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Electrophysiology Curriculum
Section of Cardiology
Dartmouth-Hitchcock Medical Center
2007-2008
I.
Overview of Rotation
Clinical cardiac electrophysiology is a rapidly expanding field that requires
additional training beyond that of the general cardiologist to be competent in all its
aspects. However, it is necessary for the general cardiologist to be aware of the various
electrophysiologic disease states, so that he/she can make appropriate management
decisions about his/her patients. The following curriculum will allow the cardiology
trainee to achieve this goal. It is based on the 2006 ACC document on Core Cardiology
Training in Adult Cardiovascular Medicine (COCATS 2006 Focused Updates),
http://www.acc.org/qualityandscience/clinical/competence/nuclear/TF6.pdf
II.
Core Competencies
At least 2 months of clinical cardiac electrophysiology rotation is required for all
general cardiology trainees to acquire knowledge and experience in the diagnosis and
management of bradyarrhythmias and tachyarrhythmias. Every cardiology trainee will
learn the indications for and limitations of electrophysiologic studies, the appropriate use
of pharmacologic and nonpharmacologic therapeutic options, and the proper and
appropriate use of antiarrhythmic agents, including drug interactions and proarrhythmic
potential. The trainee will be exposed to noninvasive and invasive techniques related to
the diagnosis and management of patients with cardiac arrhythmias that include
ambulatory electrocardiographic (ECG) monitoring, event recorders, exercise testing for
arrhythmia assessment, tilt-table testing, invasive electrophysiologic studies, and
implantation of cardiac arrhythmia control devices. Electrocardiographic manifestations
of arrhythmias will be taught on a regular basis during formal ECG and EP conferences.
They will be supplemented by rotation on the arrhythmia consultation service, during
which time the trainee will gain first-hand experience as a consultant in arrhythmia
management. Arrhythmias associated with congenital heart disease, cardiac and
noncardiac surgical patients are important components of the arrhythmia core training.
The trainee’s experience will also include learning the fundamentals of cardiac pacing,
recognizing normal and abnormal pacemaker function, knowing indications for
temporary and permanent pacing and the implantation of ICDs, knowing pacing modes,
and understanding basic techniques for interrogation, programming, and surveillance of
pacemakers and ICDs. The trainee will also learn about the indications for the use of
biventricular pacing in patients with congestive heart failure. The cardiology trainee will
be formally instructed in and gain experience with the insertion, management, and
follow-up of temporary pacemakers; measurement of pacing and sensing thresholds and
recording of electrograms for management of patients with temporary pacemakers; and
indication and techniques for elective and emergency cardioversions. Insertion of a
minimum of 10 temporary pacemakers and performance of at least 10 elective
cardioversions are required. These experiences can be obtained throughout the clinical
training period.
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As volumes permit, trainees may obtain proficiency in the surgical aspects of
transvenous bradycardia device implantation (pacemakers). The pacemaker implantation
training will include development of expertise in permanent atrial and ventricular lead
placement, threshold testing and programming of devices, principles of surgical asepsis,
surgical techniques of implantation, and management of implant related complications.
Individuals receiving qualifying training in pacemaker implantation must participate as
the primary operator (under direct supervision) in at least 50 primary implantations of
transvenous pacemakers and 20 pacemaker system revisions or replacements. The trainee
must also participate in the follow-up of at least 100 pacemaker patient visits and acquire
proficiency in advanced pacemaker electrocardiography, interrogation, and programming
of complex pacemakers.
Credentialing for permanent pacer implantation will require a total of 1 year
of advanced training beyond the cardiology core level. This will include 6 months of
training in non-invasive arrhythmia management techniques designed to develop
advanced competence and proficiency in the diagnosis, treatment and longitudinal
care of patients with complex arrhythmias. It will also involve 6 months of training
in device implantation. This may be obtained within a 3-year cardiology program if
enough electrophysiology lab time is dedicated to acquiring pacemaker implantation
skills plus related management and follow-up.
Trainees must keep a log of their activities documenting the indication for the
procedure, the device placed, and any complications, as well as a list of devices
interrogated.
III.
Portfolio Accomplishments
At the conclusion of each month on the electrophysiology service, the fellow will
have completed the following goals toward credentialing of clinical competence:
1. Completion of reading the core references (see below), and documenting this in
his/her log.
