the cardiology field..?

[swamprat]

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So I finally got accepted to med school and I have an interest in cardiology. I know there are invasive and non-invasive cardiologists. How does the training differ? I know for non-invasive its 3 year IM residency followed by a 2 year fellowship? What about invasive? Are there any other types? Thanks.

 

[MossPoh]

http://www.ama-assn.org/ama/pub/education-careers/graduate-medical-education/freida-online.shtml

You will probably change your mind a million times. There are certain fields it feels damn near every med student is interested in. It means about nothing until you experience it. Dig around that site and google a few others and read. These are the kind of questions that are better answered by looking it up and learning yourself.

 

[howelljolly]

So I finally got accepted to med school and I have an interest in cardiology. I know there are invasive and non-invasive cardiologists. How does the training differ? I know for non-invasive its 3 year IM residency followed by a 2 year fellowship? What about invasive? Are there any other types? Thanks.

With some variations, heres the basic pathway.

1. Internal Med residency (youre an internist) -->

2. Cardiovascular Disease fellowship (youre a cardiologist) -->

3. Interventional Cardio fellowship (youre an interventional cardiologist), or Cardiac Electrophysiology fellowship, or Cardiac Imaging/Nuclear Cardio fellowship, or Heart Failure Fellowship....

Interventional Cardio is basically an additional fellowship after Cardiovascular Disease aka Cardiology. And its probably the only one youve ever heard of, because you know about stents and caths from watching too much TV. But there are plenty of other types of cardiologists.

 

[amidoinitrite]

Interventional Cardio looks intense! I hear they're starting to replace entire valves percutaneously now??

 

[dikoerastenie]

I had only 1 lecture on this subject. It was not part of a cardio class. But the professor (a cardiologist) basically said that there is little proof that stents extend life vs. statins.

 

[howelljolly]

I had only 1 lecture on this subject. It was not part of a cardio class. But the professor (a cardiologist) basically said that there is little proof that stents extend life vs. statins.

Something like that. Evidence suggests that bypass vs. PCI (stents) vs. medical management (statins etc.) have no significant difference in outcome (mortality). So why not use the treatment modality with the least morbidity?

 

[scudrunner]

I had only 1 lecture on this subject. It was not part of a cardio class. But the professor (a cardiologist) basically said that there is little proof that stents extend life vs. statins.

A statin certainly isn't going to open up an artery during an MI.

 

[dienekes88]

A statin certainly isn't going to open up an artery during an MI.

*sees 80% left main occlusion*

"oh snap! Better start the statins, brah!"

 

[dienekes88]

Interventional Cardio looks intense! I hear they're starting to replace entire valves percutaneously now??

As I understand it, there's a certain population that can get percutaneous aortic valves. There are size restrictions.

Some valves are done in hybrid operations in a interventional cardiologist/cardiothoracic surgeon tagteam. Interestingly, the hybrid suites have to be 3x larger than expected... just to fit the egos. 😉

 

[Rendar5]

A statin certainly isn't going to open up an artery during an MI.

We're not talking MI, in which case intervention by far is the preferred modality in most cases. We're talking coronary artery disease. And the evidence really does show that stenting non-occluded arteries (yes, those 80-90% occluded arteries) does not improve mortality (through theoretical prevention of MI and CHF) compared with medical therapy. So when you're doing a cath to see what's occluded, doing a "oh that looks tight, let's stent it!!!!" isn't necessarily going to do anyone any good. There is a role for intervention in a lot of settings, but it's very important to realize that there are a lot of times where medical management or no management may be preferable to intervening

 

[scudrunner]

We're not talking MI, in which case intervention by far is the preferred modality in most cases. We're talking coronary artery disease. And the evidence really does show that stenting non-occluded arteries (yes, those 80-90% occluded arteries) does not improve mortality (through theoretical prevention of MI and CHF) compared with medical therapy. So when you're doing a cath to see what's occluded, doing a "oh that looks tight, let's stent it!!!!" isn't necessarily going to do anyone any good. There is a role for intervention in a lot of settings, but it's very important to realize that there are a lot of times where medical management or no management may be preferable to intervening

I just couldn't resist, the set-up was perfect.

And for the sake of discussion, if there is no difference in mortality, how about quality of life, angina, or other symptoms? Any difference there?

 

[Dral]

Don't forget cost. A stent may cost less than a good number of years on a statin...but someone who is stented will probably be on a statin anyway.

 

[Rendar5]

Don't forget cost. A stent may cost less than a good number of years on a statin...but someone who is stented will probably be on a statin anyway.

And don't forget the lifetime plavix script.

To the person above looking for anginal symptoms, if I remember the lit right (and it's not important that i do since this isn't my field), there is 6 months less symptoms on average with stenting compared with medical therapy, so there in practice, tehre is a role in stable angina for symptoms, but only after discussion about the benefits and risks of stenting. Remember, there are always real risks for every benefit in medicine. Keeping your eye on the benefits alone can yield very bad results for patients. There's a reason that there are new recommendations coming out to do fewer mammograms and pap smears than before.

 

[RySerr21]

I just couldn't resist, the set-up was perfect.

And for the sake of discussion, if there is no difference in mortality, how about quality of life, angina, or other symptoms? Any difference there?

