Diagnostic Approaches and Current Treatment of Cardiovascular Disorders

Module details

Title

Diagnostic Approaches and Current Treatment of Cardiovascular Disorders

Type

Specialist

Module code

SPS120

Credits

20

Requirement

Compulsory

Aim of this module

This module provides trainees with the knowledge that underpins the specialist modules in Cardiology and gives trainees the tools to undertake project based learning in the workplace. This module has three sections,  which include: non-invasive diagnostics, invasive diagnostics and therapeutic interventions. 

Non-Invasive Diagnostics

This module will enable trainees to perform a range of clinical diagnostic procedures undertaken to investigate disorders of the heart, interact with patients and demonstrate safe, patient-centred practice. Trainees will be expected to undertake a range of routine procedures, build practical skills in setting up and maintaining the equipment used, produce reports, interpret results, explain procedures to patients  and gain consent while developing and building their professional practice.

Invasive Diagnostics

This module provides trainees with underpinning knowledge, practical skill and understanding of cardiac invasive diagnostics. This will support trainees in the development of practical skills in the workplace and broaden understanding of the role of these procedures in the patient pathway.

Therapeutic Interventions

This module aims to develop knowledge, understanding and skills of cardiac therapeutic procedures to provide trainees with the necessary requirements to perform roles during percutaneous coronary intervention and pacemaker implantation. Pharmacology and prescribing issues will also be addressed.

Submodules

Code	Title	Action
SPS120c1	Non-invasive Diagnostics	View
SPS120c2	Invasive Diagnostics	View
SPS120c3	Therapeutic Interventions	View

