Electrophysiology - General Cardiology Rotation

Director: Shane Tsai, MD

Teaching Faculty: Drs. Daniel Anderson, Arthur Easley, Faris Khan, Niyada Naksuk, Jason Payne, William Schleifer, Shane Tsai, and John Windle

I. Core Competency Components and Curricular Milestones in Electrocardiography (ECG) and Ambulatory ECG:

Milestones are adapted for use from COCATS 4 Task Force 3 (JACC 2015; 65:1763-77). There is no established threshold number of studies to achieve Level I training in ECG interpretation. Interpretation of at least 3000 ECG within 36 months is recommended to acquire competency, and will be tracked through electronic data system (i.e. MUSE)

A. Medical Knowledge

1. 1st year milestones

a. Know the basic principles of ECG and the operation/use of the instruments to acquire, display, and store ECGs

b. Know the normal values for electrical axis and ECG intervals, durations, and voltage

c. Know the anatomy of the specialized conducting tissue and the spread of excitation in conduction system and myocardium

d. Know the indications for, and limitations of, continuous (Holter) and intermittent (event) ambulatory ECG recording

2. 2nd year milestones

a. Know the underlying cellular and ionic mechanisms in the genesis of surface ECGs and the effects of the autonomic nervous system

b. Know re-entry, automaticity, and triggered activity mechanisms for cardiac arrhythmias

c. Know the ECG changes that are commonly seen in highly trained athletes and the challenges in distinguishing normal from abnormal findings

3. 3rd year milestones

a. Know capture and fusion complexes and the ECG pattern criteria for distinguishing supraventricular arrhythmias with aberrancy, accessory pathway conduction, pacing, and artifact from ventricular arrhythmias

b. Know the concepts of concealed conduction and exit block and their manifestation on the ECG

c. Know the characteristic ECG patterns of key clinical diagnoses

B. Patient Care and Procedural Skills (n= 1000 annual interpretations recommended) 1. 1st year milestones

a. Technical skills to perform and record high-quality, standard 12-lead ECG tracings

2. 2nd year milestones

a. Skill to identify normal ECG patterns, normal variants, and artifacts (including incorrect lead placement)

b. Skill to identify ECG signs of atrial abnormalities and right and left ventricular hypertrophy or enlargement

c. Skill to identify the ECG patterns and localization of cardiac ischemia and infarction

d. Skill to identify nonspecific QRS and ST-T wave changes

e. Skill to integrate ECG findings into clinical and risk assessments and the managements of patients

3. 3rd year milestones

a. Skill to identify types and significance of intraventricular conduction delay or block (including functional or aberrant conduction abnormalities)

b. Skill to identify types of atrioventricular dissociation

c. Skill to identify 1st degree, 2nd degree (types I, II, 2:1, and high degree), and 3rd degree atrioventricular blocks

d. Skill to identify the ECG changes of electrolyte and metabolic abnormalities and drug effects

e. Skill to identify atrial, atrioventricular, nodal, and ventricular arrhythmias

f. Skill to identify each of the specific pattern in Appendix 1

g. Skill to select and interpret ambulatory ECG recording studies

h. Skill to identify normal and abnormal pacemaker rhythms/functions, and when to seek consultation from an electrophysiologist for advanced interpretation

C. Systems-Based Practice

1. 1st year milestones

a. Skill to retrieve and utilize ECG tracings in electronic data systems (MUSE)

D. Practice-Based Learning and Improvement

1. 1st year milestones (none)

a. Identify knowledge and performance gaps and engage in opportunities to achieve focused education and performance improvement E. Professionalism

1. 1st year milestones

a. Practice within the scope of expertise and technical skills

2. 2nd year milestones (none)

3. 3rd year milestones

a. Know and adhere to evidence-based and appropriate use criteria for ECG testing

F. Interpersonal and Communication Skills

1. 1st and 2nd year milestones (none)

2. 3rd year milestones

a. Communicate testing results to physicians and patients in an effective and timely manner

II. Core Competency Components and Curricular Milestones in Arrhythmia Diagnosis and Management, Cardiac Pacing, and Electrophysiology:

Milestones are adapted for use from COCATS 4 Task Force 11 (JACC 2015; 65:1854-65). Milestones for advanced clinical cardiac electrophysiology 2-yr subspecialty are addressed in separate document. Training components include didactic program, clinical experience, and hands-on experience. Level I training will occupy at least 2 months on a clinical cardiac electrophysiology (CCEP) rotation.

