Purpose:

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.

Responsibilities/Specific Duties:

1. The fellow will work with the Nuclear Exercise Laboratory staff to assess the accurate selection of stress for the patient and can be reasonably expected to answer the clinical question.
2. The UI Hospitals & Clinics Nuclear fellow will supervise the exercise stress tests with the nuclear laboratory physician assistant. Other exercise stress testing objectives are met during the UI Hospitals & Clinics echo lab rotation (for performance of exercise and dobutamine stress echocardiography) and during the VA outpatient rotation (for performance and interpretation of exercise stress test
3. The UI Hospitals & Clinics Nuclear fellow will be present in the lab most of the morning to supervise and interpret stress tests, perform tracer injections when possible. In the afternoon, the UI Hospitals & Clinics Nuclear fellow will interpret perfusion images. On the VA outpatient rotation, the VA outpatient fellow is expected to interpret studies with the VA nuclear medicine staff physician.
4. The fellows should read all stress electrocardiograms and nuclear perfusion imaging studies in preparation for the afternoon reading session with the attending cardiologist.
5. The UI Hospitals & Clinics nuclear cardiology fellow, VA outpatient fellow and VA cath fellow identify nuclear cardiology studies to be presented at the Advanced Cardiac Imaging Conference.

Supervision:

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.

Learning Objectives:

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:

1. Obtain training in the principles of noninvasive detection and prognostic assessment of patients with known or suspected coronary artery disease. (A, B)
2. Gain an understanding of the risks and benefits of various stress testing modalities. (A, B)
3. Gain an understanding of the implications of various pharmacologic agents on stress test accuracy. (A, B)
4. Gain training in safely conducting stress tests. Learn to recognize and manage emergencies arising in the course of stress testing. (A, B)
5. Gain skills in the interpretation of exercise electrocardiograms and stress and rest nuclear cardiac tests. (B)
6. Gain understanding of nuclear methods for measurement of left ventricular function and the complimentary roles of myocardial perfusion and left ventricular function in patient assessment and management. (B)
7. Gain understanding of the role of stress testing in preoperative cardiac risk assessment, using published series and guidelines. (B, C)
8. Gain understanding of the value and limitations of stress test results in the assessment of patient diagnosis and prognosis, and in clinical management. (A, B)
9. Gain an appreciation for the role of the staff members in the non-invasive lab, including the technicians, nurses, and administrative staff. (D, E, F).
10. Learn to generate an accurate and easily understood report for stress tests and nuclear perfusion studies. (D)

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.

Level Specific Goals and Objectives:

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.

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

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.

Teaching Methods:

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.

Evaluation:

1. The goals and objectives for the rotation will be verbally communicated at the beginning of the rotation.
2. A standard fellow evaluation form is completed by the attending at the end of the rotation.
3. The attending physician’s final evaluation is based on fulfillment of the rotation objectives as determined by:
   1. Personal observation during interaction with the fellow.
   2. Evidence of a growing knowledge base in exercise testing and nuclear cardiology over the course of the rotation.
   3. Ability to identify appropriate versus inappropriate test selections.
   4. Accuracy of exercise electrocardiogram interpretation.
   5. Accuracy of nuclear cardiology test interpretation, including interpretation in the Advanced Cardiac Imaging conference.
   6. Appropriate handling of any patient emergencies.
   7. Feedback from ECG monitoring technicians, nurses, and nuclear medicine technologists in the Exercise Nuclear Laboratory.

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 Medline)
• www.cardiosource.com
• Heart Disease: A Textbook of Cardiovascular Medicine (9th edition) Eugene Braunwald, editor
• www.asnc.org
• Nuclear Cardiac Imaging: Principles and Applications textbook (4th edition) Ami E. Iskandrian, Editor
• Nuclear Cardiology: Practical Applications (2nd edition) Gary Heller and Robert Hendel Editors