Learning outcomes

1. Evaluate the role of cardiac investigations in the choice of diagnostic and treatment options related to patient presentation and care pathways.
2. Describe the pathophysiology and co-morbidities associated with heart disease applying knowledge of normal anatomy and physiology.
3. Describe the haemodynamic and ECG response to exercise and posture, both normal and abnormal.
4. Justify the life-support requirements and evaluate the protocols for the management of peri-arrest, respiratory and cardiac arrest associated with each technique in accordance with Resuscitation Council guidance.
5. Discuss and appraise the environmental requirements, pharmacological influences, equipment, protocols, calibration, indications, contraindications and end-points in relation to local and national guidelines for each technique.
6. Discuss accurate data interpretation, analysis and report construction and management of results.
7. Critically evaluate the need to convey complex scientific information to inform multidisciplinary teams of the diagnostic results, conclusions and consequences, in clear reports, in a clinically appropriate time frame.
8. Describe the physics underlying the generation, propagation and detection of ultrasound waves in tissue and the application of Doppler and their clinical implications.
9. Critically appraise the technological principles involved in a diagnostic ultrasound scanner and their implications, including safety for cardiac imaging.
10. Explain the limitations and artefacts of ultrasound and Doppler in cardiac imaging.
11. Describe the features of a normal cardiac ultrasound scan.
12. Discuss the advanced, complementary techniques to include cardiac CT, MRI and cardiac nuclide imaging.
13. Evaluate the role of cardiac investigations in the choice of diagnostic and treatment options related to patient presentation and care pathways.
14. Apply knowledge of cardiovascular anatomy and physiology to the recognition of co-morbidities and the influence of these on cardiac disease processes.
15. Describe the anatomy and pathophysiology of common congenital cardiac disorders.
16. Discuss the development of ischaemic heart disease and its associated risk factors.
17. Discuss coronary artery influences on cardiac rhythm.
18. Discuss the indications for, limitations and risks of cardiac catheterisation.
19. Describe the normal pressure waveforms, normal ranges and recognise abnormal recordings.
20. Discuss the measurement of cardiac output, both by direct and estimated techniques and evaluate techniques used to measure oxygen saturation.
21. Describe the use, function and characteristics of pressure amplifiers, catheters, consumables, various transducers and factors that influence the quality of pressure waveform.
22. Describe venous and arterial access techniques, indications, contraindications and complications.
23. Recognise normal and abnormal oxygen saturations and relate these to common abnormalities.
24. Discuss the different modalities used during cardiac catheterisation for the assessment of coronary artery patency, such as intravascular ultrasound (IVUS) and pressure wire calculation.
25. Discuss the implications of clinical findings at cardiac catheterisation and its influence on patient care pathway.
26. Discuss the indications for and limitations of implantable loop recording (ILR).
27. Describe the techniques for optimal ILR recording and management of patients with implanted loop recorders.
28. Demonstrate knowledge and understanding of sensing algorithms and parameters for arrhythmia storage.
29. Discuss the concepts of ILR device implantation procedure and related complications.
30. Critically evaluate the role of cardiac investigations in the choice of diagnostic and treatment options related to patient presentation and care pathways.
31. Apply knowledge of anatomy and physiology, including myocardial/cell electrophysiology and coronary artery influence to normal and abnormal cardiac rhythms.
32. Discuss the importance of the clinical history, clinical examination and investigation prior to invasive cardiac therapeutic investigations.
33. Critically appraise the optimal care pathway for the patient’s therapeutic intervention based on their symptoms, physiology, co-morbidities and risk factors.
34. Critically appraise the range of X-ray and aseptic techniques related to invasive cardiac procedures and differentiate between a normal and abnormal chest X-ray for common cardiac presentations.
35. Discuss the clinical conditions and ECG indicators for temporary and permanent pacing.
36. Describe the characteristics, function and application of temporary pacing.
37. Discuss the fundamental physical principles of implantable cardiac device systems technology, design and construction, and the American Heart Association and European Standard Identification guidelines and databases.
38. Compare and contrast a range of rhythm management devices, including the use of timing cycles, rate modulation, sensing, stimulation and algorithms.
39. Discuss the concepts of cardiac pacing device implantation procedures and range of measurements taken at implant, and state the normal values and relate deviations from normal ranges to clinical physiology.
40. Describe the principles underpinning algorithms for bradycardia pacing systems and evaluate a range of product-specific pacing algorithms.
41. Discuss the indications, contraindications, types, risks and benefits of PCI and the parameters that need to be monitored during PCI.
42. Evaluate the role of pre-assessment of the PCI patient, including MRSA screening.
43. Discuss the application of cardiac catheterisation in PCI and pressure waveform behaviours during PCI and their physiological and clinical implication.
44. Discuss the use, indications, contra-indications, benefits and complications associated with the use of intra-aortic balloon pump therapy and the alternative therapies available.
45. Explain the principles of pharmacology, pharmacokinetics and therapeutics, including therapeutic classes of cardiac drugs.
46. Discuss the mode of action, indications, contraindications and side effects of commonly used pharmacological treatments.
47. Describe the coronary anatomy and its correlation with 2D views of the left ventricle.
48. Describe and evaluate methods used to measure and evaluate left ventricular function and recognise normal and abnormal ventricular function.
49. Describe normal Doppler mitral valve filling patterns and normal ranges.
50. Recognise the appearance of complications after myocardial infarction.
51. Discuss the echocardiographic features and assessment methods associated with cardiomyopathies, valvular disease and ventricular dysfunction and the relationship to surgical treatments.
52. Discuss the pathology, causes and echocardiographic features associated with right ventricular dysfunction and pulmonary hypertension; endocarditis and the Duke criteria for diagnosing endocarditis; pericardial disease, cardiac masses, suspected acute pulmonary embolus and blunt/penetrating cardiac trauma.
53. Discuss the types of valve replacement, criteria of normality and signs of failure.
54. Describe the echocardiographic findings typically occurring in association with a hypotensive/shocked patient and post cardiac arrest.
55. Explain the use of echocardiography in the ventilated patient and post- surgery patient.
56. Evaluate and justify the criteria for the use of transoesophaegeal echocardiography.

