Hey,
I have CARDS as my first IM internship rotation. Any tips?
I have CARDS as my first IM internship rotation. Any tips?
Internship CARDS rotation
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deleted547339
Try not to kill anyone.
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know basics of EKG. carry calipers. or just now how to take a History and physical.
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calipers lol
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Cardiologists are gunners and pedantic, plus overly focused on their organ. And that statement has enough nuance to drive a truck through. As an intern just hammer out sweet H&Ps, which you already know how to do, and which is why interns actually exist. You can calibrate from there. There are some good validated risk scores those guys always like TIMI, CHADS2, etc. look those up and be ready to toss them in. These guys also like to know any old coronary cath reports or old echocardiograms. You'll look good if you can find a way to track those down. God tier intern level stuff would be knowing which vessels got bypassed in surgery previous if you can track down the op reports. Cards is mostly old info, old info, old info, plus assigning some kind of risk score, then treating with aspirin, statins, and betablockers, plus or minus ace inhibitors. The decisions about cath or no cath, or type of stress test will be beyond you and often attending specific so just roll with it when a new one comes on service and does things different. One last interesting thing some cardiologists think amiodarone and or digoxin are/is poison, so don't feel bad if you ever suggest one or the other and your attending throws a small tantrum.
Also. It's not usually the lungs in one of their patients. It isn't.
Also. It's not usually the lungs in one of their patients. It isn't.
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deleted547339
This disappointed me so much in cardiology. It's amazing how little literature and how much attending preference drives the ship. One week, everyone is on a lasix drip, the next they're all on bumex. One week it's amio for all, the next it's just beta blockers and supportive care. One week it's get a RHC or LHC on everyone, the next it's only cath STEMIs. A patient will be too sick for a cath one week, then too healthy to need it the next.
CCU drove me crazy.
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My favorite thing about cath/no cath when I was a resident was that we had some cards attendings who worked at both the VA and the Uni (which were physically connected). One month you'd be on CCU at the Uni with Dr. Cathnocath and he'd have his lead on and groin puncture done before you could finish "Mr. Jones is a 71yo male w/ PMH significant for CAD s/p LAD stenting 6 months ago who presents with...". And 3 months later, there you are, on CCU at the VA, again with Dr. Cathnocath as your attending, who spends an hour on rounds explaining why Mr. Jones doesn't need a cath.
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Except for AS, inferior MIs, PE, tamponade, or HoCM... You know cause that will kill them.
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deleted547339
AS is probably not as big of an issue previously described.
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I wouldn't recommend it. When severe AS goes down, it doesn't get back up.
Jdh gave the best advice. Take a good history(cardiac risk factors, syncope, family history etc). Track down the most recent echo or catheterization. Print out the most recent EKG and probably an old one if any new changes- they will likely teach you and be happy they don't have to waste time looking it up.
CHF - systolic or diastolic or combined, etiology, reason for exacerbation, medical optimization. You really should know every mortality benefit medication(specifically not just a class) and device. Two new medications approved in the last 2 years, ivabradine/sacubitril-valsartan combo.
A-Fib - CHA2DS2-Vasc, HAS-BLED scores. Rate control medication, rhythm control(rare nowadays), anti-coagulation, PT/INR if Warfarin.
TIMI Score for NSTEMI, likely won't see any STEMI's unless you don't have fellows dedicated to STEMI pager?
New guidelines/evolving guidelines for dual anti platelet therapy is pretty hot topic.
Basic knowledge of murmurs/valvular heart disease are also common consults.
Basic knowledge of the NOACs.
The most common consult is probably troponin leak, learn the different types of MI, I believe there are 5?
CHF - systolic or diastolic or combined, etiology, reason for exacerbation, medical optimization. You really should know every mortality benefit medication(specifically not just a class) and device. Two new medications approved in the last 2 years, ivabradine/sacubitril-valsartan combo.
