirements is offered every other year for interested fellows. In addition to

these lecture and conferences, fellows are encouraged to attend the annual AHA or ACC

Scientific Sessions or a national subspecialty conference if they are so interested. They are

also encouraged to attend Internal Medicine Grand Rounds whenever possible.

Fellows may avail themselves of the Cardiology Learning Center. This facility is

located in the fellows office area and consists of a library of textbooks and computer

programs relevant to the discipline of cardiovascular disease. Desk carrels are available for

each fellow. Three computers with access to the main library are available to fellows, copies

of major cardiovascular and internal medicine journal are available in the nearby Cardiology

Office area. A fully equipped conference room is located next to the Cardiology Learning

Center.

Senior fellows are appointed to hospital quality assurance committees (ACS, CHF,

Cardiac Arrest) so that they may learn the quality assurance process.

III. Methods of Evaluation

Each fellow receives a summary of the goals and objectives and expectations from

the attending physician at the beginning of each rotation and an oral summative evaluation

at the end of the rotation. In addition, each fellow receives a written evaluation (ABIM

evaluation form) at the end of each rotation. Each fellow receives biannual written and oral

evaluations form the Program Director which summarize evaluations from the previous 6

months. Each fellow receives a semiannual 360 degree evaluation from attendings, peers

and paramedical staff who have worked with the fellow during the previous 6 months.

Feedback based on these 360 degree evaluations is provided by the Program Director.

Fellows also receive real-time formative evaluations from faculty relating to performance at

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conferences or ad hoc performance on clinical services. Information gleaned from fellows’

performance evaluations and from the ABIM Certifying Examination in Cardiovascular

Disease is evaluated by the Program Director. Changes in the curriculum are made to

address deficiencies. Once per year faculty meet with all of the fellows so that they (the

fellows) may critique the fellowship program. Minutes of these meetings are kept and the

Program Director is charged with evaluating criticism and implementing changes in the

curriculum/program. In addition, fellows evaluate faculty in writing at the end of each

rotation. These evaluations are analyzed by the Division Director and Program Director who

provide feedback to faculty and make changes when necessary in the exposure of faculty to

fellows.

IV. Specific Program Content

A. Clinical Experience

1. The Fellow in Cardiovascular Diseases is provided a broad spectrum of

opportunities to acquire clinical experience in and knowledge of adult

cardiovascular diseases in the inpatient setting, in the outpatient setting and in

the clinical laboratories. The following descriptions list the general goals and

objectives of rotations in these venues and summarize the scope of

cardiovascular disease and experiences encountered by fellows during various

clinical rotations. Specific duties on each rotation are listed separately in the

Cardiovascular Disease Fellowship Manual.

a. Direct Cardiology Inpatient and Coronary Intensive Care

The Fellow in Cardiovascular Disease is provided a minimum of 4

months of experience in the Coronary Intensive Care Unit. At UH this

service is coupled with the Cardiology Ward service. It is a high-volume,

high-turnover service. At the HSTMVH, the Coronary Intensive Care

Unit rotation is a low volume service that is coupled with the Cardiology

Consultation Service. During the Coronary Intensive Care Unit

component the fellow in Cardiovascular Disease is afforded the

opportunity to acquire knowledge and skill in the diagnosis and

management of definite or suspected acute myocardial infarction and its

complications, unstable angina pectoris, highly-symptomatic or life-

threatening arrhythmias and conduction disturbances, acute/severe

congestive heart failure, acute vascular disease, acute infective

endocarditis, hemodynamically-significant pericardial effusion,

hypertensive emergencies and urgencies, aortic dissection, acute

pulmonary embolism, life-threatening complications of cardiac therapy,

hypotension and shock. During the Coronary Intensive Care Unit

component fellows are provided the opportunity to become proficient in

bedside cardiac procedures including placement of a Swan-Ganz

catheter, temporary pacemakers insertion, and a temporary transvenous

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pacemaker placement of an intra-arterial catheter and management of

patients with an intra-aortic balloon pump. They are expected to

maintain proficiency in BLS and ACLS and to become familiar with

Phase I Cardiac Rehabilitation. During the non-Coronary Intensive Care

Unit Ward component of the rotation fellows have the opportunity to

gain knowledge and experience in the evaluation of management of

patients who no longer need coronary intensive care and those with

severe acute and chronic coronary artery disease, hypertensive disease,

valvular disease, cardiomyopathy, pericardial disease, congenital heart

disease, congestive heart failure and cardiac arrhythmias that require

inpatient care and/or monitoring, but not intensive care. Fellows are

expected to become proficient in the use of cardiovascular drugs and in

the judicious use of diagnostic tests and non-pharmacologic therapeutic

modalities. Fellows are provided the opportunity to learn to deal with

psychosocial and ethical considerations and to practice evidence-based,

cost-effective cardiology in a highly- professional, compassionate

manner. They are also expected to integrate their knowledge of general

internal medicine into the management of cardiovascular disease.

Finally, they are expected to learn to work within hospital systems

(including with paramedical personnel) and use external medical

systems to enhance patient care. They are expected to internalize feed

back from attendings, colleagues and paramedical personnel to improve

their practice of inpatient cardiology. (PC, MK, CS, P, SBP, PBLI).

b. Inpatient Cardiology Consultation

The Fellow in Cardiovascular Diseases is provided a minimum of 6

months of full-time experience on the Inpatient Cardiology Consultation

Services. Inpatient Cardiology Consultation Services are present at UH

and at the HSTMVH. The only difference in these services is that the

HSTMVH Inpatient Cardiology Consultation Service is coupled with the

low-volume HSTMVH Coronary Intensive Care Unit Service. During

inpatient cardiology consultation experiences the Fellow in

Cardiovascular Diseases is afforded the opportunity to acquire

knowledge of cardiovascular anatomy, physiology, pharmacology,

pathology, molecular biology, genetics and metabolism. The fellow is

provided the opportunity to learn to evaluate and manage acute and

chronic coronary artery disease, hypertension and hypertensive

cardiovascular disease, cardiomyopathies, acute and chronic valvular

disease, acute and chronic pericardial disease, adult congenital heart

disease, peripheral vascular disease, pulmonary heart disease, acute and

chronic congestive heart failure, cardiac arrhythmias and conduction

disturbances, cardiovascular risk factors, complications of

cardiovascular therapy, and cardiac complications of non-cardiovascular

therapy. Fellows are expected to become proficient in pre-operative risk

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assessment in patients undergoing cardiac and non-cardiac surgery and

the management of peri-operative and post-operative cardiac

complications of cardiac and non-cardiac surgery. Fellows are provided

the opportunity to learn to use cardiovascular tests in an efficient, yet

thorough and cost-effective manner. Fellows are expected to learn to

provide evidence-based cardiovascular advice whenever possible and are

encouraged to engage in verbal communication with requesting

physicians on a frequent basis to enhance understanding. They are

expected to be personable and humane in their interactions with patients.

Fellows will have the opportunity to learn how to co-manage patients

when necessary and when and how to terminate consultations. (PC, MK,

CS, P, SBP).

c. Outpatient Cardiology Experiences

Each Fellow in Cardiovascular Disease maintains an outpatient

cardiology clinic one-half day per week throughout their fellowship.

Half of these take place at UH and half at the HSTMVH. At their

HSTMVH clinic, fellows also work with an electrophysiologist to learn

to interrogate, trouble-shoot and reprogram pacemakers and implantable

cardioverter defibrillators (ICD’s). Fellows are typically scheduled to see

1-2 new patients and 7-8 return patients per clinic. Fellows are

encouraged to return patients to their primary care physician when

cardiovascular problems become stable or resolve, but are permitted to

co-manage patients indefinitely when appropriate. In Cardiology Clinic

fellows learn to evaluate and manage patients with chronic coronary

artery disease, hypertension and hypertensive cardiovascular disease,

cardiomyopathies, valvular heart disease, pericardial disease, adult

congenital heart disease, congestive heart failure, non-life threatening

cardiac arrhythmias and conduction disturbances, cardiovascular risk

factors and long-term sequelae to acute cardiovascular problems. They

are expected to learn to expeditiously and effectively provide pre-

operative cardiovascular risk assessment and recommendations and to

manage patients following cardiac surgery who have been discharged

from the hospital. Fellows are provided the opportunity to learn to use

cardiovascular drugs in the outpatient and to understand their diverse

effect. Conversely, they also learn to recognize cardiovascular effects of

non-cardiac drugs. Fellows are expected to learn to use diagnostic tests

judiciously and to practice in an evidence-based, cost-effective manner.

They are expected to create and maintain a compassionate relationship

with patients and to communicate with referring physicians and staff in

an effective collegial manner. Fellows are taught to utilize hospital and

community medical and social systems to enhance patient care and to

constantly evaluate their effectiveness as clinicians. (PC, MK, CS, P,

PBLI, SBP).

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d. Electrocardiography

Early in their fellowship each Fellow in Cardiovascular Disease is

scheduled to rotate for one month in the Electrocardiography Laboratory

(Graphics Rotation). The main goal during this rotation is to become

proficient in the interpretation of resting electrocardiograms, ambulatory

electrocardiograms, event monitor electrocardiograms, signal-averaged

electrocardiograms and stress electrocardiograms. Under faculty

supervision fellows are taught to determine rate, rhythm and axis on the

scalar electrocardiogram. They are also taught to identify left and right

ventricular hypertrophy, left and right atrial enlargement, intraventricular

conduction block, fascicular and bifascicular block, signs of myocardial

ischemia and infarction, signs of pericarditis and signs of drug,

metabolic and electrolyte disturbances and miscellaneous repolarization

abnormalities on the electrocardiogram. Fellows are taught to recognize

common cardiac arrhythmias and conduction disturbance on scalar

ambulatory and event monitor electrocardiogram and are taught to

interpret signal-averaged electrocardiograms. They are provided the

opportunity to perform treadmill exercise tests and to interpret the

symptom, hemodynamic and electrocardiographic responses during such

tests. By the end of the one month rotation fellows are expected to

interpret a sufficient number of electrocardiograms and perform a

sufficient number of treadmill exercise tests to become proficient based

on ACGME criteria. Additional opportunities exist for

electrocardiogram interpretation and treadmill exercise testing on

Cardiology Inpatient Service rotations, on the Cardiology Consultation

rotations, in the cardiology clinics and on the

Electrophysiology/Pacemaker Service rotations and on the HSTMVH

Non-invasive Cardiology rotations. (PC, MK, PBLI).

e. Echocardiography and Cardiac Doppler

Fellows in Cardiovascular Disease are provided a minimum of 5 months

of experience in the Echocardiography Laboratories (UH and

HSTMVH). During the initial month in the Echocardiography

Laboratory fellows are required to learn the basic principles of cardiac

ultrasound and to be able to perform a complete transthoracic

echocardiographic and cardiac Doppler study. They are taught to identify

normal echocardiographic and cardiac Doppler patterns, to begin to

recognize and interpret abnormal transthoracic echocardiograms and

Doppler (pulse wave, continuous wave, tissue) images. Fellows are

expected to learn the indications for cardiac ultrasound procedures and

to understand the value, limitations and potential complications of the

procedures. All of this is conducted under faculty supervision. During

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subsequent Echocardiography Laboratory rotations fellows are provided

the opportunity to become proficient in the interpretation of abnormal

transthoracic echocardiographic and Doppler (pulse wave, continuous

wave, tissue) studies and in the performance and interpretation of stress

echocardiogram (exercise, dobutamine), contrast echocardiograms

(saline bubble) and transesophageal echocardiograms. Fellows have the

opportunity to participate in intra-operative echocardiography. Fellows

perform and interpret a sufficient number of transthoracic

echocardiograms/Doppler studies, stress echocardiograms and

transesophageal echocardiograms by the end of their fellowship to meet

or exceed the ACGME threshold for proficiency. (PC, MK, PBLI)

f. Nuclear Cardiology

Nuclear Cardiology training is provided to the Fellow in Cardiovascular

Disease in 3 tiers. The first tier must be completed by all fellows and

consist of a 2 month experience in the HSTMVH Nuclear Cardiology

Laboratory. Under the direction of the laboratory director fellows acquire

basic knowledge of radiation safety, use of radiopharmaceuticals and

acquisition and processing of nuclear medicine images. Fellows are

expected to learn the indications for, value and limitations of cardiac

nuclear medicine studies and are provided the opportunity to interpret

myocardial perfusion images using sestamibi collected in association

with exercise or pharmacologic stress (dobutamine, adenosine). Under

faculty supervision fellows are taught to recognize normal radionuclide

images and abnormal images, and are encourage to correlate these

images with coronary angiographic anatomy when available. Fellows are

also provided the opportunity to interpret myocardial viability studies

using thallium-201. In addition, fellows are taught to interpret normal

and abnormal radionuclide ventriculograms (MUGA, first pass). The

aforementioned training serves as an introduction to cardiac nuclear

medicine. To become proficient in cardiac nuclear medicine, fellows

must complete tiers 2 and 3. Tier 2 consists of completion of nuclear

cardiology training modules that are designed to meet requirements for

certification eligibility and licensure in nuclear cardiology. This program

consists of assigned reading from nuclear cardiology textbooks, web-

based reading and quizzes, classroom lectures and examinations. Tier 3

provides advanced nuclear cardiology training over a 4-6 month period.

This training provides the fellow with qualifications to become an

authorized user of radiopharmaceuticals as defined by the Nuclear

Regulatory Commission. A total of 700 hours of training is required. A

minimum of 500 hours is spent in supervised work. A minimum of 300

cases are interpreted under the supervision of a licensed preceptor, 100

of which must be correlated with coronary angiograph. The fellow is

expected to become proficient in the selection of appropriate diagnostic

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modalities, data acquisition and processing, and interpretation of studies.

Additional training of up to 200 hours is obtained via lecture, reading,

electronic media and examinations. Areas covered included radiation

physics, radiation biology, instrumentation, radiopharmaceuticals

(handling, preparation, daring, injection) and radiation tapes. Hot lab

requirements are completed in the HSTMVH Nuclear Medicine suite.

Tiers 2 and 3 are elective, but are selected by most fellows.

g. Advanced Cardiac Imaging

At present, there is no advanced cardiac imaging rotation. MRI and PET

scanning of the heart are currently available, but are little-utilized. With

the acquisition of a 64 slice CT scanner early in 2008, we anticipate a

sufficient number of cases to provide case-based training which will be

supplemented by lectures, selected reading and web-based programs

(already available). Advanced cardiac imaging training will initially be

integrated into nuclear cardiology rotations. The major goal of this

rotation will be to provide the fellow with an introduction to the physics,

acquisition, indications, interpretation and clinical application of

advanced cardiac imaging and images. (PC, MK).

h. Cardiovascular Catheterization

The Fellow in Cardiovascular Disease is provided a minimum of four

months of experience in the cardiac catheterization laboratories. Most

fellows choose to take additional rotations in the cardiac catheterization

laboratory. The main goal of Cardiac Catheterization Laboratory

rotations is to acquire sufficient knowledge and experience to become

proficient in the performance and interpretations of diagnostic cardiac

catheterizations. During the first year fellows are provided the

opportunity to learn normal and abnormal cardiac hemodynamics,

ventricular function and coronary anatomy. They also are expected to

become proficient in gaining intravenous and intra-arterial access to the

vascular system, right heart catheterization and temporary transvenous

pacemaker placement. During the latter portion of the first year and

during the second and third years fellows are provided to opportunity to

become proficient in left heart catheterization, combined right and left

heart catheterizations, coronary angiography, aortography, and

pulmonary angiography. In addition, the fellow is afforded the

opportunity to become proficient in myocardial biopsy, intra-aortic

balloon placement and maintenance and pericardiocentesis. The Fellow

in Cardiovascular Disease is exposed to percutaneous coronary

interventions including balloon angioplasty, coronary stent deployment

(following angioplasty and primary) and rotational atherectomy. They

are also exposed to and assist on peripheral arterial interventions and

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valvuloplasties. They are not however, expected to become proficient in

these interventions during the three year training period. All cardiac

catheterizations performed by fellows are supervised by experienced

invasive/interventional cardiologists. It is anticipated that all Fellows in

Cardiovascular Disease will perform a sufficient number of invasive

procedures to meet COCATS 3 guidelines for proficiency. (PC, MK,

CS).

i. Cardiac Electrophysiology and Permanent Pacemaker Implantation

Each fellow in Cardiovascular Diseases is provided a minimum of two

months of experience in the Cardiac Electrophysiology Laboratories

(UH, HSTMVH) separate from Cardiac Catheterization Laboratory

rotations. Fellows in Cardiovascular Disease are provided instruction in

the fundamentals of cardiac electrophysiology and are afforded the

opportunity to become proficient in the performance and interpretation

of head-up tilt tests and cardiac conduction studies. They acquire

substantial exposure to programmed electrical stimulation, intracardiac

mapping and radiofrequency ablation of the AV node, slow pathways,

atrial flutter pathways, accessory pathways and automatic foci, but do

not become proficient in these procedures during the three year training

period. Fellows gain experience in permanent pacemaker (single or dual

chamber) implantation and ICD implantation during their Cardiac

Electrophysiology Laboratory rotations but not perform enough

implantations to be considered proficient in these procedures according

to ACC/AHA guidelines. Experience in pacemaker/ICD follow up,

surveillance and trouble-shooting is gained primarily in monthly

(HSTMVH) pacemaker/ICD follow-up clinics throughout the

fellowship. The fellow is afforded the opportunity to gain experience in

temporary pacemaker placement as well during cardiac catheterization

and coronary intensive care rotations. (PC, MK, CS).

j. Cardiac Rehabilitation

Experience in phase I cardiac rehabilitation is gained during Coronary

Intensive Care Unit rotations. Fellows in Cardiovascular Diseases are

introduced to phases II and III during their Electrocardiography rotation.

They spend four half – days during that month rotating in Fit-For-Life,

the cardiac rehabilitation program at UH. They are expected to learn the

design and structure of a cardiac rehabilitation program, to understand its

effect of cardiac morbidity, mortality and cardiovascular risk factors and

to be able to write an exercise prescription based on clinical information.

(PC, MK, SBP).

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k. Cardiac and Vascular Surgery

Presently, experience in cardiac and vascular surgery is gained primarily

on the Inpatient Cardiology Service and via the Inpatient Cardiology

Consultation Services. Cardiac surgery patients are transferred to the

Inpatient Cardiology Service 2-3 after surgery. Fellows gain experience

in the late post-operative care of their patients. Vascular surgery patients

are initially seen in consultation in the Cardiology Clinics or in via the

Inpatient Cardiology Consultation Service. We are presently considering

a one month elective rotation that would permit the Fellow in

Cardiovascular Disease to observe and participate in pre-operative, intra-

operative, and early post-operative care of cardiac and vascular surgery

patients, and to gain exposure to non-invasive and invasive vascular

studies. We hope to initiate this rotation in July of 2008. (PC, MK,

SBP).

l. Vascular Medicine

We are in the process of designing a one month rotation in vascular

medicine that will afford the fellow the opportunity to gain experience in

the vascular surgery clinic and in the non-invasive vascular laboratory.

We anticipate initiating this rotation in early 2009 (PC, MK).

m. Advanced Cardiac Imaging

In early 2009 we will initiate a one month rotation in advanced cardiac

imaging wherein the fellow will gain exposure to CT angiography,

cardiac MRI and cardiac PET scanning. (PC, MK).

n. Other Elective Rotations

As previously noted, we hope to initiate an advanced imaging elective

within the next year. Currently, fellows may elect a one month rotation

at an institution with an active advanced cardiac imaging program. Also,

previously-described was the elective component of the Nuclear

Cardiology experience. Fellows may elect a one month rotation in

advanced heart failure management and cardiac transplantation at an

institution with an active heart transplantation program. (PC, MK, SBP).

B. Lectures, Conferences, and Committees

1. Core Curriculum Lecture Series

This series consists of 72 weekly or biweekly lectures presented by

Cardiology faculty to Fellows in Cardiovascular Diseases. The purpose of

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this conference is to provide the Fellows in Cardiovascular Disease

information that has been identifies by the ACGME as essential to the

understanding of the principles and practice of cardiology. Each lecture is

one hour in duration and is presented in a didactic or case-based manner.

The lecture series is designed to be completed over an 18 month period.

Each lecture is presented twice during the three year fellowship to ensure

that all fellows have the opportunity to attend >80% of the lectures. The

Core Curriculum Lecture Series includes, but is not limited to topics

identified by the ACGME as essential areas of knowledge for the fellow in

Cardiovascular Disease. Core Curriculum Lectures are listed in a separate

document. (PC, MK).

2. Fellows Conference

This monthly lecture series is presented by Fellows in Cardiovascular

Disease. The purpose of this conference is to provide the fellow the

opportunity to perform a detailed literature search on a specific topic and

organize the material for the purpose of presenting it in a coherent and

stimulating manner. The lectures may be presented in a didactic or case-

based format. Although fellows may select a core topic to present, they

usually select more focused topics. Three recent fellows conference

consisted of lectures on patent foramen ovale, aspirin and clopidogrel

resistance and left main coronary artery disease. Fellows Conference

Lectures are characterized by a rigorous review of the literature on the topic

selected. Discussions stimulated during Fellows conference are invariably

spirited, vibrant and informative. (PC, MK).

3. Cardiology Grand Rounds

This weekly conference consists of one hour lectures that focus on recent

advances in cardiovascular disease and/or state of the art lectures. During a

typically month 2-3 lectures will be presented by a distinguished scientists

from other institutions, one lecture will be presented by one of the Division

of Cardiology faculty and one lecture will be presented by faculty from other

divisions or department in the medical school. Presentations may focus on

clinical cardiology, clinical research translational research or basic research.

(PC, MK, SBP).

4. Professor Rounds

The purpose of this bimonthly conference is to provide a format wherein

Fellows of Cardiovascular Disease can present cases to a single Cardiology

faculty attending and participate in a faculty-led discussion of the cases at

the fellow level. Cases are drawn from the inpatient services or from

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cardiology clinic. Whenever possible cases focus on areas of faculty interest

and expertise. (PC, MK).

5. Cardiac Catheterization Conference

This case-based conference takes place 3-4 weeks per month. Attendance

consists of Division of Cardiology faculty and fellows and faculty from the

Division of Cardiothoracic Surgery. Fellows select and present an average of

4-6 cases per conference. All cases are selected for there teaching value.

This format also facilitates discussions with cardiac surgeons about complex

or high risk cases. One conference per month is oriented toward correlation

of coronary angiographic findings with imaging studies. Each conference 1-

2 fellows prepare a brief (10 minutes) mini-literature review on a topic

germane to a case presented during the conference. Discussions are typically

brisk, and informative, and not infrequently have therapeutic implications

for patients discussed. (PC, MK, PBLI).

6. Echocardiography Conference

This case-based conference occurs 3-4 weeks per month. Fellows on the

Echocardiography rotations present 3-4 cases per conference which focuses

on diverse aspects of echocardiographic/Doppler diagnosis. Cases are

selected for teaching value and may consist of any of the echocardiographic/

Doppler modalities. A core curriculum of echocardiography topics to be

presented by noninvasive cardiology faculty is scheduled to be integrated

into Echocardiography Conference in 2008. (PC, MK).

7. Nuclear Cardiology Conference

This conference occurs monthly and consists of a series of lectures focusing

on the technical aspects of nuclear cardiology as well as general principles of

interpretation of myocardial perfusion cases and, radionuclide

ventriculography. This didactic and case-based lecture series is required for

all Fellows in Cardiovascular Disease. It is supplemented by web-based

presentations. The live lecture and web-based presentations serve as the

didactic basis for preparation for certification in Nuclear Cardiology. (PC,

MK, SBP).

8. Electrocardiography/Electrophysiology Conference

Electrocardiography/Electrophysiology conference occurs once per month. It

is a case-based conference. Electrocardiograms and electrophysiology

studies together with clinical information are presented by faculty or senior

fellows. Fellows are asked to interpret the graphics and discuss the

electrophysiological basis for the findings. Although a variety of

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electrocardiograms and electrophysiologic studies are presented at each

conference, there is often a theme focusing on a specific topic are within

each conference (eg, fascicular block, pacemaker ECG’s, pre-excitation,

etc.). This highly-interactive conference invariably engender active

discussion and debate. (PC, MK, PBLI).

9. Morbidity and Mortality Conference

This monthly conference is presented by fellows rotating on the Inpatient

Cardiology Service or Inpatient Consultation Service. Patients selected for

presentation are drawn from cases in which a patient died or suffered a non-

fatal unanticipated complication. Attending physicians involved in these

cases are required to be present. When appropriate, pathologists, radiologists

and surgeons involved in the case are invited to attend. These conferences

are typically characterized by frank discussions of the management strategies

that were used as well as alterative strategies that might have altered

outcomes. (PC, MK, PBLI, SBP).

10. Journal Club

The purpose of this monthly conference is to teach the Fellow in

Cardiovascular Disease to critically analyze research articles form the recent

literature. Each fellow is assigned one Journal Club per year and typically

presents two to three articles. Fellows are expected to summarize the

purpose and hypothesis the study, to present the methods (including

statistical methods) and results in detail and to summarize the authors’

conclusions. The fellow then provides a detailed critique of all aspects of the

study, citing strengths and weaknesses and identifying alternative

methodologies that might have been more suitable. Fellows are strongly

encouraged to review selected articles with a faculty member prior to

presentation. Articles to be presented are typically selected form the major

clinical cardiology or internal medicine journals. (PC, MK).

11. Research Conference

The purpose of this monthly conference is to allow the Fellow in

Cardiovascular Disease to present research hypotheses or work in progress

for discussion by other fellows and faculty. Fellow research is always

mentored, either by a faculty member of the Division of Cardiology or a

faculty member of another Department within the medical school.

Discussions at this conference are typically vibrant and not infrequently lead

to suggestions that strengthen proposed research or research in progress.

(PC, MK).

