Cardiac Electrophysiology 1

Details

Title

Cardiac Electrophysiology 1

Type

Stage Two

Module code

HPS136

Requirement

Optional

Module objective

By the end of this module the Clinical Scientist in HSST, with respect to cardiac electrophysiology (EP), will be able to critically analyse, synthesise, evaluate and apply knowledge, and perform a range of clinical skills to clinically evaluate a range of patients with rhythm disorders, choose and perform diagnostic techniques, and interpret and integrate the results to develop individual care plans for patients, while demonstrating the attitudes and behaviours necessary for the role of a Consultant Clinical Scientist within a patient-focused service.

Knowledge and understanding

By the end of this module the Clinical Scientist in HSST will critically analyse, synthesise, evaluate and apply their knowledge of cardiac electrophysiology, including:

• 12-lead ECG interpretation;
• haemodynamics;
• cellular electrophysiology; ion channel function and regulation; and the effects of ionic imbalance on cardiac EP;
• underlying mechanisms of arrhythmias: normal automatic behaviour, abnormal automatism, triggered activity, micro-reentry, macroreentry and other mechanisms;
• mechanisms of syncope and sudden death;
• EP principles:
  • measurement of local activation time and voltage
  • interval measurements
  • conduction velocity and tissue wavelength
  • concealed conduction
  • gap phenomenon
• cardiac anatomy relevant to the genesis and treatment of arrhythmias, including detailed anatomy of the thoracic veins, of the right and left atria and inter-atrial septum, right and left outflow tracts, aortic root, coronary artery and coronary venous systems, the AV junction (triangle of Koch, tricuspid annulus, mitral annulus) and associated accessory pathways;
• normal and abnormal electrophysiology of the different heart chambers and the major thoracic vessels;
• autonomic system influences on electrophysiology and arrhythmias;
• conditions predisposing to arrhythmias:
  • ischaemic cardiomyopathy
  • non-ischaemic cardiomyopathies:
    • idiopathic dilated cardiomyopathies
    • valvular-related cardiomyopathies
  • congenital diseases
  • channelopathies and other inherited syndromes:
    • long and short QT syndromes
    • Brugada syndromes
    • hypertrophic cardiomyopathies
    • right ventricular arrhythmogenic cardiomyopathies
    • neuromuscular cardiomyopathies (myotonic dystrophy)
    • catecholaminergic polymorphic ventricular tachycardia
    • Ryanodine syndromes
    • congenital conduction disorders
  • autonomic disorders (carotid sinus hypersensitivity, neurocardiogenic syncope)
  • other (Chagas disease, etc.)
  • other situations leading to rhythm disorders
• selection and indications for the different non-invasive diagnostic techniques used in assessing heart rhythm abnormalities;
• arrhythmia epidemiology and prognosis (genetics, pathophysiology, risk evaluation);
• techniques, modalities, indications, interpretation and the diagnostic yield of general cardiology non-invasive and imaging techniques, such as:
  • exercise testing
  • echocardiography, including transoesophageal echocardiography (TOE)
  • cardiac magnetic resonance imaging
  • cardiac computed tomography imaging
  • nuclear cardiology
  • blood sampling and other laboratory analysis
  • genetic analysis
• techniques, modalities, indications, interpretation and the diagnostic yield of non- invasive arrhythmia assessment techniques, such as:

Electrocardiography:

• conventional 12-lead ECG
• ECG monitoring (Holter, event monitoring, implantable event and loop monitoring)
• signal-averaged ECG and body surface mapping
• heart rate variability and baroreflex sensitivity
• T-wave and micro-T-wave alternans
• ECG-drug infusion tests (flecainide, etc.)
• transoesophageal electrical recording

Autonomic nervous system evaluation:

