The Cardiovascular Disease Fellowship Program
Curriculum
The Core Curriculum Includes:
CLINICAL CARDIOLOGY
- Consultative Cardiology - Consult Service
- Electrocardiography, Ambulatory Electrocardiography, Exercise Testing
- Electrophysiology, Cardiac Pacing, and Arrhythmia Management
- Preventive Cardiovascular Medicine
- Outpatient Cardiology/Continuity Clinic
- Heart Failure/Pulmonary Hypertension/Transplant
- Coronary Care Unit (Intensive Care)
- Pediatric Cardiology (elective)
NON-INVASIVE CARDIOLOGY
- Echocardiography
- Magnetic Resonance Imaging (MRI) (Elective)
- Nuclear Cardiology and Stress Testing
- Noninvasive Vascular Ultrasound Laboratory (elective)
INVASIVE CARDIOLOGY
- Diagnostic Catheterization
- Interventional Cardiac Catheterization - 4th year fellowship
- Cardiothoracic Surgery (elective)
CARDIOVASCULAR RESEARCH
ELECTIVE TIME
- Consultative Cardiology - Consult Service
When rotating on the Consult Service fellows will function as a member of a team lead by the attending consultative cardiologist. Fellows will develop communication skills to interface with referring physicians and other members of the health care team. In addition, fellows will plan the short and long-term care of patients with cardiovascular disease, assess the pre-operative risk of noncardiac surgery for patients with cardiovascular disease, and care for post-operative cardiothoracic surgical patients.
Five months are allocated to noninvasive consultative and inpatient services under supervision of senior clinicians with distinguished records as clinical teachers. Additional inpatient consultative experience is acquired on the EP service and during invasive cardiology rotations.
- Electrocardiography, Ambulatory Electrocardiography, Exercise Testing
All fellows will receive Level 2 training in ECG interpretation; interpreting 3500 ECGs over the 36-month program. The experience will include clinical correlation in patients in intensive care units, the emergency department, and pacemaker/defibrillation clinics. Fellows will participate in the weekly ECG Conference.
- Electrophysiology, Cardiac Pacing, and Arrhythmia Management
Fellows will become fluent at the consultant level in the interpretation of standard twelve lead electrocardiograms, ambulatory ECG recordings and signal-averaged electrocardiograms. Each fellow will become familiar with the indications, contraindications, complications, usage and management of temporary and permanent pacemakers. Fellows will learn the indications, contraindications, complications, and the basic elements of the usage and management of implantable defibrillators and tiered therapy devices. Also, fellows will become familiar with the basic elements of intracardiac electrophysiologic recordings, stimulation protocols for supraventricular and ventricular arrhythmias, catheter mapping and ablation. Fellows will become familiar with the essentials of clinical management of patients on a clinical electrophysiology service including the advanced usage of antiarrhythmic agents and implantable devices. All fellows will receive Level 1 training in Electrophysiology. Fellows choosing to continue their cardiovascular education with a 4th year in electrophysiology will be required to obtain Level 2 training and use their elective months to obtain the additional three months beyond the program’s required three months of electrophysiology experience.
- Preventive Cardiovascular Medicine
Fellows’ education and training in preventive cardiovascular medicine is integrated in clinical rotations to the Women’s Heart Center (Allegheny General Hospital -McCandless), Consultative Cardiology, and Outpatient Cardiology/Continuity Clinic. Fellows’ education and training will include vascular biology, atherosclerosis, hypertension, disorders of lipid metabolism, obesity and weight management, diet and nutrition, smoking cessation, diabetes mellitus, thrombosis, clinical epidemiology, cardiac rehabilitation, clinical pharmacology, genetics, and the psychosocial aspects of cardiovascular disease. All fellows will receive Level 1 training in Preventive Cardiovascular Medicine.
- Outpatient Cardiology/Continuity Clinic
Fellows will have clinical experiences in outpatient cardiology throughout their tenure in the fellowship. Fellows will learn to function as both primary cardiologists and consultants for outpatients and will continue to follow these patients longitudinally, including admissions to inpatient services when necessary. This will be accomplished by working closely with an individual faculty preceptor who supervises clinical care of these patients over time. During their tenure in the three-year program each fellow will spend ½ day per week at an AGH faculty mentor’s office.