12. Quality Assurance Committees

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Each senior fellow in Cardiovascular Disease is assigned to one of three

hospital quality assurance (QA) committees for the duration of his or her

third year. These include: (1) the ACS QA Committee, the Heart

Failure QA Committee and the Cardiac Arrest QA Committee. The purpose

of waiting until the third year is to facilitate meaningful involvement based

on clinical experience. The one year assignment allows the fellow to

observe the handling of quality issues in the aforementioned areas over an

extended period of time, thus facilitating the ability to identify quality issues

and their root causes. The fellows then learn how to design an action plan

based on root cause analysis and to evaluate the results of the action plan.

We are in the process of designing a divisional quality assurance initiative

which will provide fellows the opportunity to assess quality issues within

their own practices. (PC, MK, PBLI, SBP).

C. Technical and Other Skills

1. The program will provide sufficient experience for the cardiology resident to

acquire expertise in the performance and interpretation of a broad spectrum of

skills and procedures.

a. Cardiology History

1. Goals and Objectives

a. Characterize the role of the cardiovascular history in

diagnosis. (PC, MK, CS)

b. Describe the importance of the cardiovascular history.

(PC, MK, CS)

c. Describe the pathogenesis and clinical significance of the

following cardinal symptoms of cardiovascular disease:

chest pain/discomfort, dyspnea (including paroxysmal

nocturnal dyspnea and orthopnea), cyanosis, syncope/pre-

syncope, palpitations, edema, cough, hemoptysis and

fatigue. (PC, MK)

d. Describe and apply the New York Heart Association

Classification for cardiac disease. (PC, MK, CS)

e. Describe the Canadian Cardiovascular Society Criteria

for Cardiac Disability. (PC, MK, CS)

16

f. Be able to perform a comprehensive cardiovascular

history. (PC, MK, CS)

2. Methods of Education

a. Utilization of textbooks, journal articles, audiovisual

modules and computer programs relevant to the cardiac

history. (PC, MK)

b. Interviewing and presenting patients during rotations on

the cardiology consultation service, in the cardiology

outpatient clinic, on the coronary care unit service and in

the cardiac catheterization and echocardiography

laboratories. (PC, MK, CS)

c. Attendance at Cardiology Grand Rounds and core lecture

series. (MK)

3. Methods of Evaluation

a. Direct observation of the cardiology resident by

cardiology faculty.

b. Evaluation of verbal and written diagnostic evaluations

by cardiology faculty.

b. Cardiovascular Physical Examination


a. Identify and explain the pathogenesis and clinical

significance of non-cardiovascular physical examination

findings associated with cardiovascular disease (general

appearance, head and face, eyes, skin and mucous

membranes, extremities, thorax and abdomen). (PC,

MK)

b. Describe and perform accurate blood pressure

measurements. (PC, MK)

c. Perform accurate evaluation of arterial pulses. Describe

the characteristics of normal and abnormal arterial pulses

and describe their physiologic basis. (PC, MK)

17

d. Perform accurate evaluation of the jugular venous pulse.

Identify and explain the physiologic basis for normal and

abnormal jugular venous pulsations. (PC, MK)

e. Identify and describe the physiologic and

pathophysiologic basis of normal and abnormal

percordial movements based on inspection and

palpitation. (PC, MK)

f. Identify and describe the physiologic basis for normal

heart sounds (S1, S2, physiologic S3). (PC, MK)

g. Identify the various abnormalities of S1 and describe their

pathophysiologic basis. (PC, MK)

h. Identify and describe the pathogenesis of the ejection

click, mid-systolic click, opening snap, pericardial knock

and precordial rubs. (PC, MK)

i. Provide a differential diagnosis of systolic, diastolic and

continuous heart murmurs. (PC, MK)

j. Identify and describe the physiologic or pathophysiologic

basis for systolic ejection and regurgitant heart murmurs.

(PC, MK)

k. Identify and describe the pathophysiologic basis of

diastolic and continuous heart murmurs. (PC, MK)

l. Provide a differential diagnosis, identify and describe the

physiologic or pathophysiologic basis for non-cardiac

murmurs. (PC, MK)

m. List and describe the influence of physical maneuvers on

heart sounds and murmurs. (PC, MK)

n. List and describe the influence of pharmacologic

interventions on heart sounds and murmurs. (MK, PC)


a. Utilization of textbooks, journal articles, audio-visual

modules and computer programs relevant to the

cardiovascular examination. (PC, MK)

18

b. Clinical experience on the inpatient cardiology

consultation service, in the cardiology outpatient clinic,

on the coronary care unit rotation and to a more limited

extent on the cardiology catheterization and

echocardiography laboratory rotations. (PC, MK)


a. Direct observation by cardiology faculty on the afore-

mentioned rotations.

b. Clinical correlation with echocardiographic and cardiac

catheterization findings.

c. Performance on sections of the ABIM Subspecialty

Board Examination in Cardiovascular Diseases dealing

with the normal and abnormal cardiovascular

examination.

c. Cardiopulmonary Resuscitation and Advanced Cardiac Life Support


a. To become proficient in basic life support and advanced

cardiac life support. (PC, MK)


a. American Heart Association Provider Course and

Syllabus on Basic life support and Advanced Cardiac

Life Support. (PC, MK)


a. Successful passage of the American Heart Association

Provider Course on basic life support and advanced

cardiac life support prior to or on entering into the

training program.

b. Personal observation by cardiology faculty in various

clinical situations.

d. Elective Cardioversion


19

a. Describe the electrophysiologic basis for elective

cardioversion. (PC, MK)

b. List the indications for elective cardioversion. (PC, MK)

c. Describe the methods available to achieve elective


d. Describe preparations for elective cardioversion. (PC,

MK)

e. Describe in detail how to achieve/perform elective

medical and electro-cardioversion. (PC, MK)

f. Describe post-cardioversion management. (PC, MK).


a. Utilization of textbooks, pertinent journal articles,

audiovisual modules and computer programs relating to


b. Perform 10 elective medical or electro-cardioversions

under the direct supervision of cardiology faculty and at

least 20 cardioversions independently after discussion

with cardiology faculty. (PC, MK, CS)

e. Bedside Right Heart Catheterization

1. Goals and Objective

a. Describe the indications for bedside right heart

catheterization. (PC, MK)

b. Describe the anatomic and hemodynamic basis for

bedside right heart catheterization. (MK)

c. Perform 25 bedside right heart catheterizations prior to or

during the cardiology residency. (PC, MK)

d. Identify the key pressure wave forms detected during

bedside right heart catheterization. (PC, MK)

20

e. Describe the thermodilution method for assessing cardiac

output. (PC, MK)

f. Identify the potential complications of bedside right heart




modules and computer programs pertinent to bedside

right heart catheterization. (PC, MK)

b. Observation of 5 bedside right heart catheterizations.

(PC, MK)

c. Performance of 10 bedside right heart catheterization

under faculty supervision. (PC, MK)

d. Performance of 25 bedside right heart catheterizations

prior to or during the cardiology fellowship. (PC, MK)

e. Interpretation of the results of at least 25 bedside right

heart catheterizations prior to or during the cardiology

fellowship. (PC, MK)


a. Direct observation of 10 cases by a member of the

Cardiology faculty or equivalent.

b. Presentation of hemodynamic data and use of these data

in the clinical context in 25 cases.

f. Insertion and Management of a Temporary Cardiac Pacemaker


a. List and discuss the indications for temporary cardiac

pacing including temporary pacing during acute

myocardial infarction and after cardiac surgery. (PC,

MK)

b. Describe the various accesses for temporary cardiac

pacing. (PC, MK)

21

c. Describe the various modes of temporary cardiac pacing

and discuss the uses and comparative advantages of each.

(PC, MK)

d. Perform at least 20 insertions of a temporary cardiac

pacemaker. (PC, MK)

e. Describe how to maintain a temporary cardiac

pacemaker. (PC, MK)

f. Discuss the potential complications of temporary cardiac

pacing. (PC, MK)

g. Become proficient in the use of external temporary

cardiac pacing. (PC, MK)



modules and computer programs relevant to temporary

cardiac pacing. (PC, MK)

b. Justify insertion of 20 temporary pacemaker insertions to

a faculty cardiologist. (PC, MK)

c. Performance of 20 temporary pacemaker insertions (10

under the direct supervision of a faculty cardiologist) in

the cardiac catheterization laboratory, coronary care unit

or emergency department. (PC, MK)

d. Attempt external cardiac pacing in at least 5 patients.


a. Direct supervision by a faculty cardiologist (10 cases).

b. Discussion of indication for and efficacy of temporary

cardiac pacing during rounds on the cardiology

consultation service or coronary care unit rotation, on

call, or in the cardiac catheterization laboratory with a

faculty cardiologist (30 cases).

g. Right and Left Heart Catheterization


22

a. Discuss the historical aspects of cardiac catheterization.

(MK)

b. Describe the technical aspects of cardiac catheterization,

including cardiac catheterization facility requirements,

radiology equipment requirements, and radiation safety

requirements. (MK)

c. Describe the brachial and radial approach to access

including catheter selection. (PC, MK)

d. Describe the femoral approach to access including

catheter selection. (PC, MK)

e. Describe the trans-septal catheterization technique,

including catheter selection. (PC, MK)

f. Describe the theoretical considerations relating to

measurement of intravascular and intracardiac pressures

including systems for pressure measurement, fluid-filled

catheter systems and manometer-tipped catheter systems.

(MK)

g. Correctly identify normal pressure waveforms and

abnormal pressure wave forms. (PC, MK)

h. Describe the theoretical and practical aspects of cardiac

output measurement, including the Fick, indicator

dilution and angiographic methods. (PC, MK)

i. Discuss the theoretical aspects of intracardiac shunt

measurements. Accurately quantify intracardiac shunts

in 5 patients. (PC, MK)

j. Discuss the theoretical basis for calculation of regurgitant

flow. Be able to calculate regurgitant flow. (PC, MK)

k. Describe the anatomic and physiologic basis for coronary

blood flow. (PC, MK)

l. Describe the theoretical basis for measurement of

vascular resistance. Accurately calculate systemic

vascular, total pulmonary, pulmonary vascular and

coronary vascular resistance. (PC, MK)

23

m. Describe the clinical usefulness of obtaining

hemodynamic information during exercise and describe

the protocols used to carry out this technique. (PC, MK)

n. List the indications for cardiac catheterization. (PC, MK)

o. List the contraindications to cardiac catheterization. (PC,

MK)

p. Describe the principles used to design cardiac

catheterization protocols. Design a proto-typical cardiac

catheterization protocol. (PC, MK)

q. Describe how to prepare and pre-medicate cardiac

catheterization patients. (PC, MK)

r. Describe the complications of cardiac catheterization,

discuss the risk factors that predispose to complications

and describe their management. (PC, MK)

s. Perform at least 100 (level I) and preferably 300 (level II)

left right heart catheterizations. (PC, MK)

t. Describe the indications for, techniques of and

complications of myocardial biopsy. Perform 10

myocardial biopsies. (PC, MK)

2. Educational Methods

a. Utilization of textbooks, pertinent journal articles, audio-

visual modules and computer programs relating to

cardiac catheterization. (PC, MK)

b. Experience in the cardiac catheterization laboratory under

the supervision of qualified cardiology faculty.

Performance of at least 150 – 300 left right heart

catheterizations. (PC, MK)

c. Attendance at Cardiac Catheterization Conference. (PC)

d. Evaluation and management of prospective cardiac

catheterization candidates while rotating on the

cardiology consultation service, coronary care unit

service and in the cardiology outpatient clinic. (PC, MK)

24


a. Direct observation by faculty in the cardiac

catheterization laboratory.

b. Monthly ABIM evaluations by individual faculty.



with cardiac catheterization.

h. Coronary Angiography, Left Venticulography, Aortography and

Pulmonary Angiography


a. Describe the Judkins technique including a discussion of

the equipment required and catheterization technique.

(PC, MK)

b. Describe the Sones technique. (MK)

c. Describe an Amplatz and multipurpose catheter

techniques including discussion of equipment required

and catheterization technique. (PC, MK)

d. Perform at least 100 and preferably 300 coronary

angiograms. Utilize the Judkins technique in at least

100, the Sones technique in at least 25, the Amplatz

technique in at least 10 and the multipurpose catheter in

at least 15 cases. (PC, MK)

e. Discuss the technical features of coronary angiography.

Describe the cinéangiographic equipment needed, drugs

used during coronary angiography, and the potential

electrocardiographic and hemodynamic changes that may

occur during coronary angiography. (MK)

f. Describe and identify normal coronary anatomy and its

variations on coronary angiograms. (PC, MK)

g. Describe and use standard angiographic views of the

coronary arteries. (PC, MK)

25

h. Describe and use angulated views of the coronary

arteries. (PC, MK)

i. Describe and identify the pitfalls of coronary

angiography in reference to each of the major coronary

arteries and their branches, including early bifurcation of

the left coronary artery, catheter-induced spasm and flow

artifacts. (PC, MK)

j. Compare and contrast eccentric stenosis, unrecognized

occlusions at branches, superimposition of branches,

myocardial bridging and recanalization. (PC, MK)

k. Describe the complications of coronary angiography.

(PC, MK)

l. Recognize congenital abnormalities of the coronary

arteries on coronary angiograms, including coronary

artery fistulae, the spectrum of anomalous origins of

coronary arteries, congenital coronary stenosis, sinus of

Valvalva aneurysms and fistulae and single coronary

artery. (PC, MK)

m. Discuss the effect of stenosis on coronary blood flow.

(MK)

n. Describe the angiographic appearance of coronary artery

collaterals. Recognize coronary artery collaterals on the

coronary angiogram. (PC, MK)

o. Characterize angiographic appearance of coronary artery

spasm. Recognize coronary artery spasm on the coronary

angiogram. (PC, MK)

p. Describe the angiographic appearance of coronary artery

stenosis. Recognize concentric lesions, types I and II

eccentric lesions and lesions with over hanging ledges

and multiple irregularities on coronary angiogram.

Recognize the arteriographic appearance of coronary

artery thrombus. (PC, MK)

q. Discuss the use of coronary angiography in patients with

coronary artery disease including the patient with

myocardial infarction. Discuss the usefulness of the

coronary jeopardy score. Relate the severity of stenosis

26

to mortality risk. Describe and be able to implement

TIMI score an corrected frame count. (PC, MK)

r. Describe the techniques used for coronary bypass

angiography. Be able to recognize the appearance of

patent bypass grafts. Be able to recognize the spectrum

of angiographic abnormalities of bypass grafts. Perform

bypass graft angiography. (PC, MK)

s. Discuss theoretical basis of digital and quantitative

coronary angiography. Describe the equipment required

for these techniques. Interpret coronary angiograms

utilizing these techniques. (PC, MK)

t. List the technical requirements and standard views for

contrast left ventriculography. Perform left

ventriculography. Recognize the normal left

ventriculogram. (PC, MK)

u. Characterize and be able to recognize the various

abnormalities of ventricular wall motion seen on contrast

left ventriculography including hypokinesia, akinesia,

dyskinesia, and dysyneresis. Describe techniques used to

determine reversibility of abnormal left ventricular wall

motion during left ventriculography. Describe the

potential complications of left ventriculography and their

treatment. (PC, MK)

v. Describe the technical requirements for aortic

angiography and pulmonary angiography. Discuss views

necessary to obtain interpretable aortograms and

pulmonary angiograms. Perform proximal aortography

and pulmonary angiography. Describe the complications

of these techniques and their management. Recognize

the features and normal and abnormal proximal

aortograms and pulmonary angiograms. (PC, MK)


a. Practical experience in the cardiac catheterization

laboratory. Performance of a minimum of 100 and

preferably 300, coronary angiograms and a sufficient

number of aortograms to attain proficiency. (PC, MK)

27

b. Participation in Cardiac Catheterization Conferences.

(PC, MK)

c. Clinical correlation during cardiology consultation and

coronary care unit rotations and in the cardiology

outpatient clinics. (PC, MK)

d. Utilization of textbooks, journal articles, audiovisual

modules and computer programs relevant to coronary

angiography, left ventriculography, proximal aortography

and pulmonary angiography. (PC, MK)


a. Direct observation by a qualified cardiology faculty.

b. Presentations and discussions at Cardiac Catheterization

Conference.



with coronary angiography.

i. Exercise Stress Testing


a. Discuss exercise physiology as it applies to exercise

stress testing. Discuss the relevance of patient position

and the significance of anaerobic threshold. Define the

metabolic equivalent as it applies to exercise stress

testing. (PC, MK)

b. Describe the pathophysiology of the myocardial ischemic

exercise response. (MK)

c. Describe static exercise protocols used in clinical

practice. (PC, MK)

d. Describe arm ergometry protocols used in clinical

practice. (PC, MK)

e. Describe bicycle ergometry protocols used in clinical

practice. (PC, MK)

28

f. Describe the treadmill protocols used in clinical practice.

(PC, MK)

g. Describe the lead systems used in exercise stress testing.

Discuss the electrocardiographic and electrophysiologic

basis for these lead systems. (MK)

h. Compare and contrast normal and abnormal ST segment

depression. Describe the mechanism of ST segment

displacement. (PC, MK)

i. Quantify ischemic ST depression and describe ischemic

T wave abnormalities observed during exercise stress

testing. (PC, MK)

j. Describe the use of computer-assisted ECG analysis in

exercise stress testing. (PC, MK)

k. List the indications and contraindications for exercise

stress testing. (PC, MK)

l. Describe the techniques used to prepare the patient for

exercise stress testing. (PC, MK)

m. List the causes of a false positive stress

electrocardiogram. (PC, MK)

n. Describe the correlation of exercise test results with

coronary angiography including the relationship between

the severity of the ischemic electrocardiographic

response and the severity of coronary artery disease. (PC,

MK)

o. Discuss the use of Bayesian theory and multivariate

analysis in the interpretation of exercise stress tests.

(MK)

p. Discuss the significance of upsloping ST segments, ST

elevation and other electorcardiographic markers and

ST/beat rate measurements in exercise stress testing. (PC,

MK)

q. Discuss the significance of non-electrocardiographic

observations in stress testing, including blood pressure

response, post-exercise systolic blood pressure ratios,

29

maximal work capacity, submaximal exercise heart rate

response, rate-pressure product and the presence or

absence of chest discomfort. (PC, MK)

r. Discuss the use of exercise stress testing in evaluating

prognosis in asymptomatic patients, patients with

atypical chest discomfort, those with stable angina

pectoris and unstable angina pectoris, those with silent

myocardial ischemia and following myocardial

infarction. (PC, MK)

s. Describe the usefulness of exercise stress testing in the

evaluation of cardiac arrhythmias and conduction

disturbances, including ventricular arrhythmias, supra-

ventricular arrhythmias, atrial fibrillation, the sick sinus

syndrome, AV block, left and right bundle branch block

and the Wolff-Parkinson-White Syndrome. (PC, MK)

t. Discuss the value and limitations of exercise stress

testing in men, women, hypertensive patients with

congestive heart failure, patients on various drugs that

affect repolarization, post-coronary bypass patients,

cardiac transplant patients, patients with valvular heart

disease, patients with cardiac pacemakers. (PC, MK)

u. Characterize the safety and risks of exercise stress

testing. (PC, MK)

v. List the indications for terminating an exercise stress test.

(PC, MK)

w. Perform and interpret at least 50 exercise stress tests.

(PC, MK)


a. Performance and interpretation of exercise stress tests in

the inpatient and outpatient settings. (PC, MK)

b. Review of interpretations with faculty cardiologists. (PC,

MK)

c. Utilization of textbooks, journal articles, audiovisual

modules and computer programs relating to stress testing.

(PC, MK)

30

d. Presentation and discussion of cases at teaching rounds,

EKG Conference, Cardiology Grand Rounds and Core

Curriculum Conference. (PC, MK).


a. Observation of the performance of 10 exercise stress tests

by cardiology faculty and the interpretation of 50 exercise

stress tests by cardiology faculty.

b. Performance on sections of the ABIM Subspecialty

Board examination in Cardiovascular Diseases pertaining

to exercise stress testing.

j. Echocardiography


a. Describe the fundamental principles of ultrasound

imaging as they apply to echocardiography. Distinguish

among A-mode, B-mode and M-mode presentations.

(MK)

b. Describe the technique of M-mode echocardiography

including the standard views. (MK)

c. Describe the technique of two-dimensional

echocardiography including the standard views. (MK)

d. Describe in general the technique of three-dimensional

echocardiography. (MK)

e. Describe the technique of Doppler echocardiography

including color flow Doppler, pulse Doppler, continuous

wave Doppler, and tissue Doppler. (MK)

f. Describe the technique of transesophageal


g. Describe the technique of saline contrast


h. Describe the techniques of stress echocardiography using

treadmill exercise and pharmacologic stress. (MK)

31

i. Discuss the advantages and limitations of

echocardiography. (PC, MK)

j. Be able to accurately identify cardiac structures on the

normal M-mode, two-dimensional, transesophageal,

contrast, stress and Doppler echocardiogram. Accurately

perform standard echocardiographic measurements on a

normal echocardiogram. (PC, MK)

k. Describe the role of echocardiography and cardiac

Doppler techniques in the assessment of cardiac

performance. Include assessment of left ventricular

systolic and diastolic function and cardiac output.

l. Discuss how Doppler echocardiography is used to obtain

hemodynamic information. (PC, MK)

m. Describe the physiologic basis for the use of Doppler

echocardiography to measure pressure gradients.

Describe the formula used to measure pressure gradients.

Measure pressure gradients across the four cardiac

valves. (PC, MK)

n. Discuss the application of Doppler echocardiography to

the assessment of intracardiac pressures. Apply these

methods in clinical practice (e.g. right ventricle systolic

pressure). (PC, MK)

o. Describe the measurement of valve areas using two-

dimensional Doppler echocardiography. Measure aortic

and mitral valve areas using these techniques. (PC, MK)

p. Discuss the use of M-mode, two-dimensional

transesophageal, stress, contrast, intra-operative and

Doppler echocardiography in the evaluation of acquired

heart diseases including valvular heart disease, infective

endocarditis, congenital heart disease in adults, ischemic

heart disease, cardiomyopathies, pericardial disease,

cardiac tumors and thrombi and diseases of the aorta.

Identify the full spectrum of the cardiovascular disease

encompassed by these disorders using M-mode, two-

dimensional, Doppler, transesophageal, stress, contrast

and intra-operative echocardiography. (PC, MK)

32

q. Perform and interpret at least 150 comprehensive trans-

thoracic echocardiographic/Doppler/color flow studies.

Perform and interpret at least 100 transesophageal

echocardiograms. Perform and interpret at least 10 intra-

operative echocardiograms. (PC, MK)


a. Performance of at least 150 transthoracic echo-

cardiograms and cardiac Doppler studies under the super-

vision of qualified echocardiography technicians. (PC,

MK)

b. Interpretation of at least 150 transthoracic

echocardiograms and cardiac Doppler studies under the

supervision of a faculty cardiologist. (PC, MK)

c. Performance and interpretation of 100 transesophageal

echocardiograms under the supervision of a faculty

cardiologist. (PC, MK)

d. Performance and interpretation of at least 100 stress

echocardiograms under the supervision of a faculty


e. Performance of 10 intra-operative echocardiograms and

cardiac Doppler studies under the supervision of a faculty


f. Utilization of textbooks, journal articles, audiovisual

modules and computer programs related to

echocardiography. (PC, MK)

g. Attendance at Echocardiography Conference and

Cardiology Grand Rounds. (PC, MK)

h. Attendance at regional and national conferences with

sections devoted to echocardiography. (PC, MK)


a. Direct faculty observation.

b. Observation by echocardiography technicians.

33

c. Performance on portions of the ABIM Subspecialty

Board Examination in Cardiovascular Diseases relating

to echocardiography.

2. Acquire experience in the performance and (where applicable) the interpretation

of the following procedures:

a. Pericardiocentesis


a. List the indications for pericardiocentesis. (PC, MK)

b. Describe the equipment required for pericardiocentesis.

(PC, MK)

c. Describe the various techniques used to perform

pericardiocentesis. (PC, MK)

d. Discuss the role of echocardiography in association with

pericardiocentesis. Describe the technique of concurrent

cardiac catheterization and pericardiocentesis. (PC, MK)

e. Perform at least 5 pericardiocenteses. (PC, MK)

f. List the routine laboratory tests performed on pericardial

fluid following pericardiocentesis. (PC, MK)

g. Describe the risks and complications of



a. Utilization of textbooks, journal articles and audiovisual

modules and computer programs relating to


b. Performance of at least 5 pericardiocenteses under

faculty supervision after observing 1 procedure. (PC,

MK)


34

a. Observation by qualified cardiology faculty in the cardiac

catheterization laboratory and coronary care unit.

b. Pacemaker Followup and Surveillance


a. Describe the equipment necessary to perform permanent

pacemaker follow-up and surveillance. (MK)

b. Describe the technique of transtelephonic pacemaker

surveillance. (MK)

c. Describe the optimal frequencies of pacemaker

surveillance after permanent pacemaker implantation.

(MK)

d. Describe the use of the magnet in pacemaker

surveillance. (MK)

e. List the pacemaker parameters that can be routinely

assessed during transtelephonic checks or office visits.

Describe how these variables are measured during

evaluation. (PC, MK)

f. Describe the role of telemetry in pacemaker followup.

(MK)

g. Describe the role of long-term electrocardiographic

monitoring in pacemaker followup. (PC, MK)

h. Perform pacemaker followup, trouble-shooting or

surveillance on at least 50 permanent pacemaker patients.

