Cardiovascular - M2

Sequence Goals

Our goals for this sequence are to:

• Provide you with a solid introduction to diseases of the cardiovascular system, how they present, how they are diagnosed, how they are prevented, and how they can be treated.
• Help you identify the integral links between anatomy, physiology, pathology and other basic sciences with clinical medicine and other essential aspects of patient care for ambulatory and hospitalized patients who have cardiovascular disorders.
• Help you decide which of several drug therapies are best, most rational, or contraindicated for patients with various cardiovascular (and other) diseases.
• Encourage self-directed learning through use of textbooks, electronic media and faculty-student interaction.
• Help you become more knowledgeable so you can help intervene to manage, and reduce, the Number One cause of death in the U.S. -- cardiovascular diseases, and stroke.

How the Material is Organized

Obviously the cardiovascular system doesn’t operate as separate parts. There are many elements, all interrelated more or less, and one could argue about which is more important than others, which should be presented first or get the most time. Nevertheless, there needs to be a plan.

To help you keep organized (and, frankly, to help us too), we’re addressing several main “areas” of the cardiovascular system and cardiovascular disease. Within each of those "big six" areas we will be presenting basic physiology, pathology, and pharmacology, then move on to more clinically relevant matters. We also hope to provide the right level (for most of you) of "refresher" material (say, from prior physiology or pharmacology courses) plus the new material, of course.

We also introduce you to some special patient populations or other patient-related factors — children and the elderly, ethnicity, and gender among them — as faculty scheduling permits. You’re not likely to see these “special topics” in every other M2 sequence.

We'll work through each section and address:

Textbooks

L.S. Lilly (ed.), Pathophysiology of Heart Disease: A Collaborative Project of Medical Students and Faculty, Williams & Wilkins, 4th edition, 2007, is the required text. Many faculty will focus their presentations on material from Lilly.

Faculty have been asked to incorporate reading material from the textbook(s) in the preparation of test items, in addition to basing test items on topics presented during the plenary sessions (lectures).

Recommended Texts

We encourage you to consult other texts, including those from your M1 year and others that should serve you well throughout the M2 year (and beyond). Don’t forget to select a pharmacology text of your choice (see Dr. Shlafer’s web site for recommendations); and use Robbins pathology text that you used in your M1 year. Also, consider these, which are specific to this sequence.

Eagle K.A. and Baliga R.R., eds. Practical Cardiology: Evaluation and Management of Common Cardiovascular Disorders (Philadelphia: Lippincott Williams & Wilkins). Edited by one of your sequence co-directors (and another who was co-director until this year), with chapters by many of the faculty who also will be teaching in this sequence. Not required reading, but an excellent text for those of you who want to delve into management of cardiovascular disorders a bit deeper.

Dubin, D. Rapid Interpretation of EKGs. This very old and classic learning text has been a favorite for decades. Whether you get the latest edition, or, say, the 5th edition, you may find this a great help -- if not now, then in the M3 year. Try amazon.com to locate a used paperback version.

Learning Activities in Addition to Lectures

Please note that attendance and participation in all lectures is strongly encouraged. One MDC is scheduled and attendance is mandatory. Please realize that you will be in the presence of patients and visitors, so be sure to “dress appropriately.”

“EKG of the Day”

Periodically we will post one or several EKGs for you to look at, assess, and identify as to its nature. A couple of days after each EKG is posted we will post an explanation of the EKG, including such things as how you make the assessment of what the EKG represents. You will see some of these EKGs on the final exam. This portion was developed by Dr. Ragaven Baliga, formerly codirector for this sequence, who is now at The Ohio State University medical school. We won’t start posting this material until the general topics of the normal electrocardiogram, and some basic information on arrhythmias, have been presented.

Sequence Web Site

Various materials for the sequence [e.g., this document, faculty names and E-mail addresses, some notes and slides files, the EKG of the Day exercises, more] will be posted on a web site set up specially for this sequence. Many of them will also be available from the medical school portal and C-Tools, and we hope to have all material available there exclusively.

Grades

Grading in the Cardiovascular sequence will comply with M2 grading policies set by the Medical School. A pass/fail system will be used, and a cumulative grade of 75.00% or higher will be required for a passing score.

There will be one quiz and a final exam on the regular lecture material (including the MDC content at the end of the course). Both are scheduled by the Office of Medical Education. [Important note: topics covered before the quiz, whether or not they are “tested” on the quiz, are not exempt from inclusion on the final exam.] Questions on the quiz and those on the written sequence final have “equal weight.” As far as your overall average goes, then, quiz questions count no more or less than those on the final.

Collectively, the quiz and final exam comprise 90% of your total grade. Questions on the pathology laboratory final will count for 10% of your grade total. Your total percent correct will be used to determine your final grade for the sequence.

Although the Longitudinal Case activities run concurrent with the cardiovascular sequence, it is not a formal part of the sequence nor any part of your grade in this sequence.

