Meet the Consultants Cardiology Kerrilynn Carney MD Introduction

Meet the Consultants Cardiology Kerrilynn Carney, MD

Introduction • Cardiology is the largest fellowship training program in the hospital • 27 General fellows • >12 Advanced fellows • 1 Congenital Heart Disease fellow 2

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Introduction 10

Service Structure 1. University vs. Private Groups 2. Subspecialties: a. Heart Failure and Transplant Cardiology b. Electrophysiology c. Structural Cardiology d. Interventional Cardiology e. Peripheral Vascular and Limb Salvage f. Adult Congenital Heart Disease 3. Locations: a. York Street Campus b. Saint Raphael Campus c. West Haven Veterans Administration Hospital 11

Private Groups Heart. Care Associates of CT LLC • Margaret L Furman • Ricardo Cordido • John P Chandler • Marian Vulpe • Ajoy Kapoor • Kunal Domakonda • Robert F Morrison • Vasant Khachane • Graig Sanders PA • Mark Whelan PA • Jonathan S Siegfried • Thomas Rank APRN • Linda Hricz-Borges PA Cardiology Group (CG) • Andrea Niziolek PA • Ron Nudel • Jonathan Brier Cardiovascular Physicians and Consultants LLC • Alan Radoff • Clifford Kramer • Jeremy Nadelmann • Robert Lewis • Martin Plavec • Elliot Agin • Tina Mulinski APRN Cardiovascular Health LLC • Jonathan Gage 12 Connecticut Heart Group

Cardiology Outpatient Group • Vincent Di. Cola • Daniel Price • Lisa Freed • Donald Rocklin • Jaime Gerber • Arthur Seltzer • Douglas Israel • Steven Wolfson • Steven Jacoby • Elise Meoli • Christopher Loscalzo • • Sandip Mukerhjee • Stephen Possick Formerly Cardiology Associates* • Currently have their own coverage at York Street (Amion CA) • We see at SRC 13

Current State ED Other Service s (Surgery, MICU, IM, etc) YACCE SS Obs Interventi onal HVC Outpatient (“CANH”) The Cardiology Group Consults Admissions Obs “Consult Service” Attending + Fellow “HVC Consult Service” Attending + APP Goodyer Teaching Attending + 2 residents + Fellow Goodyer Non. Teaching Attending + APPs *Doesn’t Include CCU, CHF or EP S L I D E 14

York Street Cardiology Associates Cardiology Group VA SRC S L I D E 15

Examples of Subspecialist Consultations 16

Have a question about scheduling a test? York Street Echo lab: SRC “CDU”; Echo and York Street Nuclear lab: Nuclear labs: ● 203 -688 -1296 ● 203 -688 -4749 ● 203 -680 -2678 York Street Cath lab: SRC Cath lab: ● 203 -688 -1726 ● 203 -789 -2047 17

General Consult Coverage 7: 30 a/6: 30 p 6: 30 p/7: 30 a York Street Campus First year fellow *night float Saint Raphael’s Campus Any general fellow Second year fellow *SRC/VA traditional call West Haven VA Hospital Any general fellow Second year fellow *SRC/VA traditional call 18

Service Flow Who covers consults? • General Cardiology: General Cardiology Fellow • Subspeciaties: General Cardiology Fellow +/- Advanced Fellow/Attending What’s the best time of day to place consults? • AM, preferably after 8 am to allow us to signout When should teams expect to hear back and/or see notes in Epic? • Immediate impression/recommendations: over the phone during initial chart review • Additional urgent recommendations: face-to-face or via MHB while rounding • Notes: end of the day 19