A-Fib - CHA2DS2-Vasc, HAS-BLED scores. Rate control medication, rhythm control(rare nowadays), anti-coagulation, PT/INR if Warfarin.
TIMI Score for NSTEMI, likely won't see any STEMI's unless you don't have fellows dedicated to STEMI pager?
New guidelines/evolving guidelines for dual anti platelet therapy is pretty hot topic.
Basic knowledge of murmurs/valvular heart disease are also common consults.
Basic knowledge of the NOACs.
The most common consult is probably troponin leak, learn the different types of MI, I believe there are 5?
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Lol. Someone sounds like a cards gunner.
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I love this white coat pocket book ECG Pocket Brain by Ken Grauer I got from Amazon quick and cheap
it's as good as the Dubin test, maybe better, and it fits in your pocket
I've not awesome with EKGs and it seriously saved my ass a few times
the nephrologists told me the cardiologists only care about the heart and don't give a **** if the lasix trashes the kidneys
I don't know if that's true, but I was told never to argue with a cardiologist's recs on account of the kidneys because they don't care
just passing along the anecdote, YMMV
thoughts anyone?
it's as good as the Dubin test, maybe better, and it fits in your pocket
I've not awesome with EKGs and it seriously saved my ass a few times
the nephrologists told me the cardiologists only care about the heart and don't give a **** if the lasix trashes the kidneys
I don't know if that's true, but I was told never to argue with a cardiologist's recs on account of the kidneys because they don't care
just passing along the anecdote, YMMV
thoughts anyone?
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Loop diuretics don't trash a kidney though. At least in most cases of any kind of cardio renal syndrome. It's the ****ty pump. The drug isn't directly toxic to the kidneys or anything. The beans are already going into pre-renal injury by the time the loop diuretics are given. And you hope you can get enough intravascular volume off the heart to restore the physiology but if you can't because you are simply behind the 8ball it's not really the fault of the diuretic at that point. It's a narrow window. And I'm sure the renal guys kind of hate the consult because it's just bad bad bad news at that point. But you do need them to weigh in on how much of a bad idea it is to start dialysis in cardio renal syndrome - especially if it doesn't look like you're dealing with an acute but recoverable event. If it's the end stages of a longstanding pump problem, time for palliation.
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They know you are a new intern and your resident and attending will be extra vigilant. This first rotation will be basically a gimme. They're not going to really judge you unless you're not doing your work. So your goal should be to improve for the rest of internship and work hard. So as JDH said, your main priority is to create solid H&P.
What a cardiologist wants to know and what an intern should provide him (this probably isn't going to happen on your first rotation):
Heart failure- probably will be your more common admission diagnosis
- Warm vs cold and wet vs dry (look this up, there is a good 4x4 chart)
- Important things to get from last echo: RV function, LV function, any moderage/severe valvular function
- Pertinent classes of meds they're on: ACEi/ARB, BB, sprio/eplerenone, hydral/nitrate, dig, diuretic and dose
- QRS duration (for CRT) and rhythm, especially if it has changed (restore sinus if newly out of it)
- Type of device- PPM vs ICD, Single vs 2 chamber vs CRT
- End organ function- renal and liver
- Is it ischemic and do you need an ischemic eval
- Hold the beta blocker, cut in half or continue it?
- Any meds you can add to improve their regimen
- THIS IS COMMONLY TESTED ON IM BOARDS so knowing indiciations for meds is a good idea (there is a good ACC/AHA guideline document on this)
CAD:
- Stable, unstable, NSTEMI vs non-ischemic
- Had Prior CAD? know prior caths, locations of stents and types of stents (DES vs bare metal)
- Had CABG- what are the grafts, which ones are open
- When to go to the lab? Immediately if unstable, arrhythmias or continued CP, in first 24 hours if high risk, after ischemic evaluation for others
- Need Heparin?
