Cardiovascular Course

Anita Soni

MD FRCPC Cardiology June 10, 2013

UGME CV Course Committee Course Leader: Anita Soni Administrative Assistant: Kathy van der Vis

Basic Sciences:

Anatomy: Sabine Hombach-Klonisch Embryology: Mark Torchia Physiology: Ian Dixon Pharmacology: Don Smyth

Cardiology:

Heart Failure/nuclear: Francisco Cordova IHD/hemodynamics: John Ducas Arrhythmia: Kevin Wolfe Valvular Heart Disease/other: Anita Soni ECG/Imaging- Davinder Jassal Preventative/Rehab- Thang Nyugen

Related Medical Disciplines:

Intensive Care: Alan Schaffer Vascular Surgery: April Boyd Cardiac Surgery: Ed Pascoe

Longitudinal Themes Generalism: Travis Minish Pathology: Gabor Fischer Infectious Diseases: George Zhanel Genetics: Sandra Marles Pediatrics: Reeni Soni Radiology: Iain Kirkpatrick Geriatrics: Colette Seifer

Longitudinal Courses:

Community Health: Sharon MacDonald Clinical Skills: Karen Klym Indigenous Health: Barry Lavallee

Resident:

Robin Ducas (PGY 5 Cardiology) Student:

William Liang (CV course rep)

Y1

M0M1

Y2

Health and Disease

• FOUNDATION of MEDICINE 1.Blood & Immunology I (+ Skin I) 2.CV I & Resp (+ ET) I 3.Neurobiology I(Psych, Neuro + Opth) 4.Musculoskeletal I 5.Endocrine I & OBS/Gyn I 6.GI/ Nutrition I & Urinary system I

M2

M3

4 ---- 2014 Aug 25 - Sept 19 3------------ Sept 22 - Oct 10

5 ------------ Oct 13 - Nov 14 4.6 --------- Nov 17 - Dec 17… Dec break 2------2015 Jan 5 - Jan 16 4------------- Jan 19 - Feb 13

4------------- Feb 17 - Mar 13 TOTAL 26.6 ……………….Mar 16 - 20………Reading week

2-------------Mar 23 - April 3 3-------------Apri 6 - April 24 4-------------Apri 27 - May 22 -----------May 25- 29 …………. Rural week 4--------------Aug 24 - Sept 18 3--------------Sept 21 - Oct 9 3--------------Oct 12 - Oct 30 3 -------------Nov 2 - Nov 20 3 +3d------- -Nov 23 - Dec 17…… Dec break 6 -----2016- Jan 4 - Feb 12 4--------------Feb 18 - Mar11 ----------------Mar 14 - 18 ……. Reading week

1. Intro to ID/Intro Oncology 2. Blood & Immunology (+ autoimmune diseases) 2 3. CV 2

4. Resp + ET 2 5. Endocrine 2 6. OBS/Gyn 2 7. GI & Nutrition 2 8. Urinary system 2 9. Neurobiology 2 (Psych, Neuro, Opth) 10. Musculoskeletal 2 (+Skin 2) 3 Consolidation 10-------------Mar 21 - May 27

5

Human Biology and Health wks.days ( w. 2 days eval ) Approximate dates

CuReX DRAFT 3 March 11, 2013 CuRe Preclerkship M0, 1/2: Human Biology , Health and Disease

Goals:

①Create Outline for the CV course: Specific topics objectives content format Review current course IDENTIFY GAPS & OVERLAP (RELEVENT VS REDUNDANT) - compare to other medical schools/review MCC objectives

Ensure related medical disciplines and longitudinal themes are represented

Goals:

② Organization and Integration: Dividing into Module 1 & Module 2

- Integration of longitudinal courses to optimize learning - Integration of longitudinal themes- where they fit in

Consolidation Clerkship (academic ½ day)

Goals:

①Create Outline for the CV course: Specific topics objectives content format Review current course IDENTIFY GAPS & OVERLAP (RELEVENT VS REDUNDANT) compare to other medical schools/review MCC objectives