2. Primary operator on the interrogation and programming of at least 5 pacemakers
and defibrillators (which should encompass at least 2 major device vendors), to be
documented in his/her log
In addition, as part of the fellows electrophysiology portfolio, the fellow should
initiate and maintain, documentation of all temporary pacemakers and DC cardioversions
he /she has performed. The fellow is expected to perform 10 DC cardioversions and 10
temporary pacemaker insertions over the course of the three year fellowship.
Core References: Month 1
1.
The anatomy and physiology of the conduction system and basic cellular
electrophysiology including arrhythmia mechanisms
Genesis of Cardiac Arrhythmias: Electrophysiological Considerations.
Heart Disease. A Textbook of Cardiovascular Medicine. 7th Edition.
Braunwald 2005. Chapters 27, pages 653-687
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2.
Pharmacokinetics, actions and toxicity of antiarrhythmic medications
Therapy for Cardiac Arrhythmias. Heart Disease. A Textbook of
Cardiovascular Medicine. 7th Edition. Braunwald 2005. Chapters 30,
pages 713-736
3.
Management and Anticoagulation For Arial Fibrillation
ACC/AHA/ESC 2006 Guidelines for the Management of patients with
Atrial Fibrillation. Circulation 2006; 114:710-739
4.
Direct Current Cardioversion
Therapy for Cardiac Arrhythmias. Heart Disease. A Textbook of
Cardiovascular Medicine. 7th Edition. Braunwald 2005. Chapters 30,
pages 736-739
5.
Pacemaker timing cycles and programming. Indications for permanent and
temporary pacemakers, and Implantable Cardioverter-defibrillator
Treatment, including for the management of CHF
Cardiac Pacemakers and Cardioverter-Defibrillators. Heart Disease. A
Textbook of Cardiovascular Medicine. 7th Edition. Braunwald 2005.
Chapters 31, pages 767-802
Role of implantable cardioverter-defibrillators for the primary prevention
of sudden cardiac death after myocardial infarction. Podrid and Ganz
http://www.utdol.com/utd/content/topic.do?topicKey=carrhyth/56215&sel
ectedTitle=5~125&source=search_result
Role of implantable cardioverter-defibrillators for the secondary
prevention of sudden cardiac death. Podrid, Arnsdorf and Cheng.
http://www.utdol.com/utd/content/topic.do?topicKey=carrhyth/46703&sel
ectedTitle=4~125&source=search_result
Overview of cardiac pacing in heart failure. Saxon, Kumar and Demarco
http://www.utdol.com/utd/content/topic.do?topicKey=hrt_fail/22712&sele
ctedTitle=15~252&source=search_result
6.
Diagnosing Cardiac Arrhythmias
Diagnosis of Cardiac Arrhythmias. Heart Disease. A Textbook of
Cardiovascular Medicine. 7th Edition. Braunwald 2005. Chapters 29,
pages 697-712
7.
Indications for electrophysiologic testing
Overview of Invasive Electrophysiology studies. Podrid and Ganz
http://www.utdol.com/utd/content/topic.do?topicKey=carrhyth/35534&sel
ectedTitle=1~62&source=search_result
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Therapy for Cardiac Arrhythmias. Heart Disease. A Textbook of
Cardiovascular Medicine. 7th Edition. Braunwald 2005. Chapters 30,
pages 757-766
8.
Familiarity with intracardiac tracings and catheter placement
Core References: Month 2
1.
Pathophysiology, evaluation and treatment of syncope/ Tilt Testing
AHA/ACCF Scientific Statement on the Evaluation of Syncope. JACC
Vol47, No. 2, 2006:473-84
Pathogenesis and etiology of syncope. Olshansky
http://www.utdol.com/utd/content/topic.do?topicKey=carrhyth/56946&sel
ectedTitle=2~316&source=search_result
Evaluation of the patient with syncope. Olshansky
http://www.utdol.com/utd/content/topic.do?topicKey=carrhyth/32604&sel
ectedTitle=2~34&source=search_result
Neurocardiogenic (vasovagal) syncope and carotid sinus hypersensitivity.
Olshansky
http://www.utdol.com/utd/content/topic.do?topicKey=carrhyth/57305&sel
ectedTitle=3~34&source=search_result
Upright tilt table testing in the evaluation of syncope. Olshansky
http://www.utdol.com/utd/content/topic.do?topicKey=carrhyth/46365&sel
ectedTitle=1~34&source=search_result
Postural tachycardia syndrome. Freeman and Kaufman
http://www.utdol.com/utd/content/topic.do?topicKey=genneuro/6430&sel
ectedTitle=4~34&source=search_result
2.
