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UW Cardiovascular (CVM) Cardiology Preventive Cardiology Curriculum

Overview

The primary goal of the Preventive Cardiology curriculum for the University of Wisconsin Cardiovascular Medicine Fellowship is to provide the knowledge and skills necessary to successfully initiate and maintain long-term preventive in a general clinical cardiology practice. This curriculum satisfies all requirements of ACC 2015 Core Cardiovascular Training Statement (COCATS 4) Task Force 2: Training in Preventive Cardiovascular Medicine for each fellow to achieve all core (level 1) competencies within 24 months of clinical cardiovascular medicine fellowship. This is accomplished by each fellow actively participating in a month of dedicated training in Cardiovascular prevention, supplemented by a comprehensive, didactic/interactive lecture series offered every other year, so each fellow will have the opportunity to participate in it twice during their clinical training. The Preventive Cardiology lecture series includes several interactive methods such as case management and problem solving, in addition to didactic and written support materials. The Preventive Cardiology curriculum is introduced in the first year of a fellows’ training. Knowledge obtained during this curriculum is practiced and reinforced as part of the fellow’s weekly cardiology continuity and during rotations on the inpatient cardiology services (CCU, VA, Failure, and consultation).

Additional educational, clinical and research opportunities are available for fellows interested in a cardiology career with an emphasis in prevention. A half or full year of specific Preventive Cardiology training is available for interested fourth-year fellows, especially if they have an interest in prevention or imaging research. Specific research and learning opportunities are available in the areas of lipids, , sleep apnea, cessation, inflammatory , vascular imaging, cardiovascular epidemiology and health services research.

The Preventive Cardiology curriculum meets the program requirements for the ACGME as follows: A. Patient Care. Learned as part of the Preventive Cardiology one-month rotation. It is supervised and evaluated by an attending supervision. B. Medical Knowledge. Obtained as part of the Preventive Cardiology rotation and lecture series. It is evaluated by informal pre- and post-tests. C. Practice-Based Learning and Improvement. Obtained as part of the Preventive Cardiology rotation, supplemented by case-based learning during the lecture series and evaluated by quizzes. D. Interpersonal Communication Skills. Emphasized and role-modeled during the Preventive Cardiology rotation. E. Professionalism. Emphasized and role-modeled during the Preventive Cardiology rotation. F. Systems-Based Practice. Emphasized and role-modeled during the Preventive Cardiology rotation and supplemented by the lecture series and their clinical inpatient and experiences, including continuity .

1 Preventive Cardiology Specific Goals and Objectives

(Note: the corresponding COCATS 4, Task Force 2 Medical Knowledge Competencies are listed in parentheses next to each section)

1. and Lipids (lectures, clinic)

Goal: To understand clinical aspects of lipoprotein metabolism and diagnosis and management of lipid disorders as they relate to atherosclerotic .

Objectives: Fellows will be able to a. Describe basic mechanisms of atherogenesis and atherosclerosis. (1,8) b. Know the principles of as applied to cardiovascular disease and pharmacology (2 c. Know the risk factors for atherosclerotic cardiovascular disease, including family history, and how they affect risk (3-6) d. Describe clinical aspects of lipid and lipoprotein metabolism. (8,10, 21) e. Describe and implement the AHA/ACC lipid guidelines. (3-7). f. Describe dietary treatment of lipid disorders. (10,12) g. Describe pharmacologic treatment of lipid disorders. (10, 21) h. Describe the major clinical trials that affect lipid and guidelines. (10) i. Evaluate clinical and recommend treatment strategies based on case presentations.(10) j. Understand the methodology and appropriate use of advanced lipoprotein testing. (7,10) k. Know the effects of systemic diseases and inflammation on cardiovascular disease risk and its management (16)

2. Hypertension Management (lectures, clinic)

Goal: To understand clinical aspects of the diagnosis and management of hypertension.