A. Medical Knowledge

1. 1st year milestones

a. Know the mechanism and characteristics of normal sinus rhythm and of sinus node dysfunction

b. Know the pathophysiology, differential diagnosis, clinical significance, and approach to management of atrial fibrillation and flutter, including the assessment of stroke and bleeding risk, indications of anticoagulation, and selection of anticoagulant medications

c. Know the risk factors for stroke and for bleeding in patients with atrial fibrillation or atrial flutter, as well as the indications for, and use of, anticoagulant medications

d. Know the types, mechanisms, differential diagnosis, clinical significance, and approach to management of atrioventricular dissociation and atrioventricular heart blocks (1st, 2nd, and 3rd degree)

e. Know the pathophysiology, differential diagnosis, natural history, and approach to management of syncope, including neurocardiogenic causes and syncope in athletes

f. Know the principles and practice of radiation safety as applied to the evaluation and management of cardiac electrical disorders

2. 2nd year milestones

a. Know the pathophysiology, differential diagnosis, clinical significance, and approach to management of re-entrant tachycardia (atrioventricular nodal re-entrant tachycardia (AVNRT); atrioventricular reciprocating tachycardia (AVRT)), ectopic atrial tachycardia, and accelerated atrioventricular junction rhythm

b. Know the pathophysiology, differential diagnosis, clinical significance, and approach to management of sustained and non-sustained ventricular tachyarrhythmias

c. Know the pathophysiology, differential diagnosis, and approaches to risk stratification and management of sudden cardiac death and cardiac arrest, including sudden cardiac death in athletes

d. Know the physical examination characteristics (eg findings of AV dissociation)

e. Know the significance of underlying structural or congenital heart disease in the likelihood and significance of cardiac arrhythmias, including sudden death risk, and their impact in clinical management decisions

f. Know the indications, contraindications, and clinical pharmacology of anti-arrhythmic medications, including drug-drug- and drug-device interactions and pro-arrhythmia potential (including acquired long QT syndrome)

g. Know the indications and limitations of non-invasive testing in the diagnosis and management of patients with arrhythmias: electrocardiograph, ambulatory, event, implantable loop recorder, and tilt-table testing

h. Know the indications for, and limitations and implications of, invasive electrophysiological testing, as well as catheter ablation for cardiac arrhythmias

i. Know the indications and contraindications for permanent pacemaker placement, cardiac resynchronization therapy, and implantable cardioverter-defibrillator placement

j. Know the mechanisms, findings, clinical significance, and approach to management of ventricular pre-excitation

k. Know the pathology, clinical significance, and approach to evaluation (including the role of genetic testing) and management of inherited diseases that may cause cardiac arrhythmias due to ion channel abnormalities or structural change in the heart (including the long QT syndrome, Brugada syndrome, arrhythmogenic right ventricular dysphasia, hypertrophic dilated cardiomyopathy, and myotonic dystrophy)

l. Know the basic principles of programming and interrogating implanted devices (permanent pacemakers (PPM), implantable cardioverter-defibrillators (ICD), cardiac resynchronization therapies, and implantable monitors)