Quick Cardiology Consult Survey 20

MUST Consult List Emergent • STEMI • VT/VF cardiac arrest • Cardiogenic shock • Life-threatening arrhythmia • Symptomatic bradycardia • Sustained WCT (ex: VT) • Pericardial tamponade • Post-cardiac intervention bleeding • Critical Limb Ischemia Urgent • Non-STEMI ACS (type I) • Unstable Angina • New cardiomyopathy • Acute decompensated heart failure • Flash pulmonary edema • Myocarditis • Atrial arrhythmia with uncontrolled RVR • Tachy-brady syndrome • Significant pulmonary hypertension • Symptomatic and/or new advanced valvular heart disease: • • Severe aortic stenosis Severe mitral regurg/stenosis • Large pericardial effusion w/o tamponade • Suspected post-procedure complication 21

Curbside Question List What doesn’t require a formal consult? • • • Peri-procedural management of DAPT Selection of anticoagulant for NVAF Assistance reading EKGs: QTc determination Low risk chest pain Chest pain, known CAD recent cath/stress, uptitration of anti-anginals How do teams reach you in these instances? • Text, Call, or Page the Consult Fellow at your site 22

Consult List for Outpatient Issues that are better addressed in an outpatient setting If the patient HAS a cardiologist: • Non-urgent device placement: (planned ICD for known cardiomyopathy) • SVT controlled with nodal blockade • Moderate valvular heart disease without symptoms • Palpitations 23

“Good” Consult Example Prior to placing the consult: • Interview and examine the patient • Find out who their cardiologist is • Review EKG, dates/results of cardiology data Where to place the consult: Place routine consults in EPIC order system Call in STAT consults What to include in your consult: 1. Reason for consultation: A specific question or way we can help you 2. One liner: Age, sex, relevant co-morbidities, presenting symptom, relevant exam findings/test results, and working diagnosis/treatment plan 24

“Good” Consult Example 1. Reason for consult: Assistance with diuresis, rate control, and management of new cardiomyopathy. 1. One liner: 64 year old male with a history of prior tobacco use, hypertension, diabetes, and atrial fibrillation presents with dyspnea on exertion found to have new systolic heart failure and atrial fibrillation with RVR. 25

“Bad” Consult Examples “Bad consult” characteristics: • Vague in detail • Unclear question • Unclear acuity �Details help us to triage urgency • • Be specific with symptom acuity Know the vitals Comorbidities/ risk factors High risk findings on your initial exam 26

“Bad” Consult Examples 1. 64 year old male with shortness of breath ? CHF • Why are you considering CHF as a diagnosis? 2. 46 year old female with positive troponin • What is her risk of ACS? (symptoms, risk factors) 3. 70 year old male with possible cardiogenic syncope • What were the circumstances of the syncope? • Are there telemetry findings supporting your concern? 27

Is the patient stable? Symptoms: Ongoing chest pain, respiratory distress/hypoxia, altered mental status Vitals: ● Rate-related symptoms are unlikely unless the heart rate is <50 or >150 bpm ● Hypotension is relative to normal resting BP Markers of Hypoperfusion: Mottling, Cool extremities, Decreased urine output, Lab abnormalities 28

Preparation for Common Tests and Procedures Interventional (Right and Left Heart Catheterization, Pericardiocentesis) ● ● ● NPO-sips with meds INR<1. 8 Platelet- no specific cut-off, ideally >50 K Interventional-Prefer heparin to other anticoagulants All procedures can be done on DAPT Turn heparin off when patient is called to the cath lab EP ● NPO-sips with meds ● EP-Avoid heparin prior to device placement 29

Preparation for Common Tests and Procedures (2) Stress Testing: ● NPO-sips with meds ● No caffeine TEE: ● NPO-sips with meds ● Confirm ability to safely swallow, open mouth, flex neck, and receive sedation 30

Summary Slide • Key things to remember • 24 hour consult coverage at all 3 training sites • Urgent/Emergent consults should be called directly to the fellow on call • If you are not sure if the consult can wait, call us to discuss • Contact information is available on AMION • “Yedoc acar” York Street Saint Raphael and VA 31

Questions? 32

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