Pathophysiology, evaluation and treatment of sudden cardiac death
Overview of sudden cardiac arrest and sudden cardiac death. Siscovick
and Podrid
http://www.utdol.com/utd/content/topic.do?topicKey=carrhyth/29910&sel
ectedTitle=1~3791&source=search_result
Pathophysiology and etiology of sudden cardiac arrest. Podrid, Arnsdorf
and Cheng.
http://www.utdol.com/utd/content/topic.do?topicKey=carrhyth/34030&sel
ectedTitle=2~364&source=search_result
Sudden cardiac death in the absence of apparent structural heart disease.
Pinto and Josephson.
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http://www.utdol.com/utd/content/topic.do?topicKey=carrhyth/47754&sel
ectedTitle=3~364&source=search_result
Outcome of sudden cardiac arrest. Podrid, Arnsdorf and Cheng
http://www.utdol.com/utd/content/topic.do?topicKey=carrhyth/33730&sel
ectedTitle=4~364&source=search_result
Evaluation of the survivor of sudden cardiac arrest. Podrid, Arnsdorf and
Cheng.
http://www.utdol.com/utd/content/topic.do?topicKey=carrhyth/33002&sel
ectedTitle=5~364&source=search_result
3.
Pathophysiology, evaluation and treatment of SVT and atrial fibrillation
Specific Arrhythmias: Diagnosis and Treatment. Heart Disease. A
Textbook of Cardiovascular Medicine. 7th Edition. Braunwald 2005.
Chapters 32, pages 810-841
4.
Pathophysiology, evaluation and treatment of Non Sustained VT
Nonsustained VT in the absence of apparent structural heart disease.
Morton F Arnsdorf, MD, MACC
http://www.utdol.com/utd/content/topic.do?topicKey=carrhyth/21687&sel
ectedTitle=1~83&source=search_result
Management of nonsustained ventricular tachycardia. Zimetbaum,
Josephson, and Wylie
http://www.utdol.com/utd/content/topic.do?topicKey=carrhyth/16544&sel
ectedTitle=2~83&source=search_result
Prognosis of nonsustained VT in the presence of structural heart disease.
Zimetbaum, Josephson, and Wylie
http://www.utdol.com/utd/content/topic.do?topicKey=carrhyth/23754&sel
ectedTitle=3~83&source=search_result
5.
Pathophysiology, evaluation and treatment of Sustained VT
Specific Arrhythmias: Diagnosis and Treatment. Heart Disease. A
Textbook of Cardiovascular Medicine. 7th Edition. Braunwald 2005.
Chapters 32, pages 841-854
4.
Catheter Ablation
Catheter ablation of cardiac arrhythmias: Overview and technical
aspects. Ganz
http://www.utdol.com/utd/content/topic.do?topicKey=carrhyth/42652&sel
ectedTitle=15~842&source=search_result
Additional Suggested Reading:
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The following references are provided as a starting point to the further
understanding of Electrophysiology and management of arrhythmias,
devices and syncope. Up to Date®, is also provided by DHMC, and is an
excellent resource on virtually all topics in Electrophysiology, and is highly
recommended as a resource.
1.
2.
3.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
IV:
Genetics of Cardiac Arrhythmias. Heart Disease. A Textbook of
Cardiovascular Medicine. 7th Edition. Braunwald 2005. Chapters 28,
pages 689-695
Cardiac Arrest and Sudden Cardiac Death Heart Disease. A Textbook of
Cardiovascular Medicine. 7th Edition. Braunwald 2005. Chapters 33,
pages 865-908
Hypotension and Syncope. Heart Disease. A Textbook of Cardiovascular
Medicine. 7th Edition. Braunwald 2005. Chapters 34, pages 909-919
A Simplified Method to Predict Occurrence of Complete Heart Block
During Acute Myocardial Infarction. G Lamas et al. AJC Vol. 57, No 15,
June 1, 1986:1213-19
Desai AD, Chun S, Sung RJ. The role of intravenous amiodarone in the
management of cardiac arrhythmias. Annals of Internal Medicine. 1997;
127(4):294-303.
Kowey PR, Marinchak RA, Rials SJ, Filart RA. Intravenous amiodarone.