Ensure related medical disciplines and longitudinal themes are represented

Current CV Course Objective (OPAL)

CV.1 Describe the scope and burden of illness of cardiovascular disease in our community. CV.2 Explain normal anatomy, physiology, and pathology of the cardiovascular system. CV.3 Explain the abnormal anatomy, physiology, and pathology in cardiovascular disease: including ischemic heart disease, heart failure, rhythm disorders, valvular heart diseases, pericardial/myocardial disorders, shock, peripheral vascular diseases, thoracic aortic disease, hypertension, endocarditis and congenital heart disease. CV.4 Perform a cardiovascular history and physical examination in patients with cardiovascular disease. CV.5 Evaluate the clinical presentations of cardiovascular diseases, including the work-up of chest pain syndromes, shortness of breath, palpitations and syncope. CV.6 Describe primary prevention, risk factors and risk factor modification for cardiovascular diseases. CV.7 Discuss and implement the clinical tools and investigations available for the evaluation of cardiac patients. Have an approach to ECG interpretation. CV.8 Describe the treatment options of cardiovascular diseases, both acute and chronic

Current Cardiovascular Course

Cardio-vascular Course

Intro, Reviews &

Instructional tests Embryology

Anatomy

Physiology

EKG

Arrhythmia

HTN

Lipids Ischemic

Heart Disease Valvular

Heart Disease Imaging

Congenital &

Pediatrics

Pericardial and Cardiomyopathy

Genetics/ Molecular

Heart Failure

Shock /Vascular and

Autonomic Drugs

Infections

Aorta & PVD

Community Health

Current Cardiovascular Course

Cardio-vascular Course

Intro, Reviews &

Instructional tests Embryology

Anatomy

Physiology

EKG

Arrhythmia

HTN

Lipids Ischemic

Heart Disease Valvular

Heart Disease Imaging

Congenital &

Pediatrics

Pericardial and Cardiomyopathy

Genetics/ Molecular

Heart Failure

Shock /Vascular and

Autonomic Drugs

Infections

Aorta & PVD

Community Health

Current Cardiovascular Course

Cardio-vascular Course

Intro, Reviews &

Instructional tests Embryology

Anatomy

Physiology

EKG

Arrhythmia

HTN

Lipids Ischemic

Heart Disease Valvular

Heart Disease Imaging

Congenital &

Pediatrics

Pericardial and Cardiomyopathy

Genetics/ Molecular

Heart Failure

Shock /Vascular and

Autonomic Drugs

Infections

Aorta & PVD

Community Health

Course ID Topic Type

ID Duration Dept ID

Session Leader

CV001 Introduction to Cardiovascular L 1 IN-CV Anita SoniCV059 Mid Term Review IT 1 IN-CV Anita SoniCV041 Cardiovascular Review T 2 IN-CV Anita SoniCV002 Anatomy of the Heart I L 1 AN Sabine Hombach-KlonischCV003 Anatomy of the Heart & Mediastinum and Thorax 1 GLP 1 AN Sabine Hombach-Klonisch AnatomyCV008 Anatomy of the Heart II GLP 2 AN Sabine Hombach-KlonischCV041 CV Anatomy Review - Combined with RS 80 GLP 1 AN Sabine Hombach-KlonischCV044 Development of the Heart L 2 AN Mark TorchiaCV048 Development of the Heart and Lung A/GLP 2 AN Mark TorchiaCV014 Autonomic Nervous System L 2 PC Don SmythCV004 Cardiovascular Physiology L 2 IN-CV Rohit SingalCV010 Blood Pressure Regulation L 1 IN-CV Bojan PaunovicCV011 Regulation of Cardiac Output and Venous Return L 2 IN-CV Bojan PaunovicCV013 Hemodynamics 1 A 2 IN-CV Bojan PaunovicCV015 Hemodynamics 