Patient Care Rotations
Coronary Care Unit
At NMH the coronary care unit (CCU) contains 12 acute coronary beds. Medical housestaff members are assigned to this area. A full-time attending cardiologist/intensivist makes daily rounds and is available for consultation. Approved clinical pathways guide treatment options for patients with acute coronary syndromes and chest pain.
The cardiology fellow rotating through the CCU is in charge of the service, clinically evaluating all new admissions, teaching and advising housestaff members and medical students about acute coronary and cardiovascular intensive care. Duties also include supervising bedside hemodynamic monitoring, insertion of pulmonary artery catheters and temporary pacemakers, and electrical cardioversions. The fellow also works with members of the catheterization laboratory to treat patients requiring pericardiocentesis or intra-aortic balloon pumps.
Fellows also rotate through the CCU service at the Jesse Brown VA Medical Center (JBVAMC). The CCU there comprises acute care beds and monitored intermediate care beds. The responsibilities of the cardiology fellow in the JBVAMC CCU are similar to those at NMH.
Cardiology Consultation Services
The cardiology fellow plays a pivotal role in the Cardiology Consultation Services at NMH, including the evaluation of patients referred for cardiac catheterization and angioplasty, inpatient cardiac consultations, and the preoperative and postoperative care of patients with cardiac disease who undergo cardiac or noncardiac surgery. The fellow organizes the activities of the medical residents and students who rotate through the service and plays an active role in the teaching functions of the service.
Fellows also rotate in the cardiac surgery liaison service. There fellows interact closely with the cardiac surgeons, perform intraoperative transesophogeal echocardiography, and assist in the management of the patients during the post-operative period.
The Division of Cardiology also offers programs in adult congenital heart disease and heart disease in pregnancy. Fellows with particular interests in these areas may request specialized training.
Cardiac Surgery Liaison Service
Fellows also rotate in the cardiac surgery liaison service. There fellows interact closely with the cardiac surgeons and assist in the management of the patients during the post-operative period.
Cardiac Rehabilitation Program
The Cardiac Rehabilitation Program encompasses outpatient (Phases II and III) exercise and education programs. Fellows learn how to evaluate and supervise outpatient exercise sessions, conduct aerobic and resistance training of high-risk patients, and work with a multidisciplinary team for the long-term follow-up of patients with cardiovascular disease.
Preventive Cardiology Rotation
This rotation introduces the cardiology fellow to expert management of lipoprotein and other metabolic disorders structured to arrest the progression of atherosclerotic vascular disease. The cardiology fellow will spend one half-day weekly in the outpatient offices of the Preventive Cardiology Center in which they will develop treatment plans with the faculty members. The cardiology fellow will be involved in the monthly journal club with the entire Division of Cardiology and a bi-weekly journal club for the Preventive Cardiology staff. Opportunities are available for fellows wishing to pursue additional didactic education leading to a Masters Degree in Public Health (MPH) or a Master of Science in Clinical Investigation (MSCI). There is also an NIH-funded Training Program in Cardiovascular Disease Epidemiology and Prevention that allows Cardiology Fellows to spend an intensive period of study and research (usually 2 years) focused on Cardiovascular Disease Prevention. The two programs (Cardiology and Cardiovascular Disease Prevention) can be integrated to allow Cardiology Fellows to participate.
Heart Failure Program
On the Heart Failure Rotation, the cardiology fellow will work closely with the attending physicians and advanced practice nurses caring for the patients seen by the program. The rotation will provide both inpatient and outpatient experience caring for patients with all degrees of left ventricular dysfunction (symptomatic and asymptomatic), including patients who may require evaluation for cardiac transplantation. During the inpatient portion of the rotation, the fellow will round with the inpatient heart failure attending and advanced practice nurse on the patients on the service, which includes both primary patients (on the coronary care unit, telemetry unit, and medical floors) and patients on whom consultation is requested by other physicians in the hospital. The fellow will have the opportunity to perform the initial evaluation of any new consultations received by the service. The fellow will also have the opportunity to manage patients before and after heart transplantation.
In the outpatient setting the fellow will work with the outpatient heart failure attendings in seeing the new patients referred to the program as well as in seeing outpatients who return for follow-up visits. The fellow will be encouraged to participate in the performance of cardiopulmonary exercise tests.
During the rotation the fellow will have the opportunity to perform the right heart catheterizations and right ventricular endomyocardial biopsies required by the heart failure / cardiac transplant population, under attending physician supervision. The fellow will also attend the weekly Heart Failure team meeting.