- Risk scores Personally I think the risk scores don't add much. TIMI risk score is largely worthless. Your high risk people are going to have a TIMI risk score of 4 no matter if they're coming in with chest pain or a UTI. Personally I prefer (as do many cardiologists) the GRACE score but again, don't think it adds much.
AF- when to use rate vs rhythm control
When to use BB vs CCBs for rate control
Contraindications for certain antiarrhythmics (tested on boards occasionally)
Do they need AC? (Chads-vasc is your go-to)
NOACs and contraindications
What a cardiologist wants to know and what an intern should provide him (this probably isn't going to happen on your first rotation):
Heart failure- probably will be your more common admission diagnosis
- Warm vs cold and wet vs dry (look this up, there is a good 4x4 chart)
- Important things to get from last echo: RV function, LV function, any moderage/severe valvular function
- Pertinent classes of meds they're on: ACEi/ARB, BB, sprio/eplerenone, hydral/nitrate, dig, diuretic and dose
- QRS duration (for CRT) and rhythm, especially if it has changed (restore sinus if newly out of it)
- Type of device- PPM vs ICD, Single vs 2 chamber vs CRT
- End organ function- renal and liver
- Is it ischemic and do you need an ischemic eval
- Hold the beta blocker, cut in half or continue it?
- Any meds you can add to improve their regimen
- THIS IS COMMONLY TESTED ON IM BOARDS so knowing indiciations for meds is a good idea (there is a good ACC/AHA guideline document on this)
CAD:
- Stable, unstable, NSTEMI vs non-ischemic
- Had Prior CAD? know prior caths, locations of stents and types of stents (DES vs bare metal)
- Had CABG- what are the grafts, which ones are open
- When to go to the lab? Immediately if unstable, arrhythmias or continued CP, in first 24 hours if high risk, after ischemic evaluation for others
- Need Heparin?
- Risk scores Personally I think the risk scores don't add much. TIMI risk score is largely worthless. Your high risk people are going to have a TIMI risk score of 4 no matter if they're coming in with chest pain or a UTI. Personally I prefer (as do many cardiologists) the GRACE score but again, don't think it adds much.
AF- when to use rate vs rhythm control
When to use BB vs CCBs for rate control
Contraindications for certain antiarrhythmics (tested on boards occasionally)
Do they need AC? (Chads-vasc is your go-to)
NOACs and contraindications
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deleted547339
No one would recommend it. But it's probably a significantly overblown concern. I've given nitro and put a patient on bipap that was crumping before I had any info on them only later to find out they have tight AS several times. They've all done fine. There is some retrospective literature to suggest the same.
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One of us treats AS everyday. The other calls me down to the ER to treat the patient with AS.
Regarding the retrospective study- (http://www.ncbi.nlm.nih.gov/pubmed/26002298) Have you actually read the full study, because I have after i fought with our ED over the same thing (incidentally after I was admitting a hypotensive AS patient to the CICU). It is a garbage study.
- Both the mean and peak gradients within the "severe AS" group were not actually severe. They weren't low-flow-low-gradient either as the mean EF was essentially normal
- Doses of IV NTG were lower and the proportion who got SL NTG (ie a larger dose) were lower in the severe AS group
- Despite the above, there was a 30% rate of sustained hypotension in the "severe AS" group vs 13% with no AS. The only reason this wasn't statistically significan was because there were only 65 patients in each arm
- In hospital mortality was almost triple for the severe AS population.
- Most importantly, this was in a patient population with high enough filling pressurs to have severe pulmonary edema- so this was the safest AS population you could have chosen.
-Finally, since they based this on d/c diagnosis, those killed in the ER with NTG werent included
In the absolutely best circumstance, this study tells you that NTG could be safe when filling pressures are very hight. In the more likley scenario, the authors came to an illusory conclusion because of just how underpowered this study was. How this passed the peer review process is beyond me.
Bad data is worse than no data
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deleted547339
Whoa there buddy.
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You should have known that was coming.
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deleted547339
You're not wrong.
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And this is why I LOVE EBM lol
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