2 T 2 IN-CV Bojan PaunovicCV017 Cardiac Pathology: Consequences of Abnormal Hemodynamics A 1 PA Gabor FischerCV025 Cardiac Cycle L 2 IN-CV Andrew MorrisCV027 Cardiac Indices L 1 IN-CV Malek KassCV029 Cardiac Performance L 2 PC Ian DixonCV030 Abnormalities in Cardiac Performance L 1 PC Ian DixonCV019 Excitation - Contraction Coupling L 2 IN-CV Larry HryshkoCV020 Cardiac Electrical Properties L 2 IN-CV Ali KhademCV058 Exercise Physiology and Stress Testing L 2 IN-CV Ivan BaracCV045 Cardiovascular Physiology of Aging T 1 IN-CV Colette SeiferCV023 Introduction to ECG 1 L 2 IN-CV Nasir ShaikhCV022 Introduction to ECG 2 L 1 IN-CV Davinder JassalCV024 ECG Interpretation 1 T 2 IN-CV Nasir ShaikhCV026 ECG Interpretation 2 T 2 IN-CV Nasir ShaikhCV059 ECG in IHD T 1 IN-CV Nasir ShaikhCV033 Arrhythmias I L 2 IN-CV Kevin WolfeCV034 Arrhythmias II L 1 PC Kevin WolfeCV037 Arrhythmias III L 2 PC Kevin WolfeCV038 Arrhythmias IV T 2 IN-CV Kevin WolfeCV016 Hypertension I L 1 IN-CV Brian PennerCV078 Hypertension II L 1 IN-CV Brian PennerCV079 Hypertension III L 1 IN-CV Brian PennerCV080 Hypertension IV A 1 IN-CV Brian Penner

Hypertension

Introduction, Reviews, Instrucitonal Tests

Embryology

Physiology

ECG

Arrhythmias

CV057 Lipid Metabolism and IHD I L 1 IN-CV David MyminCV064 Lipid Metabolism and IHD II L 1 IN-CV David MyminCV063 Lipid Metabolism and IHD III T 2 IN-CV David MyminCV005 Cardiac Pathology: Atherosclerosis L 2 PA Gabor FischerCV061 Cardiac Pathology: IHD LP 1 PA Gabor FischerCV058 Exercise Physiology and Stress Testing L 2 IN-CV Ivan BaracCV051 Acute Coronary Syndromes L 2 IN-CV Kunal Minhas Ischemic Heart DiseaseCV052 Chronic IHD L 2 IN-CV John DucasCV056 Revascularization in IHD L 1 SG Kunal MinhasCV066 IHD I A 1 IN-CV Kunal MinhasCV059 ECG in IHD T 1 IN-CV Nasir ShaikhCV059 IHD II T 2 IN-CV Kunal MinhasCV059 Cardiac Pathology: Valvular Heart Disease T 1 PA Gabor FischerCV062 Valvular Heart Disease I A 1 IN-CV Anita SoniCV062 Valvular Heart Disease II T 3 IN-CV, SGAnita Soni/Rizwan ManjiCV062 Valvular Heart Disease III T 2 IN-CV Anita SoniCV062 Cardiac Pathology: Pulmonary Vascular Disease and Cor Pulmonale L 1 PA Gabor FischerCV062 Cardiac Pathology: Heart Failure L 1 PA Gabor FischerCV062 Heart Failure & Therapy I L 2 IN-CV Shelley ZierothCV081 Heart Failure & Therapy II L 1 PC Anita SoniCV053 Heart Failure & Therapy III L 1 PC Anita SoniCV040 Heart Failure & Therapy IV T 2 IN-CV Shelley ZierothCV040 Congenital Heart Disease I A 1 PD Reeni SoniCV040 Acquired Conditions in Pediatric Heart Disease L 1 PD Reeni Soni Congenital & Pediatric Heart DiseaseCV040 Congenital Heart Disease II L 2 PD Reeni SoniCV042 Congenital Heart Disease III T 2 PD Reeni SoniCV040 Pericarditis & Cardiomyopathies L 1 IN-CV John DucasCV Genetic Aspects of Cardiomyopathy L 1 BC GN-GNAb ChudleyCV046 Molecular Aspects of Cardiac Disease L 1 IN-CV Davinder JassalCV043 Shock I L 1 IN-CV Rizwan ManjiCV021 Shock II T 2 IN-CV Rizwan ManjiCV028 Vascular and Autonomic Drugs I L 1 PC Don SmythCV031 Vascular and Autonomic Drugs II L 1 PC Don SmythCV041 Vascular and Autonomic Drugs III T 2 PC Don SmythCV045 Cardiac Infections L 1 MM Fred AokiCV032 Diseases of the Thoracic Aorta L 1 SG Ed PascoeCV039 Vascular Disease I L 2 SG Josh Koulack Aorta/Peripheral Vascular Disease (Surgery)