Objectives: Fellows will be able to a. Understand the major secondary causes of hypertension and their initial evaluation.(8,11,17) b. Describe key aspects of management of patients with hypertension. (11, 21) c. Describe and implement the AHA/ACC and ASH hypertension guidelines. (11, 21) d. To understand the approach to the diagnosis and treatment of the patient with resistant hypertension. (11)

3. Mellitus, Metabolic Syndrome, and (lectures, clinic)

Goal: To understand the prevalence, cardiovascular implications, and treatment of obesity, metabolic syndrome, and diabetes mellitus, including sleep apnea and cardiovascular disease risk

Objectives: Fellows will be able to a. Describe the pathophysiology of obesity and metabolic syndrome (insulin resistance syndrome). (8,9)

2 b. Describe the mechanisms by which obesity and metabolic syndrome increase cardiovascular risk. (8,9) c. Describe lifestyle management of obesity and metabolic syndrome. (8,9,12) d. Describe pharmacological therapy of obesity and metabolic syndrome. (8,9) e. Describe treatment of diabetes mellitus and diabetic lipid disorders. (8,9,12) f. Describe the initial approach to recognizing and managing obstructive sleep apnea and its effect on CVD risk. (17)

4. Smoking Cessation (lecture, clinic, smoking cessation module)

Goal: To understand the cardiovascular effects of exposure and strategies for -assisted smoking cessation.

Objectives: Fellows will be able to a. Describe the effects of smoking on cardiovascular disease incidence. (8,15) b. Describe primary methods for smoking cessation. (15, 21) c. Describe the key components of office-based smoking management systems. (15)

5. Exercise and (cardiac rehabilitation clinic and inpatient experience)

Goal: To understand the physiological principles and processes of cardiac rehabilitation for patients with a wide range of cardiovascular diseases.

Objectives: Fellows will be able to a. Describe cardiovascular and pulmonary responses to exercise in patients with cardiovascular disease. (12,14) b. Understand exercise testing protocols and accurately determine functional capacity. (12,14) c. Provide the basic components of an exercise prescription for patients with cardiovascular disease. (12,14) d. Understand principles of early mobilization and cardiovascular response to low-level exercise following , coronary bypass , and cardiac transplant. (12,14) e. Understand guidelines for home activities upon discharge. (12,14) f. Understand physiology of exercise training in patients with cardiovascular disease. (12,14) g. Understand the metabolic cost and cardiovascular response to activities of daily living. (12,14) h. Incorporate secondary prevention into cardiac rehabilitation goals of the patient. (12,14) i. Work with a multi-disciplinary team to achieve treatment and rehabilitation goals. (12,14)

6. Nutrition (lecture, clinic, nutrition clinic)

Goal: To understand the metabolic, epidemiological, and clinical rationale for nutritional recommendations for patients with cardiovascular disease.

Objectives: Fellows will be able to a. State the primary dietary elements related to atherosclerosis prevention. (12)

3 b. Describe dietary interventions for hypertension and . (5, 12)

7. Psychosocial and Behavioral Aspects of Cardiovascular Diseases (lecture, clinic, cardiac rehabilitation clinic, nutrition clinic, smoking cessation module)

Goal: To understand how depression, anxiety, and patient behavior affect cardiac outcomes, as well as interventions to motivate behavioral change.

Objectives: Fellows will be able to a. Describe the effects of depression and anxiety on cardiovascular outcomes. (12,13,15) b. Describe strategies for motivating behavior change in patients with heart disease. (12,13,15) c. Outline treatment strategies for cardiovascular disease patients with concomitant depression and/or anxiety. (12,13,15)

8. Screening Tests (lecture, clinic)

Goal: To understand proper use of new/emerging serological and imaging tests for evaluating cardiovascular risk and detecting subclinical atherosclerosis.

Objectives: Fellows will be able to a. Describe the appropriate clinical use of screening tests such as lipoprotein(a), high sensitivity C-reactive protein, and advanced lipoprotein testing. (4,6) b. Understand imaging tests for screening such as measurement of carotid intima-media thickness, ankle-brachial index, coronary calcium scoring, and AAA screening. (7,18)

9. Special Populations (lecture, clinic)

Goal: To review differences in cardiovascular prevention strategies between men and women, young and old patients, and people of different racial backgrounds.