Journal of the American College of Cardiology. 1997; 29(6):1190-8.12
Supraventricular Tachycardia. L. Ganz. NEJM Jan. 1995 Vol. 332 No 3:
162-73
Supraventricular Tachycardia. L. Ganz. NEJM Jan. 1995 Vol. 332 No 3:
162-73
Ventricular Premature Depolarizations and Non-sustained Ventricular
Tachycardia. A. Buxton and J. Duc. Cardiac Arrhythmia: Mechanism,
Diagnosis and Management. Second Edition. P. Podrid and P. Kowey.
Chapter 18 pages 549-571
Sustained Monomorphic Ventricular Tachycardia. D. Martin and J.M.
Wharton. Cardiac Arrhythmia: Mechanism, Diagnosis and Management.
Second Edition. P. Podrid and P. Kowey. Chapter 19 page 573-601
Atrial Fibrillation. Jahangir A, et al. Cardiac Arrhythmia: Mechanism,
Diagnosis and Management. Second Edition. P. Podrid and P. Kowey.
Chapter 15 page 459-499
Guidelines for the Management of patients with Atrial Fibrillation.
Circulation 2006; 114:700-752
Ommen SR, Odell JA, Stanton MS. Atrial arrhythmias after cardiothoracic
surgery. New England Journal of Medicine. 1997; 336(20):1429-34.
Zimetbaum P, Josephson ME. Evaluation of patients with palpitations.
New England Journal of Medicine. 1998; 338(19):1369-73.
Professionalism:
In order to achieve these expectations, the fellow will have full access to an
attending electrophysiologist both in the EP lab and on the wards to discuss and learn
appropriate patient management. The fellow will read independently on issues that are of
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interest (above and beyond the suggested reading) and the attending electrophysiologist
will be available to supply the relevant material. The fellow's responsibilities will
include:
●Performing consults
●Being responsible for admissions to the EP service
●Being responsible for rounding and writing notes on the EP service patients.
●Being the primary contact person for the house staff covering the EP service
patients.
●Observing one VT study, one SVT study, and one tilt test per week. The fellow
should also observe/participate in at least one of each type of pacer and ICD
implantation during the month.
●Spending as much time as possible participating in pacemaker programming and
troubleshooting.
●The fellow will not be responsible for placing or removing catheters or sheaths
except in cases where the fellow is positioning catheters to develop
competency, or on special occasions to help out the attending.
Practice-Based Learning:
Fellows will be given the opportunity to participate in ongoing EP research
activities and quality improvement efforts. This includes those specific to the
electrophysiology laboratory and arrhythmia management in other venues such as the
outpatient clinics, ER and general medical floors.
Systems-Based Practice, Interpersonal and Communication Skills:
The electrophysiology program is integrated into the overall cardiovascular
disease treatment paradigm at DHMC. As a regional center, the electrophysiology section
offers unique tertiary and quaternary expertise not available at other centers in the region.
Therefore, the general cardiology fellow will get insights into the role of a referral center
to provide high intensity diagnostic and therapeutic interventions for appropriate patients.
Further, the fellow will learn to important communication skills to relay
electrophysiologic data and treatment plans to referring physicians within and outside
DHMC.
V:
Evaluation.
At the beginning of each electrophysiology rotation, the above document will be
given to the fellow, along with a detailed discussion outlining the expectations, duties and
functions of the fellow for the upcoming rotation. Midway through and at the end of each
rotation the fellow will be given feedback as to his or her performance and knowledge
base, with appropriate suggestions for improvement. At this time, solicitation of
comments from the fellow for improvements to the electrophysiology program will also
be elicited. This interaction is designed to foster mutual respect and facilitate an
improvement of the electrophysiology program, its teaching methods, and opportunities
afforded to the fellow.
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VI.
Faculty
Mark Greenberg, MD. Director Clinical Electrophysiology (Board Certified Cardiology,
Electrophysiology, and Pacing)
Peter Holzberger, MD. Associate Director Clinical Electrophysiology (Board Certified
Cardiology, Electrophysiology, Pacing and Defibrillation)
Barbara Gerling, MD. Staff electrophysiologist (Board Certified Cardiology,
Electrophysiology, Pacing and Defibrillation)
Steven Weindling, MD. Staff pediatric electrophysiologist (Board Certified Pediatric
Cardiology)
Paul Steiner, MD; Staff electrophysiologist (Board Certified Cardiology,
Electrophysiology)
Rajbir Sangha, MD; Staff electrophysiologist
Mark Kiesling, PA;
Steven Holderman NP,
Terry Hall, RN
Mary Ann Coackley, RN