CV041 Vascular Disease II T 1 SG April BoydCV059 Prevention of Vascular Disease L 1 CH Sharon MacdonaldCV041 Applying Community Heal th Concepts to Resp and Cardiovascular Disease 1 A 0 CH Sharon Macdonald

Community Health

Pericardial Disese & CardiomyopathiesGenetics-CardiomyopathiesMolecular Aspects

Shock/Vasclar & Autonomic Drugs

Infections

Lipids

Valvular Heart Disease

Heart Failure

Clinical Skills 1. Intro session- 2 hours of

demonstration with 5 groups- rotating through 5 stations:

1. History 2. JVP 3. BP 4. Heart Sounds 5. Peripheral exam

2. Three 2 hour small group sessions (5-6 students) with a cardiologist using real patients on ward

Gaps • Preventative medicine- primary prevention –

cover HTN and Lipids directly, but no specific lecture formally dedicated to smoking, diet, DM, obesity (from a clinical perspective)

• Diet and nutrition (ie. Mediterranean diet). • Cardiac rehabilitation • Presyncope / syncope • Pericardial disease and cardiomyopathies should

be separated • Indigenous health • Interprofessionalism/ multidisciplinary care

Overlap- relevant vs redundant • Physiology section- combination of lecturers from different

fields leading to some redundancy. Also, some ICU oriented sessions with question of relevancy

• IHD- some redundancy; review content relevancy • Autonomic nervous system- how much to cover with new

curriculum (no longer being taught prior to course) • Lipids- also covered in Endocrine ?combine • pulmonary HTN/cor pulmonale- one pathology lecture

(combined with resp), not covered in CV otherwise • Pathology- ?some redundancy based on student evaluations • Anticoagulants/antiplatelet drugs- overlap with heme? • Shock- cover all types of shock ?relevant / ensure not

redundant

Goals:

② Organization and Integration: Dividing into Module 1 & Module 2

- Integration of longitudinal courses to optimize learning - Integration of longitudinal themes- where they fit in

Consolidation Clerkship (academic ½ day)

Module 1 Positive Aspects:

Combined with Resp- ideal!

Integrate anatomy, embyrology, and some imaging (ie. CXR).

Number of lecturers can be limited: Course leader: intro, mid and

final test/review, diagnostic testing/imaging, ECG (may need one more cardiologist).

1 for Anatomy 1 for Embryology 2-3 for physiology 1 for pharmacology (also

some physiology) 1 radiologist

Module 1 Challenges:

Ensuring enough baseline

knowledge to understand pharmacology/drugs (ie. autonomic nervous system, heme / nephro background)

Challenge to teach diagnostic testing/imaging, ECG and drugs without clinical context, but will be spiraling with M2.

Integration into longitudinal courses (?what topics to cover)

Timing of M1 is during 2 of the most popular Cardiology Conferences

Module 1

Consider? Pathology: in CV, pathology

lectures presently go though pathological processes (ie. atherosclerosis, or LV systolic dysfunction), from a cellular level. Introduces disease states at a very basic level (ie. IHD, CHF). It may be okay to demonstrate some of these abnormal processes (also taught in physiology section as it differs form normal processes) in M1. This would serve to introduce disease states that will be unavoidably discussed in diagnostic testing, imaging, pharmacology and clinical skills.

