Learning Objectives Patient Care: Prevention/General Cardiology

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1 Rotation: Director: Faculty: Preventive /General Cardiology Emily G. Kurtz, M.D./Waleed Irani, M.D. Prevention: Jeff Boord, M.D., Sergio Fazio, M.D., Emily G. Kurtz, M.D., MacRae Linton, M.D., David Maron, M.D. General: All General Cardiology Faculty Learning s Patient Care: Prevention/General Cardiology s 1. Perform a complete evaluation of the patient (personal medical history, medications, social and relevant family medical history, accurate examination with an emphasis on cardiovascular and cardiovascular-related findings, etc.). 2. Write a concise H&P or progress note with emphasis on medical and therapeutic lifestyle strategies, behavior modification, patient education/counseling. Performance Feedback 3. Understand relevant screening and/or diagnostic tests appropriate for cardiovascular risk stratification. 4. Ability to write accurate, informative, and helpful consultation notes, outlining the recommendations and explaining the rationale, referencing evidence-based science where appropriate. 5. Ability to interpret electrocardiogram, cardiovascular biomarkers, exercise treadmill tests (including both electrocardiographic and hemodynamic data), rhythm strips, coronary artery calcium scoring. 6. Ability to calculate BMI and counsel patients regarding ideal weight. 7. Ability to educate and counsel patients on risk factor modification to reduce the risk of cardiovascular disease. 8. Ability to identify, address, and treat cardiovascular risk factors according to evidence-based guidelines. 9. Ability to write an exercise prescription for a patient, and/or to establish a cardiac rehabilitation program. 10. Ability to counsel patients regarding therapeutic lifestyle changes (exercise, heart-healthy dietary habits, weight management, tobacco cessation, stress management, and behavior modification) according to AHA guidelines, where appropriate. 11. Ability to establish short- and long-term follow-up continuity plans (e.g. self-bp monitoring, weight monitoring, appropriate laboratory monitoring) and to establish appropriate intervals for outpatient clinic follow-up and outpatient telephone/ (My Health and Vanderbilt) communication.

2 Medical Knowledge: Prevention/General Cardiology 1. Understand the effects of cardiovascular risk factors on vascular biology (heart and blood vessels). 2. Understand the use of clinical epidemiology, biostatistics, clinical trials, and outcomes-based research. 3. Understand the principals of assessment of short- and lifetime cardiovascular risk and cardiovascular risk prevention. 4. Understand the evidence and/or AHA guidelines supporting screening strategies for coronary, cerebrovascular, and peripheral vascular atherosclerosis. 5. Understand the lifestyle and medical treatment of coronary artery disease/subclinical atherosclerosis. 6. Understand the lifestyle and medical treatment of peripheral vascular disease. 7. Understand the medical treatment of cerebrovascular disease (e.g. carotid artery disease). 8. Understand the strategies for diagnosis and treatment of hypertension, and anti-hypertensive medication side effects. 9. Understand the diagnosis and treatment of primary and secondary dyslipidemias, and lipid-lowering medication side effects. 10. Understand the diagnosis of metabolic syndrome and the ways in which this diagnosis influences treatment goals. 11. Understand the diagnosis and treatment of obesity. 12. Understand the management of smoking cessation and nicotine addiction. 13. Understand phase I through phase IV cardiac rehabilitation and return-to-work recommendations. 14. Understand exercise capacity, its impact on overall cardiovascular health, and estimation of METs/functional capacity. 15. Understand nutritional components of a heart-healthy diet. 16. Understand the psychosocial, behavioral, and stress management aspects of cardiovascular disease. 17. Understand gender-specific differences in recommendations for primary prevention (e.g. ASA). 18. Familiarity with evidence-based guidelines for cardiovascular risk factors, primary cardiovascular prevention, secondary cardiovascular prevention. 19. Understand the diagnosis and treatment of atrial fibrillation including pharmacologic and nonpharmacologic therapies 20. Understand the evaluation and management of patients with syncope 21. Understand the evaluation and management of patients with valvular heart disease Evidence-Based Literature Professionalism Prevention/General Cardiology 1. Demonstrate accountability and professional behavior towards patients, family members, and members of the health care team. 2. Demonstrate compassion and respect for others, including an appreciation for the spiritual, social, and cultural contexts of wellness and illness.