Indicative content

Diagnostic Approaches and Current Treatment of Cardiac Disorders – Non-Invasive Diagnostics

Anatomy and physiology

• Anatomy and physiology of the cardiovascular system
• Coronary circulation
• Anatomy of the thorax related to ultrasound imaging
• Cardiac cycle
• Normal and abnormal haemodynamic and ECG response to exercise
• Overview of pathophysiology of acquired, congenital and ischaemic heart disease

Exercise tolerance/Cardiopulmonary exercise testing

• History taking and gaining informed consent
• Indications, contraindications and end-points for exercise tolerance testing (ETT)/cardiopulmonary exercise testing (CPx)
• Differences between and indications for physiologist and physician-led testing
• Pharmacology related to provocative testing
• Environmental requirements for ETT/CPx equipment characteristics, functions, use and care
• Protocols and methods of exercise and their application
• Recording of ECG and blood pressure
• National and local guidelines, policies and procedures
• Normal responses to exercise and ECG findings
• Physiological, BP and ECG findings associated with outcome quantification
• Interpretation, presentation and reporting of results
• Management of results
• Impact of results on patient care pathway
• Calibration of CPx equipment

Tilt table testing

• History taking and gaining informed consent
• Pharmacology related to tilt table testing (TTT)
• Environmental requirements for TTT equipment characteristics, functions, use and care
• Indications, contraindications and end-points for TTT
• Protocols for TTT
• National and local guidelines, policies and procedures
• Normal physiological BP and ECG findings
• Recording of ECG and blood pressure
• Physiological, BP and ECG findings associated with outcome quantification
• Interpretation, presentation and reporting of results
• Management of results
• Impact of results on patient care pathway

Ultrasound physics

• Basic principles and physics of ultrasound, spectral Doppler and colour flow Doppler
• Application of these principles to cardiac imaging
• Instrumentation associated with 2D, 3D, spectral Doppler, colour flow Doppler
• Near and far fields; amplitude, intensity; power and frequency
• Velocity, elasticity and density; acoustic impedance. Attenuation in tissue with reference to reflection, refraction, scattering and absorption. Dynamic range concept
• Specular reflection, curved and irregular surfaces
• Focusing using lenses
• Speed of sound in soft tissue: 1540 ms-1 and its significance
• Range determination
• Recording methods: choices, advantages and disadvantages

Storage and display of images

• Basic concept of digital acquisition and system systems
• Scan converters and digital memories
• Display devices and controls and recording techniques

Transducers

• Piezo-electric effect
• Concepts of 2D and 3D transducer construction
• Characteristics of the ultrasound beam
• Beam steering methods
• Focusing methods and the use of dual focus
• The role of intracardiac echocardiography

Image optimisation

• Use of gel, to include infection risk from transducer and operator
• Positioning of the patient
• Standard views
• Use of non-standard views
• Adapting procedure where necessary

Knowledge of evolving technologies

• Deformation analysis
• Quantification of myocardial strain and strain rate by tissue Doppler
• Speckle tracking echocardiography/2D strain

Cardiac function parameters

• Measurements and calculations
• Doppler determination of cardiac haemodynamics
• Overview of a range of advanced techniques used in the diagnosis of cardiovascular and related diseases

 

Diagnostic Approaches and Current Treatment of Cardiac Disorders – Invasive Diagnostics

Cardiac catheterisation

• MRSA screening and pre-assessment for cardiac catheterisation procedures
• Detailed anatomy and physiology of the cardiovascular system
• Pathophysiology related to cardiac catheterisation
• Overview of common congenital heart disease
• Development of ischaemic and valvular heart disease and associated risk factors
• Influence of coronary artery anatomy and patency on cardiac rhythm
• Implications of findings from cardiac catheterisation and the effect on patient care pathway
• Indications, contraindications, limitations and risk factors associated with the procedure
• Importance of ECG, blood pressure and O2 saturation monitoring during the procedure
• ECG abnormalities and required interventions
• Normal pressure waveforms and normal value ranges
• Abnormal recordings and associated pathology
• Measurement of cardiac output by thermodilution and Fick principle
• Haemodynamic measurements made during cardiac catheterisation
• Characteristics and functions of transducers, pressure amplifiers
• The influence of equipment and consumable characteristics on the quality of pressure recordings
• Techniques for venous and arterial access, indications, risks and complications
• Characteristics and use of catheters and connecting tubing
• Oxygen saturation measurement techniques and application
• Recognition of normal and abnormal oxygen saturation measurements and their relationship to common abnormalities
• Different modalities used for the quantification analysis of disease progression and coronary artery lesions to include intravascular ultrasound (IVUS) and pressure wires
• Immediate/Advanced life support in line with Resuscitation Council UK
• Production and structure of findings and storage of results