Can shock/vascular & autonomic drugs be taught in M1- also serves as an intro into disease states as above

Module 2 Positive Aspects:

Excellent opportunity for

optimal integration with longitudinal courses- would like CV to be involved with these sessions- (see later slide) though also need to consider resources with tutors

‘Spiral’ curriculum- review diagnostic tests/imaging/ECG/drug treatment -now under each disease entity after being taught in M1 first.

Module 2 Challenges: A lot of material to cover, only

appropriate in M2 (not M1)

Difficult to go only theme based (ie. approach to dyspnea) without background of disease first, and without being paired with respirology

Some topics better to be theme based (ie. syncope)- where to fit in?

No time for integration/unknown patient case (except at final review session)- unless move pathology/shock to M1

Very tight timing with 19 teaching days, and new material on week of exam (more ideal to combine with Respirology also for resource allocation)

Module 2 Challenges: Clinical skills- do not want to

compromise this section at all, as it is the strongest part of the current course: very very challenging in this

format of 4 weeks. Initially allotted 4 hours 2x/ week. This is impossible.

Intro session (one lecture, one rotating stations), then leaves 3 weeks (one session per week per student).

To keep status quo: even if given flexibility (2 hour time slots, once per day), would mean 4 groups (5-6 students per group) per day, 5 days per week (each group gets a 2 hour session), and repeat next 2 weeks.

Timing/location- 8am best; predominantly at SBGH- need to consider travel time.

Patient fatigue- Cardio ward Resources- same tutor per

group; and also with teaching in the am hours

Module 2 Challenges:

There will be more lecturers

than what is perceived as ideal: Course leader: intro, mid

and final test/review ECG review Arrhythmia HTN Dyslipidemia IHD HF Valvular heart disease Pericardial disease Cardiomyopathies Genetic Molecular aspects ID Shock Autonomic Drugs Vascular Pediatrics/Congenital **Cardiologist-based topics

Considerations: Clinical skills- extreme challenge

want to maintain current format

Incorporating ‘theme-based’ approach into clinical reasoning. Ideal to have CV involvement:

ie- go through case from H & P, to ECG, to diagnostic imaging (include angiographic & echo images or reports) and treatment.

Expand community health

Professionalism: can we incorporate a

multidisciplinary session into professionalism: include clinical psychology, rehab, etc..

?transplant case-ethical issues

Incorporate indigenous health topics specific to CV

Longitudinal Courses:

Considerations: - Most themes well integrated into M1 and M2 - consider interprofessional care case- ?into professionalism course - many are not specific to CV- fit into TTC/JC/SC/TTR portions

Longitudinal Themes

26

Composite Clinical Presentations CP4* UGME Sept 2012 DRAFTV6 HEALTH CONDITIONS SYMPTOMS & SIGNS 34 hemoptysis ABNORMAL LABS 99 ADHD spectrum

1 abdominal mass 35 hirsutism 66 acidosis 100 adrenal disorders 2 abd pain: acute & chronic 36 hoarse voice 67 alkalosis 101 arthritis 3 allergic reactions 37 impotence 68 hemoglobin disorders 102 CVD 4 anxiety 38 incontinence 69 calcium/phopshate/magnesium 103 cirrhosis

5 ascites 39 jaundice 70 cardiac markers/EKG 104 CNS infections 6 blunt trauma 40 joint pain-acute & chronic 71 coagulation abnormalities 105 diabetes

7 burns 41 low back pain 72 creatinine:acute & chronic 106 Drug OD

8 bleeding 42 lymphadenopathy 73 CXR abnormalities 107 eating disorders

9 cardiac murmurs 43 neck mass/thyroid 74 lipid abnormality 108 fungal infections