3 Interpersonal and Communication Skills: Prevention/General Cardiology 1. Communicate findings, diagnoses, and recommendations effectively and in a timely fashion with physician colleagues and members of the health care team. 2. Present findings, diagnoses, and recommendations effectively, compassionately, and professionally to patients and family members. 3. Provide patient counseling and/or educational instruction to patients to reinforce behavioral modification. 4. Maintain timely and comprehensive medical records. Practice-Based Learning and Improvement: Prevention/General Cardiology 1. Use of current evidence-based preventive cardiology. 2. Broad reading of the cardiovascular literature, with emphasis on primary and secondary prevention, cardiovascular risk stratification, wellness, therapeutic lifestyle changes, and cardiac rehabilitation. 3. Identify both strengths and gaps in knowledge and expertise and set appropriate learning goals. Evidence-Based Literature Systems Based Practice: Prevention 1. Work effectively as a member of the health care team, including coordination of patient care. 2. Demonstrate understanding of cost-effectiveness and risk-benefit analysis and incorporate these into patient care. 3. Understand the use of medical resources and how these affect patient care and the community at large. 4. Understand the complexities of preventive cardiovascular care and how these strategies affect the patient and the larger community. 5. Advocate for and work towards patient safety and improved quality of care. 6. Understand how to partner with a team of health care providers to assess, coordinate, and improve preventive cardiovascular care. Rotation Format and Responsibilities: The intention of the preventive cardiology rotation is to provide fellows with a fundamental understanding of atherosclerotic vascular disease risk assessment, screening, diagnosis, and management; cardiovascular risk reduction strategies; and management of cardiovascular risk factors. The responsibilities of the fellow are to attend outpatient preventive cardiology and lipid clinics, to document their participation in patient care, to assist interpretation of relevant screening/diagnostic studies, and to become familiar with relevant evidence-based literature and/or guidelines relevant to preventive cardiovascular medicine and dyslipidemia. Recommended Reading: See Prevention/General Cardiology Core Curriculum. Evaluation and Feedback: Fellows are directly observed and given real time feedback on their performance.

4 Rotation s: 1. To obtain a thorough understanding of the guidelines for lipid management, hypertension, and diabetes management (NCEP, JNC VII, ADA, ACC/AHA policy statements). 2. Understand the role of traditional and novel risk factor assessment in cost-effective preventive cardiovascular care. 3. Learn how to accurately assess a patient s risk for developing cardiovascular disease using available risk prediction models, and understand the strengths and weaknesses of each. 4. Review current recommendations for behavior and therapeutic lifestyle modification (heart-healthy diet, exercise, weight management, smoking cessation) for cardiovascular risk reduction. 5. Understand how to decide among lifestyle, medical, and/or interventional management of cardiovascular disease. 6. Understand how to interpret the results of atherosclerosis screening/diagnostic studies, how to apply the results to improve cardiovascular disease risk assessment, and how study results influence patient care/management. Subject Areas for Suggested Review in ACCSAP: 1. Cardiovascular Screening and Risk Assessment strategies for coronary heart disease and peripheral vascular disease. 2. Calculation of CVD risk appraisal (e.g. Framingham, PROCAM, Reynolds risk score). 3. Pathophysiology and treatment of Atherosclerotic Vascular Disease (CAD, PAD, cerebrovascular disease). 4. Pathophysiology and treatment of Diabetes/Hyperglycemia. 5. Optimal management of Dyslipidemia (elevated LDL, low HDL, high triglycerides, high non-hdl, and mixed dyslipidemias). Review mechanism of action and side effects of Lipid-Lowering Agents. 6. Optimal assessment, management, and treatment of Hypertension (including renovascular hypertension and other secondary causes). 7. Risks and benefits of Hormone Replacement Therapy (HERS, WHI). 8. Review of basic Statistical Techniques used in preventive cardiology literature. 9. Role of Psychosocial Factors in the development of atherosclerotic vascular disease. 10. Development of Exercise Prescription and fundamentals of Cardiac Rehab programs. 11. Applications and appropriate use of Cardiovascular Screening Diagnostic Tests [e.g. coronary artery calcium scanning and carotid ultrasound (CIMT)] to detect subclinical atherosclerosis. 12. Appropriate Primary and Secondary Prevention strategies for Coronary Artery Disease. 13. Appropriate evaluation and management (lifestyle, medical, interventional) of Peripheral Arterial Disease and Carotid Atherosclerosis (ABIs, ultrasound techniques, MRI/CT). 14. Understand techniques to assess Endothelial Function and Vascular Compliance (e.g. brachial artery testing, pulse wave velocity). 15. Mediators of CAD and PAD (inflammation, plaque stability, and vulnerability), e.g. biomarkers of cardiovascular disease. 16. Management of Obesity (lifestyle, medical, and surgical management). 17. Smoking Cessation. 18. Preparticipation (Athletic) evaluation. 19. Preoperative Cardiovascular Risk Evaluation for non-cardiac surgery. 20. Management of atrial fibrillation 21. Workup and management of patients with syncope 22. Evaluation and management of patients with valvular heart disease

5 Suggested Schedule Options: Prevention Monday: 8:30 - Noon Lipid Clinic with Dr. Linton 1:00 4:00 PM Preventive Cardiology Clinic with Dr. Maron Tuesday: 8:30 - Noon Preventive Cardiology Clinic with Dr. Kurtz 1:00 4:00 PM General Cardiology Clinic with provider of choice Wednesday: Thursday: 8:30 - Noon Lipid Clinic with Dr. Boord 1:00 4:00 PM Nutrition Clinic with Cindy Osborn, RD and/or self-learning, documentation, interpretation of diagnostic studies. 8:30 - Noon Self-learning, documentation, interpretation of diagnostic studies. 1:00 4:00 PM General Cardiology Clinic with provider of choice Friday: 8:30 - Noon Lipid Clinic with Dr. Fazio 1:00 4:00 PM Self-learning, interpretation of diagnostic studies, documentation.

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