(PC, MK)



modules and computer programs relating to pacemaker

followup, trouble-shooting and surveillance. (PC, MK)

b. Participation in Pacemaker Followup Clinic. Reprogram

or trouble-shoot at least 50 permanent pacemakers. (PC,

MK)

35

c. Attendance at EKG/Electrophysiology Conferences. (PC,

MK)

d. Participation in industry-sponsored meetings related to

pacemaker implantations and/or followup. (PC, MK)


a. Direct observation by qualified cardiology faculty.

b. Performance on portions of ABIM Subspecialty Board

Examination in Cardiovascular Diseases relating to pace-

maker followup.

c. Feedback from computer-based training programs.

c. Intra-cardiac Electrophysiologic Studies


a. Describe the electrophysiologic basis for His bundle

studies, sinus node function studies and programmed

electrical stimulation. (MK)

b. Describe the equipment required to perform the

aforementioned studies. (MK)

c. Describe the technique of His bundle electrography.

Describe the intervals that are measured. (PC, MK)

d. Describe how to perform sinus node function tests

including the sinus node recovery time and the sinoatrial

conduction time. (PC, MK)

e. Describe how to perform programmed ventricular and

atrial stimulation studies for assessment of tachycardia.

(PC, MK)

f. Describe the role of intra-cardiac electrophysiologic

testing inpatients with unexplained syncope and in those

with palpitations. (PC, MK)

g. Describe the potential risks and complications of intra-

cardiac electrophysiologic studies. (PC, MK)

36

h. Describe the clinical indications for, and the applications

of, intra-cardiac electrophysiologic mapping. (PC, MK)

i. Assist in the performance and interpretation of 10 – 15

intracardiac electrophysiologic studies. (PC, MK)

j. Describe the indications for and techniques for

performing ablations for paroxymal supraventricular

tachycardia, atrial flutter, atrial fibrillation and ventricular

tachycardia.



modules and computer programs related to intra-cardiac

electrophysiology. (PC, MK)

b. Assist in the performance and interpretation of 10 – 15

intra-cardiac electrophysiologic studies under faculty

supervision in the Cardiac Electrophysiology Laboratory.

(PC, MK)

c. Attendance at EKG/Electrophysiology and Core

Curriculum Conferences. (PC, MK)

d. Attendance at national cardiac meetings with sections

devoted to cardiac electrophysiology. (PC, MK)


a. Personal supervision by qualified faculty cardiologists.

b. Performance on portions of the ABIM Subspecialty


to performance of intra-cardiac electrophysiology tests.

d. Intra-aortic Balloon Counterpulsation


a. Discuss the physiologic rationale for intra-aortic balloon

counterpulsation. (MK)

b. Describe the equipment required for intra-aortic balloon

counterpulsation. (MK)

37

c. Describe the indications for and clinical application of

intra-aortic balloon counterpulsation. (PC, MK)

d. Discuss the various hemodynamic effects of intra-aortic

balloon counterpulsation. (PC, MK)

e. Perform intra-aortic balloon insertion and maintain

counterpulsation on at least 5 patients. (PC, MK)

f. Discuss the risks and complications of intra-aortic



a. Perform intra-aortic balloon counterpulsation in the

Cardiac Catheterization Laboratory and maintain

counter-pulsation in the intensive care unit on at least 5

patients. (PC, MK)

b. Utilization of textbooks, journal articles, audiovisual

modules and computer programs relating to intra-aortic


c. Attendance at national meetings with sections devoted to

intra-aortic balloon counterpulsation. (PC, MK)

d. Attendance at Cardiac Catheterization Conference. (PC,

MK)


a. Direct observation by qualified faculty and technicians in

the cardiac catheterization laboratory, in the coronary

care unit and in the operating room.

e. Percutaneous Transluminal Coronary Angioplasty (PTCA), Coronary

Atherectomy, Coronary Stent (Bare metal and Drug-eluting)

Deployment And Valvuloplasty


a. Describe the historical development of PTCA, coronary

atherectomy, coronary stent deployment and

valvulopasty. (MK)

38

b. List the indications for PTCA, coronary atherectomy

(directional and rotational), coronary stent deployment

and valvuloplasty. (PC, MK)

c. Describe the procedures of PTCA, coronary atherectomy,

coronary stent deployment and valvuloplasty. (PC, MK)

d. Describe the potential complications of PTCA, coronary

atherectomy, and coronary stent deployment, and

valvuloplasty. (PC, MK)

e. Observe the performance of PTCA, thrombectomy,

coronary atherectomy, coronary stent deployment and

valvuloplasty. (PC, MK)


a. Experience gained in the Cardiac Catheterization

Laboratory. Assistance in the performance of

interventional techniques. (PC, MK)

b. Attendance at Cardiac Catheterization Conference and


c. Utilization of textbooks, journal articles, and audiovisual

modules and computer programs dealing with

interventional procedures. (PC, MK)

d. Attendance at regional and national meetings with

sections devoted to interventional procedures. (PC, MK)


a. Assistance on interventional procedures under faculty

supervision in the cardiac catheterization laboratory.



to interventional procedures.

f. Cardiovascular Rehabilitation


39

a. Discuss the role of exercise in cardiac rehabilitation and

physical reconditioning including factors influencing

physical capacity, iatrogenic and physiologic factors, left

ventricular dysfunction, myocardial ischemia,

concommitant diseases and drugs. (PC, MK)

b. Discuss the effects of exercise training in cardiac

rehabilitation including the roles of skeletal muscle and

myocardial performance and the effect on morbidity and

mortality. (PC, MK)

c. Describe the eligibility requirements for cardiovascular

rehabilitation. (PC, MK)

d. Discuss the role of exercise testing in cardiovascular


e. Describe how to formulate an individualized exercise

prescription. (PC, MK)

f. Describe the components of exercise sessions. (PC, MK)

g. State how to advance the exercise prescription. (PC, MK)

h. Describe special considerations in patients with

myocardial ischemia, heart failure and cardiac

arrhythmias. (PC, MK)

i. Characterize the risks of exercise training. Discuss the

role of patient selection and surveillance and the safety of

the personal program. (PC, MK)

j. Describe the components of secondary prevention of

coronary artery disease. (PC, MK)

k. Discuss the psychosocial benefit of cardiovascular


l. Discuss the role of vocational rehabilitation in

cardiovascular rehabilitation. (PC, MK, SBP)

m. Describe phases I, II, and III in cardiovascular

rehabilitation programs. (PC, MK)

40

n. Discuss sexual aspects of cardiovascular rehabilitation.

(PC, MK)


a. Participation in Fit for Life during Graphics rotation and

Cardiology Inpatient rotations. (PC, MK).

b. Utilization of textbooks, journal, and computer programs

relating to cardiac rehabilitation. (PC, MK).

c. Attendance at regional and national meetings with sections

devoted to cardiac rehabilitation. (PC, MK).


a. Performance on the ABIM Certifying Examination in

Cardiovascular Disease.

b. Observation on Fit for Life rotation.

3. The program must provide sufficient experience for fellows to acquire skill in

the interpretation of:

a. Chest X-rays


a. Describe and be able to identify normal cardiac anatomy

on the chest x-ray in the frontal (posterior-anterior),

lateral and right and left anterior oblique views. (PC,

MK)

b. Discuss the methods used to assess cardiac size on a

chest x-ray. (PC, MK)

c. Describe and be able to identify normal pulmonary

vascular anatomy on a chest x-ray. (PC, MK)

d. Describe and be able to identify the signs of increased

pulmonary blood flow on a chest x-ray, including those

associated with pulmonary arterial hypertension,

pulmonary venous hypertension, decreased pulmonary

vasculature, asymmetric blood flow and pulmonary

edema. (PC, MK)

41

e. Describe and be able to identify the signs of cardiac

calcification on a chest x-ray including those associated

with pericardial calcification, valvular calcification,

calcification of the great vessels and tumor calcification.

(PC, MK)

f. Describe and be able to identify the signs of valvular

heart disease on a chest X-ray including those associated

with aortic stenosis, aortic regurgitation, mitral stenosis,

mitral regurgitation, pulmonic stenosis, pulmonic

regurgitation and tricuspid regurgitation. (PC, MK)

g. Describe and be able to identify the signs of ischemic

heart disease on a chest X-ray including pulmonary

edema, Dressler’s syndrome, left ventricular aneurysm,

papillary muscle rupture and ventricular septal rupture.

(PC, MK)

h. Describe and be able to identify the signs of

cardiomyopathies on chest x-ray including those

associated with dilated cardiomyopathy, hypertrophic

cardiomyopathy and restrictive cardiomyopathy. (PC,

MK)

i. Describe and be able to identify post-operative signs on a

chest x-ray including the signs of the early and late

normal post-operative file, the signs associated with late

complication after cardiac surgery, the signs of various

prosthetic heart valves, specific signs associated with a

coronary artery bypass and the signs associated with

cardiac transplantation. (PC, MK)

j. Describe and be able to identify the signs of congenital

heart disease in the adult on a chest x-ray including those

of congenital bicuspid aortic valve, coarctation of the

aorta, atrial septal defects, patent ductus arteriosus,

ventricular septal defects, congenital pulmonic stenosis,

transposition of the great arteries, Tetralogy of Fallot, and

the Ebstein’s anomaly. (PC, MK)

k. Describe and be able to identify the signs of a normal

pericardium on a chest x-ray as well as the signs of

pericardial abnormalities including pericardial effusion,

pericardial constriction, pericardial tumor, pericardial

42

cyst, herniation of the pericardium and congenital

absence of the pericardium. (PC, MK)

l. Describe and discuss the use of fluoroscopy in defining

the cardiac structures. Describe specific cardiac

abnormalities that can be identified on fluoroscopy and

discuss their signs. (PC, MK)


a. Utilization of text books, journal articles, and audiovisual

modules and computer programs related to

cardiovascular aspects of chest x-ray diagnosis. (PC,

MK)

b. Clinical experience gained from rotations on the

Cardiology Consultation Services, in the Cardiology

Clinic, on the Coronary Intensive Care unit, on the

Cardiac Catheterization Rotation and in the Core

Curriculum lecture series. (PC, MK)


a. Direct observation by cardiology faculty on the

aforementioned rotations.



to chest x-ray diagnosis.

b. The Resting Electrocardiogram (EKG)


a. Describe the theoretical electrical basis for

electrocardiography. Discuss the concepts of

depolarization and repolarization as they apply to

electrocardiogaphy. Discuss the effect of boundary of

depolarization on the polarity of the records of the

potential. Describe the sequence of normal cardiac

activation. Describe the ventricular gradient and the

theoretical basis of surface leads as it applies to

electrocardiography. Discuss the theoretical basis for

unipolar and bipolar leads and their positions. (MK)

43

b. Describe and discuss the electrical basis for elements of

the routine EKG including the P wave, the PR interval,

the QRS complex, the ST segment, the T wave, the U

wave and the QT interval. (MK)

c. Be able to calculate P wave, QRS and T wave axes.

(MK)

d. Describe the EKG criteria for and be able to recognize

left atrial enlargement, right atrial enlargement, biatrial

enlargement, altered atrial depolarization and atrial

infarction. (MK)

e. Describe the EKG criteria for left ventricular, right

ventricular and biventricular hypertrophy and be able to

recognize those abnormalities on the EKG. (PC, MK)

f. Describe and be able to recognize the EKG patterns

typically associated with acute cor pulmonale and

chronic cor pulmonale. (PC, MK)

g. Describe the EKG criteria for non-specific

intraventricular conduction defects, left bundle branch

block, right bundle branch block, left anterior fascicular

block, bifasciular block and bilateral bundle branch

block. Be able to recognize these abnormalities on EKG.

(PC, MK)

h. Describe the criteria for and be able to recognize the

various forms of aberrant conduction on the EKG

including pre-excitation, Ashman’s phenomenon,

acceleration-dependent aberrancy, deceleration-

dependent aberrancy, concealed conduction, aberrancy

associated with myocardial depression and post-

extrasystolic aberration. Describe the criteria for and be

able to recognize the Wolff-Parkinson-White syndrome.

(PC, MK)

i. Describe the criteria for and be able to recognize signs of

myocardial ischemia, injury and infarction on the EKG.

Describe the criteria for and be able to recognize the

initial ECG in myocardial infarction, the classical

patterns of evolution, subtle atypical and non-specific

patterns of infarction, old infarction, infarction in the

44

presence of conduction defects, the EKG and locale of

infarction and non-infarction. (PC, MK)

j. Describe the criteria for and differential diagnosis of and

be able to recognize the full spectrum of ST segment and

T wave abnormalities (including rate-related T-wave

changes, T-wave alternans, notched or bifid T-waves and

non-specific ST and T wave changes), U wave

abnormalities, QT interval abnormalities electrical

alternans, and the Osborn wave. (PC, MK)

k. Describe the criteria for and be able to recognize the

signs of hyperkalemia, hypokalemia, hypercalcemia,

hypocalcemia and hypomagnesemia on the EKG. (PC,

MK)

l. Describe the specific electrocardiographic signs of

digitalis toxicity. (PC, MK)

m. Describe the criteria for and be able to recognize the full

spectrum of cardiac arrhythmias on the EKG (discussed

later in the section on cardiac arrhythmias). (PC, MK)

n. Interpret at least 3000 EKGs, at least 1500 under faculty

supervision. (PC, MK)



modules and computer programs relevant to EKG

interpretation. (PC, MK)

b. Attendance at EKG/Electrophysiology Conference.

c. Daily interpretations of EKG under faculty supervision

when on the Cardiology Consultation Services, in the

Cardiology Clinic, on the Inpatient Cardiology Services

and on the Graphics rotation. (PC, MK)

d. Attendance at board review courses and other national

courses dealing with EKG interpretation. (PC, MK)


a. Faculty observation during daily EKG interpretation.

45

b. Performance during EKG/Electrophysiology Conference.

c. Performance on portions of the ABIM Subspecialty

Board Examination in Cardiovascular Diseases relevant

to EKG interpretation.

c. Radionuclide Studies of Myocardial Perfusion and Cardiac Performance.

1. Goals and Objective

a. Describe the instrumentation required for radionuclide

evaluation of myocardial perfusion and cardiac

performance including the gamma camera, collimation

equipment, and computing instrumentation. (MK)

b. Describe and discuss the radiopharmaceuticals available

for myocardial perfusion imaging with emphasis on

thallium-201 and Tc-Sestamibi. (MK)

c. Discuss the technical considerations in myocardial

perfusion imaging including those relating to the gamma

camera, collimation, energy window, computer

acquisition and imaging protocols. (MK)

d. Describe patient imaging techniques in myocardial

perfusion studies including adequate count density,

patient position and the zoom factor. (MK)

e. Describe, discuss, compare and contrast planar and

SPECT imaging in the assessment of myocardial

perfusion. (MK)

f. Describe and be able to recognize the characteristics of

myocardial perfusion images. (PC, MK)

g. Describe and be able to recognize normal variations in

the thallium 201 image, the normal Tc-Sestamibi image,

normal Tc-Teboroxime images, and normal SPECT

images. (PC, MK)

h. Describe and be able to identify typical artifacts of

myocardial perfusion imaging. (PC, MK)

46

i. Compare and contrast the following aspects of

myocardial perfusion image interpretation: normal,

defect, reversible defect, fixed defect, reverse

redistribution thallium-201, lung uptake and transient left

ventricular dilation. (PC, MK)

j. Be able to quantify thallium-201 planar images. (PC,

MK)

k. Describe myocardial thallium-201 kinetics. (MK)

l. Discuss computer processing and analysis in myocardial

perfusion imaging. (MK)

m. Discuss the use of tomography computer processing and

analysis in myocardial perfusion imaging. (MK)

n. Discuss the clinical application of myocardial perfusion

imaging in myocardial infarction including those relating

to detection, patient triage, thrombolytic therapy,

prognosis, unstable angina and detection of old

myocardial infarction. (PC, MK)

o. Discuss the clinical application of myocardial perfusion

imaging in patients with chronic coronary artery disease

including those relating to physical exercise,

pharmacological vasodilatation (dipyridamole,

adenosine), dobutamine stress, assessment of myocardial

vi-ability, detection of high-risk coronary artery disease,

thallium-201 imaging and prognosis, tomographic

thallium-201 stress imaging, perfusion imaging for pre-

operative screening, Tc-Sestamibi stress imaging, Tc-

Teboroxime imaging, patient selection, myocardial

perfusion imaging in left bundle branch block and

thallium-201 stress imaging in the non-coronary artery

disease. (PC, MK)

p. Describe and discuss the instrumentation,

radiopharmaceuticals and protocols used for infarct

imaging including Tc pyrophosphate imaging, Indium-

111 leukocyte imaging, and Indium-111 antimyosin

imaging. Describe the clinical applications of these

agents. Be able to recognize normal and abnormal

images derived from infarct imaging. (PC, MK)

47

q. Interpret at least 150 myocardial perfusion scans. (PC,

MK)

r. List the radionuclide tests used to assess cardiac

performance. (PC, MK)

s. Describe the equipment required, radiopharmaceticuals

necessary, and standard protocols for the performance of

equilibrium radionuclide angiography. Describe how

equilibrium radionuclide angiography can be used to

assess global left ventricular systolic function, regional

left ventricular systolic function, and ventricular volume.

(MK)

t. Interpret at least 50 equilibrium radionuclide angiograms.

(PC, MK)

u. Describe the equipment needed, technical considerations,

radiopharmaceuticals, process and protocols for first pass

radionuclide angiography. (MK)

v. Describe how first pass radionuclide angiography can be

used to assess left ventricular systolic function, diastolic

function and intracardiac shunts. (PC, MK)

w. Interpret 25 first pass radionuclide angiograms. (PC,

MK)

x. Discuss the use of equilibrium and first pass techniques

on the assessment of left ventricular function after

myocardial infarction. Discuss the use of exercise

protocols in association with techniques. Discuss the use

of these techniques in the assessment of silent myocardial

ischemia, congestive heart failure, doxirubicin toxicity,

valvular heart disease, congenital heart disease and

chronic obstructive lung disease. (PC, MK)



media and computer programs relating to radionuclide

cardiac studies. (PC, MK)

b. Attendance at Nuclear Cardiology Conference. (PC, MK)

48

c. Interpretation of at least 250 radionuclide studies on the

Nuclear Cardiology rotation, Cardiology Consultation

Services, on the Cardiology Inpatient Services, in the

Cardiac Catheterization Laboratory and in the Cardiology

Clinic. (PC, MK)

d. Attendance at national or regional courses related to

nuclear cardiology. (PC, MK)


a. Assessment by faculty supervisors on nuclear cardiology

and other clinical rotations.

b. Faculty observations during Nuclear Cardiology

rotations.

c. Performance on sections on the ABIM Subspecialty

Board Examination in Cardiovascular Diseases as

relevant to nuclear cardiology.

d. Fast Computed Tomography (CT) of the Heart and Great Vessels


a. Describe the technology necessary to perform fast CT of

the heart including EBCT. (PC, MK)

b. Describe imaging protocols for fast CT of the heart. (PC,

MK)

c. Discuss the use and be able to recognize images of fast

CT including EBCT in the evaluation of coronary artery

disease. (PC, MK)

d. Discuss the use and be able to recognize images of fast

CT in the evaluation of valvular heart disease. (PC, MK)

e. Discuss the use and be able to recognize images of fast

CT in the evaluation of the great vessels. (PC, MK)

f. Discuss the use and be able to recognize images of fast

CT in the evaluation of the pericardium. (PC, MK)

49

g. Discuss the use and be able to recognize images of fast

CT in the evaluation of cardiomyopathies. (PC, MK)

h. Discuss the use and be able to recognize images of fast

CT in the evaluation of congenital heart disease. (PC,

MK)

i. Discuss the use and be able to recognize images of fast

CT in the evaluation of cardiac tumors. (PC, MK)



modules and computer programs dealing with fast CT of

the heart and great vessels. (PC, MK)

b. Attendance at Core Curriculum Conference, Journal

Club and Advanced Imaging Conference. (PC, MK)

c. Attendance at national meetings and courses with

sections devoted to fast CT of the heart and great vessels.

(PC, MK)


a. Performance on sections of the ABIM Subspecialty


with fast CT of the heart and great vessels.

e. Magnetic Resonance Imaging (MRI) of the Heart and Great Vessels


a. Describe the physical fundamentals of MRI. (PC, MK)

b. Describe MRI techniques and cardiac anatomy as it

applies to MRI. (PC, MK)

c. Describe flow quantification and myocardial tagging and

ultra-fast imaging. (PC, MK)

d. Describe and discuss the use of MRI to assess ventricular

function. Describe functional information and be able to

recognize images obtained with MRI. (PC, MK)

50

e. Describe the use of MRI in the evaluation of ischemic

heart disease (acute and chronic and be able to recognize

images) including evaluation for viable myocardium vs.

scar and contrast enhancement. (PC, MK)

f. Describe and discuss the use of MRI and be able to

recognize images in the evaluation of cardiomyopathies.

(PC, MK)

g. Describe and discuss the use of MRI and be able to

recognize images in the evaluation of cardiac masses and

thrombi. (PC, MK)

h. Describe the use of MRI and be able to recognize images

in the evaluation of pericardial diseases. (PC, MK)

i. Describe the use of MRI and be able to recognize images

in the evaluation of congenital heart disease. (PC, MK)

j. Describe the use of MRI and be able to recognize images

in the evaluation of vascular abnormalities including

aortic dissection, aneurysm and coarctation. (PC, MK)

k. Compare and contrast the use of MRI with other imaging

techniques (echocardiography, radionuclide technique,

fast CT, PET scanning) for each type of heart disease.

(PC, MK)



modules and computer programs relating to MRI of the

heart and great vessels. (PC, MK)

b. Attendance at Core Curriculum Conference, Advanced

Imaging Conference and Journal Club. (PC, MK)


sections devoted to MRI of the heart and great vessels.

(PC, MK)


51



with MRI of the heart and great vessels.

f. Position Emission Tomography (PET)


a. Describe the tools for probing myocardial tissue function

related to PET. Describe tools to assess myocardial

blood flow, myocardial glucose utilization, myocardial

fatty acid metabolism, myocardial oxygen consumption,

neuronal control of cardiac function and protein

synthesis. (MK)

b. Describe and discuss the application of PET in coronary

artery disease including detection of coronary artery

disease, quantitation of blood flow, assessment of

myocardial viability, possible mechanisms of blood-

metabolism patterns, dietary standardization and

prediction of long-term morbidity and mortality. (PC,

MK)

c. Compare and contrast PET with other imaging

techniques in the aforementioned clinical applications.

(PC, MK)



modules, and computer programs relating to PET of the

heart. (PC, MK)

b. Attendance at Core Curriculum Conference, Journal

Club, and Advanced Imaging Conference (PC, MK)


sections devoted to PET of the heart. (PC, MK)




with PET of the heart.

52

g. Ongoing Research Projects


a. Participate in ongoing Division of Cardiology research as

a principle and/or co-investigator. (MK)

b. Present research findings at regional, national or

international selective scientific meetings. (MK)

c. Prepare or assist in the preparation of one or more

research manuscript(s) and submit it/them for publication

in (a) peer-reviewed scientific journal(s). (MK)


a. Mentoring by faculty experienced in clinical or basic

cardiovascular research. (MK)

b. Attendance at Research Conference, Cardiology Grand

Rounds and Journal Club. (MK)

c. Peer-review of manuscripts submitted for publication.

(MK)


a. Direct observation by faculty and research mentors.

b. Presentation of research findings in Research

Conference.

c. Success in attaining acceptance of research abstracts for

presentation and manuscripts for publication.

h. Cardiovascular Literature


a. Develop skills in critically assessing the medical

literature in cardiovascular diseases. (MK)

53

b. Develop a working understanding of biostatistics,

epidemiology, population studies, formulation of

research hypotheses and research protocols. (MK)


a. Participate in and attendance at Journal Club, Research

Conference, Core Curriculum Conference and

Cardiology Grand Rounds. (MK)

b. Participation in discussions concerning pertinent medical

literature during attending rounds on the Cardiology

Inpatient Services, in the Cardiology Clinics and during

Cardiac Catheterization Conference, Graphics and

Echocardiography Laboratory rotations. (PC, MK)


a. Effectiveness of presentations at Journal Club.

b. Socratic discussions involving the medical literature on

clinical services and in clinical conferences.



with the evaluation of cardiovascular literature.

D. Formal Instruction

1. The program must provide didactic instruction opportunities to acquire

knowledge in:

a. Cardiovascular Anatomy


a. Be able to recognize and describe the gross external

features of the normal heart. (MK)

b. Be able to recognize and describe the gross anatomy of

the fibrous skeleton of the normal heart. (MK)

c. Be able to recognize and describe the gross anatomy of

the normal right atrium. (MK)

54

d. Be able to recognize and describe the gross anatomy of

the normal right ventricle. (MK)

e. Be able to recognize and describe the gross anatomy of

the normal left atrium. (MK)

f. Be able to recognize and describe the gross anatomy of

the normal left ventricle. (MK)

g. Be able to recognize and describe the gross anatomy of

the normal semilunar valves. (MK)

h. Be able to recognize and describe the gross anatomy of

the normal atrioventricular valves. (MK)

i. Be able to recognize and describe the gross anatomy of

the normal papillary muscles and chordae tendineae.

(MK)

j. Be able to recognize and describe the gross anatomy of

normal endocardium. (MK)

k. Be able to recognize and describe the gross anatomy of

the normal pericardium. (MK)

l. Be able to recognize and describe the gross anatomy of

the normal cardiac conduction system. (MK)

m. Be able to recognize and describe the gross anatomy of

the heart’s normal lymphatic system. (MK)

n. Be able to recognize and describe the gross anatomy of

the normal epicardial and intramyocardial coronary

arteries and their branches. (MK)

o. Be able to recognize and describe the gross anatomy of

the normal coronary veins. (MK)

p. Be able to recognize and describe the gross anatomy of

the aorta, pulmonary artery, inferior vena cava and

superior vena cava. (MK)

q. Be able to recognize and describe the histological

appearance of the aforementioned structures. Include a

55

description of the histology of normal myocardium.