Quality of life after surgical myocardial revascularization, angioplasty or medical treatment.
[Article in English, Portuguese]

Takiuti ME, Hueb W, Hiscock SB, Nogueira CR, Girardi P, Fernandes F, Favarato D, Lopes N, Borges JC, de Góis AF, Ramires JA.

Instituto do Coração, Hospital das Clínicas, FM, USP, São Paulo, SP, Brazil.
BACKGROUND: Although the clinical benefits of coronary interventions seem to be confirmed, their effects on quality of life (QoL) are still scarcely studied. OBJECTIVE: To assess the QoL in multivessel coronary disease in patients randomly undergoing surgery, angioplasty or medical treatment. METHODS: The Short-Form Health Survey (SF-36) questionnaire was answered by 483 patients. Of these, 161 underwent surgical revascularization, 166 underwent angioplasty, and 153 were medically treated. RESULTS: At baseline, 86% of the patients referred angina, 34% referred infarction, and 32% were smokers. Medical Treatment: 12 patients (7.7%) had AMI, 24 (15.3%) underwent surgery, and 19 (12.1%) died. In addition, 5 (3.2%) had stroke, and 40 (25.6%) had angina. As regards the mental component, 64.1% and 30.8% had their condition improved and worsened, respectively. As regards the physical component, 70.5% and 27.6% had their condition improved and worsened, respectively. Surgery: 13 patients (8.1%) had AMI, 2 (1.2%) underwent surgery, and 12(7.4%) died. Also, 9 (5.6%) had stroke and 30 (18.6%) had angina. As regards the mental component, 72.7 % and 25.5% had their condition improved and worsened, respectively. As regards the physical component, 82.6% and 16.1% had their condition improved and worsened, respectively. Angioplasty: 18 patients (10.9%) had AMI, 51 (30.7%) underwent interventions, and 18 (19.9%) died. Additionally, six (3.6%) presented stroke and 35 (21%) reported angina. As regards the mental component, 66.9% and 26.5% had their condition improved and worsened, respectively. As regards the physical component, 77.1% and 20.5% had their condition improved and worsened, respectively. CONCLUSION: Improvement was observed in all domains and in the three therapeutic modalities. Comparatively, surgery had provided a better quality of life after a four-year follow-up.


This to me is even more interesting.....

Effects of intensified lifestyle modification on the need for further revascularization after coronary angioplasty.
Wallner S, Watzinger N, Lindschinger M, Smolle KH, Toplak H, Eber B, Dittrich P, Elmadfa I, Klein W, Krejs GJ, Wascher TC.

Department of Internal Medicine, Karl-Franzens University, Graz, Austria.
Comment in:

Eur J Clin Invest. 1999 May;29(5):365-8.
BACKGROUND: In patients with coronary artery disease (CAD), a rate of restenosis as high as 50% is observed after percutaneous transluminal coronary angioplasty (PTCA). Frequently, this results in further revascularization procedures. Lifestyle intervention has been shown to slow the progression of CAD and to reduce cardiovascular events after myocardial infarction. However, no information exists whether such treatment influences the rate of restenosis in patients with CAD. The present study was performed to investigate the effects of an intensified lifestyle intervention on the need for further revascularization procedures in patients with established CAD after successful PTCA. DESIGN: A total of 60 patients were included and randomized to either conventional treatment by cardiologists and general practitioners or additional intensified lifestyle intervention in a diabetes and metabolism outpatient clinic for 12 months. The mean observation time after successful PTCA was 26 months. The primary outcome variable was the need for further revascularization procedures because of clinical restenosis. Secondary outcome variables were lifestyle-related measures. RESULTS: Intervention resulted in a reduction in body weight and blood pressure, and in increased physical activity. Furthermore, nutritional habits were changed towards less fat intake, and body composition changed towards a higher proportion of fat-free mass. The need for further revascularization procedures was reduced from a total of 14 out of 32 in the conventionally treated group to 3 out of 28 in the intervention group. This resulted in an event-free survival probability of 0.89 in the intervention group and 0.57 in the control group (P = 0.0055, log rank) with a resulting relative risk of 0.26 (95% CI 0.09-0.74). CONCLUSION: In conclusion, our data strongly suggest that intensified lifestyle modification is able to reduce the need for further revascularization procedures after PTCA in patients with CAD.

 

[doctor712]

Interventional Cardio looks intense! I hear they're starting to replace entire valves percutaneously now??

A,

Yes, Percutaneous Aortic Valves are being put in now, I work on the PARTNER trial going on right now in about 21 centers. Though I only work at one center. 🙂 The valves can be put in trans femoral or trans apical, depending on whether patient's fems/iliacs are diseased, tortuous, or generally small in size. Trans apicals are more invasive of course.

These Aortic Valve procedures are being done solely by Intvl Cards. CT surgeons are always close by in case they need to convert to open, but this isn't a hybrid procedure per se. These valves are being put in really sick patients. However, things are, as you say, moving in general to lots of hybrid procedures between CT surgery and Intvl Cards.

It's an AMAZING thing to see that valve expanded in place, like a stent, when they have severe AI, no hope, and suddenly, no more AS and little AI. Bright futures ahead!

D712