Implantable loop recorders

• MRSA screening and pre-assessment for ILR implantation
• Indications for and contraindications to use of ILR
• Benefits and limitations of ILR
• Characteristics and functions of ILR
• Implant techniques for ILRs
• Electrogram characteristics and device positioning for optimal ILR electrogram recording
• Implant measurements and observations
• Patient management pre-implant, during the procedure and post implantation
• Monitoring of BP, ECG and O2 saturations during implantation of ILRs
• Management of patients before, during and after implant of ILRs

Diagnostic Approaches and Current Treatment of Cardiac Disorders – Therapeutic Interventions

Rhythm management devices

• Normal cardiac conduction system and its relationship with the ECG
• Abnormal cardiac conduction and ECG manifestations
• The development of ischaemic heart disease and associated risk factors
• NICE guidelines for device implantation
• Procedural differences between adult and paediatric device implantation
• Initial diagnostic assessment and symptom history
• Clinical indications for device implantation, including national guidelines and classifications
• Device selection related to patient physiological needs
• Complications associated with anatomical anomalies and device implantation
• Conscious sedation, intravenous sedation, analgesia in the lab setting
• ILS/ALS in line with the Resuscitation Council UK
• Asepsis techniques
• Implantation procedure: Seldinger technique, cephalic/subclavian access
• Hardware selection criteria: device and leads
• Identify normal positions of leads on X-ray and fluoroscopy

Measurements at implantation, including normal ranges

• Battery voltage
• Pacing threshold
• Lead impedance
• Current drain
• Sensing threshold
• Slew rate

Sensing

• Cardiac signals, A/V/T wave/injury currents/pericardial signals
• Principles of undersensing, oversensing and sensitivity
• Relationship between sensing and programmed sensitivity
• Adjustment of the sensitivity for accurate
• Intracardiac signals of basic electrophysiology

Capture thresholds

• Role of capture threshold in the implantation process
• Identify capture and loss of capture
• Measurement of the output threshold
• Adjust the capture output in line with the threshold with an appropriate safety margin
• Familiarity of the hardware used for the implantation for pacemakers (single/dual/CRT)
• Troubleshooting implantation complications

Types of emergency temporary pacemaker characteristics

• Percussion
• Trans-thoracic external
• Endocardial
• Epicardial
• Oesophageal

Adjustment/programming of temporary pacemakers

• Output
• Sensitivity
• Mode

Potential problems with temporary pacemakers

• Oversensing
• Undersensing
• Interactions with permanent implanted devices
• Infection risk
• Loss of capture and output adjustment, including amplitude and pulse duration

Chronological development of implantable devices

• Dates of first implants
• Unipolar/bipolar
• Epicardial system – patches/sense pace leads/abdominal implant
• Endocardial – tunnelled lead/abdominal implant
• Endocardial – single pass lead/pectoral implant

Construction and interaction of different types of pacemaker lead and header connectors

• Unipolar/bipolar
• Types of connector
• Hex wrench sizing
• Connectivity between lead and header

Algorithms

Principles behind bradycardia algorithms

• Mode switching
• Pacemaker mediated tachycardia algorithms
• Noise response
• Rate smoothing

Product-specific algorithms allowing mode switching

Product-specific discriminating algorithms in current devices

Battery technology

• Pacemaker battery chemical composition and depletion characteristics
• Battery impedance, voltage, battery charge
• Elective replacement indicators

Function and connection of circuitry components

• Band pass filtering – intracardiac intracardiac electrograms (EGM)frequency
• Input and output amplifiers