(MK)

r. Be able to recognize and describe the normal variations

of the aforementioned structures. (MK)




cardiovascular anatomy. (MK)

b. Attendance at Core Curriculum Conference,

Echocardiography Conference, EKG/Electrophysiology

Conference, and Cardiac Catheterization Conference.

(MK, PC)

c. Clinical experience gained on the cardiology consultation

service, on the coronary care unit rotation, in the cardiac

catheterization laboratory and echocardiography

laboratory. (MK, PC)

d. Attendance at post-mortem examinations. (MK)

e. Attendance at sections of national meetings dealing with

cardiovascular anatomy. (MK)


a. Faculty observation in the aforementioned clinical

venues and conferences.



with cardiovascular anatomy.

b. Cardiovascular Physiology


a. State the three basic functions of the cardiovascular

system. (MK)

b. Describe and discuss normal myocardial excitation-

contraction coupling. (MK)

56

c. Discuss fundamental myocardial muscle mechanics

including the role of pre-load, afterload, contractility, and

heart rate. (MK)

d. Describe Starling’s law of the heart. Describe and

discuss ultrastructural basis of Starling’s law and the

influences of fiber length and heart rate on force-velocity

relationships. (MK)

e. Discuss aortic impedance as a manifestation of afterload.

(MK)

f. Discuss factors that contribute to contractility or the

inotropic state. Describe the effect of post-extrasystolic

potentiation on contractility. (MK)

g. Describe and discuss mechanisms of cardiac reserve

including increased heart rate, increased stroke volume,

increased oxygen extraction, redistribution of blood flow,

anaerobic metabolism, cardiac dilatation and cardiac

hypertrophy. (MK)

h. Describe and discuss regulation of regional blood flow

including mechanics, endothelial control of blood flow,

and neural control of blood vessels. (MK)

i. Describe and discuss the major determinants of

myocardial oxygen consumption including myocardial

mass, intramyocardial tension or wall stress, the inotropic

state, heart rate, external work, board oxygen

requirements and activation energy. (MK)

j. Discuss the physiology of the coronary circulation

including physical factors influencing coronary blood

flow, metabolic factors influencing coronary blood flow,

humoral factors influencing coronary blood flow, neural

factors influencing coronary blood flow (sympathetic

nerves, parasympathetic nerves and coronary reflexes),

coronary collateral circulation and distribution of

coronary blood flow. (MK)

k. Describe the cardiac cycle including individual

components. (MK)

57

l. Describe the normal arterial pulse characteristics. (MK)

m. Describe the components of the normal venous pulse.

(MK)

n. List normal pressure and flow rates in the cardiovascular

system. (MK)

o. Describe the physiologic cardiovascular response to

exercise. (MK)

p. Describe the normal distribution of systemic blood flow

and oxygen consumption at rest. (MK)

q. Describe the structure of the blood vessel wall. (MK)

r. Describe and discuss the physiology of the endothelial

cell including endothelial cell metabolism and secretions.

Discuss the endothelial cell and thrombosis. Discuss

barrier function and endothelial cell permeability. (MK)

s. Discuss the physiology of the vascular smooth muscle

cell including biochemical signals traditionally associated

with contraction, biochemical signals traditionally

associated with proliferation, the contraction cascade and

growth. (MK)

t. Discuss endothelial cell-vascular smooth muscle

interactions including endothelial control of vascular

tone. Discuss the role of EDRF (nitric oxide),

prostacyclin, adenosine and related compounds,

endothelin and angiotensin converting enzymes. Also

discuss endothelial control of vascular growth including

angiotenesin endothelial-derived inhibitors of smooth

muscle cell growth, endothelial derived stimulators of

smooth muscle cell growth and potential signaling

mechanisms. (MK)

u. Discuss cell-leukocyte interactions. (MK)

v. Discuss endothelial responses to hemodynamic

influences. (MK)

58

w. Discuss endothelial dysfunction and vascular smooth

muscle abnormalities as they relate to atherosclerosis,

hypertension, restenosis and gene transfer. (MK)




cardiovascular physiology. (MK)

b. Attendance at Core Curriculum Conference, Research

Conference, Cardiology Grand Rounds Conference and

Journal Club. (MK)

c. Participation in clinical translational and basic research.

(MK)

d. Attendance at sections of national meetings dealing with

cardiovascular physiology. (MK)




with cardiovascular physiology.

c. Cardiovascular Metabolism


a. Discuss the central role of ATP in energy production on

the normal heart. Discuss ATP synthesis from carbon-

based fuels. (MK)

b. Discuss glucose metabolism in the heart including the

metabolic pathways, the role of glycogen, the use of the

glucolytic pathway for energy production and regulation,

and aerobic and anaerobic glycolysis. (MK)

c. Discuss oxidative metabolism and the heart. Discuss the

roles of pyruvate dehydrogenase, fatty acid metabolism,

beta-oxidation, the tricarboxylic acid cycle, the malate-

aspastate shuttle and oxidative phosphorylation. (MK)

59

d. Describe and discuss new methods for metabolic

evaluation of the heart including magnetic resonance

imaging and position emission tomography. (MK)



modules and computer programs relating to cardiac

metabolism. (MK)

b. Attendance at Core Curriculum Conference and the

Distinguished Scientist lectures. (MK)


cardiac metabolism. (MK)



Board Examination in Cardiovascular Diseases relevant

to cardiac metabolism.

d. Molecular Biology of the Cardiovascular System and Receptor

Morphology Channels and Physiology


a. Provide a historical perspective of molecular biology.

(MK)

b. Discuss the role of nucleic acids in molecular biology

including the essentials of nucleic acids, transcription,

translation, gene structure, gene expression, gene

regulation and the basis for recombinant DNA

technology. (MK)

c. Describe the techniques of molecular biology including

those associated with isolation of DNA, digestion and

electrophoretic separation of DNA, development of a

DNA probe, southern and northern blotting, DNA

cloning, development of gene libraries and polymerase

chain reaction. (MK)

d. Describe the molecular basis of cardiac contraction.

Discuss the contractile proteins (myosin, actin,

60

tropomyosin, troponin) and the molecular basis for

contraction and relaxation. (MK)

e. Discuss the biology of the cytoskeletal proteins including

microfilaments, microtubules, and intermediate

filaments. (MK)

f. Discuss the molecular basis for cellular growth including

patterns of growth, receptors and signaling proteins

underlying the growth response, oncogenes, growth

factors and their oncogenic derivatives and intracellular

ionic changes of the growth response. (MK)

g. Discuss the molecular basis for the cardiac growth

response including autocrine, paracrine or intracrine

mechanisms mediating cardiac hypertrophy, cardiac

hypertrophy associated with re-expression of fetal

proteins, stimuli and receptors mediating cardiac

hypertrophy, oncogenes as signaling proteins, for cardiac

hypertrophy and clues from inherited abnormalities of the

contractile protein. (MK)

h. Describe and discuss the structure and function of cardiac

membranes. (MK)

i. Describe and discuss the structural function of ion

channels in the heart. (MK)

j. Describe and discuss the structures and function of

cardiac receptors including receptor structure, receptor

coupling, receptor function, receptor regulation (list the

modes of receptor signaling regulation), G protein

regulation and receptor signaling in the heart. (MK)



modules and computer programs relating to the structure

and function of the heart. (MK)

b. Attendance at Core Curriculum Conference, and the

Distinguished Scientist lectures. (MK)


the cardiac membranes, channels and receptors. (MK)

61

3. Methods of evaluation


Board Examination in Cardiovascular Diseases

pertaining to cardiac membranes, channels, and

receptors.

e. Cardiovascular Pharmacology


a. Describe and discuss the pharmacology,

pharmacokinetics, metabolism, elimination, dosages,

routes of administration, adverse effects and drug-drug

interactions of individual drugs in the following groups

used in cardiovascular diseases: nitrates, beta-blockers,

calcium channel blockers, diuretics, inotropic agents,

direct acting, vasodilators, sympatholytic drugs, ACE

inhibitors, alpha 1 and alpha 2 blockers, ganglionic

catecholamine depleters, drugs that prevent re-uptake of

catecholamine at the synapse, angiotensin II receptor

blockers, aldosterone antagonist, ganglionic blockers,

anti-cholinergics, purine agonists, class IA, IB, IC, 2B

and 4 anti-arrhythmics, immuno-suppressive drugs,

aspirin and other anti-platelet drugs, intravenous and oral

anti-coagulants, potassium compounds, calcium

compounds and magnesium compounds. (PC, MK)



modules and computer programs relating to cardio-

vascular pharmacology. (PC, MK)

b. Experience gained from the inpatient cardiology

consultation service, cardiology clinic, coronary care unit

rotation, and cardiac catheterization laboratory rotation.

(PC, MK)

c. Attendance at Core Curriculum Conference, Cardiology

Grand Rounds, Cardiac Catheterization Conference and

the Distinguished Scientist Series. (PC, MK)

62

d. Attendance at national meetings with sections devoted to

cardiovascular pharmacology. (PC, MK)





Board Examination in Cardiovascular Diseases

pertaining to cardiovascular pharmacology.

f. Risk Factors for Cardiovascular Disease


a. Discuss and explain the declining mortality relative to

coronary artery disease over the last 40 years in the

United States. (PC, MK)

b. Discuss the role of dyslipidemia as a cardiovascular risk

factor. (PC, MK)

c. Discuss the use of tobacco as a risk factor for

cardiovascular atherosclerosis. (PC, MK)

d. Discuss the role of systemic hypertension as a risk factor

for cardiovascular disease. (PC, MK)

e. Discuss the role of obesity as a possible risk factor for

cardiovascular disease. Include fat distribution in the

discussion. (PC, MK)

f. Discuss the role of family history of early cardiovascular

disease as a risk factor for coronary artery disease. (MK)

g. Discuss the role of diabetes mellitus as a risk factor for

cardiovascular disease. (MK, PC)

h. Discuss the role of inadequate physical activity as a risk

factor for cardiovascular disease. (PC, MK)

i. Discuss the roles of estrogen and gender as a risk factor

for cardiovascular disease. (PC, MK)

63

j. Discuss the possible roles of trace elements, hard water,

hypercalcemia, hypercoagulability, vasectomy, coffee

consumption, hyperuricemia and cardiac transplantation

as cardiovascular risk factors. (PC, MK)

k. Discuss the value of favorably modifying established

coronary risk factors in preventing, retarding and/or

causing regression of coronary atherosclerosis. (PC, MK)



modules, and computer programs relating to

cardiovascular risk factors. (PC, MK)

b. Participation in lipid clinic under faculty supervision.

(PC, MK)

c. Experience gained on the Cardiology Consultation

Service, in Cardiology Clinic and on the Cardiology

Inpatient Services under faculty supervision. (PC, MK)

d. Attendance at Core Curriculum Conference, Cardiology

Grand Rounds, Research Conference, and Journal Club.

(PC, MK)

e. Attendance at regional or national meetings with sections

devoted to coronary risk factors. (PC, MK)

f. Participation in a cardiac rehabilitation program. (PC,

MK)


a. Faculty observation on the aforementioned clinical

services and in the aforementioned conferences.

b. Performance on the ABIM Certifying Examination in

Cardiovascular Disease relating to coronary risk factors.

g. Lipid Disorders


a. Define dyslipidemia. (PC, MK)

64

b. Describe and discuss the major classes of plasma lipids

including chylomicrons, very low density lipoproteins,

intermediate density lipoproteins, high-density

lipoproteins and Lp(a). (PC, MK)

c. Describe and discuss the role of apoprotiens in relation to

the major lipid classes. Include a discussion of

apoprotiens A, B, D, E including the subtypes. (PC, MK)

d. Describe the exogenous and endogenous pathways for

lipid production and metabolism. (PC, MK)

e. Discuss the role of cholesterol, triglycerides and free fatty

acids as they apply to normal lipid metabolism. (PC,

MK)

f. Discuss the genetic variations of apoproteins. (PC, MK)

g. Summarize the lipid hypothesis of atherogenesis. (PC,

MK)

h. List and discuss primary prevention trials as they apply to

lipids. (PC, MK)

i. List and discuss the results of secondary prevention trials

as they apply to lipids. (PC, MK)

j. Discuss the pathogenesis, epidemiology and clinical

significance of hypertriglyceridemia as it relates to

coronary atherosclerosis. (PC, MK)

k. Discuss whether the progress of atherosclerosis can be

retarded or reversed by treatment of dyslipidemia. (PC,

MK)

l. Discuss, in a general sense, the diagnosis of

hyperlipidemia. (PC, MK)

m. Formulate a screening program for the detection of

hyperlipidemias that predispose to coronary

atherosclerosis. (PC, MK)

n. Describe the Frederickson classification of

hyperlipidemia. (PC, MK)

65

o. Describe the genetic forms of hypercholesterolemia

including familial hypercholesterolemia, polygenic

hypercholesterolemias, (familial combined

hyperlipidemia, familial dysbetalipoprotienemias). (PC,

MK)

p. Discuss the pathogenesis and clinical significance of

hypertriglyceridemia. (PC, MK)

q. Discuss genetic forms of hypertriglyceridemia including

familial betalipidemia, familial endogenous

hypertriglyceridemias and type V hyperapoprotienemia.

Also discuss secondary causes of hypertriglyceridemia.

(PC, MK)

r. Discuss the relationship between genetic lipid disorders

and the Fredrickson classification. (PC, MK)

s. Discuss the use of current drugs in treatment of

dyslipidemias. (PC, MK)

t. Discuss the indications for therapy of dyslipidemias. (PC,

MK)

u. Discuss the role of dietary therapy in treating

dyslipidemia. Be able to prescribe an appropriate low

cholesterol/low triglyceride diet. (PC, MK)

v. Discuss the role of omega-3 unsaturated fatty acids and

of anti-oxidants in the treatment of dyslipidemias. (PC,

MK)

w. Discuss the role of nicotinic acid in the treatment of

dyslipidemias. (PC, MK)

x. Discuss the role of bile acid sequestrants ezetimibe, and

plant phytols in the treatment of dyslipidemias. (PC, MK)

y. Discuss the role of HMG Co-A reductase inhibitors in

the treatment of dyslipidemias. Including discussion of

these pleiotrophic effects.

z. Discuss the role of fibric acid derivatives in the treatment

of dyslipidemias. (PC, MK)

66

aa. Discuss the non-pharmacologic and pharmacologic

treatment of specific hyperlipidemias. Discuss whether

specific pharmacotherapy of hyperlipidemias can cause

retardation or regression of atherosclerosis. (PC, MK)


a. Utilization if textbooks, journal articles, audiovisual

modules and computer programs related to lipid

disorders. (PC, MK)

b. Attendance at Core Curriculum Conference, Cardiology

Grand Rounds and Journal Club. (PC, MK)

c. Participation in attending rounds on the Cardiology

Consultation and Cardiology Inpatient Services, in the

Cardiology Clinics. (PC, MK)

d. Attendance at regional or national meetings relating to

lipid disorders. (PC, MK)


a. Faculty observation of performance in Cardiology

Clinics, in other clinical venues and during the

aforementioned conferences.

b. Performance on sections of the ABIM Certifying

Examination in Cardiovascular Diseases relating to lipid

disorders.

h. Atherosclerosis


a. Define atherosclerosis. (PC, MK)

b. List the risk factors for atherosclerosis. (PC, MK)

c. Describe the morphology of the normal artery including

the intima, media and adventitia. (MK)

67

d. Describe the role of the endothelium, vascular smooth

muscle, macrophages, platelets and T lymphocytes in the

genesis of atherosclerosis. (MK)

e. Describe the lesions of atherosclerosis including the fatty

streak, the lipid core, diffuse intimal thickening and the

fibrous cap. (MK)

f. Describe the hypothesis of atherogenesis. Discuss the

response-to-injury hypothesis and the monoclonal

hypothesis. (MK)

g. Describe and discuss the role of lipids and lipoproteins in

atherogenesis. (PC, MK)

h. Describe the role of growth factors in atherogenesis.

(MK)

i. Describe cellular events that occur during atherogenesis

including early changes, and later changes. (MK)

j. Characterize regression of atherogenesis in animals and

humans. (PC, MK)

k. Discuss the role of thrombosis in atherogenesis. (PC,

MK)




atherosclerosis. (PC, MK)

b. Attendance at Core Curriculum Conference, the

Distinguished Scientist Lecture Series, Cardiology Grand

Rounds, Cardiac Catheterization Conference, Research

Conference and Journal Club. (PC, MK)

c. Experience gained from the Inpatient Cardiology

Consultation Services, Cardiology Clinic, and the

Cardiac Catheterization Laboratory. (PC, MK)

d. Attendance at post-mortem examinations. (PC, MK)

68

e. Attendance at regional and national meetings with

sections devoted to atherosclerosis. (PC, MK)


a. Direct faculty observation in the aforementioned clinical



Examination in Cardiovascular Diseases dealing to

atherosclerosis.

i. Hemostasis, Thrombosis, Fibinolysis and Cardiovascular Disease


a. Describe the basic mechanisms of hemostasis and

thrombosis as it relates to cardiovascular disease with

particular references to the role of the vascular

endothelium and the coagulation cascade. (PC, MK).

b. Describe mechanisms of endogenous anticoagulation

including the fibrinogen/plasminogen relationship, anti-

thrombian, and proteins C and S. (PC, MK).

c. Describe the role of platelets in thrombosis and

hemostasis including mechanisms of adhesion, activation

and aggregation.

d. Describe the mechanisms that control the production of

thrombus.

e. Describe the genetics pathophysiology, clinical features,

diagnosis, natural history, treatment and prognosis of the

fibinolytic syndromes including Factor V leiden

mutation, prothrombin gene mutation, antothrombin

deficiency, protein C and S deficiencies,

hyperhomocystinemia, the

antiphospholipid/anticardiolipin antibody syndrome and

elevation of serum Lp(a).

f. Describe the mechanisms of antithrombolic and

antiplatelet therapy. Describe specific indications,

dosages, routes of administration, complications and

contraindications to/for the use of heparins

69

(unfractionated and low molecule weight), warfarin,

direct thrombin inhibitors, factor Xa inhibitors

fibrinolytics, aspirin, ADP receptor blockers,

phosphodiesterase inhibitors and glycoprotein IIb/IIIa

receptor blockers.


a. Rotations on the Cardiology Inpatient Services,

participation Cardiology Clinics. (PC, MK).

b. Utilization of textbooks, journals, audiovisual modules

and computer programs relating to hemostasis,

Thrombosis and fibrinolysis. (PC, MK).

c. Attendance at the Core Curriculum lecture series,

Cardiology Grand Rounds and Research Conference. (PC,

MK).

d. Attendance at regional or national meetings with sections

devoted to hemostasis, thrombosis or fibrinolysis. (PC,

MK).




b. Faculty observation on clinical services and at

conferences.

j. Acute Myocardial Infarction


a. Discuss the epidemiology of acute myocardial infarction

including the diminishing mortality over the last 30

years. (PC, MK)

b. Describe the pathology of acute myocardial infarction

including gross pathologic changes, histological and

ultrastructural changes, the role of coronary thrombosis,

the role of coronary artery spasm, collateral circulation,

non-atherosclerotic causes of myocardial infarction, and

70

myocardial infarction associated with angiographically

normal coronary arteries. (PC, MK)

c. Discuss the pathophysiology of acute myocardial

infarction including the effect on systolic and diastolic

function, regulation (including the effects of treatment,

ventricular remodeling with infarct expansion and

ventricular dilatation), and the pathophysiologic changes

in the other organ systems. (PC, MK)

d. Describe the clinical features of acute myocardial

infarction. Describe precipitating factors, the clinical

history (including prodromal systems, the nature of pain

and other symptoms) and the differential diagnosis of

acute myocardial infarction. (PC, MK)

e. Characterize the entity of silent myocardial infarction.

(PC, MK)

f. Discuss the physical examination in acute myocardial

infarction including general appearance, vital signs, the

carotid pulse and the chest and cardiac examinations.

(PC, MK)

g. Discuss the use of cardiac biomarkers in the diagnosis of

acute myocardial infarction. Compare and contrast

available biomarkers. Also discuss the effect of acute

myocardial infarction on blood sugar, serum lipids and

the hemogram. (PC, MK)

h. Describe the ECG abnormalities in acute ST segment

elevation and non ST segment elevation myocardial and

infarction. Be able to use the ECG to locate and time the

infarct. Be able to recognize ischemia at a distance, right

ventricular infarction and atrial infarction on the ECG.

(PC, MK)

i. Discuss the use of the chest x-ray in acute myocardial


j. Discuss the use of radionuclide techniques, CT and MRI

in the diagnosis of acute myocardial infarction. (PC, MK)

k. Discuss the role of echocardiography in the diagnosis of


71

l. Describe pre-hospital care of patients with acute


m. Discuss the role of the coronary care unit in the

management of acute myocardial infarction. (PC, MK)

n. Discuss general measures in the care of patients with


o. Discuss the value and limitations of the use of nitrates,

analgesics, oxygen or beta-blockers, calcium blockers,

ACE inhibitors, angiotensin receptor blockers,

aldosterone blockers, aspirin and heparins in acute

myocardial infarction. List available medications,

dosages and frequencies of these medications. Discuss

the role of physical activity early in acute myocardial


p. Discuss hemodynamic assessment of patients with acute

myocardial infarction including pulmonary artery


q. Characterize the role of the intermediate coronary care

unit in patients with acute myocardial infarction

including early measures for cardiac rehabilitation. (PC,

MK)

r. Discuss the value and limitations of measures designed

to limit infarct size. In doing so, discuss the dynamic

nature of infarction, routine measures and specific

measures. (PC, MK)

s. Discuss the concept of myocardial reperfusion. Include a

discussion of reperfusion injury. (PC, MK)

t. Discuss the value and limitations of the use of coronary

thrombolysis in myocardial infarction. Be able to

employ all currently available drugs used for

thrombolysis. Discuss intravenous thrombolysis

including choice of agents, effect on mortality, effect on

left ventricular function, patient selection, adjunctive

treatment and complications. (PC, MK)

72

u. Discuss the use of coronary angioplasty and stent

placement (bare metal and drug-eluting) in acute

myocardial infarction, as primary therapy, as adjunctive

therapy and as rescue therapy. (PC, MK)

v. Discuss the role of surgical reperfusion in acute


w. Recognize and be able to manage arrhythmias and

conduction disturbances associated with acute

myocardial infarction including sinus bradycardia, first

degree AV block, second degree AV block,

intraventricular (fascicular) blocks, asystole, sinus

tachycardia, atrial premature beats, paroxysmal

supraventricular tachycardia, atrial fibrillation and flutter,

junctional rhythms, ventricular premature beats,

accelerated idioventricular rhythm, ventricular

tachycardia and ventricular fibrillation. (PC, MK)

x. List and discuss hemodynamic disturbances in acute

myocardial infarction. Include discussion of

hemodynamic subsets (Forrester classification), the role

of invasive hemodynamic monitoring treatment of

hypotension in the pre-hospital phase, treatment of

hypovolemic hypotension and treatment of the

hyperdynamic state. Discuss recognition and treatment

of congestive heart failure with and without cardiogenic

shock (including pharmcotherapy and device therapy)

and right ventricular infarction. Recognize and be able to

manage mechanical causes of heart failure and shock

such as free wall rupture, ventricular septal rupture,

papillary muscle rupture and left ventricular aneurysm.

Recognize and be able to manage other complications of

acute myocardial infarction including left ventricular

thrombus and arterial embolism, venous thrombosis and

embolism, post-infarction ischemia and infarct extension,

and pericarditis/pericardial effusion (including Dressler’s

syndrome). (PC, MK)

y. Discuss methods of secondary prevention of acute

myocardial infarction including the use of beta-blockers,

anticoagulants, anti-platelet agents, calcium channel

blockers, ACE inhibitors, angiotesin receptors blockers,

aldosterone antagonists, aspirin and other antiplatelet

73

agents, nitrates, anti-arrhythmics and risk factor

modification. (PC, MK)

z. Describe methods to assess risk in patients who have

suffered acute myocardial infarction including those who

have and have not undergone percutaneous coronary

revascularization or thrombolysis. Describe how

assessment for residual myocardial ischemia, evaluation

of left ventricular function and detection of ventricular

arrhythmias can influence short-term and long-term risk

after myocardial infarction. (PC, MK)



models and computer programs relating to acute


b. Clinical experience on the Cardiology Inpatient Services

and in the Cardiac Catheterization Laboratory. (PC, MK)

c. Attendance at Cardiology Grand Rounds, Core

Curriculum Conference, EKG/Electrophysiology

Conference and Nuclear Cardiology Conference. (PC,

MK)

d. Attendance at regional and national meetings dealing

with acute myocardial infarction. (PC, MK)


a. Direct faculty observation on the aforementioned clinical

services.


Examination in Cardiovascular Diseases.

j. Stable and Unstable Angina Pectoris and Silent Myocardial Ischemia


a. Describe the pathology, pathophysiology and clinical

manifestations of chronic stable angina pectoris including

the characteristics of angina pectoris, mechanisms,

history, fixed vs. variable threshold angina pectoris,

74

grading of angina pectoris and clinical-pathological

correlations. (PC, MK)

b. Develop a differential diagnosis for causes of angina-like

chest pain. (PC, MK)

c. Describe the physical examination and cardiac

examination in chronic stable angina pectoris. (PC, MK)

d. Describe the use of the ECG in patients with chronic

stable angina pectoris. (PC, MK)

e. Describe the use of exercise electrocardiography in

patients with chronic stable angina pectoris. Include

discussions of their use in the diagnosis of coronary

artery disease, assessment of prognosis, influence of anti-

anginal therapy and inconclusive tests. (PC, MK)

f. Discuss the role of nuclear imaging in the assessment of

chronic stable angina pectoris including thallium-201 and

sestamibi scintigraphy and exercise radionuclide

angiography. (PC, MK)

g. Discuss the use of echocardiography in the assessment

and management of chronic stable angina pectoris. (PC,

MK)

h. Discuss the role of cardiac catheterization and coronary

angiography in the diagnosis and treatment of chronic

stable angina pectoris. (PC, MK)

i. Discuss the management of chronic stable angina

pectoris including general measures and the use of

nitrates, beta-blockers calcium channel blockers and

ranazoline. Compare and contrast the uses of these drugs

and discuss their efficacy as montherapy and

combination therapy. Develop guide lines for the

medical treatment of chronic angina pectoris. (PC, MK)

j. Discuss the role of PTCA and stent placement in the

management of chronic angina pectoris. Also discuss the

use of coronary atherectomy (directional and rotational)

laser atherectomy and percutaneous myocardial

revascularization in patients with chronic angina pectoris.

