The purpose of this rotation is for the fellow to acquire knowledge about the indications, the performance, interpretation and limitations of diagnostic nuclear cardiology and stress testing. Fellows are expected to understand the basic principles of radioisotopes and myocardial perfusion imaging and gain skills required to independently interpret nuclear perfusion studies. Each cardiology fellow will spend at least 2 months in the nuclear cardiology laboratory; one month is at University of Iowa Hospitals & Clinics and the other month is completed during the afternoons on the VA outpatient cardiology service.
Extensive experience with nuclear cardiology and stress testing are provided during the outpatient consults rotation at the Iowa City VAMC and during the nuclear cardiology rotation at University of Iowa Hospitals & Clinics. The fellow is directly responsible to the attending of the exercise/nuclear lab for all components of this rotation. The fellow will be given primary responsibility to perform stress tests, under direct supervision of an attending or a specially trained exercise physiology professional. Fellows will be instructed in the interpretation of stress testing following myocardial infarction for the purpose of identifying high risk patients and prescribing appropriate exercise regimens for cardiovascular rehabilitation.
Stress Testing:
The studies performed will include maximal and sub maximal exercise tests as well as pharmacologic tests with dobutamine, or regadenoson. The fellow will become familiar with exercise physiology and will learn the essentials of preparation for exercise testing (skin preparation, electrode placement, etc) and know the clinical importance of the study findings. Fellows will also be instructed in the interpretation of stress testing for the purpose of identifying high risk patients and for prescribing appropriate exercise regimens for cardiac rehabilitation. In addition to the nuclear cardiology laboratory, exercise testing and dobutamine stress testing is performed in the UI Hospitals & Clinics exercise treadmill laboratory, echocardiography laboratory and the VA medical center nuclear laboratory and echocardiography laboratory.
The attending physician will review with the fellow the appropriateness of test selection at the time of the afternoon reading session. Suggestions for improvement in test selection will be made when appropriate and the rationale and literature basis for an alternative test selection will be discussed. The attending physician will interpret the exercise electrocardiograms and exercise and rest nuclear scans with the fellow each day. Changes in interpretation compared to the fellow’s preliminary interpretation will be discussed, incorporating literature based principles. Staff physicians from cardiology and nuclear medicine will review the myocardial perfusion studies with the fellow in the Advanced Cardiac Imaging conference.
The overall basic objectives of this rotation include understanding the principles of myocardial perfusion and blood flow, factors determining flow, coronary flow regulation, vasoreactivity, coronary flow reserve, regional flow differences, and flow variability; understand the principles of radioactivity, radioactive decay, radionuclide production, radionuclide generators, photon interactions with matter, and radiation detectors; develop a basic understanding of the instrumentation, techniques, and principles involved in nuclear imaging, including collimation, resolution, contrast, localization, noise, SPECT, PET, image reconstitution methods, and attenuation and scatter correction; become familiar with the various methods of stress testing (treadmill, upright and reclining bicycle, pharmacologic), including indications, exclusions, safety, and technique and understand the advantages, disadvantages, and differences between various protocols for image acquisition; understand the differences between the various radioisotopes used in nuclear cardiology, including their energy, half lives, and organs of elimination and gain a proper understanding of the value of perfusion imaging in the diagnosis, prognosis, and management of patients with coronary artery disease.
The specific objectives are:
Each fellow is expected to perform and interpret over the 2 year period a minimum of 80 hours of nuclear cardiology study interpretation during the two month training period in Nuclear Cardiology, which fulfills level 1 ACC guidelines for training. These studies include SPECT and planar myocardial perfusion imaging, gated blood pool studies, and PET perfusion and viability studies. The fellow will participate in daily readout sessions with the attending physician from nuclear medicine or cardiology responsible for the interpretation of the studies. Level 2 training may be attained in nuclear cardiology upon completion of fellowship by spending four to six months in the nuclear cardiology laboratory and by interpreting at least 300 studies including 40 hands on cases studies with direct patient experience. In order to obtain a nuclear license, fellows are required to take mandatory physics courses. These didactic sessions may be undertaken at the University of Iowa or through commercial vendors targeted to providing the didactic courses in an intensive two - four week period.
Junior Fellows (first year fellows)
Fellows may be requested to monitor the stress portion of the stress myocardial perfusion imaging studies. Each study will then be reviewed by the fellow before the patient leaves the testing area to assure safety for the patient. High risk scan findings will be communicated with the reading staff physician as well as the referring physician. Fellows will review all scans with the staffing physicians and generate a report in the medical record. Fellows will keep a log of patient studies reviewed and performed.
Senior Fellows (second year fellows and above)
In addition to the goals and objectives of junior fellows, senior fellows will be given more independence in decision making and communication with the patient and health care team.
The training in Nuclear Cardiology is based at UI Hospitals & Clinics for one month and half-day afternoon during the VA outpatient rotation for 2 months. In addition, fellows may choose to undertake additional training in nuclear cardiology during their elective rotations. Training based at UI Hospitals & Clinics includes men and women of all adult ages, with a wide range of body habitus and medical co-morbidities, and varied ethnic and socioeconomic backgrounds. Although the majority of patients present with chronic or subacute symptoms, many patients present from the Emergency Department after acute myocardial infarction has been excluded and the patient’s presenting symptoms have been stabilized. Most patients are referred for evaluation of chest pain or exertional dyspnea, but a significant proportion of patients are referred for preoperative cardiac risk assessment, assessment of myocardial viability, or assessment of known or suspected arrhythmias. Diagnostic test options include exercise electrocardiography, exercise and rest myocardial perfusion imaging, pharmacologic coronary vasodilation stress, and inotropic (dobutamine) stress tests. The training in Nuclear Cardiology at the VA includes predominantly male patients with a wide variety of cardiovascular disorders or cardiovascular risk factors.
Nuclear cardiology studies are formally read each day in the late afternoon. The attending physician will review the studies read by the fellow (baseline ECG, stress ECG, and perfusion imaging) and offer constructive criticism and further instruction as needed. In addition to study interpretation, didactic lectures covering the basics of nuclear cardiology are given during the core curriculum conference series and during the Advanced Cardiac Imaging conference.