- Heart Failure/Pulmonary Hypertension/Transplant
Through the Cahouet Center for Advanced Heart Failure and Transplantation, fellows will have the opportunity to be a member of the cohesive Cardiac Transplant Team, a multidisciplinary team comprised of specialists from medical and surgical disciplines, nursing, social work and financial support, cardiac rehabilitation, immunopathology testing, and biomedical engineering. Fellows’ will be exposed to medical therapies, sophisticated diagnostic imaging tools, investigational therapies, device therapies - Tandem Heart and ventricular assist systems, and surgical therapies. AGH’s Pulmonary Hypertension Program is a Center for Excellence, designed specifically for the diagnosis and treatment of pulmonary hypertension. Fellows’ training will include both inpatient and outpatient settings and will include a broad spectrum of etiologies of heart failure. As a member of the Cardiac Transplant Team fellows will participate in the multidisciplinary Transplant Conference. All fellows will receive Level I (one month in each of three years) education and training in heart failure and pulmonary hypertension. Fellows choosing to continue their cardiovascular education with a 4th year in heart failure and pulmonary hypertension will be required to obtain Level 2 training and use their elective months to obtain the additional three months beyond the program’s required three months of heart failure and pulmonary hypertension experience.
- Coronary Care Unit (Intensive Care)
Fellows will be exposed to management of acute coronary syndromes, ST-elevated myocardial infarction, cardiogenic shock, acute decompensated congestive heart failure, symptomatic arrhythmias, hypertensive crisis, infective endocarditis, aortic dissection, pericardial tamponade, and pulmonary embolism. Fellows will gain skills in the appropriate use of hemodynamic monitoring; intra-aortic balloon counterpulsation; and thrombolytic, percutaneous, and surgical therapy will be emphasized. Due to comorbidities presented by acutely ill cardiovascular patients, fellows will gain additional skills in airway and ventilator management, use of renal replacement therapy and treatment of sepsis and other infectious complications.
The very active CCU service sees patients with myocardial infarction admitted directly to Allegheny General or transferred to Allegheny General from community hospitals in the region for primary angioplasty or management of post-infarction complications. During three CCU months (2 months in the second year, and 1 month in the third year) of the fellowship, the cardiology fellows direct a team of residents and students in the CCU under the supervision of the CCU attending cardiologist. The unit provides an excellent experience in the management of patients with infarction, including all of the relevant invasive and noninvasive procedures. Because of a very active program in therapeutics for acute infarction, including primary angioplasty in myocardial infarction, our fellows are assured a cutting edge experience in this area.
- Pediatric Cardiology (elective)
A pediatric cardiology elective is available as a rotation to the Children's Hospital of Pittsburgh.
- Echocardiography
Each fellow will learn to perform and interpret transthoracic echocardiography for evaluation of all of the forms of heart disease enumerated above, including M mode, two-dimensional, pulsed, and continuous wave and color flow Doppler echocardiography. Also, each fellow will learn indications, risks, complications and essentials of interpretation of transesophageal and stress echocardiography. In addition, they will review and learn how to interpret clinical and research studies during their rotation through the echocardiography laboratory.
All fellows will receive Level I training in echocardiography. Fellows choosing to continue their cardiovascular education with a 4th year in echocardiography will be required to obtain Level 2 training.
- Magnetic Resonance Imaging (MRI) (Elective)
The cardiovascular MRI program is the only one in the state of Pennsylvania, to have a dedicated cardiac program and magnet. Fellows will become familiar with the essentials of cardiac MRI, indications, contraindications and potential patient risks through rotation in the MRI Lab and didactic sessions. In addition, they will review and learn how to interpret clinical and research studies during their rotation through the Noninvasive Laboratory (echocardiography).
Fellows will receive a minimum of Level 1 training in cardiovascular MRI, and selected fellow will have the option of Level 2 training by choosing additional elective rotations in the CVMRI lab and will be exposed to the imaging capabilities of this modality. Fellows will receive didactic exposure through a combination of periodic lectures, conferences or CVMRI imaging sessions.
- Nuclear Cardiology and Stress Testing
Each fellow will learn the indications, contraindications and potential complications of both exercise and pharmacologic vasodilator stress testing. Also, each fellow will learn to perform treadmill electrocardiographic exercise stress testing (a minimum 50 studies) and to prevent and manage complications thereof. In addition, fellow will learn to interpret radionuclide ventriculograms and perfusion scans (SPECT and planar thallium, SPECT Sestimibi). Fellows will have available, through advanced electives, the opportunity to acquire sufficient additional skills and experience to become eligible, with completion of required didactic course work, for independent function as a nuclear cardiologist and nuclear licensure.