10 chest pain 44 pain syndrome 75 leukocyte disorders 109 HIV/AIDS

11 constipation 45 palpitations 76 liver enzymes/function 110 hypertension 12 cough- acute & chronic 46 pruritus 77 potassium abnormalities 111 infertiltiy

13 cyanosis 47 red eye 78 platelet disorders 112 kidney disease-chronic 14 delirium 48 paralysis 79 pulmonary function tests 113 lung disease-chronic 15 dementia 49 pelvic pain/mass 80 sodium abnormalities 114 malnutrition 16 diarrhea- acute & chronic 50 seizures 81 urinalysis abnormalities 115 menses/menopause

17 diplopia 51 skin growths FACTORS EFFECTING HEALTH 116 mood disorders

18 dysphagia 52 skin rashes 82 adverse drug reactions 117 multiple sclerosis

19 dyspnea-acute & chronic 53 sleep disorders 83 chronic disease 118 osteoprosis 20 dysuria/UTI 54 somnolence 84 Contraception 119 pediatric emergencies 21 ear pain 55 sore throat 85 Culture 120 palliative care

22 edema 56 syncope 86 WHO Determinants of Health 121 pituitary disorders

23 extremity pain 57 tendon rupture 87 developmental pediatric delay 122 pregnancy/complications 24 eye trauma 58 testicular swelling/pain/mass 88 Disabilities 123 psychosis 25 fever 59 tinnitus 89 neglect/abusive relationship or behavior 124 suicidal behavior 26 fatigue 60 vomiting 90 educational level 125 shock/resuscitation 27 foot ulcers 61 vision loss acute&chronic 91 elderly/frail 126 sports injuries 28 fracture/dislocation 62 weakness 92 environmental health 127 STI

29 GI bleed 63 wheezing- acute & chronic 93 infectious epidemic/prevention 128 Venous thrombosis 98 smoking 133

Clerkship

• Internal Medicine Selective or Elective • Academic ½ day:

– Internal medicine- ½ day CV topics (CP, CHF, ECG, HTN) – Surgical ½ day – request to consider cardiac surgery

topic(s)- ie. post CABG or post valve replacement care (at the level of a generalist). This topic would be better after some clinical exposure (ie. not in M1 or M2).

Overall- Positive Aspects • Excellent opportunity to scrutinize the course, find

gaps/redundancies, improve course in terms of objectives, content, organization, sequencing and teaching methods.

• Dividing into M1 and M2 is logical; M2 will be far better understood after learning the basic sciences of all the systems first.

• Large course, crosses over many other related disciplines and longitudinal themes

• Current course- minimal gaps (but still some); have identified areas to decrease redundancy

• Excellent opportunity to enhance learning with optimal integration of the longitudinal courses

Overall- Challenges • Very condensed timing for M2- would have been ideal to

combine with Respirology for obvious reasons • Division of M1 & M2 and sequencing • Number of lecturers will be more than ‘ideal’-- even just for

the core Cardiology lectures (I can’t do them all), and adding the other related disciplines (ICU/vascular surgery, cardiac surgery) and longitudinal themes (geriatrics, peds, genetics, ID, pathology, radiology, etc…)

• There are a lot of GFT cardiologists (25) – trying to be fair in distributing the teaching ‘duties’ while at the same time, focusing on student needs to have the best teachers. Agenda of CuRE is fewer teachers- but if only 4-6 teachers, huge amount of hours for them (difficult to sell this model to these 4-6 teachers when majority not participating). Also, some want to teach, but may not get ‘picked’- may be ‘hard feelings’.

• Clinical skills

Next Steps • Committee to be subdivided to ‘clean up’

gaps/redundancies in their area (ie. physiology, IHD sections), develop objectives, then develop content.

• Teaching format to be determined- direction from CuRE. Challenges with being such a large course- difficult to reduce lectures to <25%; ideal to use on-line module teaching methods, but development will be a lot of work up front. May need to gradually make changes.

• Consider role for purchasing material- ie. ECG tutorials etc… for student self study.