(PC, MK)

75

k. Discuss the role of coronary artery bypass surgery in the

management of chronic angina pectoris. (PC, MK)

l. Compare the effectiveness of the various therapeutic

modalities used in the treatment of chronic angina

pectoris in terms of pain relief, prevention of myocardial

infarction, effect on left ventricular function, and

survival. (PC, MK)

m. Define unstable angina pectoris and discuss its

pathophysiology. (PC, MK)

n. Describe the history and physical examination in unstable

angina pectoris. (PC, MK)

o. Describe the ECG abnormalities in patients with unstable


p. Discuss the use of exercise testing, echocardiography and

myocardial perfusion scanning in the diagnosis of

unstable angina pectoris. (PC, MK)

q. Discuss the indications for cardiac catheterization and

coronary angiography in patients with unstable angina

pectoris. (PC, MK)

r. Discuss general measures used in the management of


s. Discuss the role of nitrates, beta-blockers, calcium

channel blockers, manolazine anticoagulants, anti-

platelet agents, thrombolytic therapy, intra-aortic balloon

counter-pulsation, percutaneous interventions and

coronary artery bypass surgery in the management of


t. Compare and contrast the prognosis of patients with

stable and unstable angina pectoris. (PC, MK)

u. Discuss variant angina pectoris including its mechanism,

clinical manifestations, electrocardiographic features, the

features of hemodynamic and angiographic studies

(including the ergonovine test), the use of

hyperventilation, acetylcholine and myocardial perfusion

76

studies. Discuss management and prognosis of variant


v. Discuss the differential diagnosis, pathogenesis, clinical

features, diagnosis and treatment of patients with angina-

like chest pain and normal coronary arteries. (PC, MK)

w. Discuss the diagnosis, pathogenesis, diagnosis, prognosis

and management of silent myocardial ischemia. (PC,

MK)



modules and computer programs relating to chronic

stable angina pectoris, unstable angina pectoris and silent

myocardial ischemia. (PC, MK)

b. Rotations on the Cardiology Inpatient Services, in the

Nuclear Cardiology Laboratory, in the Echocardiography

Laboratory, on the Graphics Rotation in the Cardiac

Catheterization Laboratory and in the Cardiology Clinics.

(PC, MK)

c. Attendance at Cardiology Grand Rounds, the Core

Curriculum lecture series, the Echocardiography, the

EKG/Electrophysiology Conference, the Nuclear Cardio-

logy Conferences and the Cardiac Catheterization

Conference. (PC, MK)

d. Attendance at regional and national meetings dealing

with acute and chronic coronary artery disease. (PC, MK)


a. Faculty observation on the aforementioned clinical

rotations and in clinical conferences.



k. Cardiac Arrhythmias


77

a. Describe and discuss the anatomy of the cardiac

conduction system. Include the sinus node, the

internodal and interatrial tracts, the atrioventricular (AV)

junction; the AV node, the bundle of it is and the bundle

branches. Also describe atrial and ventricular Purkinje

fibers. Describe pathologic cardiac abnormalities

associated with arrhythmias and conduction disturbances.

(PC, MK)

b. Discuss basic cardiac electrophysiologic principles.

Discuss the role of the sarcolemma and intercalated

disks. Describe the phases of the action potential and

their role in maintaining or producing normal cardiac

rhythm or abnormal rhythm. (PC, MK)

c. Define cardiac arrhythmia. (PC, MK)

d. Define automaticity, conductivity and refractoriness as

they apply to arrhythmias. (PC, MK)

e. Describe disorders of automaticity including

enhancement, depression, parasystole and triggered

activity. (PC, MK)

f. Describe disorders of conduction including various forms

of re-entry, decremental conduction, exit block, entry

block, concealed conduction and super-normal

conduction. (PC, MK)

g. Describe methods used to diagnose cardiac arrhythmias

including telemetry ambulatory monitoring, event

monitoring, external and implantable loop recorders,

assessment of T wave alternans, exercise testing,

invasive electrophysiologic studies, resting electro-

cardiography, signal-averaged electrocardiography,

esophageal electrocardiography, cardiac mapping and tilt

testing. (PC, MK)

h. Describe the principles of clinical pharmacokinetics as

they apply to pharmacotherapy of cardiac arrhythmias

including the one compartment and two compartment

models. (PC, MK)

i. Describe and discuss general considerations regarding

anti-arrhythmic drugs. Describe the Vaughn-Williams

78

classification of anti-arrhythmic drugs. Discuss the

concept of use dependence, stereoselectivity, drug

metabolites and side effects. (PC, MK)

j. Describe the electrophysiologic actions, hemodynamics

effects, dosage and administration and adverse effects of:

quinidine, procainamide, disopyramide, lidocaine,

mexiletene, tocainide, phenytoin, moricizine. flecainide,

propafenone, beta-blockers, amiodarone, ibutalide,

defetilide, bretylium, sotalol, verapamil, diltiazem,

adenosine and digitalis. (PC, MK)

k. Describe the indications for and methods of

electrocardioversion. (PC, MK)

l. Discuss the use of ablation therapy in the treatment of

cardiac arrhythmias. Describe the creation of complete

AV block by AV nodal or His bundle ablation in patients

with atrial fibrillation or flutter, ablation of atrial flutter

re-entry pathways, ablation of automatic foci at the

pulmonary vein, left atrium, and AV junction, AV nodal

slow pathway ablation for patients with AV nodal re-

entry tachycardia, ablation of accessory pathways in

patients with the Wolff-Parkinson-White syndrome,

ablation of various forms of ventricular tachycardia and

chemical ablation. (PC, MK)

m. Discuss surgical therapy of supraventricular tachy-

arrhythmias and ventricular tachycardia. Describe

cardiac mapping procedures, surgical options and

techniques in the Wolff-Parkinson-White syndrome and

in AV nodal re-entry tachycardia. Discuss the “corridor”

and maze procedures in connection with treatment of

atrial fibrillation. (PC, MK)

n. Describe the history, physical examination,

electrocardiographic mechanisms, electrocardiographic

features, differential diagnosis and management of the

following variations of sinus rhythm and arrhythmias:

normal sinus rhythm, sinus tachycardia, sinus

bradycardia, sinus arrhythmia (respiratory, non-

respiratory, ventriculo-phasic), sinus arrest, sinus exit

block, sinus pause, wandering pacemaker, the sick sinus

syndrome, the hypersensitive carotid syndrome, AV

nodal tachycardia, premature atrial beats, atrial flutter,

79

atrial fibrillation, automatic atrial tachycardia, re-entry

atrial tachycardia, multifocal atrial tachycardia, AV

junctional premature beats, AV junctional rhythm, non-

paroxysmal AV junctional tachycardia, AV nodal re-

entry tachycardia, AV reciprocating tachycardias, the pre-

excitation syndrome, the Wolff-Parkinson-White

syndrome, ventricular premature beats, various forms of

ventricular tachycardia, the long QT syndrome,

ventricular flutter and fibrillation, first degree AV block,

second degree AV block (types I and II), third degree AV

block (AV nodal, His bundle, trifascicular), the

differentiation of supraventricular tachycardia with

aberrant ventricular conduction from ventricular

tachycardia, the various forms of AV dissociation,

idioventricular beats and rhythms, and reciprocal beats

and rhythms. (PC, MK)

o. Be able to recognize and manage the aforementioned

arrhythmias in a broad spectrum of clinical situations.

(PC, MK)

p. Describe the technique of temporary cardiac pacing and

its role in the treatment of cardiac arrhythmias and

conduction disturbances. (PC, MK)

q. List the indications for permanent cardiac pacing. (PC,

MK)

r. Discuss the history of permanent cardiac pacing. (PC,

MK)

s. Discuss the methods of permanent pacemaker

implantation. (PC, MK)

t. Discuss the concepts of capture threshold, sensing and

lead technology and selection. (PC, MK)

u. Discuss the technical aspects and uses of single chamber

pacemakers and dual chamber pacemakers. Describe the

AOO, VOO, VVI, VVIR, AAI and VVT modes. For

dual chamber pacing describe the DVI, DDDR, VDD,

and DDI modes, the role of rate responsive pacing, the

clinical significance of timing intervals, crosstalk and

retrograde conduction with endless loop tachycardia.

Describe the process of programmability. (PC, MK)

80

v. Discuss the hemodynamic aspects of permanent cardiac

pacing including the pacemaker syndrome, and the use of

rate responsive (adaptive) pacemakers. (PC, MK)

w. Describe the criteria for selection of a specific pacing

mode. (PC, MK)

x. Discuss the complications of pacemakers including

malposition of leads, pocket infection, hematoma or

seroma, perforation of the right ventricle, venous

thrombus/obstruction, contraction of the diaphragm,

“twiddler’s syndrome”, loss of capture, abnormal pacing

rate, undersensing and oversensing. (PC, MK)

y. Describe pacemaker follow-up (discussed previously).

(PC, MK)

z. Discuss the use of pacing for termination of tachycardias.

(PC, MK)

aa. Discuss implantable cardioverter defibrillators. Describe

their technical features, arrhythmia sensing, implantation

procedures, complications and follow-up. Discuss

indications for their use their impact on survival. (PC,

MK)



modules and computer programs relevant to cardiac

arrhythmias. (PC, MK)

b. Experience gained while rotating on the Cardiology

Inpatient Service, in the Cardiology and Pacemaker

Follow-up Clinics, and in the Cardiac Electrophysiology

Laboratory. (PC, MK)

c. Attendance at EKG/Electrophysiology Conference,

Cardiology Grand Rounds and Core Curriculum Lecture

Series. (PC, MK)


cardiac arrhythmias. Attendance at industry-sponsored

pacemaker workshops. (PC, MK)

81

e. American Heart Association ACLS syllabus. (PC, MK)


a. Faculty observation in the aforementioned venues.



c. Successful passage of the American Heart Association

ACLS provider course.

l. Cardiac Arrest and Sudden Cardiac Death


a. Define sudden cardiac death. (PC, MK)

b. Discuss the epidemiology and causes of sudden cardiac

death. Discuss factors influencing sudden cardiac death

including population subgroups and sudden cardiac

death, time-dependence of risk, age, gender, heredity,

race, the presence of underlying organic heart disease,

life-style and psychosocial factors. (PC, MK)

c. Discuss sudden cardiac death in those with coronary

heart disease including the influence of left ventricular

ejection fraction and ventricular ectopy. (PC, MK)

d. List the causes of sudden cardiac death. (PC, MK)

e. Discuss the risks of sudden cardiac death in those with

coronary artery abnormalities including coronary heart

disease, ventricular hypertrophy, hypertrophic

cardiomyopathy, heart failure (acute and chronic),

myocarditis, neoplastic disease of the heart, infiltrative

and degenerative heart disease, valvular heart disease,

electrophysiologic abnormalities, QTc prolongation,

electrical instability resulting from neurohumoral and

central nervous system influences and the sudden infant

death syndrome. Also discuss pro-arrhythmia as a cause

of sudden cardiac death. (PC, MK)

82

f. Describe the pathology of sudden cardiac death including

sudden cardiac death in coronary heart disease and

ventricular hypertrophy. (PC, MK)

g. Characterize the mechanisms and pathophysiology of

cardiac arrest. Include discussions of the role of coronary

artery structure and function, the unstable myocardium

and initiation of lethal arrhythmias, electrophysiologic

effects of acute ischemia and the transition from

myocardial instability to potentially lethal arrhythmias.

(PC, MK)

h. Describe clinical characteristics of the patient with

cardiac arrest including prodromal symptoms, the onset

of the terminal event, clinical features, hospital course of

survivors and the clinical profile of survivors of out-of-

hospital cardiac arrest. (PC, MK)

i. Discuss the general management of cardiac arrest

including community-based interventions in out-of-

hospital cardiac arrest and the importance of electrical

mechanisms. (PC, MK, SBP)

j. Discuss management of the individual cardiac arrest

victims including the initial response, basic life support,

advanced life support and definitive resuscitation

(including pharmacotherapy, management of tachy-

arrhythmic, bradyarrhythmic and asystolic arrest). (PC,

MK)

k. Describe appropriate post-cardiac arrest care in primary

cardiac arrest and secondary cardiac arrest in patients

with acute myocardial infarction in those with cardiac

arrest and non-cardiac abnormalities and in survivors of

pre-hospital cardiac arrest. (PC, MK)

l. Discuss prevention of recurrent cardiac arrest including

the use of long-term antiarrhythmic therapy. Also

discuss the role of surgical management and implantable

defibrillators. Describe a management algorithm for

diagnostic evaluation and long-term management of

cardiac arrest victims who have been successfully

resuscitated. (PC, MK)


83

a. Utilization of textbooks, the BLS and ACLS syllabi,

journal articles, audiovisual modules and computer

programs dealing with cardiac arrest. (PC, MK)

b. Experience gained from rotations on the Cardiology

Inpatient Services, in the Cardiac Electrophysiology

Laboratory and in the Cardiac Catheterization


c. Attendance at EKG/Electrophysiology Conference, the

Core Curriculum Lecture Series and Cardiology Grand

Rounds. (PC, MK)


cardiac arrest. (PC, MK)


a. Successful passage of the AHA BLS and ACLS tests.

(PC, MK)

b. Faculty observation in the aforementioned clinical

venues. (PC, MK)

c. Performance on sections of the ABIM Certifying

Examination in Cardiovascular Disease. (PC, MK)

m. Systemic Hypertension


a. Provide guidance for blood pressure measurement

including sphygmomanometic and cellometric

techniques. (PC, MK)

b. Define hypertension. (PC, MK)

c. Define borderline or pre-hypertension. (PC, MK)

d. List the secondary causes of hypertension. (PC, MK)

e. Discuss the prevalence of essential and secondary

hypertension. (PC, MK)

84

f. Be able to assess individual risk in hypertensives.

Include assessment of cardiovascular risk and target

organ damage as a prognostic guide. (PC, MK)

g. Discuss the complications of hypertension. Describe

vascular complications including those related to

pulsatile flow, endothelial cell dysfunction and smooth

muscle hypertrophy. Discuss the risk of hypertension in

blacks and women. (PC, MK)

h. Discuss vascular and end-organ pathology in


i. Describe the mechanisms of essential hypertension

including hemodynamic patterns, genetic predisposition,

vascular hypertrophy, the role of hyperinsulinemia,

defects in cell transport or binding and the rennin

angiotensin system. (PC, MK)

j. Discuss the role of renal-angiotension system,

catecholamines, atrial natriuretic peptide, vasopressin and

serotonin in essential hypertension. (PC, MK)

k. Characterize the association of essential hypertension and

obesity, sleep apnea, physical inactivity, alcohol intake,

cigarette smoking, diabetes mellitus, polycythemia and

gout. (PC, MK)

l. Discuss and describe secondary forms of hypertension

including oral contraceptive use, renal parenchymal

disease, renovascular hypertension, Conn’s syndrome,

Cushing’s syndrome, pheochronocytoma, adrenal hyper-

plasma. other drug-induced hypertension, coarctation of

the aorta, hyperparathyroidism and hypertension after

heart surgery. (PC, MK)

m. Discuss hypertension during pregnancy including it

pathogenesis, clinical features and treatment. Include

discussion of gestational hypertension, chronic

hypertension, management of eclampsia/pre-eclampsia

and consequences of pregnancy-related hypertension.

(PC, MK)

n. Discuss the special considerations of diagnosis and

treatment hypertension in the elderly. (PC, MK)

85

o. Define hypertensive emergencies and urgencies.

Describe each in terms of incidence, pathophysiology,

clinical manifestations and course and differential

diagnosis. (PC, MK)

p. Cite indications for therapy of hypertension. Discuss

clinical trials pertinent to treatment. Establish guidelines

for treatment. Describe the thresholds of systolic and

diastolic pressure used to decide whether to treat. Be able

to employ JNC 7 management guidelines (PC, MK, SBP)

q. Discuss the optimal blood range to reach as a result of

treatment. Discuss the “J” curve as it relates to hyper-

tension. (PC, MK)

r. Describe the role of non-pharmacologic therapy in the

treatment of hypertension including weight reduction,

dietary sodium restrictions, potassium supplementation,

magnesium supplementation, calcium supplementation,

the use of fish oil, cessation of alcohol intake and

cigarette smoking, exercise and relaxation techniques.

Discuss the potential of non-pharmacologic therapy. (PC,

MK)

s. Develop general guidelines with respect to therapy of

hypertension. Base these guidelines on JNC-7

recommendations. Include discussions on the issues of

efficacy, compliance, cost, and side-effects. Discuss the

role of individualized therapy. (PC, MK)

t. Describe the mechanisms of actions, clinical effects,

dosages, routes of administration, and side-effects of the

following: the broad spectrum of diuretics, reserpine,

guanethidine, methyldopa, clonidine, guanabenz,

guanaficine, prazosin, terazosin, doxazosin, the broad

spectrum of beta-blockers, hydralazine, minoxidil, the

broad spectrum of calcium channel blockers, the broad

spectrum of angiotensin and receptor blockers (ARBs),

angiotension converting enzyme (ACE) inhibitors and

renin-blockers. (PC, MK)

u. Discuss therapy of hypertension in special situations

including systolic hypertension in the elderly,

hypotension during pregnancy, hypertension with

86

congestive heart failure, hypertension with ischemic heart

disease, hypertension with diabetes mellitus,

hypertension with hyperlipidemia, hypertension with

psychotic illness and hypertension in African-Americans.

(PC, MK)

v. Discuss specific pharmacologic therapy of the broad

spectrum of hypertensive emergencies and urgencies.

Justify therapeutic choices. (PC, MK)


a. Utilization of textbooks, journal articles, JNC-7

guidelines, audiovisual modules and computer programs

relating to systemic hypertension. (PC, MK)

b. Attendance at the Core Curriculum Lecture Series,

Cardiology Grand Rounds, Research Conference and

Journal Club.

c. Experience gained from rotations on the Cardiology

Inpatient Services and in the Cardiology Clinic. (PC,

MK)


systemic hypertension. (PC, MK)





Examination in Cardiovascular Disease.

n. Cardiomyopathies, Myocarditis, Toxic Heart Disease and Cardiac

Tumors


a. Define cardiomyopathy and myocarditis. (PC, MK)

b. Discuss dilated cardiomyopathy including pathology,

pathogenesis etiologies, the history, the physical

examination, non-invasive evaluation, cardiac

87

catheterization, findings, angiographic evaluation

prognosis and management. (PC, MK)

c. Define the various forms of hypertrophic cardio-

myopathy. Describe its pathology, etiology (including its

genetic basis), pathophysiology, symptoms, signs,

electrocardiographic features, chest x-ray features,

echocardiogaphic/Doppler features and radionuclide

scanning features. Discuss the hemodynamics features of

hypertrophic cardiomyopathy (including the reasons for

the lability of the gradient, its natural history, and

management [including the use of calcium channel

blockers, beta-blockers, disopyramide, pacing, alcohol

septal ablation, and surgical therapy). (PC, MK)

d. Define restrictive and infiltrative cardiomyopathies and

provide a differential diagnosis of the causes. Discuss

hemodynamics in restrictive cardiomyopathies. Also

discuss pathology, pathogenesis, symptoms, signs, non-

invasive evaluation, cardiac catheterization findings and

management. Discuss each of these issues as they relate

to cardiac amyloidosis, Fabry disease, Gaucher disease,

hemochromatosis, sarcoidosis, ischemic heart disease

and endomyocardial disease (including Löffler’s

endocarditis, endomyocardial fibroelastosis and carcinoid

heart disease). (PC, MK)

e. Provide a differential diagnosis of infectious and non-

infectious causes of myocarditis. Include discussions of

bacterial infections, spirochetal infections, fungal

infections, parasitic infections, rickettsial infections and

viral infections. (PC, MK)

f. Discuss myocardial damage associated with the use or

presence of cocaine, alpha interferon, tricyclic anti-

depressants, interleukin-2, phenothiazines, emetine,

methasergide, chloroquin, antimony compounds, lithium,

hydrocarbons, catecholamines, CO, hypocalcemia,

hypophosphatemia, hypomagnesemia, taurine deficiency,

carntine deficiency, selenium deficiency, scorpion sting,

wasp and spider stings, snake bite, arsenic,

cyclophosphamide, azide, paracetamol, 5FU

dauaorubicin and adriamycim. (PC, MK)

88

g. Describe hypersensitivity myocarditis including its

causes and clinical manifestations. (PC, MK)

h. Characterize myocarditis associated with collagen

vascular diseases and vasculitides (especially systemic

lupus erythematosus, scleroderma, polymyositis and

giant cell arteritis). (PC, MK)

i. Discuss the effects of heat stroke, hypothermia and

radiation on myocardium. (PC, MK)

j. Compare and contrast the clinical features, chest x-ray

findings, EKG findings, echocardiographic findings,

radionuclide findings and cardiac catheterization findings

of dilated, hypertrophic and restrictive cardiomyopathies.

(PC, MK)

k. Describe the technique of endomyocardial biopsy and be

able to perform the procedure. (PC, MK)

l. List indications for endomyocardial biopsy, specific

diagnoses that can be confirmed by endomyocardial

biopsy and diagnoses for which there is a proven therapy.

Compare and contrast endomyocardial biopsy

characteristics of dilated cardiomyopathy, hypertrophic

cardiomyopathy and myocarditis. (PC, MK)

m. Discuss the epidemiology of primary cardiac tumors.

(PC, MK)

n. Provide a differential diagnosis of primary tumors of the

heart. (PC, MK)

o. Describe the pathology, clinical manifestations, embolic

phenomena, echocardiographic and cardiac

catheterization/angiographic features and natural history

of cardiac myxomas (including left atrial, right atrial,

right ventricular and left ventricular myxomas). Provide

a differential diagnosis of conditions that may be

confused with atrial myxoma. (PC, MK)

p. Describe the pathology, clinical manifestations, non-

invasive features, cardiac catheterization/angiographic

features and natural history of other benign cardiac

tumors including papillary tumors of the heart valves,

89

rhabdomyomas, fibromas, lipomas, lipomatous,

hypertrophy of the atrial septum, angiomas, teratomas,

benign cystic tumors and endocardial tumors. (PC, MK)

q. Provide similar descriptions of malignant cardiac tumors

including angiosarcomas, rhabdomyosarcomas,

fibrosarcomas, myxofibrosarcomas lymphosarcomas and

pulmonary artery sarcomas. (PC, MK)

r. Discuss management of the spectrum of benign and

malignant cardiac tumors. (PC, MK)

s. List the malignant tumor most likely to metastasize to the

heart. Discuss their pathology, clinical features,

diagnostic methods, management and natural history.

(PC, MK)




cardiomyopathies, myocarditis, toxic heart disease and

cardiac tumors. (PC, MK)

b. Attendance at Cardiology Grand rounds, Core

Curriculum Conference, Echocardiography Conference

and Cardiac Catheterization Conference. (PC, MK)


Inpatient Services, in the cardiology clinic, in the

Echocardiography Laboratory and in the Cardiac

Catheterization Laboratory. (PC, MK)



cardiac tumors. (PC, MK)


a. Direct observation of the aforementioned conferences

and clinical venues by faculty.


Examination in Cardiovascular Disease relating to

90


cardiac tumors.

o. Valvular Heart Disease


a. Describe the etiology and pathology of mitral stenosis.

(PC, MK)

b. Discuss the pathophysiology of mitral stenosis. (PC,

MK)

c. Discuss the history and physical examination in mitral

stenosis. (PC, MK)

d. Describe the electrocardiographic and echocardiographic

signs of mitral stenosis. (PC, MK)

e. Describe cardiac catheterization and angiographic

findings in mitral stenosis. (PC, MK)

f. Describe the natural history of mitral stenosis. (PC, MK)

g. Discuss the use of medical, therapy, valvuloplasty and

surgical therapy of mitral stenosis. Also discuss the

outcomes of the various forms of therapy. (PC, MK)

h. Discuss the etiologies and pathology of mitral

regurgitation. Provide a differential diagnosis of causes

of mitral regurgitation in terms of valve leaflet

abnormalities, annular dilation, chordae tendoneae

abnormalities, papillary muscle abnormalities and left

ventricular dilatation. (PC, MK)

i. Discuss the pathophysiology of the various forms mitral

regurgitation. Include discussions of assessment of

myocardial contractility and end-systolic volume,

hemodynamics and left atrial compliance. (PC, MK)

j. Discuss the history and physical examination of patients

with mitral regurgitation. (PC, MK)

91

k. Describe electrocardiographic, radiographic, echocardio-

graphic and radionuclide angiographic abnormalities in

mitral regurgitation. (PC, MK)

l. Describe the natural history of the various forms of mitral

regurgitation. (PC, MK)

m. Discuss medical and surgical therapy of the various

forms of mitral regurgitation. Discuss the indications for

surgical therapy of mitral regurgitation. Also discuss the

results of various forms of therapy. (PC, MK)

n. Discuss the etiologies, pathology, history, physical

findings, electrocardiographic, echocardiographic,

cardiac catheterization and angiographic abnormalities of

mitral valve prolapse and the mitral valve prolapse

syndrome. Describe the Perloff criteria for diagnosis of

mitral valve prolapse. Discuss other diagnostic criteria.