Objectives: Fellows will be able to: a. Identify sex-related differences in risk factors for heart disease (4). b. Consider differences in prevention strategies among young and older patient (4). c. Consider differences in evaluation of patients of different racial backgrounds (4).

Note: these COACTS 4, Take Force 2 items are covered elsewhere in the UW CVM Fellowship: 19. Know the impact of reproductive stages, , and hormonal treatment for reproductive disorders on cardiovascular risk. 20. Know the principles of antithrombotic therapy in cardiovascular disease.

4 Rotation for First-Year Fellows

A one-month rotation during the first year of the cardiology fellowship will be dedicated to in- depth participation in the care of patients in the Preventive Cardiology and cardiac rehabilitation programs. A personalized schedule with the components below will be created by fellowship staff in consultation with the Preventive Cardiology Program Director. Fellows will be exposed to, and when appropriate, manage patients with direct observation by Preventive Cardiology faculty and staff. Fellows will work in the inpatient rehabilitation (Phase I), outpatient rehabilitation (Phases II-III), and specialty programs in Preventive Cardiology. They will obtain experience managing patients recovering from myocardial infarction, percutaneous coronary intervention, coronary artery bypass graft surgery, cardiac transplantation, and with other cardiac problems. The fellows will

1. Learn to implement comprehensive primary and secondary prevention strategies including management of cardiovascular risk factors, exercise prescription, behavioral change, and management of new/emerging risk factors. 2. Develop a working knowledge of all phases of cardiac rehabilitation. 3. Learn how to provide individualized exercise and activity prescriptions to patients with cardiovascular disease.

The one-month rotation will consist of activities primarily at the UW Research Park Clinic rotation, unless otherwise noted. Each week, ~3 days will be spent in preventive cardiology clinics with physician staff and ~1 day will be in preventive cardiology nutrition clinic with dietician staff. The 5th day a week will be flexible and used for cardiac rehabilitation and smoking cessation experiences.

1. Preventive Cardiology Clinic (“clinic”) – 2.5-3 days/week = 5-6 half-day sessions/week). The UW Preventive Cardiology Clinic includes “Lipid Clinic,” the “Advanced Hypertension Clinic,” “Sudden Cardiac Prevention Clinic,” and provides broad exposure to the range of topics in the COCATS 4, Task Force 2 core curriculum. Each clinic includes Physician, Registered Dietician, and Registered Nurse. a. Dr. James Stein, MD (Director) – Tuesday AM, Thursday PM (Tuesday PM clinic is non- teaching) b. Dr. Heather Johnson – Thursday AM c. Dr. Amita Singh – Wednesday AM and PM, Friday AM and PM d. Dr. Matthew Tattersall – Monday PM • These add on clinics other days of the week that are open to fellows with permission. • If not enough clinics are available, fellows may be scheduled with Dr. Mary Zasadil or Kjersten Busse, RN, NP. • Fellows are not expected to show up for assigned morning clinics until 845 PM on days they have 730 AM teaching conferences, however they are expected to show up for assigned afternoon clinics by 1245 PM. 2. Preventive Cardiology Nutrition Clinic – 1 day/week (Monday AM and PM, Wednesday PM) • Alternatively, if fellows can’t attend enough dedicated preventive cardiology nutrition clinics they may be scheduled to see patients in Preventive Cardiology Clinic with a Registered Dietician (rather than the physician) when the dietician is in clinic (most mornings)

5 3. Outpatient Cardiac Rehabilitation – ½ day twice during ration (UW Research Park Clinic) • This also can be at the TAC if it fits the fellows schedule better 4. Inpatient Cardiac Rehabilitation – ½ day twice during rotation (UW Hospital CSC) 5. Smoking cessation/reading – during unassigned/flexible time. See “Smoking Cessation” addendum at the end of this document for details.