All fellows will receive Level 2 (minimum of four months) education and training in nuclear cardiology. Fellows choosing to continue their cardiovascular education with a 4th year in nuclear cardiology will be required to use their elective months to obtain the additional two months (6 months total) beyond the program’s required four months of nuclear cardiology experience, and perform more than the required 300+ procedures.
- Noninvasive Vascular Ultrasound Laboratory (elective)
Fellows will learn to perform and interpret vascular duplex ultrasound studies involving the cervical, carotid, vertebral circulation as well as venous and arterial circulation (PVR) with and without stress testing. The vascular lab is a high volume lab with the opportunity for certification with additional training that is available. (One month rotation;*could be a 2 week elective combined with a 2 week elective in cardiothoracic surgery.)
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INVASIVE CARDIOLOGY
Each fellow will learn the indications, risks, complications and contraindications of common invasive procedures. The training will include invasive procedures required for coronary care (arterial lines, Swan Ganz catheter, temporary pacemaker, percutaneous intra-aortic balloon pump). Also, each fellow will be trained in diagnostic coronary angiography, ventriculography, aortography and relevant types of pulmonary angiography by one or more approaches (e.g. percutaneous femoral with preformed catheters, Sones, femoral multipurpose). In addition, each fellow will be trained in the invasive assessment of right and left heart hemodynamics and ventricular function, assessment of common forms of valvular stenosis and insufficiency, shunt lesions and other common forms of adult congenital heart disease, pericardial disease. Each fellow will become familiar with the general approach to and selection of patients for various coronary angioplasty methods, trans-septal catheterization and balloon valvuloplasty, but in-depth skills will be reserved for the separate interventional fellowship. Fellows will be trained in the prevention and management of complications of cardiac catheterization, including contrast reactions, vascular dissection and false aneurysm and hematoma.
- Diagnostic Catheterization
All fellows will receive Level 1 training in invasive cardiology.
Fellows will have 3 months of cardiac catheterization in the first year and 2 months in the second year. Fellows choosing to continue their cardiovascular education with a 4th year in Interventional Cardiology will be required to use their elective months to obtain the additional three months (8 months total) beyond the program’s required five months of interventional cardiology experience, and perform the required 300 procedures.
Training in all techniques, including Judkins, Sones, multipurpose and trans-septal techniques is available. A clinical volume of 8,500 procedures a year provides ample opportunity for training and experience. Interventional training is available in an optional fourth year interventional fellowship and the laboratory's volume of 2800 primary and elective angioplasties, stents and athrectomies provides ample training opportunities. In addition to procedural training, 20% of the time spent on invasive rotations is devoted to inpatient clinical cardiology each month.
- Interventional Cardiac Catheterization - 4th year fellowship
Fellows choosing to continue their cardiovascular education with a 4th year in interventional cardiology may wish to be considered for one of the three positions in AGH’s Interventional Cardiology Fellowship.
- Cardiothoracic Surgery (elective)
Clinical elective rotations are available in cardiothoracic and vascular surgery. If the fellow chooses this elective, he or she will be involved in the pre-operative assessment of patients (consultation), observation in the operating room and participation in the post-operative care in the surgical intensive care unit. (One month elective; *could be a 2 week elective combined with a 2 week elective in the noninvasive vascular ultrasound laboratory).
CARDIOVASCULAR RESEARCH
The Division of Cardiology has a strong commitment to providing rewarding research experiences for cardiology fellows, including first author presentation of abstracts and first author manuscripts in leading journals. The program includes a wide range of research interests in the areas of primary angioplasty, supported high risk angioplasty, athrectomy and other new interventional devices, echocardiography, cardiac MRI, new tracers and devices for nuclear cardiology, pharmacologic treatment of congestive heart failure, implantable defibrillators and arrhythmia ablation. In addition, the division requires and vigorously supports applications for AHA fellowship research grants and, when appropriate, applications for National Research Science Awards.
Elective time is provided in the second year and third years of the program. Most fellows choose to do at least two additional months each in advanced echocardiography and nuclear cardiology. Each fellow is expected to develop a carefully thought-out, well integrated training plan for elective rotations, working closely with the Fellowship Director. Fellows are expected to use the elective time in a coherent fashion to obtain additional in-depth advanced training and experience in one or two aspects of clinical cardiology. Used in this fashion, the elective block permits each trainee to develop a unique training program that achieves a highly individualized set of objectives, preparing each trainee for a clinical or academic career. Fellows choosing to continue their cardiovascular education with a 4th year in a subspecialty will be required to obtain Level 2 training in that subspecialty.