Discuss the natural history complications, treatment and

prognosis of mitral valve prolapse. (PC, MK)

o. Discuss the etiology and pathology of aortic stenosis.

Include discussions of congenital and acquired aortic

stenosis. (PC, MK)

p. Describe the pathophysiology of aortic stenosis. (PC,

MK)

q. Describe the history and physical examination of aortic

stenosis. (PC, MK)

r. Describe the electrocardiographic, radiologic, and

echocardiographic and Doppler abnormalities of aortic

stenosis. (PC, MK)

s. Describe cardiac catheterization and angiographic

findings in aortic stenosis. (PC, MK)

t. Describe medical and surgical treatment of aortic

stenosis. Describe the role of valvuloplasty in the

treatment of aortic stenosis. Include a discussion of the

results of surgical therapy. (PC, MK)

u. Describe the natural history of aortic stenosis. (PC, MK)

92

v. Describe the etiologies, and pathology of aortic

regurgitation. Include valvular and aortic root etiology in

the discussion. Provide a differential diagnosis of he

causes of aortic regurgitation. (PC, MK)

w. Discuss the pathophysiology of aortic regurgitation.

Distinguish between acute and chronic aortic

insufficiency. (PC, MK)

x. Describe the history and physical examination in aortic


y. Describe electrocardiographic, radiographic, echocardio-

gaphic, Doppler and radionuclide angiographic ab-

normalities in aortic regurgitation. (PC, MK)

z. Distinguish acute and chronic aortic regurgitation from

an etiologic, pathologic, pathophysiologic and clinical

point of view. (PC, MK)

aa. Describe the natural history of acute and chrome aortic


bb. Discuss management of acute and chronic aortic

regurgitation. Include discussions of medical and

surgical therapy. Describe the indications for and the

results of surgical therapy. (PC, MK)

cc. Discuss the etiology, pathology, pathophysiology,

history, physical examination, electrocardiographic

abnormalities, radiographic abnormalities, echocardio-

graphic abnormalities, cardiac catheterization abnormal-

ities, management and natural history of tricuspid

stenosis. (PC, MK)

dd. Discuss the etiologies and pathology of tricuspid

regurgitation. Provide a differential diagnosis of causes

of tricuspid regurgitation. (PC, MK)

ee. Describe the history and physical examination of

tricuspid regurgitation. (PC, MK)

93

ff. Describe the electrocardiographic, radiographic, echo-

cardiographic Doppler, hemodynamic and angio-graphic

abnormalities of tricuspid regurgitation. (PC, MK)

gg. Describe the natural history of tricuspid regurgitation.

(PC, MK)

hh. Describe medical and surgical management of tricuspid

regurgitation. Discuss surgical results. (PC, MK)

ii. Describe the etiologies, pathology, pathophysiology,

history, physical examination, electrocardiographic ab-

normalities, radiologic and echocardiographic abnormal-

ities, hemodynamic and angiographic abnormalities of

pulmonic stenosis and regurgitation. (PC, MK)

jj. Discuss the natural history of pulmonic stenosis and the

various forms of pulmonic regurgitation. (PC, MK)

kk. Discuss management of pulmonic stenosis and re-

gurgitation.

ll. Describe the pathology, pathophysiology, clinical man-

ifestations, natural history and management of various

forms of multi-valvular disease.

mm.Compare and contrast the technical features, hemo-

dynamics, durability, thrombogenicity, and criteria for

selection of biomechanical valve prostheses, porcine

heterografts, pericardial valves and homografts. Describe

medical management of patients with these prosthetic

valves. (PC, MK)

nn. Discuss special considerations of patients with artificial

valves who are pregnant, are undergoing non-cardiac

surgery, and/or are receiving dialysis. (PC, MK)

oo. Describe anticoagulation requirements for prosthetic

heart valves. (PC, MK)

pp. Discuss methods for detecting and criteria for prosthetic

valve dysfunction. (PC, MK)


94


modules and computer programs dealing with valvular

heart disease. (PC, MK)

b. Attendance at Cardiology Grand Rounds, the Core

Curriculum Lecture Series, Journal Club,

Echocardiography Conference and Cardiac

Catheterization Conference. (PC, MK)


Inpatient Rotations, in the Cardiology Clinic and on the

EKG, Echocardiography and Cardiac Catheterization

Laboratory rotations. (PC, MK)

d. Attendance at regional and national conferences with

sections devoted to relevant to valvular heart disease.

(PC, MK)




b. Performance at selected divisional conferences.

c. Performance on sections of the ABIM Certifying


p. Infective Endocarditis


a. Discuss the demographic characteristics of infective

endocarditis in children, adults, those with rheumatic

heart disease, the elderly, diabetics and pregnant women.

(PC, MK)

b. Discuss the microbiology of infective endocarditis.

Distinguish among patients with native valve

endocarditis, intravenous drug-abusers and patients with

prosthetic valve endocarditis. (PC, MK)

c. Discuss the pathology and pathophysiology of native

valve endocarditis. Discuss the role of non-bacterial

thrombotic endocarditis. Discuss the pathogenesis of

95

prosthetic valve endocarditis and endocarditis in

intravenous drug-abusers. Include discussions of

conditions predisposing to bacteremia. Also discuss the

immunologic response to bacteremia and its relationship

to clinical sequelae. Discuss the pathogenesis of embolic

phenomena. (PC, MK)

d. Discuss the history and physical (cardiac and non-

cardiac) examination of patients with infective

endocarditis with special reference to heart murmurs,

cutaneous and ocular manifestations, splenomegaly,

petichiae, other hematologic abnormalities,

musculoskeletal complaints, congestive heart failure, and

neuron- logic manifestations. (PC, MK)

e. Provide a differential diagnosis for infective endocarditis.

(PC, MK)

f. Describe the proper technique for culturing the blood in

infective endocarditis. (PC, MK)

g. Discuss other laboratory abnormalities in infective

endocarditis including anemia, leukocytosis and

leukopenia, thrombocytopenia, acute phase reactants,

rheumatoid agglutinins, and other immunologic tests,

leukocyte, morphology, and the urinalysis. (PC, MK)

h. Discuss the role of transthoracic and transesophageal

echocardiography in the diagnosis of infective

endocarditis. Describe the Duke criteria for diagnosis.

(PC, MK)

i. Discuss the role of radioisotope scanning (indium and

gallium) in infective endocarditis. (PC, MK)

j. Discuss anti-microbial therapy of infective endocarditis

including the choice, duration, route of administration,

frequency of dosing, isolation of micro-organisms,

timing of initial therapy and intravenous home therapy.

Discuss criteria for initiating therapy prior to isolation of

a micro-organism. Provide specific anti-microbial

regimens for specific organisms. (PC, MK)

k. Discuss the indications for surgical management of

endocarditis, including refractory heart failure, late

96

embolism, prosthetic valve and fungal involvement and

perivalvular abscess. (PC, MK)

l. Describe the complications of infective endocarditis.

(PC, MK)

m. Describe how to assess response to therapy. (PC, MK)

n. Describe what to do if there are relapses or new episodes

of infective endocarditis. (PC, MK)

o. Describe the prognosis of native valve, prosthetic valve

and intravenous drug-abuse related to endocarditis. (PC,

MK)

p. Describe current guidelines for infective endocarditis

prophylaxis. (PC, MK)

q. List general methods for treating infective endocarditis.

(PC, MK)

r. Cite specific antibiotic regimens for infective

endocarditis prophylaxis based on specific indications

including the dental (oral) regimen, genitourinary

regimen, and foreign material regimen. (PC, MK)



modules and computer programs relating to infective

endocarditis. (PC, MK)

b. Clinical experience on the Cardiology Inpatient Services

and in the Cardiology Clinics. (PC, MK)

c. Attendance at Cardiology Grand Rounds, the Core

Curriculum Lecture Series and Echocardiography



sections devoted to infective endocarditis. (PC, MK)


97



b. Performance on portions of the ABIM Certifying


q. Adult Congenital Heart Disease


a. Describe the pathology, pathophysiology,

electrocardiographic, radiographic, echocardiographic,

hemodynamic and angiographic characteristics and

natural history of the following congenital heart diseases

in adults: bicuspid aortic valve, coaortation of the aorta,

pulmonic valve stenosis, ostium primum and secundum

atrial septal defects, sinus venous defect, partial and total

anomalous pulmonary venous return, patent ductus

arteriosus, ventricular septal defect, tetralogy of Fallot,

transposition of the arteries, congenitally corrected

transposition of the great vessels, situs inversu with

dextrocardia, situs solitus with dextrocardia, congenital

complete heart block, congenital mitral regurgitation,

Ebstein’s anomaly, congenital tricuspid atresia,

congenital pulmonic valve regurgitation, Lutembacher’s

syndrome, aneurysm of the sinus of Valsalva, coronary

arteriovenous fistulae and congenital pulmonary

artervenous fistulae. (PC, MK)

b. Discuss survival following surgical therapy of the

aforementioned congenital abnormalities (where

appropriate). (PC, MK)

c. Describe the Fontan procedure. (PC, MK)

d. Describe medical management of cyanotic congenital

heart disease with special reference to hematologic

abnormalities (including abnormalities of hemostatsis),

renal function and urate metabolism. (PC, MK)

e. Describe the dynamics of oxygen uptake and control of

ventilation in patients with cyanotic congenital heart

disease. (PC, MK)

98

f. Discuss the risk of endocarditis in various forms of

congenital heart disease and its treatment. (PC, MK)

g. Discuss the implications of pregnancy in various forms

of adult congenital heart disease. Discuss management

of the pregnant woman and the fetus. (PC, MK)

h. Discuss genetic, epidemiology, counseling and

prevention as they apply to adult congenital heart disease.

(PC, MK)

i. Discuss limitations concerning exercise and athletics

before and after surgery or interventional catheterization

in patients with adult congenital heart disease. (PC, MK)

j. Discuss insurability, employability and psychosocial

considerations in patients with adult congenital heart

disease. (PC, MK, SBP)

k. Discuss cardiac surgical considerations regarding

operation and re-operation in adults with congenital heart

disease. (PC, MK)

l. Discuss the use of cardiac catheterization as a therapeutic

intervention in adult congenital heart disease. (PC, MK)

m. Describe the electrophysiological, valvular, ventricular,

vascular and non-cardiovascular residua from cardiac

surgery in patients with adult congenital heart disease.

(PC, MK)

n. List congenital heart defects that require infective

endocarditis prophylaxis. (PC, MK)



modules and computer programs relevant to adult

congenital heart disease. (PC, MK)

b. Experience gained on the Inpatient Cardiology Services,

in the Cardiology Clinics, in the Echocardiography and

EKG Laboratories and in the Cardiac Catheterization


99

c. Attendance at Core Curriculum, EKG/Electrophysiology

and Cardiac Catheterization Conferences. (PC, MK)


adult congenital heart disease. (PC, MK)






r. Pericardial Disease


a. Describe the anatomy of the pericardium. (MK)

b. Describe the function of the pericardium. Include a

discussion of intra-pericardial pressure, limitations of

cardiac distention and ventricular interdependence. (MR)

c. Describe the pathology of acute pericarditis. (MR)

d. Provide a differential diagnosis and causes of acute

pericarditis. (PC, MK)

e. Describe the history in acute pericarditis with special

emphasis on chest pain. (PC, MK)

f. Describe physical examination in acute pericarditis with

special emphasis on the pericardial friction rub. (PC,

MK)

g. Describe the electrocardiographic features of acute


h. Describe chest x-ray, echocardiographic, and

hematologic abnormalities in acute pericarditis. (PC,

MK)

i. Provide a rational approach to the diagnosis of acute


100

j. Describe general principles of management of acute


k. Provide a differential diagnosis of causes of pericardial

effusion. (PC, MK)

l. Discuss the history and physical examination of patients

with clinically significant pericardial effusion. Describe

the pathophysiology, diagnostic criteria and

consequences of cardiac tamponade. Discuss the

pathogenesis of the normal and abnormal paradoxical

pulse. (PC, MK)

m. Discuss the EKG, chest x-ray, and echocardiographic

/Doppler abnormalities in patients with pericardial

effusion including those with a symptomatic effusion and

cardiac tamponade. Describe the cardiac catheterization

findings in patients with clinically significant pericardial

effusion and cardiac tamponade. (PC, MK)

n. Discuss the entities of chronic pericardial effusion and

regional tamponade, low pressure tamponade and tension

pneumopericardium. (PC, MK)

o. Describe the procedure of pericardiocentesis in the

treatment of pericardial effusion. Discuss potential

complications. Also describe the use of pericardiectomy

pericardiotomy, pericardioscopy and pericardial biopsy in

patients with pericardial effusion. (PC, MK)

p. Describe the causes, pathology, pathophysiology, history,

physical examination, EKG findings, chest x-ray

findings, echocardiographic abnormalities, CT and MRI

findings and other laboratory findings in chronic

constrictive pericarditis. Describe cardiac catheterization

and angiographic findings in chronic constrictive

pericarditis. Compare and contrast findings associated

with subacute elastic constriction, from chronic rigid

constriction from cardiac tamponade from restrictive

cardiomyopathy. (PC, MK)

q. Discuss the entities of occult constrictive pericarditis and

effusive-constrictive pericarditis. (PC, MK)

101

r. Describe management of constrictive pericarditis.

Include a discussion of the results of pericardiectomy.

(PC, MK)

s. Discuss the pathology, pathophysiology, clinical features,

EKG findings, chest x-ray findings, echocardiographic

findings, cardiac catheterization findings angiographic

finding and management of specific types of pericarditis

including viral, tuberculous bacterial, fungal, post-

myocardial infarction, uremic, neoplastic, radiation, acute

rheumatic related, connective tissue disease-related, drug

and toxin-related, trauma-related, cholesterol-related and

myxedema-related pericardial disease. (PC, MK)

t. Describe the pathology, clinical features, diagnostic

criteria and management of pericardial cysts and

total/partial absence of the pericardium. (PC, MK)



modules, and computer programs relating to pericardial

diseases. (PC, MK)


in the Cardiology Clinics, in the Cardiac Catheterization

Laboratory, in the EKG and Echocardiography Lab-

oratories. (PC, MK)


Grand Rounds, EKG/Electrophysiology Conference,

Echocardiography Conference, Cardiac Catheterization

Conference and Journal Club. (PC, MK)


pericardial diseases. (PC, MK)






102

s. Acute and Chronic Congestive Heart Failure


a. Describe the structure of the myocyte, myofibrils, the

sarcomere, the sarcolemma, intercalated discs and the

sarcoplasmic reticulum. Include a discussion of

contractile proteins (myosin, actin, troponin,

tropomyosin). (MK)

b. Describe the process of excitation-contraction coupling

including the role of calcium. Discuss the role of the

cardiac action potential, sodium-calcium exchange,

cardiac relaxation, inotropic effects and calcium kinetics,

the action of beta-agonists on calcium, cyclic AMP and

control of cytoplasmic calcium on excitation contraction

coupling. (MK)

c. Describe and discuss calcium channels including voltage

dependent channels, receptor operated channels, and the

effects of calcium antagonists. (MK)

d. Discuss the structures and functions of cardiac

adrenoreceptors. (MK)

e. Describe and discuss the mechanics of cardiac

contraction including isometric contraction, isotonic

contraction (the force-length and force-velocity relation),

muscle models, resting muscle stiffness, resting length-

tension relations and force-velocity curves. (MK)

f. Describe the ultrastuctural basis of Starling’s law of the

heart including the sliding filament theory of striated

muscle, length-dependent activation and the length-

tension relation, the relation between sarcomere length

and the length active curve of heart muscle and the

sarcomere length-ventricular performance relaxation.

(MK)

g. Describe the determinants of contraction of the intact

heart. (MK)

h. Describe the changes in ventricular size and shape during

the cardiac cycle. (MK)

103

i. Describe the diastolic properties of the ventricles

including the determinants of ventricular diastolic

properties and ventricular filling and the role of the

pericardium. (MK)

j. Describe the performance of the normal intact ventricle

including the interrelation of factors determining

ventricular performance, the cardiac cycle, the pressure

volume relation, LaPlace’s law, pre-load (influence on

ventricular contraction, atrial contribution, descending

limb of Starling’s curve, and the apparent descending

limb, the role of venous return, the role of total blood

volume and the distribution of blood volume). Also

discuss the role of afterload including ventriculo-arterial

coupling, the basis for afterload reduction and the control

of afterload. (MK)

k. Discuss contractility including the interval-strength

(force-frequency) relation, the control of contractility

(sympathetic nerve activity, circulatory catecholamines,

the force-frequency relation, exogenous inotropic agents,

physiological and pharmacological depressants, loss of

contractile mass and intrinsic myocardial depression).

(MK)

l. Discuss the role of heart rate in cardiac performance.

(MK)

m. Discuss neural control of cardiac contraction including

anatomic considerations, the role of norepinephrine and

the parasympathetic system. (MK)

n. Discuss cardiac control in the intact organism including

circulatory adjustment during exercise (peripheral

circulatory response, ventricular volume and dimensions,

heart rate, the adrenergic system, the Frank-Starling

mechanism and integrated responses). (MK)

o. Discuss other circulatory adjustments include the

response to hypovolemia, the Bainbridge reflex, chemo-

receptor reflexes, sympathetic/parasympathetic inter-

actions and the actions of acetylcholine. (MK)

p. Describe and discuss the pathophysiology of heart

failure. Include discussions of adaptive mechanisms,

104

redistribution of cardiac output, autonomic control of the

heart and peripheral circulation, the role of the

renin/angiotension aldosterone axis and changes in the

affinity of hemoglobin for oxygen. (MK)

q. Discuss contractility of hypertrophied and failing

myocardium. Describe studies on isolated myocardium

and the intact heart. Describe the manifestations of

depressed contractility. Discuss the causes of hyper-

trophy including volume overload and pressure overload.

Describe other forms of hypertrophy and the effects of

depressed contractility in the hypertrophied heart.

Discuss the concept of afterload mismatch. Discuss

cardiac response in various forms of volume and pressure

overload and patterns of ventricular hypertrophy. discuss

the pathophysiology of diastolic heart failure including

chronic changes in pressure-volume relations, the role of

ischemic heart disease and the role of collagen in

ventricular dysfunction. (MK)

r. Describe and discuss the mechanisms responsible for

depressed contractility including those responsible for

myocardial energy production, myocardial energy supply,

alterations in contractile proteins and excitation-

contraction coupling and the role of calcium. (MK)

s. Describe neurohormonal adjustments in heart failure

including alterations in norepinephrine, adresergic

nervous functions in the peripheral circulation, down-

regulation of cardiac beta receptors, the role of G

proteins, the role of the renin/angiotensin/aldosterone

axis, the role of arginine vasopressor and the role of atrial

natriuretic peptide. (MK)

t. Discuss the role of parasympathetic function in heart

failure. (MK)

u. Discuss theoretical considerations regarding assessment

of cardiac function including limitations of cardiac

output in assessing cardiac function, the relation between

cardiac output and contractility, the need for assessing

myocardial contractility and the role of the Frank-Starling

mechanism. (MK)

105

v. Discuss assessment of cardiac performance based on

pressures, flows, volumes, and dimensions. Include

discussions of assessment of cardiac output, AVO2

difference intra-cardiac pressures, volume measurements

(contrast angiographic and non-invasive), left ventricular

mass, left ventricular force, ventricular wall motion,

ejection fraction and fractional shortening, ventricular

dimensions and the velocity of shortening, the ventricular

pressure-volume loop and ventricular end-systolic

pressure volume relations. (PC, MK)

w. Discuss assessment of isovolumetric phase indices of

contractility including ventricular dP/dt and V max. (PC,

MK)

x. Discuss assessment of contractility including directional

changes in contractility and contractility in the basal

intake (isovolumetric phase indices and contractility

indices based on the force velocity relation). Describe

ejection phase indices and their usefulness in various

forms of heart disease (aortic or mitral regurgitation,

aortic stenosis or hypertension, cardiomyopathy and

ischemic heart disease). (PC, MK)

y. Describe assessment of the ventricular response to stress

including dynamic exercise, increase in afterload and

tachycardia. Describe the role of cardiopulmonary

exercise testing in assessing the ventricular response to

stress. (PC, MK)

z. Describe methods that assess diastolic function including

those that measure the rate of diastolic relaxation, the

peak filling rate and time to peak filling and the diastolic

ventricular pressure-volume relation. (PC, MK)

aa. Summarize the pathophysiology of heart failure. (PC,

MK)

bb. Define heart failure. (PC, MK)

cc. Describe the Framingham criteria for congestive heart

failure. Discuss the epidemiology of heart failure. (PC,

MK)

106

dd. Discuss the various forms of heart failure including

forward vs. backward, right-sided vs. left-sided, acute vs.

chronic, low-output vs. high-output, and systolic vs.

diastolic. (PC, MK)

ee. List the underlying causes and precipitating factors of

heart failure. (PC, MK)

ff. List and discuss the symptoms of heart failure including

lassitude, exertional dyspnea, paroxysmal nocturnal

dyspnea, nocturea, oliguria, altered menstruation, edema

and right upper quadrant discomfort. Describe how to

differentiate cardiac from pulmonary dyspnea. Describe

these symptoms in acute, chronic and refractory heart

failure. (PC, MK)

gg. Describe the New York Heart Association functional

classification for heart failure and AHA clarification.

(PC, MK)

hh. List and describe the non-cardiac physical findings of

heart failure including general appearance, evidence of

increased adrenergic activity, pulmonary crackles,

systemic venous hypertension, hepatojugular reflux,

congenital hepatomegaly, edema, signs of pleural

effusion and ascites, fever, cardiac cachexia and Cheyne-

Stokes respiration. Also discuss cardiac findings

including cardiomegaly, gallop rhythm, pulses alternans,

accentuation of P2 and systolic murmurs. Correlate

physical findings with pathological sequelae. Describe

these findings in acute, chronic and refractory heart

failure. (PC, MK)

ii. Discuss serum electrolytes and the use if Valsalva’s

maneuvers in heart failure. (PC, MK)

jj. Describe chest radiographic abnormalities in heart

failure. Discuss the role of echocardiography, radio-

nuclide angiography, CT and MRI in the evaluation of


kk. Discuss the natural history and prognosis of heart failure.

Describe factors influencing survival in heart failure.

Discuss the cause of progression of heart failure and

causes of death. (PC, MK)

107

ll. Describe the causes, history, physical examination,

laboratory evaluation, hemodynamic abnormalities and

prognosis of high output heart failure. (PC, MK)

mm. Describe a general therapeutic strategy for the

management of heart failure. Specifically discuss

removal of underlying causes and precipitating factors

and measures to control the heart failure stake

(redistribution of the heart’s workload, improvement of

its pumping performance, and control of excess salt and

water retention). (PC, MK)

nn. Describe general measures used in the treatment of heart

failure including dietary, sodium restriction, activity

restriction, modification of underlying causes and

precipitating factors, oxygen, anti-coagulation and

thoracentesis. (PC, MK)

oo. Describe the value and limitations of inotropic agents

(digitalis, beta-agonists, bipyridine derivatives) in acute,

chronic and refractory heart failure. (PC, MK)

pp. Describe the value and limitations of diuretic (loop,

thiazides, carbonic anhydrase inhibitors, metolazone) in

the management of acute, chronic and refractory heart

failure. (PC, MK)

qq. Describe the value and limitations of direct acting

vasodilators, sympatholytic agents, ACE inhibitors

ARB’s beta-blockers, calcium channel blockers and

nesteritide in the management of acute, chronic and

refractory heart failure and in patients with asymptomatic

left ventricular dysfunction. (PC, MK)

rr. Describe the potential value of combination

pharmacotherapy in patients with heart failure. (PC, MK)

ss. Discuss the effect of pharmacotherapy on survival in


tt. Describe therapeutic endpoints in the treatment of heart

failure. Also discuss factors which may adversely

influence the efficacy of pharmacotherapy. (PC, MK)

108

uu. Discuss the role of hemofiltration, ultrafiltration and

hemodialysis. (PC, MK)

vv. Describe reasonable clinical approaches to the following

presentations of heart failure: mild to moderate heart

failure treated in the outpatient setting, severe heart

failure treated in the inpatient setting, refractory heart

failure, diastolic heart failure, heart failure in patients

with myocardial ischemia, acute cardiogenic pulmonary

edema and high-output heart failure. (PC, MK)

ww.Discuss the role of permanent pacing, biventricular

pacing and implantable cardioverter defibrillator in the

treatment of heart failure.

xx. Describe the rationale for circulatory support in selected

patients with heart failure including criteria for patient

selection. (PC, MK)

yy. Describe the uses and techniques of intra-aortic balloon

counter-pulsation, extra-corporeal membrane

oxygenation (ECMO), external centrifugal and roller

pumps, external pulsatile ventricular assist devices as

implantable left ventricular assist devices. (PC, MK)

zz. Discuss the current status of artificial hearts. (PC, MK)

aaa. Discuss the criteria for proper device selection. Discuss

the clinical results of these devices, both in acute salvage

and as a bridge to transplantation. Discuss management

in acute deterioration and special problems associated

with these devices. (PC, MK)

bbb. Discuss determinants of survival in patients requiring

mechanical circulatory support including those with

cardiogenic shock (post MI and post-pericardiotomy) and

as a bridge to transplantation. (PC, MK)



modules, and computer programs relating to acute and

chronic congestive heart failure. (PC, MK)

109


in the Cardiology Clinics, and in the Cardiac

Catheterization, EKG and Echocardiography Lab-

oratories. (PC, MK)

c. Attendance at the Core Curriculum Conference Lecture

Series, Cardiology Grand Rounds, EKG/Electrophysio-

logy Conference, Echocardiography Conference, Cardiac

Catheterization Conference and Journal Club. (PC, MK)


sections devoted to acute and chronic congestive heart

failure. (PC, MK)






t. Heart and Heart-Lung Transplantation


a. Provide a historical perspective for heart and heart-lung

transplantation. (PC, MK)

b. Discuss recipient selection relating to heart or heart-lung

transplantation. List indications and criteria for heart and

heart-lung transplantation. Describe the major diagnoses

of patients undergoing heart and heart-lung

transplantation. List contraindications to heart and heart-

lung transplantation. (PC, MK)

c. Discuss management of patients awaiting heart and

heart-lung transplantation. (PC, MK)

d. Discuss evaluation and management of the heart donor or

heart-lung donor. (PC, MK)

e. Describe the operative techniques of heart and heart-lung

transplantation. Distinguish between orthotopic and

heterotopic transplantation. (PC, MK)

110

f. Discuss early post-operative management. Also discuss

early complications including right ventricular failure.

