Purpose:

The overall purpose of the EP rotation is to provide trainees with a general overview of all aspects of cardiac electrophysiology and to ensure fellows acquire the necessary expertise required to manage the electrophysiology disorders routinely encountered in the practice of cardiology. A minimum of 2 months is dedicated to this area and should include 10 elective cardioversions, fulfilling level 1 ACC guidelines for training. During this rotation, the fellow will work under the supervision of electrophysiology attending physician and interact with the subspecialty electrophysiology fellows. The fellows are expected to acquire knowledge and experience in the diagnosis and management of arrhythmias, the indications and limitations of electrophysiologic studies, the appropriate use of antiarrhythmic agents and defibrillator devices, understand noninvasive and invasive techniques used to assess patients with arrhythmias and become acquainted with the basics of pacemaker/ICD management and device interrogation.

Responsibility/Specific Duties:

1. The University of Iowa Hospitals & Clinics general cardiology fellow rotating on the EP service is the point of contact for the EP consult service at UI Hospitals & Clinics; this service includes all inpatient and most outpatient consults such as from other clinics and emergency department. EP consults at the VAMC are performed by the VA outpatient and inpatient fellows under the supervision of the EP staff physician designated to the VA.
2. The UI Hospitals & Clinics fellow receives and reviews all EP inpatient consults, performs the initial evaluation within one hour of being called, reviews all pertinent laboratory data and related test results, develops an initial management strategy, presents the patient to the EP attending as soon as feasible, and writes the final consult. The fellow will communicate to the consulting team caring for the patient and the EP attending will communicate with the requesting attending.
3. The fellow will conduct daily rounds on all EP inpatients and communicate management plans to the patient’s primary team. The fellow will review each patient with the EP attending and write an appropriate follow up consult progress note.
4. The fellows will evaluate patients in the EP consult clinic, held daily at 2:00 p.m., or as instructed by the EP staff physician.
5. The fellow will be supervised by the EP fellow or EP attending for all device interrogation/programming of inpatients and outpatients. However, the fellow will be the primary agent for all OR reprogramming as proscribed and supervised by the EP attending working days from 0730-1700.
6. The fellow will assist the EP attending during procedures such as interrogation of devices or cardioversions performed on the wards or in the EP lab and will progress to higher levels of participation including performance of EP studies as the fellow’s skill level allows. The fellow will communicate patient study information to the house staff post-procedure and do the appropriate post-procedure checks (x-ray, operative site, labs, etc).
7. The fellow will participate, perform and/or interpret Holter monitor studies, event recorders, exercise stress tests for dysrhythmia management, tilt table tests, and signal-averaged ECGs.
8. The fellow is responsible to present selected cases, with guidance of the attending, at the Friday EP patient care conference at 7:15 a.m.

Supervision:

The attending physician and fellow will care for patients as a team to facilitate patient care and teaching as it relates to the etiology, pathogenesis, clinical presentation, natural history, and the treatments of the various electrophysiology disorders seen. The attending will review the fellow’s presentation, review and constructively critique the fellow’s plan of care, confirm the fellow’s physical exam findings, review and confirm the fellow’s notes, and review and supplement the fellow’s teaching of other members of the team. The attending may assign readings or other learning activities as necessary. The attending will supervise the fellow during invasive procedures based on the level of the fellow’s skills.

Learning Objectives:

1. Obtain basic training in the concepts of clinical cardiac electrophysiology, including: normal physiology of the cardiac conduction system, pathophysiology of brady dysrhythmias and tachy dysrhythmias, and mechanisms of AV block. (A, B)
2. Gain basic understanding of the indications, use limitations, and complications of diagnostic EP studies and radiofrequency ablation therapy. (A, B)
3. Gain basic training and experience in the use of pharmacologic and non-pharmacologic options for treating cardiac dysrhythmias. (A, B)
4. Gain basic training in the indications, interpretation, and clinical application of ECG interpretation, ambulatory electrocardiography (Holter) monitoring, event recorders, exercise testing for dysrhythmia assessment, tilt table testing, signal-averaged ECG, and implantable loop recorders. (A, B)
5. Gain basic training in the fundamentals of cardiac pacing, recognition of normal and abnormal pacer function, knowledge of temporary pacing and permanent pacing, knowledge of pacing modes and the general approach to programming, surveillance, and troubleshooting of pacemakers and implantable cardioverter-defibrillators (ICDs). (A, B)
6. Understand the indications for cardiac pacemakers, ICDs, and resynchronization devices. (A, B)
7. Gain basic training in the insertion of temporary pacemakers and the indications and techniques for elective and emergent DC cardioversion. (A, B)
8. Gain basic training in arterial and venous access for the placement of catheters and performance of EP studies. (A, B)
9. Evaluate patients in both the inpatient and outpatient setting who may have an electrophysiology disorder by taking a thorough problem-directed history, performing a careful physical examination, and generating a differential diagnosis and plan of care. (A, B)
10. Provide follow-up care for both inpatient and outpatient consult patients to assess success and adverse effects of treatment, including anti dysrhythmic agents. (A, B)
11. Explain the etiology, pathogenesis, clinical presentation, and natural history of major EP disorders, including syncope, brady dysrhythmias, tachy dysrhythmias, and sudden cardiac death. (B)
12. Learn to choose appropriate EP related diagnostic tests. (A, B)
13. Learn to recognize and manage EP emergencies. (A, B)
14. Gain an appreciation for the role of the staff members in the electrophysiology laboratory, including technicians, nurses, and administrative staff. (D, E, F)
15. Learn to generate a comprehensive written consultation carefully explaining the diagnosis and management plan for patient’s with EP disorders. (D, E, F)