B. Patient care and Procedural Skills

1.1st year milestones a. Skill to perform electrical cardioversion (n= 20)

b. Skill to perform defibrillation

2. 2nd year milestones

b. Skill to evaluate and management patients with palpitations

c. Skill to evaluate and manage patients with syncope

d. Skill to evaluate and manage patients with supraventricular tachyarrhythmias

e. Skill to evaluate and manage patients with atrial fibrillation and flutter (including rate and rhythm control and anticoagulation strategies)

f. Skill to evaluate and manage patients with wide-QRS tachycardia

g. Skill to manage patients with nonsustained and sustained ventricular arrhythmias

h. Skill to evaluate and manage patients with bradycardia and/or heart block

i. Skill to perform temporary pacemaker placement (n= 5)

j. Skill to integrate the information provided in cardiac electrophysiology consultation, and reports of procedures and device interrogation, into the overall clinical assessment of the patient and plan of management

k. Skill to evaluate and manage patients with cardiac arrest

l. Skill to prescribe and interpret the results of electrocardiographic recording devices

3. Level II milestones (6 months total training required)

a. Without training in pacemaker implantation

i. Skill to perform tilt-table testing (n= 5 recommended)

ii. Skill to perform PPM and ICD interrogation, programming, and surveillance (n= 100 required)

iii. Skill to follow-up, interrogate, and troubleshoot patients with implanted devices (PPM, ICD, CRT), including remote interrogation (n= 25 required)

iv. Skill to perform implantation of implantable loop recorders (ILR) (n=5 recommended), interpret results to guide patient management, and manage complications

b. Including pacemaker implantation

i. Skill to perform single and dual chamber PPM implantation and manage complications, including device infections and chronic lead failure (n= 40 required, including 20 single chamber and 20 dual chamber devices)

c. Defibrillator implantation i. Additional 12 months beyond a standard 3-year cardiovascular fellowship are required for training to implant ICDs and biventricular devices, but without necessarily satisfying the full requirements for Level III training in advanced cardiac electrophysiology.

C. Systems-Based Practice

1. 1st year milestones (none)

2. 2nd year milestones

a. Utilize an interdisciplinary coordinated approach for patient management, including transfer of care and employment-related issues

b. Use technology and available registries to assess appropriateness, performance, and safety of implanted devices

c. Incorporate risk/benefit analysis and dose considerations in diagnostic and treatment decisions

D. Practice-Based Learning and Improvement

1. 1st year milestones (none)

2. 2nd year milestones

a. Identify knowledge and performance gaps and engage in opportunities to achieve focused education and performance improvement

b. Utilize decision support tools for accessing guidelines and pharmacological information at the point of care

E. Professionalism

1. 1st year milestones

a. Interact respectfully with patients, families, and all members of the healthcare team, including ancillary and support staff

2. 2nd year milestones

a. Demonstrate sensitivity to patient preferences and end-of-life issues

b. Practice within the scope of expertise and technical skills

F. Interpersonal and Communication Skills

1. 1st year milestones (none)

2. 2nd year milestones

a. Communicated with and educate patients and families across a broad range of cultural, ethnic, and socioeconomic backgrounds b. Engage in shared decision-making with patients, including decision regarding options for diagnosis and treatment

III. Fellow Rotation Expectations and Responsibilities: A. Actively participate on daily inpatient rounds with EP faculty attending and team, including presentation and discussion of all patient related hospital care B. Primarily responsible for performance of service admission/consultation with emphasis on dysrhythmia and/or device management. Fellow will perform up to 5 admissions/consultations daily. • EP advanced practice provider (APP) will be responsible for anti-arrhythmic drug load admissions and MRI PPM/ICD consultations, although fellow will participate in discussion • EP APP will assist with additional admissions/consultations, at the discretion of the EP faculty or advanced fellow C. Interpret ECG to achieve expected milestone (1000 monthly recommended) • Appropriate studies for review based on Medical Knowledge and Procedural Skill milestones, as described above • EP faculty expected to review study interpretations with fellow D. Perform device interrogations, including PPM, ICD, and CRT • 1st and 2nd year fellows expected to perform all device interrogations; 3rd year fellows may perform interrogations at discretion, if basic competence achieved as determined by faculty (unless Level II certification desired- see above) • Supervision provided by MD, APP, and designated device team members E. Perform procedures to achieve expected milestones of Level I certification, including: • Cardioversions (n= 20) • Temporary pacemakers (n= 5) • Tilt table test observation is recommended, although not required (unless Level II certification desired- see above)

Appendix 1