(PC, MK)

g. Describe detection and treatment of allograft rejection.

(PC, MK)

h. Discuss the value and limitations of endomyocardial

biopsy in heart transplant patients. (PC, MK)

i. Discuss the specific treatment if acute rejection. (PC,

MK)

j. Discuss the immuno-suppressive agents used in heart and

heart-lung transplant patients. Describe the

complications of immuno-suppressive therapy in these

patients including early infection, late infection and

CMV infection. Discuss other complications of

immunosuppressive therapy including cyclosporine and

corticosteroid toxicity. (PC, MK)

k. Discuss the evaluation, clinical significance and

management of graft atherosclerosis. (PC, MK)

l. Discuss late follow up of the heart and heart-lung

transplant patient. Include discussions of methods of

surveillance for rejection and its treatment. (PC, MK)

m. Describe current survival expectations for heart and

heart-lung transplant recipients. (PC, MK)

n. Describe the physiology of the transplanted heart. (PC,

MK)

o. Discuss the issue of re-transplantation. (PC, MK)



modules and computer programs relevant to heart and

heart-lung transplantation. (PC, MK)

b. Attendance at Core Curriculum Conference, and Journal

Club. (PC, MK)

111

c. Participation in a cardiac transplantation elective. (PC,

MK)


heart and heart-lung transplantation. (PC, MK)


a. Direct observation by heart transplant faculty during

elective rotations.



u. Syncope and Pre-syncope


a. Define syncope and pre-syncope. (PC, MK)

b. Provide a differential diagnosis of syncope and pre-

syncope. (PC, MK)

c. List the cardiovascular causes of syncope including

reflex forms, arrhythmias, conduction disturbances and

obstructive forms. Discuss how the following disorders

produce syncope or pre-syncope: reflex forms

(vasodepressor or neurcardiogenic syncope, carotid sinus

hypersensitivity, micturition and defecation syncope,

cough syncope, stretch syncope, diver’s syncope, and

swallow syncope), arrhythmias and conduction

disturbances (ventricular tachycardia, supraventricular

tachyarrhythmias, arrhythmias associated with sinus node

dysfunction, high degree AV block, bifascicular block),

obstructive carotid stenosis, hypertrophic

cardiomyopathy, pulmonary hypertension, pulmonic

stenosis, mitral stenosis, left atrial myxoma, Valsalva’s

maneuver, chronic venous insufficiency);

cerebrovascular (subclavian steal syndrome,

cerebrovascular insufficiency, the Klippel-Feil

abnormality, cervical osteoarthritis, syncope migraine,

diffuse cerebral vasoconstriction associated with

hyperventilation or severe hypertension, autonomic

insufficiency; pharmacologic (drugs that produce

112

autonomic insufficiency, drugs that produce pre-load

reduction); hypovolemia, metabolism (hypoxia,

hyperventilation, hypoglycemia); psychiatric (panic

disorder, hyperventilation and conversion reaction). (PC,

MK)

d. List the causes and pathophysiology of orthostatic hypo-

tension. Differentiate clinical features of those with and

without autonomic insufficiency. (PC, MK)

e. Discuss the importance of the history and physical

examination in the evaluation of syncope and pre-

syncope. (PC, MK)

f. Discuss the relative contributions of the following non-

invasive tests in the evaluation of syncope and pre-

syncope: the resting EKG, the chest x-ray; 24 hour

ambulatory EKG monitoring, event monitoring,

implantable loop recorders the signal-averaged EKG, the

echocardiogram, the stress test and the tilt table test. (PC,

MK)

g. Discuss the evaluation of the patient with suspected

autonomic insufficiency. (PC, MK)

h. Discuss the indications for and usefulness of invasive

electrophysiology studies in patients with syncope and

pre-syncope. (PC, MK)

i. Discuss the importance of age in the evaluation of

syncope and pre-syncope. (PC, MK)

j. Provide an alogorthim for the evaluation of syncope and

pre-syncope. (PC, MK)



modules and computer programs dealing with syncope

and pre-syncope. (PC, MK)

b. Clinical experience gained on the Inpatient Cardiology

Services, Cardiology and Pacemaker Clinics, EKG

Laboratory, Electrophysiology Laboratory and

Echocardiography Laboratory. (PC, MK)

113


Grand Rounds, EKG/Electrophysiology Conference, and

Journal Club. (PC, MK)


syncope and pre-syncope. (PC, MK)






v. Hypotension and Shock


a. Define hypotension and shock. (PC, MK)

b. Provide a differential diagnosis of causes of hypotension

and shock. (PC, MK)

c. Discuss hemodynamic parameters as they apply to

hypotension and shock including arterial pressure, blood

flow and perfusion, transportation of nutrients and

clinicopathologic correlations. (PC, MK)

d. Describe hemodynamic alterations in hypotension and

shock. (PC, MK)

e. Describe myocardial function in hypotension and shock.

(PC, MK)

f. Discuss oxygen consumption and anaerobic metabolism

in hypotension and shock. Include discussions of

elevated blood lactate, metabolic and endocrine

abnormalities and the role of other mediators (kinins,

histamine, serotonin, arachadonic acid, prostaglandins,

endorphins, lipid A and complement). Describe the

immunologic mechanisms in hypotension and shock.

Also describe secondary effects of shock on the heart,

114

kidneys, skeletal muscle, liver, pancreas, blood and brain.

(PC, MK)

g. Provide a clinical classification of shock. (PC, MK)

h. Describe and discuss general principles in the diagnosis

and management of shock. Emphasize ventilation,

perfusion, and cardiac pump function. (PC, MK)

i. Discuss the use of the standardized fluid challenge

pneumatic anti-shock garments and the Swan-Ganz

catheter in the evaluation and/or management of shock.

(PC, MK)

j. Describe and discuss the etiologies, pathophysiology,

clinical and hemodynamic features, differential

diagnosis, prognosis and management of cardiogenic

shock. Discuss the use of inotropes, diuretics and

vasodilators and methods to achieve myocardial

reperfusion such as the intra-aortic balloon pump.

Describe and discuss the role of PCI and CABG in the

treatment of cardiogenic shock. (PC, MK)

k. Describe and discuss the etiologies, pathophysiology,

clinical features and management of hypovolemic shock.

Discuss the shock relating to compensatory volume,

shifts and anaphylaxis. (PC, MK)

l. Describe and discuss the etiologies, pathology,

pathophysiology, clinical and hemodynamic

manifestations, laboratory abnormalities, prognosis and

management of shock related to gram-negative sepsis,

septic shock caused by other organisms, toxic shock and

obstructive shock. (PC, MK)



modules, and computer programs relating to hypotension

and shock. (PC, MK)

b. Clinical experience gained in the Inpatient Cardiology

Services and in the Cardiac Catheterization Laboratory.

(PC, MK)

115

c. Attendance at the Core Curriculum Lecture Series,

Cardiology Grand Rounds and Cardiac Catheterization



hypotension and shock. (PC, MK)






w. Traumatic Heart Disease


a. Provide a differential diagnosis of myocardial,

pericardial, valvular, coronary arterial and arrhythmic

complications of blunt cardiac trauma. Describe the

clinical presentations, natural history, diagnosis and

management of each complication. (PC, MK)

b. Describe the complications of CPR as they relate to

cardiac trauma. (PC, MK)

c. List the causes of penetrating cardiac trauma. Describe

the clinical features, diagnosis and management of

penetrating cardiac trauma involving the myocardium,

pericardium, valves and coronary arteries. Describe the

peri- and post-operative prognosis of patients with such

injuries. (PC, MK)

d. Provide a rational evaluation scheme for patients with

suspected cardione trauma.



modules and computer programs dealing with traumatic

heart disease. (PC, MK)

116

b. Clinical experience gained in the Cardiology Inpatient

Services, in the Echocardiography Laboratory, and in the

Cardiac Catheterization Laboratory. (PC, MK)

c. Clinical experience gained on the cardiology consultation

service, on the coronary care unit rotation, in the

echocardiography laboratory and on the cardiac

catheterization laboratory. (PC, MK)


traumatic heart disease. (PC, MK)


a. Direct observation by faculty in the aforementioned

clinical venues and conferences.



x. Diseases of the Aorta, Peripheral Vessels, and Cerebral Vessels


a. Describe the structure and functions of the normal aorta.

(MK)

b. Be able to examine the aorta in health and disease. (PC,

MK)

c. Describe the pathogenesis of aortic disease in general.

(PC, MK)

d. Describe the etiology, pathology, pathogenesis, clinical

manifestations, imaging findings, diagnosis sizing,

natural history, surgical management, peri-operative

management, operative risk and complications of

atherosclerotic abdominal and thoracic aortic aneurysms.

(PC, MK)

e. Describe the etiologies, pathology, pathophysiology,

symptoms, signs, radiographic abnormalities,

echocardiographic abnormalities, CT and MRI

abnormalities, contrast aortographic abnormalities,

hematologic abnormalities, natural history and

117

management of acute and chronic aortic dissection.

compare and contrast trans-esophageal

echocardiography, CT, cine MRI and aortography in the

diagnosis of dissection. Provide specific indications for

endovascular, surgical and medical therapy in acute and

chronic aortic dissection with special reference to

classification. Describe indications for endovascular

interventions in aortic dissection and characterize the

procedures. Discuss the outcomes of these

recommendations. Discuss specific medical therapy

during the acute phase of and for the long-term in aortic

dissection. (PC, MK)

f. Discuss the etiologies, pathology, pathophysiology,

clinical manifestations, diagnosis, and natural history of

annulo-aortic ectasia. (PC, MK)

g. Discuss the etiologies, pathology, pathophysiology,

clinical features, diagnosis, complications, natural

history, and management if each of the following:

vasculitic syndromes affecting the aorta; Takayasu’s

arteritis, giant cell arteritis and aortitis associated with

ankylosing spondylitis, psoriasis, inflammatory bowel

disease, Reiter’s syndrome, relapsing polychondritis and

Bechet’s syndrome. (PC, MK)

h. Discuss the pathology, pathophysiology, clinical

manifestations, diagnosis (especially radiographic and

angiographic), natural history, and management of

cardiovascular syphilis. (PC, MK)

i. Describe the etiologies, pathology, pathophysiology,

clinical manifestations, diagnosis and treatment of

pseudo-coarctation of the aorta. (PC, MK)

j. Describe the spectrum of aortic trauma. Describe the

etiologies, pathology, pathophysiology, clinical

manifestations, diagnosis (including radiographic

features), course, prognosis and management of blunt

and penetrating aortic trauma. (PC, MK)

k. Discuss the etiologies, pathology, pathophysiology,

clinical manifestations, diagnosis and management of

acute aortic embolism. Also discuss these features in

118

patients with aortic thrombosis and atheromatous emboli

as above. (PC, MK)

l. Discuss the pathogenesis, clinical manifestations,

diagnosis and management of aortic bacterial infections.

(PC, MK)

m. Describe and discuss the endemiology and clinical

presentations of peripheral arterial disease including

claudication, variants of claudication and critical limb

ischemia. (PC, MK)

n. Describe and be able to perform an arterial examination

including assessment of/for pulses, aneurysms, and

bruits. Describe the Allen test, Adson’s maneuver, the

hyperabduction maneuver, the costocervical maneuver,

and timing of elevation pallor and refilling in the lower

extremities. List the causes of claudication. Describe

skin abnormalities associated with peripheral arterial

vascular disease. (PC, MK)

o. Describe the etiology, pathology, pathophysiology,

natural history, clinical manifestations, differential

diagnosis, laboratory evaluation, medical management, ,

percutaneous catheter-based treatment, endovascular

management and surgical management of chronic arterial

occlusial disease. (PC, MK)

p. Describe the etiologies, pathology, pathophysiology,

clinical manifestations, laboratory and cardiographic

assessment, and medical and surgical management of

acute arterial occlusion. (PC, MK)

q. Describe the etiologies, pathology, pathophysiology,

clinical manifestations, laboratory diagnosis and

management of microcirculatory disorders including

traumatic occlusial disease, microembolism (due to

instrumentation, surgery or anti-coagulation), vasculitis,

hematologic disease, ergot toxicity, cold injury,

malignancy, hepatitis B antigenemia, polycythemia rubra

vera, thrombocythemia, intravascular coagulapathy,

cryoglobulins, cold agglutinins, lupus anti-coagulant,

TTP and heparin-induced thrombocytopenia. (PC, MK)

119

r. Describe and discuss the etiologies, pathology,

pathogenesis, natural history, clinical manifestations,

laboratory diagnosis and management of peripheral

vasospastic disorders including Raynaud’s phenomenon,

livedo reticularis and acrocyanosis and Buerger’s disease.

(PC, MK)

s. Discuss the etiology, pathogenesis, clinical

manifestations, natural history, laboratory diagnosis and

management of aneurysmal disease and upper extremity

arterial disease. (PC, MK)

t. Describe and discuss the etiologies, pathology and

pathogenesis, clinical manifestations, natural history,

laboratory diagnosis imaging and medical and surgical

management of peripheral venous disease including

varicose veins, superficial thrombophlebitis, deep vein

thrombophlebitis and thrombosis, the post-phlebitic

syndrome, central venous thrombosis, chronic venous in-

sufficiency and acute venous thrombosis of the inferior

vena cava or iliac veins. (PC, MK)

u. Provide a differential diagnosis for causes for a swollen

leg. (PC, MK)

v. Describe and discuss the cardiac sources for peripheral

and cerebral embolism. (PC, MK)

w. Describe and discuss the etiologies, pathology,

pathophysiology, clinical manifestations, natural history,

laboratory diagnosis and management of cerebral

embolism. (PC, MK)

x. Describe and discuss the etiologies, pathology,


laboratory diagnosis and management of thrombotic

cerebral infarction. (PC, MK)

y. Describe and discuss the etiologies, pathology,


laboratory diagnosis and management of subarachnoid

hemorrhage, intracerebral hemorrhage and hemorrhage

from an AV malformation. (PC, MK)

120

z. Describe and discuss the etiologies, pathology,


laboratory diagnosis and management of cerebral

vasculitis and mycotic intra-cerebral aneurysms. (PC,

MK)

aa. Describe and discuss the etiologies, pathology,


laboratory diagnosis and management of the subclavian

steal syndrome. (PC, MK)

bb. Describe the causes and clinical sequelae to diffuse

cerebral vasoconstriction. (PC, MK)



modules and computer programs relevant to aortic,

peripheral and cerebrovascular disease. (PC, MK)

b. Attendance at Core Curriculum Conference, Cardiology

Grand Rounds, Echocardiography Conference and

Cardiac Catheterization Conference. (PC, MK)

c. Clinical experience gained on the Cardiology Inpatient

Services in the Cardiac Catheterization Laboratory and in

the Echocardiography Laboratory. (PC, MK)

d. Attendance at national meeting with sections devoted to

aortic, peripheral and cerebrovascular disease. (PC, MK)






y. Pulmonary Heart Disease


a. Describe the pathology, etiologies, pathogenesis and

pathophysiology of pulmonary embolism and infarction

121

with special emphasis on primary and secondary

hypercoagulable states and deep venous thrombosis. (PC,

MK)

b. Describe the clinical presentation of pulmonary

embolism and infarction. Provide a differential diagnosis

for acute and chronic forms based on the history. (PC,

MK)

c. Describe the physical examination in patients with

pulmonary embolism and infarction. (PC, MK)

d. Describe electrocardiographic and scintigraphic findings

in pulmonary embolism and infarction. (PC, MK)

e. Describe hemodynamic and pulmonary findings in

pulmonary embolism and infarction. Describe the role of

pulmonary angiography in diagnosis. (PC, MK)

f. Describe the role of echocardiography, digital subtraction

angiography, helical CT, MRI and fiberoptic angioscopy

in the diagnosis and management of pulmonary

embolism and infarction. (PC, MK)

g. Provide a management algorithm for patients with acute

pulmonary embolism and infarction. (PC, MK)

h. Describe the role of unfractionated and low molecular

weight heparins, warfain and thrombolytic therapy

(streptokinase, urokinase, t-PA) in patients with

pulmonary embolism and infarction. Cite complications

of anticoagulant therapy. provide specific dose regimens

and guidelines for intensity of anti-coagulation.

Differentiate when anti-coagulation vs. thrombolytic

therapy should be used. Discuss the use of adjunctive

medical therapy (oxygen, pressors, analgesics). (PC, MK)

i. Discuss the procedures and devices used to provide vena

cava interruption. List the indications for vena cava

interruption. (PC, MK)

j. Discuss the role of pulmonary embolectomy in patients

with acute and chronic recurrences of pulmonary

embolism. (PC, MK)

122

k. Discuss the concept of prevention of pulmonary

embolism including the use of heparins, warfain, aspirin,

elastic stockings, intermittent pneumatic compression,

inferior vena cava interruption, and use of combined

modalities in surgical and medical patients. Provide a

strategy for prophylaxis in such patients. (PC, MK)

l. Define chronic pulmonary hypertension and cor

pulmonale. (PC, MK)

m. Discuss normal right ventricular structure and function.

Also discuss normal pulmonary vascular anatomy and

the physiology of the normal pulmonary circulation.

Discuss the determinants of pulmonary gas exchange and

the distribution of pulmonary blood flow, distribution of

ventilation, ventilation and perfusion ratios and other

causes of abnormal arterial blood gases (i.e. alveolus,

hypoventilation). Describe the effects of gas tension on

the pulmonary circulation including the effects of

hypoxia and acidosis. (PC, MK)

n. Describe the pathology, pathophysiology, causes, clinical

manifestations, electrocardiographic abnormalities, radio-

graphic abnormalities, echocardiographic abnormalities,

hemodynamic abnormalities and angiographic

abnormalities of chronic pulmonary hypertension.

Discuss the incidence, etiology, pathophysiology

(including right and left ventricular dynamics), clinical

manifestations (EKG findings, radiographic findings,

scintigraphic findings, echocardiographic findings,

hemodynamic findings, angiographic findings), natural

history and management of chronic cor pulmonale with

special emphasis on the use of oxygen, diuretics,

vasodilators, phlebotomy and digitalis. Also provide

special emphasis on cor pulmonale associated with

chronic obstructive lung disease, the

obesity/hypoventilation syndrome, the sleep apnea

syndrome, primary alveolar hyperventilation, chronic

mountain sickness, upper airway disorders,

bronchiectasis fibrosis, restrictive lung diseases and

disorders of the neuromuscular apparatus and chest wall.

(PC, MK)


123


modules, and computer programs dealing with

pulmonary heart disease. (PC, MK)


Services, in the Cardiology Clinics and in the EKG and

Echocardiography Laboratories. (PC, MK)

c. Attendance at Core Curriculum Conference, Journal

Club, Cardiology Grand Rounds,

EKG/Electrophysiology Conference, Echocardiography

Conference, Nuclear Cardiology Conference and Cardiac

Catheterization Conference. (PC, MK)


pulmonary heart disease. (PC, MK)






z. Medical Management of Cardiac Surgery Patients and Risk Assessment

of Cardiac Patients Undergoing Non-Cardiac Surgery


a. Describe the pre-operative evaluation of patients

undergoing cardiac surgery. Include discussions of the

patient’s knowledge base, general medical condition,

hemodynamic compensation, risk of myocardial

ischemia, anesthesia, cardiac rhythm status and drug

therapy. (PC, MK)

b. Describe principles of nutritional support in cardiac

surgery patients. (PC, MK)

c. Provide a list of risk factors for adverse outcomes in

patients undergoing cardiac surgery. (PC, MK)

d. Provide the general sequence of elective cardiac

operations. (PC, MK)

124

e. Describe post-operative management of cardiac surgery

patients. Include discussions of fluid and electrolyte and

acid-based management, respiratory management (effects

of anesthesia, sternotomy and cardiopulmonary bypass

ventilator management), management of pathogenesis,

clinical features and special problems (pulmonary edema,

underlying chronic lung disease, diaphragmatic failure,

prolonged ventilatory insufficiency, hypertension, peri-

operative myocardial infarction, low output syndrome

and shock states, cardiac arrhythmias, hemostatic

disturbances, infection (wound, mediastinitis, infective

endocarditis, viral, fungal) peripheral vascular

complications, pericarditis, renal failure, gastrointestinal

complications, neurological complications, chylothorax

and chylopericardium. (PC, MK)

f. Discuss early rehabilitation of cardiac surgery patients

and preparation for discharge. (PC, MK)

g. Be able to evaluate cardiac surgery patients and manage

all of the aforementioned complications and sequelae.

(PC, MK)

h. Describe the cardiovascular effects of currently-used

general anesthetics (inhalation agents, intravenous

agents, muscle relaxants), spinal anesthetics and epidural

anesthesia. Place specific emphasis on intra-operative

hemodynamics and arrhythmias. (PC, MK)

i. Discuss the physiological effects, direct consequences,

and expected responses to non-cardiac surgery. Include

implications of the type of the operation, duration of the

surgery and emergency surgery. (PC, MK)

j. Discuss the assessment of peri-operative cardiac risk of

patients with ischemic heart disease including that

imposed by prior myocardial infarction, stable and

unstable angina, the type of surgery, the location of

surgery, the type of anesthetic, the implications of peri-

operative myocardial infarction, the role of rhythm

monitoring and the role of hemodynamic monitoring.

Provide recommendations concerning evaluation and

management of patients undergoing major vascular

surgery as it applies to ischemic heart disease. Provide

125

recommendations concerning the use and effects of anti-

ischemic medications in the peri-operative period. Be

able to diagnose and manage peri-operative myocardial


k. Describe current AHA/ACC guidelines for patients with

heart disease who are undergoing non-cardiac surgery

with special emphasis on functional capacity and current

ischemia status. Provide an algorithm for evaluation of

such patients. (PC, MK)

l. Discuss the peri-operative risks imposed by the presence

of various forms of valvular heart disease with special

emphasis on severe aortic and mitral stenosis in patients

undergoing non-cardiac surgery. State current guidelines

for infective endocarditis prophylaxis. Discuss the peri-

operative management of patients with prosthetic heart

valves with special emphasis on anti-coagulation. (PC,

MK)

m. Discuss the influences of systemic hypertension on peri-

operative risk. Describe the effect of anti-hypertensive

medications on hemodynamics in patients undergoing

non-cardiac surgery. Provide recommendations

concerning the use of anti-hypertensive medications peri-

operatively. Discuss the potential complications and

management of post-operative hypertension. (PC, MK)

n. Discuss the peri-operative risks associated with dilated,

hypertrophic and restrictive cardiomyopathies. Provide

recommendations to reduce risk peri-operatively in

patients with these diseases. (PC, MK)

o. Discuss the peri-operative risks associated with acute

pericarditis, pericardial effusion and constrictive

pericarditis. Provide recommendations to reduce peri-

operative risks in such individuals. (PC, MK)

p. Discuss the peri-operative cardiac risks associated with

congenital heart disease and severe pulmonary hyper-

tension in patients undergoing non-cardiac surgery.

Discuss infective endocarditis prophylaxis in such

individuals. Provide contraindications to surgery in such

individuals. Provide recommendations aimed at reducing

126

peri-operative cardiac risks in such individuals. (PC,

MK)

q. Discuss the peri-operative risk associated with congestive

heart failure in patients undergoing non-cardiac surgery,

Discuss the role of hemodynamic monitoring. Provide

recommendations aimed at reducing peri-operative risk

in patients undergoing non-cardiac surgery. (PC, MK)

r. Discuss the evaluation, management and risk of

implications of pre-operative, peri-operative, and post-

operative cardiac arrhythmias and conduction

disturbances. Place special emphasis on ventricular

premature beats, ventricular tachycardia, atrial

fibrillation, sinus node dysfunction and bifascicular

block. Also discuss the implications of a permanent

pacemaker. (PC, MK)

s. Discuss the effects of common medical conditions on

cardiac risk in patients undergoing non-cardiac surgery.

(PC, MK)

t. Describe the role of the cardiology consultant in the

evaluation and management of the patient undergoing

non-cardiac surgery. (PC, MK)

u. Become familiar with and be able to utilize the Goldman,

Zeldin, Detsky and Jeffrey classifications. Be able to

utilize their criteria to estimate peri-operative cardiac

risk. (PC, MK)



modules and computer programs pertaining to medical

management of cardiac surgery and cardiovascular risk

management in patients undergoing non-cardiac surgery.

(PC, MK)


Services, in the Cardiac Catheterization Laboratory, and

in the Cardiology Clinic. (PC, MK)

c. Attendance at the Core Curriculum Lecture Series and


127


medical management of cardiac surgery patients and

cardiovascular risk assessment in patients undergoing

non-cardiac surgery. (PC, MK)






aa. Pregnancy and the Heart


a. Describe the cardiovascular physiological changes during

pregnancy and the peripartum period. Place emphasis on

blood volume, cardiac output, stroke volume, heart rate,

blood pressure, and systemic vascular resistance.

Describe the hemodynamic changes during labor and

delivery and during cesarean section. Describe

hemodynamic changes post-partum and in response to

exercise. (PC, MK)

b. Describe the cardiovascular history in pregnant women.

Discuss how normal symptoms of pregnancy may be

misinterpreted as symptoms of cardiovascular disease.

(PC, MK)

c. Describe the cardiovascular examination in pregnant

women. Include discussions of normal auscultatory

changes with special emphasis on systolic murmurs. (PC,

MK)

d. Apply the NYHA classification to pregnant women.