Level Specific Goals and Objectives:

Junior Fellows (first year fellows)

Junior fellows will perform history and physical examinations on all patients on whom they are consulted. Findings will then be reviewed with the EP staff and a plan will be generated as well as a note for the electronic medical record. Fellows will obtain informed consent on the patients who are to undergo electrophysiology study/procedures and review the case with the electrophysiology faculty. They will obtain vascular access and emphasis will be given to the technical aspect of the procedure with the electrophysiology staff. They will also perform ICD/device interrogation at the direction of the EP staff and EP subspecialty fellows.

Senior Fellows (second year fellows and above)

In addition to the goals and objectives of junior fellows, senior fellows will be given more independence and will expand emphasis to the performance of electrophysiology testing/procedures with EP staff.

Patient Characteristics/Mix of Diseases/Types of Clinical Encounters:

Training occurs at both UI Hospitals & Clinics and the VAMC providing a wide range of pathology and a diverse patient population. Both men and women of all adult ages and of various ethnic backgrounds are seen. Clinical encounters including inpatient consultation, outpatient consultations, and peri-procedural care. Both non-invasive and invasive procedures are performed, including the interpretation of ECGs, Holter monitors, event monitors, exercise testing for dysrhythmia management, tilt table testing, and signal-averaged ECGs as well as the participation in performing temporary and permanent pacemaker placement, ICD and cardiac resynchronization device placement, DC cardioversion, diagnostic EP studies, radiofrequency ablation, loop recorder implantation, and trans-septal catheterization.

Teaching Methods:

The attending will review the fellow’s presentation, review and constructively critique the fellow’s plan of care, confirm the fellow’s physical exam findings, review and confirm the fellow’s notes, and review and supplement the fellow’s teaching of other members of the team. The attending may assign readings or other learning activities. The attending will supervise the fellow in the performance of procedures. The fellow will assume progressive levels of responsibility for patient care and procedure performance under the supervision of the attending.

Evaluation:

1. The goals and objectives for the rotation will be verbally communicated at the beginning of the rotation.
2. The fellow’s progress will be reviewed verbally mid-rotation.
3. A standard fellow evaluation form will be completed by the attending at the end of the rotation.
4. The final evaluation of the staff physician will be based on the fulfillment of the rotation objectives as determined by:
   1. Personal observation during interaction with the fellow.
   2. Evidence of extensive literature reviews appropriate for the individual patient and topic.
   3. Ability to construct a logical management plan.
   4. Inclusion of appropriate physical examination.
   5. Appropriateness of use of diagnostic tests.
   6. Correct interpretation of diagnostic tests.
   7. Appropriate selection of pharmacologic and non-pharmacologic therapies.
   8. Competent performance of cardiac procedures relative to the fellow’s level of training.
   9. Appropriate follow-up.
   10. Feedback from other team members, other healthcare providers, and patients.

Resources:

• University of Iowa Hardin Medical Library (Up to Date, electronic journals including New England Journal of Medicine, Circulation, Journal of the American College of Cardiology, Journal of the American Medical Association and Heart Rhythm and Medline)
• www.cardiosource.com
• Heart Disease: A Textbook of Cardiovascular Medicine (9th edition) Eugene Braunwald, editor
• Fogoros’ Electrophysiologic Testing 4th Ed
• Zipes and Jalife’s Cardiac Electrophysiology: From Cell to Bedside (most recent edition)
• Epstein AE, et al, ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities. J Am Coll Cardiol 2008 May 27;51(21):e1-62.