1. Cardiac Muscle. In its most basic form, the cardiovascular system is a delivery conduit, and the heart is the pump. This section focuses on the myocardium, at both the cellular and whole organ levels. Much of the emphasis will be on congestive heart failure (CHF), but we'll also address cardiomyopathies of various sorts (e.g., ischemic and nonischemic; inflammatory and infiltrative).
2. The coronary arteries. We'll present such relevant conditions as coronary artery disease, ischemic heart disease, and the various types of angina pectoris; acute myocardial infarction (AMI); and lipid disorders and atherosclerosis.
3. The peripheral vasculature. One part of this theme addresses the common issue of hypertension, including both the causes and consequences of it, and its management. We include content on peripheral vascular disease; thromboembolic disorders, including deep venous thrombosis (DVT); and dissection.
4. Cardiac electrophysiology and the conduction system. Irregularities of cardiac rhythm are common and can have considerable impact on how well the heart provides its essential pumping function. We'll look first at basic cardiac electrophysiology, and the genesis and interpretation of the normal electrocardiogram (EKG). Then we go on to the main arrhythmias and also take a look at sudden cardiac death/cardiac arrest, where arrhythmias are usually the proximate cause of death. You'll learn more about the EKG, and how to interpret some of the more common EKG findings (and self-test yourself with "EKG of the day" exercises). Here, too, we'll try to keep things basic, covering (for example) bradyarrhythmias and their "flip side," tachyarrhythmias; and those arrhythmias that can be classified as supraventricular (atrial, etc.) or as ventricular.
5. The cardiac valves. In this sort section we address such clinically important concepts as stenosis and regurgitation of the various cardiac valves - those structures critical to controlling the direction of blood flow from the heart (and, to a degree, blood flow through the heart itself), and overall circulatory status through hemodynamic effects.
6. The circulatory system – normal and pathologic – overall.
7. The pericardium. While you might view the pericardium as little more than a sac in which the heart lies, it is the crux of some important cardiovascular diseases. We give an overview of such topics as acute and chronic pericarditis, pericardial effusion, and tamponade.
   • Some relevant highlights of epidemiology — incidences and causes of those disorders on which we will be focusing, and such preventative measures as healthy nutrition;
   • Relevant physiology and pathophysiology (and anatomy) — what we hope will be the "right amount" of constructive review/refresher, plus the necessary new content or a closer look;
   • Investigations and "Approach to the Patient" — how you go about assessing the patient so you can come up with a proper diagnosis and effective management plan. This will include the "basic tools," including key elements of the H&P and the interview, and initial (or at least well-informed) steps for drug therapy.
   • When appropriate we'll also introduce and discuss some of the investigative tools that are, more or less, most applicable to or useful for "things cardiovascular" - the EKG, echocardiography, cardiac catheterization, and (something that may be underutilized nowadays) the chest x-ray. We'll also touch upon the less common or more specialized investigative tools, including nuclear scans, proton emission tomography (PET), MRI, and others;
   • Interventions/treatment — the main medical, pharmacologic, and surgical approaches: what they are, how you assess risk-benefit factors of the various options, and why you may select the approach you eventually or initially take;
   • Outcomes and follow-up — what you need to do, and why, to determine whether your interventions have been efficacious;
   • Prevention — nutrition, other aspects of lifestyle/risk factor management, and some of the other important ways you can prevent recurrences or complications or — better yet — prevent, minimize, or at least delay some problems to begin with.

Textbooks

L.S. Lilly (ed.), Pathophysiology of Heart Disease: A Collaborative Project of Medical Students and Faculty, Williams & Wilkins, 4th edition, 2007, is the required text. Many faculty will focus their presentations on material from Lilly.

Faculty have been asked to incorporate reading material from the textbook(s) in the preparation of test items, in addition to basing test items on topics presented during the plenary sessions (lectures).

Recommended Texts

We encourage you to consult other texts, including those from your M1 year and others that should serve you well throughout the M2 year (and beyond). Don’t forget to select a pharmacology text of your choice (see Dr. Shlafer’s web site for recommendations); and use Robbins pathology text that you used in your M1 year. Also, consider these, which are specific to this sequence.

Eagle K.A. and Baliga R.R., eds. Practical Cardiology: Evaluation and Management of Common Cardiovascular Disorders (Philadelphia: Lippincott Williams & Wilkins). Edited by one of your sequence co-directors (and another who was co-director until this year), with chapters by many of the faculty who also will be teaching in this sequence. Not required reading, but an excellent text for those of you who want to delve into management of cardiovascular disorders a bit deeper.

Dubin, D. Rapid Interpretation of EKGs. This very old and classic learning text has been a favorite for decades. Whether you get the latest edition, or, say, the 5th edition, you may find this a great help -- if not now, then in the M3 year. Try amazon.com to locate a used paperback version.