Relate functional class to maternal cardiovascular risk

during pregnancy. (PC, MK)

e. Describe normal changes in the EKG, chest x-ray and

echocardiogram during pregnancy. Describe the safety

(or lack thereof) of stress testing, pulmonary artery

catheterization, cardiac catheterization and angiography

128

and radionuclide cardiac imaging during pregnancy. (PC,

MK)

f. Discuss the maternal and fetal risks associated with

congenital heart disease in pregnant women. Include

atrial septal defect, ventricular septal defect, patent

ductus arteniosis, congenital aortic valve disease,

coarctation of the aorta, pulmonic stenosis, tetralogy of

Fallot, Ebstein’s anomaly, complex cyantotic congenital

heart disease, and Eisenmenger’s syndrome. Describe

pre-conception counseling, labor and delivery and

antibiotic prophylaxis in such individuals. (PC, MK)

g. Discuss the implications of acute rheumatic fever and

chronic rheumatic heart disease with special emphasis on

mitral and aortic valve disease. Also discuss the

implications of mitral valve prolapse in pregnancy. List

the indications for infective endocarditis prophylaxis.

Discuss the implications of prosthetic heart valves in

pregnant women with special emphasis on anti-

coagulation. (PC, MK)

h. Discuss the risks and management of the Marfan

syndrome in pregnant women. (PC, MK)

i. Discuss the maternal and fetal risks associated with

hypertrophic cardiomyopathy. Describe acceptable

treatment regimens. (PC, MK)

j. Discuss the etiology, pathophysiology, clinical

manifestations, diagnostic laboratory studies, natural

history and management of peripartum cardiomyopathy.

(PC, MK)

k. Discuss the pathogenesis, diagnosis and management of

coronary artery disease and peripartum myocardial


l. Discuss the implications of cardiac arrhythmias and

conduction disturbances during acute myocardial

infarction. Discuss the concept of arrhythmogenesis

during pregnancy. Discuss treatment of maternal

arrhythmias during pregnancy. (PC, MK)

129

m. Discuss the pathogenesis, clinical manifestations,

diagnosis, natural history, and management of aortic

dissection during pregnancy. Provide similar information

for Takayasu’s arteritis. (PC, MK)

n. Describe the implications of primary pulmonary

hypertension and other forms of severe pulmonary

hypertension. Provide recommendations for termination

of pregnancy in patients with severe pulmonary


o. Discuss the risks and benefits of cardiac surgery during

pregnancy. List indications for cardiac surgery during

pregnancy. (PC, MK)

p. Discuss the potential maternal and fetal risks of

cardiovascular drugs during pregnancy. Provide specific

recommendations concerning the use of the following

drugs during pregnancy: cardiac glycosides, luinidine,

procainamide, disopyramide, lidocaine, mexiletene,

amiodarone, calcium channel blockers, beta-blockers,

sodium nitropuasside, organic nitrates, ACE inhibitors,

ARBs, renin blockers aldosterone antagonist diuretics,

anticoagulants, anti-platelet agents and prophylactic

antibiotics. (PC, MK)

q. Be able to evaluate, counsel and manage normal pregnant

women and those with the aforementioned

cardiovascular diseases. (PC, MK)



modules and computer programs dealing with pregnancy

and the heart. (PC, MK)

b. Attendance at the Core Curriculum Lecture Series and


c. Clinical experience gained in the Inpatient Cardiology

Services, in the Cardiology Clinics, in the Cardiac

Catheterization Laboratory and in the EKG and

Echocardiography Laboratories. (PC, MK)

130


pregnancy and the heart. (PC, MK)






bb. Cardiovascular Disease in Women


a. Discuss the relation of gender to the mechanisms of

cardiovascular disease including the role of gender-

related hormones, the relation of gender and genomics to

the vulnerable plaque, gender differences in cardiac and

remodeling and psychological differences between

gender as they relate for cardiovascular disease. (PC,

MK).

b. Compare and contrast the effects of cardiovascular risk

factors between women and men. Include discussions of

diabetic mellitus, the metabolic syndrome, hypertension,

cigarette smoking dyslipidemias and estrogen. Discuss

the evidence that risk factor modification can improve

cardiovascular outcomes in women. (PC, MK).

c. Discuss differences in the clinical approach to chest pain-

based on gender. Also, describe gender-related

differences in the diagnosis and management of chronic

coronary artery disease acute coronary syndromes.

Include discussions of the use of thrombolysis,

percutaneous coronary interventions, CABG, medical

therapy and secondary prevention. (PC, MK).

d. Compare and contrast the demographics, clinical

presentation, diagnosis, natural history, management and

prognosis of peripheral arterial disease. (PC, MK).

e. Describe the relation of gender on cardiac arrhythmias

including gender effects on electrophysiology, causes of

131

syncope, atrial arrhythmias, ventricular arrhythmias and

sudden cardiac death. (PC, MK).

f. Discuss the role of gender in valvular heart disease with

particular emphasis on mitral valve prolapse, rheumatic

valvular disease, non-rheumatic aortic valve disease and

the Marfan and related syndromes. (PC, MK).

g. Compare and contrast the etiology, pathogenesis clinical

presentation, diagnosis, natural history, management and

prognosis of heart failure in women and men. (PC, MK).

h. Discuss gender differences in the process of death and

dying. (PC, MK).


a. Rotations on the Inpatient Cardiology Services,

participation in Cardiology Clinics and rotations in the

Cardiac Catheterization Laboratories.

b. Utilization of textbooks, journals, audiovisual modules,

computer programs relating to cardiovascular disease in

women.

c. Attendance at the Core Curriculum Lecture Services and

Cardiology Grand Rounds.


sections on heart disease in women.


a. Faculty observation at conferences and on clinical

services.



cc. Cardiovascular Disease in the Elderly


a. Discuss the demographics and epidemiology of

cardiovascular disease in the elderly. (PC, MK).

132

b. Discuss potential modification of medications in the

elderly including loading, doses, adverse effects and

schedules. Also, discuss drug-drug interactions,

inappropriate prescribing and adherence issue in the

elderly. (PC, MK)

c. Characterize vascular disease in the elderly. Compare

and contrast the following conditions in the elderly and

younger individuals: systemic hypertension, coronary

artery disease (including acute coronary artery disease

and revascularization, carotid disease and peripheral

arterial disease. Discuss differences in diagnosis

treatment and preventions. (PC, MK)

d. Compare and contrast valvular heart disease in the

elderly, with that in younger people including aortic

stenosis, aortic regurgitation, mitral stenosis, mitral

regurgitation and mitral annular calcification. (PC, MK)

e. Describe heart failure in the elderly. Discuss how cases,

clinical presentation, diagnosis treatment and prognosis

differ from that in younger people. (PC, MK).

f. Describe and discuss cardiac arrhythmias that occur with

high frequency in the elderly including arrhythmias

associated with sinus node dysfunction, AV block, atrial

fibrillation and ventricular arrhythmias. Focus on

pathogensis, clinical presentation and treatment. (PC,

MK)


a. Rotations on the Cardiology Inpatient Services and

experiences in the Cardiology Clinic. (PC, MK)

b. Use of books, journals, audiovisual modules and

computer programs dealing with geriatric cardiology.

(PC, MK)

c. Attendance at the Core Curriculum Lectures and



sections on geriatric cardiology. (PC, MK)

133




b. Observation by faculty on clinical cardiology rotation, in

clinic and at conferences.

dd. Cardiovascular Disease in Athletes


a. List the causes of cardiovascular disease and sudden

cardiac death in athletes ≤ 35 years old and in those > 35

years old.

b. Describe the incidence and prevalence of cardiovascular

disease in athletes. Also discuss gender differences.

c. Provide recommendations for screening for cardiovascular

disease in young athletes.

d. Discuss the clinical and laboratory evaluation of heart

disease in athletes.

e. Describe the physiology and clinical presentation of the

athlete’s heart. Compare and contrast the effects of

isometric and isotonic exercise on the heart.

f. Provide specific guidelines for limitation of activity in

prospective athletes with heart disease with special

emphasis on hypertrophic cardiomyopathy, valvular

heart disease, congenital heart disease and cardiac

arrhythmias.


a. Rotation on the Cardiology Inpatient Services and

participation in Cardiology Clinics. (PC, MK).

b. Utilization of textbooks, journal, audiovisual modules, and

computer programs relating to cardiovascular disease in

athletes. (PC, MK).

134


Echocardiography Conference, EKG-Conference,

Cardiology Grand Rounds and Fellows Conference. (PC,

MK).

d. Attendance at regional and national meeting with sections

on cardiovascular disease in athletes.




b. Observation by faculty on clinical cardiology rotations in

clinic and at conferences.

ee. Rheumatic Disease and the Cardiovascular System


a. Describe the pathogenesis, biology, clinical features,

diagnosis, natural history, management and prognosis of

the following large vessel vasculitides that may affect the

heart: giant cell arteritis, Kawasaki’s syndrome,

Takayasu’s arteritis and idiopathic aortitis.

b. Provide similar information for medium to small vessel

vascultitides including Churg-Strauss disease and

polyarteritis nodosa.

c. Describe the cardiovascular complications of rheumatoid

arthritis with special emphasis on the valves and

pericardium. Discuss the pathogenesis, clinical features,

diagnosis and management of these complications.

d. Discuss the cardiovascular complications of systemic

lupus erythematosus with special emphasis on

pericardial, valvular, myocardial, coronary artery and

conduction system complications. Discuss their

pathogenesis, clinical features, diagnosis and

management. Describe the antiphospholipid syndrome

including its treatment.

135

e. Describe the cardiovascular complications of scleroderma

and its variants with special emphasis on the coronary

arteries, myocardium, pulmonary arteries and the

conduction system. Compare and contrast the

pathogenesis, pathology, clinical features, natural history,

management and prognosis of heart disease associated

with progressive systemic sclerosis with that of the

CREST syndrome.

f. List the cardiac complications of polymyositis/

dermatomyositis with special emphasis on the conduction

system and myocarditis. Describe the clinical features

diagnosis and treatment of their complications.

g. Describe the cardiovascular complications of mixed

connective tissue disease with special emphasis on

pericardial and pulmonary arterial complications. Discuss

management of these complications.

h. Describe the cardiovascular complications of ankylosing

spondylitis concluding aortitis, aortic valve insufficiency

and conduction system disease. Provide similar

information for the other spondyloarthropathies.

i. Discuss the pathogenesis, pathology, clinical features,

diagnosis, (including laboratory) natural history,

management (early and late), prevention

(primary/secondary) and prognosis of acute rheumatic

fever. List the major and minor Jones criteria. List the

major long-term complications of acute rheumatic fever.

j. Describe the pathogenesis, pathology, clinical features,

diagnosis and natural history of sarcoidosis with special

emphasis on the myocardium, the conduction system and

pulmonary heart disease. Describe treatment as it pertains

to the heart.


a. Rotations on Inpatient Cardiology Services, participation

in Cardiology Clinics, and experience in the Clinical

Laboratories. (PC, MK).

136

b. Textbooks, journal, audiovisual modules, and computer

programs relating to rheumatic disease and the

cardiovascular system. (PC, MK).


Grand Rounds and Fellows Conference. (PC, MK).

d. Attendance at regional and national meetings with sections

devoted to rheumatic disease and the heart. (PC, MK).




b. Observation by faculty on clinical rotations in clinic and at

conferences.

ff. Diabetes Mellitus and Heart Disease


a. Describe the role of diabetes mellitus in acceleration of

atherogenesis.

b. Discuss the relation of diabetes mellitus to acute coronary

syndromes. Describe the effects of diabetes mellitus on the

clinical presentation and management of acute coronary

syndromes. (PC, MK).

c. Discuss the effects of sulfonylureas, thiazolidinediones

and metformin on the heart with special emphasis on their

effects on heart failure and cardiovascular disease. (PC,

MK).

d. Compare and contrast the outcomes of percutaneous

coronary revascularization and CABG in diabetics and

non-diabetics. (PC, MK).

e. Describe the pathophysiology and clinical manifestations

of cardiovascular autonomic neuropathy associated with

diabetes mellitus Cite the effect of cardiac autonomic

neuropathy on cardiovascular risk. (PC, MK).

137

f. Describe the relation of diabetes mellitus to heart failure.

Discuss the epidemiologic pathologic and pathophysiologic

and clinical evidence for diabetic cardiomyopathy.

Describe measures that reduce the risk of heart failure in

diabetes mellitus. Discuss the importance of blood pressure

control, beta-blockade, ACE inhibitors, ARB’s and

aldosterone antagonist in the treatment of heart

failure in diabetes mellitus. (PC, MK).


a. Clinical rotations on Cardiology Inpatient Services and


b. Core Curriculum Lecture series, Cardiac Catheterization

Conference, and Cardiology Grand Rounds. (PC, MK).

c. Attendance at regional and national cardiovascular

meetings with sections on diabetes mellitus and the heart.

(PC, MK).

d. Utilization of textbooks, journals, audiovisual modules

and computer programs relating to diabetes mellitus and

the heart. (PC, MK).


a. Performance of the ABIM Certifying Examination in


b. Observation by faculty on rounds and at conferences.

gg. Endocrine Disorders and the Heart


a. Describe the normal effects of growth hormone, adrenal

corticostesoids and ACTH, thyroid hormone, parathyroid

hormone and sex hormones on the heart. (PC, MK).

b. Cite the cardiovascular manifestations of acromegaly and

discuss their diagnosis and therapy. (PC, MK).

138

c. Describe and discuss the cardiovascular manifestations of

Cushing’s disease including their diagnosis and therapy.

(PC, MK).

d. Describe the cardiovascular effects of hyperaldosteronism

with special references to hypertension. Discuss diagnosis

and treatment of Conn’s Syndrome. (PC, MK).

e. List the cardiovascular manifestations of Addison’s

disease and describe their diagnosis and treatment. (PC,

MK).

f. Describe the cardiovascular effects of hyperparathyroidism

and hypopacathroidism with special reference to hyper-and

hyppocalemia. Discuss their diagnosis and treatment.

(PC, MK).

g. Describe the cardiovascular effect of hyperthyroidism

including thyroid hormone catecholamine interactions and

hemodynamic alterations. Discuss the role of atrial

fibrillation and heart failure in hyperthyroidism. Cite the

cardiovascular manifestations of hyperthyroidism and

discuss their diagnosis and treatment. (PC, MK).

h. Describe the cardiovascular manifestation of

hypothyroidism including their diagnosis and treatment.

Discuss the effect of hypothyroidism or serum lipids and

on metabolism of cardiovascular drugs. Discuss the effects

of cardiovascular or thyroid function. (PC, MK).

i. Cite the cardiovascular manifestations of

pheocromocytoma with special reference to hypertension and cardiac

arrhythmias. (PC, MK).

j. Discuss the effects of excessive quantities of testosterone,

and estrogen/progestin on the heart. (PC, MK).


a. Cardiology Inpatient services and participation in

Cardiology Clinics (PC, MK).


and computer programs relating to endocrine disorders and


139


Cardiology Grand Rounds and Fellows Conference.


devoted to endocrine disorders and the heart. (PC, MK).




b. Observation by faculty on clinical rotations and at

conferences.

hh. Obesity and the Heart


a. Describe the hemodynamic effects of obesity and their

effect on cardiac structure and function. (PC, MK).

b. Describe the development of heart failure in obese persons

with special reference to obesity cardiomyopathy. Describe

the pathogenesis, clinical features, diagnosis and

treatment of obesity cardiomyopathy. (PC, MK).

c. Cite evidence that obesity is a cardiovascular risk factor

with special reference to the metabolic syndrome. (PC,

MK).

d. Discuss the use of PCI, CABG and valve surgery in obese

persons with emphasis in morbidity and mortality. (PC,

MK).

e. Describe the pathogenesis, clinical features and treatment

of obesity hypertension and discuss its effect on cardiac

structure and function. (PC, MK).

f. Describe the endocrine and metabolic effects of obesity

and the heart and discuses their cardiovascular

implications. (PC, MK).


140

a. Rotation on Cardiology Inpatient Services and



and computer programs relating to obesity and the heart.

(PC, MK).

c. Attendance at Core Curriculum Lecture Series, Research

Conference, Cardiology Grand Rounds and Fellows

Conference.

d. Attendance at regional and national conferences with

sections devoted to obesity and the heart. (PC, MK).




b. Observation by faculty in clinical rotations and at

conferences and by faculty research mentors.

ii. Cancer and the Heart


a. Describe the etiology, pathogenesis, clinical

manifestations, diagnosis (clinical and laboratory),

differential diagnosis, treatment and prognosis of direct

complications of neoplasia including cardiac tamponade,

constrictive pericarditis, superior vena cava obstruction,

valvular heart disease, ischemic heart disease and cardiac

arrhythmias.

b. Cite and discuss indirect cardiovascular complications of

cancer. Include discussions of hyperviscosity,

thrombocytosis, leukocytosis, and plasma proteins.

c. Describe the pathogenesis, clinical manifestations,

diagnosis, treatment, prognosis and prevention of cardiac

complications of chemotherapy including anthracycline

cardiotoxicity, hercetpin cardiotoxicity, cyclophosphamide

cardiotoxicity, taxane toxicity, doxorubicin and paclitaxel

combinations, all-trans-retinoic acid syndrome, 5

141

fluorouracil toxicity, cisplatin toxicity, interferon toxicity

interleukin-2 toxicity and granisetron toxicity.

d. List cardiac complications of radiation therapy. Describe

their clinical and laboratory features and therapy. Discuss

prevention of radiation cardiotoxicity.

e. Discuss cardiac complications of combined radiation and

drug-related cardiotoxcity.

f. Discuss cardiac involvement of lymphoma and Kaposi’s

sarcoma in the setting of AIDS.


a. Clinical rotations in the Cardiology Inpatient Services and

participation in Cardiology Clinics.

b. Attendance at Core Curriculum Lecture Series, Cardiology

Grand Rounds, Echocardiography Conference, EKG

Conference and Fellows Conference. (PC, MK).

c. Utilization of textbooks, journals, audiovisual modules and

computer programs relating to cancer and the heart. (PC,

MK).


devoted to cancer and the heart. (PC, MK).





conferences.

jj. Cardiovascular Implications of Renal Disease


a. Discuss the relation of chronic kidney disease (CKD) to

cardiovascular risk. Cite evidence showing increased

cardiovascular risk at all levels of CKD. Describe the

vascular biology of chronic kidney disease. (PC, MK).

142

b. Cite important cardiovascular causes of morbidity and

mortality in stages 4 and 5 CKD. (PC, MK).

c. Describe the pathogenesis, etiology, clinical and laboratory

features and diagnostic criteria for contrast-induced

nephropathy in patients undergoing coronary and other

vascular interventions. Cite the risk factors for contrast

induced nephropathy and describe measures designed to

reduce the risk of contrast induced nephropathy. Describe

treatment of contrast-induced nephropathy. Discuss the

prognosis of contrast-induced nephropathy. (PC, MK).

d. Describe the specific effects of CKD on the hear. Compare

and contrast cardiovascular effects of hemodialysis,

peritoneal dialysis and renal transplantation on the heart.

e. Describe the treatment of acute myocardial infarction in

patients with renal insufficiency with special emphasis on

drug therapy and PCI. (PC, MK).

f. Discuss how treatment of CHF is altered in CKD and acute

renal failure. Also describe alternations in renal function

patients with CHF. (PC, MK).

g. Describe the relation of CKD to valvular and perivlvular

disease. Discuss the pathogenesis, clinical features,

diagnosis, prognosis and treatment of valvular heart

disease and perivalvular disease in patients with CKD

with special emphasis on aortic valve calcification/stenosis

and mitral annular calcification. (PC, MK).

h. Discuss the epidemiology, pathogenesis, etiology, clinical

and laboratory features diagnosis, treatment, prognosis and

prevention of infective endocarditis and endovasculitis.

(PC, MK).

i. Discuss the relation of renal dysfunction to cardiac

arrhythmias.

j. List cardiovascular drugs whose metabolism is affected by

acute or CKD. Also list renal drugs that may induce

changes in cardiac structure and function. Cite treatment

alterations recessitated by altered renal function or cardiac

function. (PC, MK).

143


a. Rotation on Inpatient Cardiology Services and


b. Utilization of textbook, journals, audiovisual modules, and

computer programs relating to cardiorenal issues. (PC,

MK).

c. Attendance at Core Curriculum Lecture Series, Cardiology

Grand Rounds, Fellows Conference and Cardiac

Catheterization Conference. (PC, MK).

d. Attendance at regional or national conference with

sections devoted to cardiorenal relationships.




b. Observation by faculty on clinical rotation and at

conferences.

kk. Neurological Disorders and Cardiovascular Disease


a. Describe the genetic basis, pathology, pathogenesis clinical

presentation, cardiovascular manifestations,

electrocardiographic manifestations arrhythmic

complications of the following neurologic diseases:

Duchenne’s and Becker’s muscular dystrophies, myotonic

muscular dystrophy, Emery Dreifus muscular dyphrophy

and associated disorders, limb-girdle muscular dystrophy,

humeral muscular dyptrophy, Friedrich ataxia, the acute

periodic paralyses, mitochondrial disorders spinal

muscular atrophy, Guillian Barré syndrome and

myasthenia gravis. Be able to diagnose and treat cardiac

complications of these disorders and cite prognosis.

b. Describe the cardiovascular manifestations of acute

cerebrovascular disease with special emphasis on the

144

repolarization and arrhythmias. Discuss treatment of there

complications.

c. Describe the mechanism, clinical features, diagnosis

treatment and prevention of anoxic encephalopathy after

cardiac arrest.


a. Rotations on the Cardiology Inpatient Services

and participation in Cardiology Clinics. (PC, MK).

b. Utilization of textbooks, journal, audiovisual modules and

computer programs relating to neurological disease and the

heart. (PC, MK).



MK).


devoted to neurology and the heart. (PC, MK).


a. Performance on the ABIM Certifying Exam in


b. Observation by faculty on clinical services and at

conferences.

ll. Cardiovascular Manifestations of Autonomic Dysfunction


a. Describe general principals of the relationship of the

autonomic nervous system and the heart including

autonomic cardiovascular control, baroreflex function, the

arterial baroreflex response, cardiopulmonary receptor

function and postural response. (MK).

b. Describe the etiology, pathogenesis, clinical features,

diagnosis treatment, prognosis and cardiovascular

complications/implications of baroeflex failure,

glossopharyngeal neuralgia, acquired multiple systems

145

atrophy, pure autonomic failure, automimmune autonomic

dysfunction, various autonomic neuropathies, Guillian-

Barré syndrome, congenital forms of autonomic

dysfunction mild postural tachycardia, neurally – mediated

syncope, norepinephrine transporter dysfunction drug-

related autonomic dysfunction and autonomic dysfunction

associated with bedrest.





and computer programs relating to autonomic function and




MK).


devoted to autonomic dysfunction and the heart. (PC,

MK).




b. Observation by faculty on clinical cardiology rotations

and at conferences.

mm. Sleep Disorders and Cardiovascular Disease


a. Describe the various forms of sleep apnea including

obstructive sleep apnea and central sleep apnea.

b. Discuss the epidemiology and risk factors for an

physiologic changes associated with these forms of sleep

apnea with special reference to effects on cardiac rhythm,

blood pressure, ventilation, and arousal.

146

c. Describe and discuss the cardiovascular complications of

obstructive and central sleep apnea with special focus on

cardiac arrhythmias, systemic and pulmonary hypertension

and sudden death.

d. Discuss the diagnosis and treatment of obstructive and

central sleep apnea. Include discussions of general

measures, avoidance of alcohol and sedatives and specific

measures including ventilatory assist devices.

e. Describe the relation of central sleep apnea to heart failure.


a. Clinical rotations on the Cardiology Inpatient Services and


b. Attendance at the Core Curriculum Lecture Series,


MK).

c. Utilization of textbooks, journals, audiovisual modules and

computer programs related to sleep disorders and

cardiovascular disease. (PC, MK).


sections devoted to sleep disorders and the heart. (PC,

MK).


a. Performance on ABIM Certifying Examination in


b. Observation by faculty on clinical services and at

conferences.

nn. Psychiatric and Behavioral Interface with Cardiovascular Disease


a. Describe the relation of type A behavior, anger, depression

and anxiety to cardiovascular disease. Cite mechanisms

linking the two. Discuss the role of psychosocial factors in

the presentation and treatment of cardiovascular disease

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including, social isolation, lack of social support, local

disruption, life stress, job strain, sociodemographic

characteristics, acute mental stress and sudden emotion.

b. Discuss the relation of psychotic disturbances and cardiac

arrhythmias and sudden cardiac death including potential

mechanism and pathophysiology.

c. Describe the relation of psychological stress to

hypertension.

d. Discuss psychiatric and behavioral aspects of congestive

heart failure including the roles of depression and the

importance of social support.

e. Discuss palpitations as a symptom of psychiatric

disease/stress. Cite mechanisms, a diagnostic approach and

treatment.

f. Discuss psychiatric care in cardiac patients including

anxiety and delirium in hospitalized patients and

depression in recovering patients. Describe clinical features

and treatment.

g. Describe the value of cardiac rehabilitation programs in

preventing depression and anxiety in cardiac patients.

h. Describe the cardiac complications of tricyclic anti-

depressants, buproprion, ventaxafine, mutazapine,

neuroleptics, lithium, anticonvulsants

and benzodiazepines.

i. List psychiatric side effects of antihypertensive drugs,

beta-blockers calcium channel blockers, ACE-inhibitors

anti-arrhythmics, digitalis and diuretics.

j. Cite interactions of cardiac and psychotropic drugs.




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and computer programs dealing with psychiatric and

behavioral aspects of heart disease. (PC, MK).



MK).


devoted to psychiatric aspects of heart disease. (PC, MK).





conferences.

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