• carotid sinus massage
• tilt testing
• clinical presentation, ECG and electrophysiology of the different types and variants of cardiac arrhythmias, conduction disturbances, arrhythmic clinical syndromes, genetic disorders and autonomic system-mediated disorders (induction, cardiac activation, responses to electrical stimulation and to drug administration, cardiac activation, EP diagnosis):
  • sinus node and atrial impulse formation and conduction disorders
  • AV nodal and His-Purkinje conduction disorders
  • atrial flutter
  • junctional and AV node ectopy and tachycardias
  • accessory pathway-mediated tachycardias
  • atrial (and thoracic vein) ectopy and tachycardias
  • atrial fibrillation
  • ventricular ectopy and tachycardias
  • ventricular fibrillation
• patient and procedure-type selection for specific arrhythmia management strategies/targets (risks and benefits);
• indications, techniques, performance and response interpretation of therapy modalities in electrophysiology other than ablation, such as:
  • medical therapy
  • autonomic system manoeuvres
  • cardioversion and defibrillation
  • anti-tachycardia pacing and device therapies
• pharmacological tests and modulation, for example:
  • adenosine
  • type I drugs for unmasking Brugada ECG
  • adrenaline for unmasking congenital long QT syndrome.normal and abnormal electrophysiology of the different heart chambers and the major thoracic vessels;sinus node and atrial impulse formation and conduction disorders

Technical and clinical skills

By the end of this module the Clinical Scientist in HSST will be able to demonstrate a critical understanding of current research and its application to the performance, adaptation and mastery of a range of clinical and communication skills and will:

• clinically evaluate patients with rhythm disorders (history, physical exam);
• perform and interpret the different non-invasive diagnostic techniques specifically related to arrhythmia management (operate non-invasive cardiology equipment – ECG machines, Holter ECG monitoring systems and recorders, etc.) and evaluate each diagnostic procedure in the clinical context and in reference to other non- invasive or invasive techniques;
• choose the diagnostic techniques, modalities and protocols in a clinically useful and cost-effective way, avoiding over- and under-utilisation of tests;
• integrate the results of the different diagnostic techniques into the individual care of patients with rhythm disorders;perform and interpret the different non-invasive diagnostic techniques specifically related to arrhythmia management (operate non-invasive cardiology equipment – ECG machines, Holter ECG monitoring systems and recorders, etc.) and evaluate each diagnostic procedure in the clinical context and in reference to other non- invasive or invasive techniques;
• interpret the results of general cardiology non-invasive and imaging techniques.

Attitudes and behaviours

By the end of this module the Clinical Scientist in HSST will be expected to critically evaluate their own response to both normal and complex situations. They will consistently demonstrate the professional attributes and insights required of a Clinical Scientist in HSST working within the limits of professional competence referring as appropriate to senior staff and will:

• recognise and minimise the anxiety of patients before, during and after procedures, and appreciate the psychological impact of the patient’s arrhythmogenic disease/syndrome on the patient and their family, and manage it sensitively;
• communicate diagnostic and procedure results to patients and relatives in an understandable, objective and calm manner;
• educate patients about the treatment options available to them and explain the treatment strategies;
• develop a critical attitude towards therapeutic techniques in EP and contribute to the selection of the best available therapy according to procedure results, clinical evidence and practice guidelines;
• commit to the audit of long-term outcomes and procedural complications and strive to continuously improve the quality of services and safeguard high standards of care;
• provide an example of good scientific practice and foster an environment in which excellence will flourish;
• foster a team approach to procedures, including a close relationship with clinicians and other healthcare professionals, and cooperate with cardiologists and other physicians to maximise patient management;
• attend official national/international subspecialty meetings of scientific societies in the field;
• recognise and remain current with developments in the field of arrhythmogenic diseases and syndromes and emerging therapies;
• respond to medico-legal issues concerning care provision, consent and information for patients and their families;
• establish solid concepts of ethics in professional practice;
• adopt a positive attitude to understanding and applying cost-effective strategies;
• adopt a positive attitude to implementing guidelines in clinical practice;
• adopt a positive attitude and consistently behave in an ethical manner;communicate diagnostic and procedure results to patients and relatives in an understandable, objective and calm manner;
• work closely with other healthcare professionals as necessary: cardiologists, infection control, care of the elderly, etc.