6 Didactic/Interactive Lecture Series

The Preventive Cardiology lecture series is the major Preventive Cardiology experience of the UW Cardiovascular Medicine Fellowship. This lecture series is repeated such that each fellow typically participates in the lecture series twice during their fellowship. All fellows are required to attend and sign in, indicating their attendance. They will receive a written quiz 1-2 weeks before the lecture series with feedback provided. The quiz will be repeated after the lecture series, as well. The information presented as part of the lecture series will be reinforced during their general cardiology clinical training.

The lecture series is as follows:

Stein Atherogenesis and Atherosclerosis Stein Clinical Lipid Metabolism Stein Dyslipidemias and Lipid-Lowering Therapy Stein Management of Dyslipidemia Non-Traditional Risk Factors for Cardiovascular Disease Prediction: HsCRP, Advanced Lipoprotein Testing, and Lp(a) Stein

Effects of Systemic Diseases and Inflammation on Cardiovascular Tattersall Disease Risk and its Management Orland Common Genetic Variants for CVD Risk and Risk Factors Johnson Pathophysiology of Hypertension Johnson Hypertension Treatment and Guidelines Johnson Resistant and Secondary Causes of Hypertension Gepner or Singh Obesity and Metabolic Syndrome Poddar or Portz Nutrition, Diet and Cardiovascular Disease – I Poddar or Portz Nutrition, Diet and Cardiovascular Disease - II Exercise Physiology and How to Write an Exercise Zasadil Prescription What a Cardiologist Needs to Know about Diabetes Management and Kulstad Cardiovascular Disease Jorenby Smoking Cessation Barczi What a Cardiologist Needs to Know about Sleep Apnea Primer: Clinical Pharmacology and Pharmacogenetics of Dopp Cardiovascular Drugs

7 Core Reading Materials (to be provided to each fellow)

1. Goff DC, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(25_PA):2935- 2959. doi:10.1016/j.jacc.2013.11.005. 2. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(25_PA):2889-2934. doi:10.1016/j.jacc.2013.11.002. 3. Stone NJ, Robinson JG, Lichtenstein AH, Goff DC, Lloyd-Jones DM, Smith SC, et al. Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Disease Risk in Adults: Synopsis of the 2013 American College of Cardiology/American Heart Association Cholesterol Guideline. Ann Intern Med. 2014; 160:339-343. doi:10.7326/M14-0126. 4. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS Guideline for the Management of and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. J Am Coll Cardiol. 2014;63(25_PA):2985-3023. doi:10.1016/j.jacc.2013.11.004. 5. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(25_PA):2960-2984. doi:10.1016/j.jacc.2013.11.003. 6. Katz DL. Diets, Diatribes, and a Dearth of Data. Circulation Cardiovascular Quality and Outcomes. 2014 Nov; 7(6):809-11. doi: 10.1161/CIRCOUTCOMES.114.001458. Epub 2014 Nov 11. PMID: 25387773. 7. Smith Jr SC, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, Gibbons R, Grundy S, Hiratzka L, Jones D, Lloyd-Jones D, Minissian M, Mosca L, Peterson E, Sacco R, Spertus J, Stein JH, Taubert KA. AHA/ACC secondary prevention and risk reduction therapy for patients with coronary and other : 2011 update. Circulation 2011;124 2458-2473. PMID: 22052934. Also in J Am Coll Cardiol 2011; 58:2432-46. PMID: 22055990. 8. Secondary Prevention of Atherosclerotic Cardiovascular Disease – Adult Inpatient/Ambulatory Clinical Practice Guideline. UW Health. 2015. 9. Thompson, PD. Exercise Prescription and Proscription for Patients With . Circulation. 2005 Oct 11; 112(15):2354-63. PMID: 16216979. 10. Leon A, Franklin B, Fernando C, Balady G, Berra K, Stewart K, Thompson P, Williams M, and Lauer M. Cardiac Rehabilitation and Secondary Prevention of Coronary Heart Disease. Circulation, 2015; 111, 369-376. 11. Webber, M., Schiffrin, E. et. al Clinical Practice Guidelines for the Management of Hypertension in the Community A Statement by the American Society of Hypertension and the International Society of Hypertension. The Journal of Clinical Hypertension 2014 Jan; 16(1):14-26. PMID: 24341872. 12. James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014; 311(5):507-520. doi:10.1001/jama.2013.284427. 13. Mosca L, et. al. Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update. Circulation. 2011; 123: 1243-1262. 14. Tobacco Cessation – Adult & Adolescent – Ambulatory/Primary Care – Clinical Practice Guideline. UW Health, CCKM, 2017.