Rate response technology

• Types of sensor multisensor pacemakers

Physics related to pacing technology

• Ohms law: energy calculation, power, resistance and slew rate
• Measurements related to optimal settings

Normal parameter changes over time

• First week
• First three months
• Lead/device lifetime

Lead hardware problems

• Fracture
• Insulation break
• Perforation
• Poor header connection
• Leads reversed in header

Device hardware problems

• Header connection
• Deformation of can

Assessment of implanted system in order to ascertain potential problems

• Provocative manoeuvres
• EMI
• Lead impedance, pacing and sensing threshold
• Oversensing
• Undersensing
• Upper rate behaviour
• Inappropriate ICD detection and therapy
• EGM assessment and understanding

Theoretical and practical aspects of pulse generator technology

• Theory of pulse generator technology
• Theoretical aspects and application of the technology related to underlying physical conditions
• Anatomical placement and locations of pulse generators
• Identification of pulse generator components
• Principles of pulse generator interrogation

American Heart Association and European Standard Identification

• Use of pulse generator modes
• Use of pulse generator codes
• Appropriate use of the mode/code criteria relating to underlying medical conditions

Materials used in the construction of pulse generator leads

• Knowledge of different types of lead insulation
• Significance of type of lead insulation
• Lead fixation technology and implications
• Lead length related to patient size
• Lead construction and element separation

Pulse generator lead connection

• Types of connector
• Appropriate use and application of adaptors
• Implications of incorrect lead connections
• Practical implications of single vs dual electrode technology
• Practical implications of unipolar vs bipolar electrode technology
• Surface material/surface structure
• Electrode materials
• Spacing implications

Use of single chamber devices

• Appropriate use of single chamber devices
• Underlying medical conditions
• Long-term implications

Use of dual chamber devices

• Appropriate use of dual chamber devices
• Underlying medical conditions
• Long-term implication

Use of timing cycles

• Relationship between mechanical and physiological timing cycles
• Relative and absolute refractory
• Blanking period
• Atrial-based timing vs ventricular-based timing
• Mechanical timing limitations

Rate modulation

• Rate response mechanisms within pulse generators
• Technology of rate response sensors
• Implications of single vs dual sensors
• Rate smoothing algorithms
• Limitations of rate modulation

Differences between pulse generator technologies

• Use, application and limitation of pacemakers
• Use, application and limitation of ICDs
• Use, application and limitation of CRT devices
• Combined technology

Stimulation

• Anode/cathode stimulation
• Stimulation/defibrillation threshold
• Ohm’s law; current, voltage and impedance (calculation of)
• Strength duration; stimulation threshold. Rheobase and chronaxie time
• Power and energy

Timing cycles

• Single chamber
• Dual chamber – atrial based and ventricular based
• Rate modulation – rate responsive AV delay and post ventricular atrial refractory period (PVARP)
• CRT (bivent) V-V timing

Review of chest X-ray post device implant

• Pneumothorax
• Haemothorax
• Lead position/displacement

Percutaneous coronary interventions (PCI)

• Anatomy and physiology of the coronary circulation
• Development of ischaemic heart disease and associated risk factors
• Application of cardiac catheterisation to PCI
• Types of coronary intervention and indications for
• Risks and complications associated with coronary intervention
• Management of risks and complications associated with PCI
• Influence of coronary arteries on cardiac rhythm
• Identification and evaluation of coronary lesions
• Choice, design, construction, application and use of guide wires, balloon catheters and stents
• Techniques for the introduction of catheters,
• Angioplasty and stenting techniques and equipment
• Role of pressure measurement during procedures

Pharmacology and prescribing (in context of cardiovascular disease)

• Major classes of cardiac drugs
• Mode of actions
• Indications
• Contraindications
• Clinical uses and applications
• Significant side effects
• Interactions
• Anti-arrhythmic agents
• Class I – sodium channel blockers (a, b, c)
• Class II – beta blockers
• Class III – potassium channel blockers
• Class IV – calcium channel blockers
• Cardioinhibitory
• Cardiostimulatory
• Diuretic
• Anti-hypertension
• Thrombolytic agents
• Vasoconstrictor
• Vasodilator
• Anti-hyperlipidemic agents
• Miscellaneous, e.g. ivabradine, ranolazine