More than 6,000 catheterization procedures are performed annually at NMH. At the three cardiac catheterization laboratories at NMH, full-time attending cardiologists perform all diagnostic and interventional procedures and supervise the activities of the cardiology fellows.
The fellows evaluate patients before and after cardiac catheterization and participate in catheterization procedures, including catheter placement, angiography, and percutaneous coronary interventions. They also are responsible for evaluating hemodynamic and angiographic data. Percutaneous coronary revascularization is performed using state-of-the-art devices that include intracoronary stents, medically coated stents, as well as atherectomy and laser techniques. Intravascular ultrasound imaging accompanies a large number of the interventional procedures. Primary angioplasty for acute myocardial infarction is performed routinely according to the acute myocardial infarction clinical pathway. Active programs also are in place for percutaneous balloon valvuloplasty and endomyocardial biopsy techniques.
There are ongoing research trials involving the use of new interventional devices and pharmacologic therapies. Fellows are encouraged to participate in all research projects.
An accredited fourth year of advanced training in interventional cardiology is available for those interested in a career in catheterization and interventional procedures. This program prepares fellows for the American Board of Internal Medicine subspecialty examination in interventional cardiology.
Laboratories specifically designed for and dedicated to invasive electrophysiology permit complete electrophysiologic evaluations at both NMH. Over 1,000 procedures are performed annually. Full-time cardiology attending staff members, specially trained in these techniques, perform the studies and supervise the activities of the cardiology fellows.
The fellows rotating on the service help conduct pre-study assessments and electrophysiologic evaluations in the laboratory. Techniques such as radiofrequency ablation are used to treat a variety of tachyarrhythmias. Fellows participate in the implantation of permanent pacemakers, antitachycardia/defibrillator devices, and in the care of patients who have received these devices. They also provide inpatient arrhythmia consultations.
Fellows attend a weekly electrophysiology outpatient clinic weekly research conference and a pacemaker evaluation clinic. Training also is provided in interpreting results of Holter monitors, long-range event monitors, and tilt-table testing.
An accredited fourth year of advanced training in electrophysiology is available for those interested in a career in electrophysiology, arrhythmia ablation, and device implantation. This program prepares fellows for the American Board of Internal Medicine subspecialty examination in cardiac electrophysiology.
Noninvasive Cardiology Rotations
Fellows receive extensive training in interpretation of electrocardiograms (ECGs), Holter and Event Monitor Studies during rotations on the cardiology clinical service, VA services, CCU, and electrophysiology service. More than 60,000 ECGs are performed per year at NMH, and 30,000 at the VA hospital. Individualized ECG interpretation with an attending cardiologist is scheduled during several of the rotations. A biweekly ECG conference provides in-depth coverage of basic and complex ECG abnormalities and rhythm disorders.
More than 30,000 echocardiographic procedures are performed annually including two-dimensional, Doppler, transesophageal and stress (both exercise and pharmacologic) echocardiography. The laboratory is among the largest in the country and receives many outside referrals to evaluate complicated cases using advanced echocardiographic techniques. The laboratory is also responsible for the echocardiographic studies of all patients in the combined NMH/Children's Memorial Hospital (CMH) adult congenital heart disease program. The laboratory sponsors continuing medical education programs for cardiologists and cardiac ultrasound technologists. An active ongoing research program is evaluating new ultrasound modalities including contrast and 3D echo. Fellows rotating on the service clinically assess each patient, review the results of echocardiographic studies, make preliminary interpretations of the data, and then evaluate the studies with a full-time attending echocardiographer. Level I and II certification is available in the program. Fellows seeking level III certification have the opportunity to perform an additional year of advanced training.
Fellows conduct and interpret exercise and pharmacologic stress tests under the supervision of full-time faculty members in the Echocardiography and Nuclear cardiology labs. More than 9,000 exercise tests are performed annually.
A full complement of diagnostic radionuclide procedures for evaluating cardiac disease is offered, including exercise and pharmacologic stress tomographic myocardial perfusion studies, cardiac PET, and radionuclide ventriculography. Gated SPECT imaging with technetium-99m–based perfusion tracers is performed routinely. More than 4,200 stress tests and over 800 gated blood pool (MUGA) studies are performed annually. Many physicians and cardiology fellows from other programs obtain advanced training in nuclear cardiology in the Northwestern laboratories.
All fellows receive training in radiation safety and radiation physics. Those interested in receiving the required hours of physics and safety training to be eligible for Nuclear Regulatory Commission licensure may obtain this training during their fellowship. Cardiology fellows rotating on the nuclear cardiology service clinically assess each patient, make a preliminary interpretation of the data, and then interpret the studies with the attending cardiologist or nuclear medicine physician at a structured reading session each afternoon.