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Fellow Learning Evaluation

(Note: corresponding COCATS 4, Task Force 2 Patient Care Competencies are listed in parentheses next to each section)

Evaluations will include reviews of:

1. Fellow participation in Preventive Cardiology activities described above, as observed by faculty. (1-10; additionally, will provide competencies in systems-based practice, practice- based learning and improvement, professionalism, and interpersonal and communication skills). 2. Evaluations of Preventive Cardiology case management in the Preventive Cardiology Clinic (such as management of lipids, hypertension, and cardiovascular disease risk) as well as interpretations of exercise during cardiac rehabilitation and risk assessment during patient encounters. (1-10; additionally, will provide competencies in systems-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills 3. A quiz will be provided prior to and after the lecture series and a score of 75% correct will be required to pass. (1-10; additionally will provide competencies in systems-based practice, practice-based learning and improvement) 4. Pass UW Smoking Cessation on-line CME quiz. Requires a score of 70% or higher. (4; additionally, will provide competencies in systems-based practice, practice-based learning and improvement, and interpersonal and communication skills

9 Addendum: Smoking Cessation Education and Assessment

Smoking Cessation experience will involve a 1 credit hour on-line CME course (~60 minutes) from the UW Center for Tobacco Research and Intervention (CTRI) plus review of a series of short education videos (~75 minutes of education) that cover hospital and clinical interventions, as well as motivational interviewing and the Wisconsin QuitLine (www.ctri.wisc.edu). Each video is patient/encounter based. This information will be reinforced during the preventive cardiology rotation in the office and hospital as well as in a didactic lecture. Skills assessment will be demonstrated by completion of the tobacco cessation CME course exam and by observation in clinic and on the wards by attending cardiologists.

Materials and Competency Demonstration

1. Review CME materials first: UW CME at http://cme.uwisc.org/index.pl?iid=532379 2. Then review the four sets of videos below (Clinic interventions, hospital interventions, motivational interviewing, and QuitLine). 3. Competency demonstration: got back to the CME and take the test. Passing requires 70% score or higher to pass – to be completed after the CME and videos below are reviewed.

Clinic Interventions

http://www.ctri.wisc.edu/video-clinic.htm

Alcoholism (4:04) Ready to Quit Depression (4:40)

(2:58) Diabetes (3:59) Clinician/Patient Brief Counseling Examples (19:00)

Hospital Interventions

http://www.ctri.wisc.edu/video-hospitals.htm

CVD 1 (3:06) CVD 2 (2:38) Pulmonary 1 Pulmonary 2

(2:11) (5:20) Discharge

(3:54)

Motivational Interviewing Videos

http://www.ctri.wisc.edu/HC.Providers/healthcare_ondemand_mi.htm

Clinician/Patient Tug-of-War (:21) Empathy: How NOT to Express It to a Smoker (:27)

10 Empathy: How to Express It to a Smoker (2:00) Developing Discrepancies: How NOT to Do It (1:18) Developing Discrepancies: How to (4:43) Rolling with Resistance (:46) Self-Efficacy: How to Support It (6:00) Incorporating Techniques Into Practice (3:00) A Call to Action from Dr. Michael Fiore (1:00)

Pharmacy Interventions http://www.ctri.wisc.edu/providers-pharmacy.htm

Plan to Quit (3:58)

Asthma (2:35)

Birth Control (2:28)

CVD (4:21)

COPD 1 (2:02)

COPD 2 (4:25)

Quit Line Videos http://www.ctri.wisc.edu/video-ql.htm

1-800-QUIT-NOW Quit Line Web Coach

Overview (8:04) Feature (2:00)

Updated: October 2, 2017 – JHS

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