 

Activities

Non-Invasive Diagnostics

• Identify a patient referred for echocardiography or provocative electrocardiography procedures and, with permission, follow the progress of the patient from the initial consultation, through procedures, follow-up appointment and/or surgery, and reflect on your learning from this process.
• Observe history taking in a range of patients with cardiac disease and symptoms. Develop and practise the skill of history taking. Present your history findings and suggest appropriate procedures based on this information.
• Attend a meeting at which the outcome of a clinical audit, research, innovation or service development is presented and discuss with your training supervisor how evidence-based practice is implemented with respect to non-invasive cardiac procedures.
• Take part in a multidisciplinary meeting and reflect on the way the multidisciplinary team contributes to the care of patients with disorders of the heart.
• Attend a range of outpatient clinics that patients with cardiac diseases may attend and discuss the role of the multiprofessional team in the care of patients with cardiac disease. This may include medical outpatients, primary care chronic disease management clinics and cardiac rehabilitation.

It is also recommended that trainees undertake the following clinical experiential learning:

• Observe the recording of a paediatric echocardiogram and discuss the indications, contraindications and adaptations that need to be made and reflect on how this will inform your future practice.
• Observe the surgical treatment of patients with valvular heart disease and discuss the impact of this treatment on patient recovery and survival.
• Observe head-up tilt testing (HUTT) and discuss the role of HUTT in the relevant care pathway.
• Assist in performing a paediatric 12-lead ECG and reflect on the differences between working with adults and children.

Invasive Diagnostics

• Identify a patient referred for invasive diagnostic testing and, with permission, follow the progress of the patient from the initial consultation through procedures, follow-up appointment and/or surgery and discharge, and reflect on your learning from this process.
• Observe a range of invasive diagnostic techniques including intravascular ultrasound (IVUS) and pressure wire studies and discuss the indications for and contraindications to each procedure with your training supervisor.
• Take part in a multidisciplinary meeting and reflect on the way the multidisciplinary team contributes to the care of patients with disorders of the heart.

 It is also recommended that trainees undertake the following clinical experiential learning:

• Attend a range of outpatient clinics that patients with cardiac co-morbidities may attend and discuss the role of the multiprofessional team in the care of these patients. This may include medical outpatients, primary care chronic disease management clinics and cardiac rehabilitation.
• Observe paediatric invasive diagnostic procedures.
• Observe a coronary optical coherence tomography (OCT) case.

Therapeutic Interventions

• Assist doctor/nurse/pharmacist during drugs round on a cardiac ward and discuss the mode of action, uses and significant side effects of drugs commonly used to treat patients with cardiac disease.
• Observe an elective DC cardioversion and discuss the role of cardioversion in the short- and long-term treatment of patients with arrhythmias with your training supervisor. 
• Follow a primary percutaneous coronary intervention (PPCI) patient pathway from acute admission through to rehab and discharge.
• Observe percutaneous aortic valve replacement/transcatheter aortic valve implantation (PAVR/TAVI), including attending relevant multidisciplinary team meeting
• Observe atrial septal defect (ASD) closure device implantation and discuss the role of echo guidance
• Observe electrophysiological (EP) mapping and ablation

It is also recommended that trainees undertake the following clinical experiential learning:

• Attend a cardiac clinic, heart failure clinic and cardiac rehabilitation clinic session and reflect on the role of pharmacological treatment for heart disease.
• Attend a smoking cessation clinic, dietetics clinic or exercise session and reflect on the role of non-pharmacological treatment for heart disease.
• Observe a formal lead extraction procedure and reflect on the risks of the procedure. 
• Observe a coronary artery bypass graft surgery. 
• Observe a paediatric interventional produre. 
• Observe clinical research in the catheter laboratory