PROGRAM DESCRIPTION

The Nuclear Cardiology Section is within the Division of Cardiology, Department of Medicine of the College of Physicians & Surgeons of Columbia University. Training is offered both to physicians in the Cardiovascular Diseases Fellowship (clinical cardiology fellows) and to physicians in the dedicated Advanced Imaging Fellowship, a one year program offering training in cardiac SPECT, PET, CT angiography, calcium scoring, and cardiovascular MRI.

Clinical cardiology fellows rotate through the laboratory on a monthly basis. Each month is divided between the Clinical Nuclear Cardiology Laboratory and CT/MRI. In the Nuclear Cardiology rotation, they perform treadmill stress and pharmacological stress testing under supervision and interpret scans with the attending cardiologist of the day. In CT/MRI they spend time observing the performance of CTA and MR examinations and interpret images with attending physicians from Cardiology and Radiology, both at Columbia University Medical Center and at an off-site clinical laboratory. The amount of time each fellow spends on this imaging rotation during fellowship is selected by the fellow, in accordance with his/her desire to be eligible to take the certifying examination in Nuclear Cardiology. Fellows have the opportunity to spend sufficient time in the laboratory to satisfy COCATS level II training.

The one-year fellowship in Advanced Cardiac Imaging is a competitive program, open both to candidates who have completed their cardiology fellowship and seek additional training in imaging, and also to applicants who have a year between medical residency and cardiology fellowship. Completion of this year provides COCATS level III training in nuclear cardiology, as well as advanced clinical training in accordance with COCATS guidelines for CT and MRI.

The Nuclear Cardiology section of the division has an active, academically oriented, nuclear cardiology program. Currently, the Laboratory has 2 SPECT cameras (Siemens e.cam), one SPECT/CT camera (Philips Precedence), and 1 PET camera (Siemens ECAT) and performs over 5,000 imaging procedures per year. The Laboratory is located on the Columbia University Medical Center campus and performs tests on both outpatients as well as patients admitted to the hospital.

Didactic lectures are given to the fellows that include a curriculum in the fundamentals of nuclear medicine and PET imaging as well interesting case reviews with attending physicians. Fellows are encouraged to participate in the numerous basic and clinical research activities of the Section.

APPLICATION PROCESS

Candidates for the one-year Advanced Imaging Fellowship should apply each fall by e-mail to Sabahat Bokhari, MD at sb605@columbia.edu. Include an updated CV.

We take affirmative action towards equal employment opportunity. Applications from women and minorities are encouraged.

OBJECTIVES FOR FELLOWS

Stress Testing

• To understand the indications and contraindications of treadmill and pharmacologic stress testing, as well as to learn the normal and abnormal hemodynamic and electrocardiographic responses to exercise and pharmacologic stress tests
• To be able to take a directed medical history and physical examination for patients presenting to the Laboratory
• To become proficient in the safe performance, monitoring, and interpretation of exercise and pharmacologic stress tests

Imaging

• To understand the indications, protocols, and differences between different myocardial imaging agents including the physical characteristics, dosimetry, and advantages/disadvantages
• To understand the indications and advantages/disadvantages of PET imaging for cardiac disease
• To gain proficiency in the interpretation of normal and abnormal gated myocardial perfusion, radionuclide angiography, and PET perfusion and metabolism studies
• To learn the safe handling of radioactive material and the handling of radiation emergencies
• To learn the basics of the physics of nuclear cardiology; cameras, quality control, acquisition and reconstruction protocols
• To understand principles of operation of a CT scanner with a focus on CT coronary angiography and coronary artery calcium scoring, including acquisition protocols, processing, interpretation, and dosimetry. Be involved in the evolving field of coronary CTA and understand its clinical indications.
• To understand principles of cardiovascular MRI including pulse sequences, paramagnetic contrast agents, assessment of anatomy, function, and flow, delayed contrast enhancement, data processing, image interpretation, and clinical indications.

COURSE OF INSTRUCTION

Stress Testing

All fellows will be instructed in the medical evaluation and performance of both exercise and pharmacologic stress testing, including indications, contraindications, safe performance, and treatment of complications, including cardiac and respiratory collapse and resuscitation. It is anticipated that fellows completing COCATS Level 2 training will complete approximately 500 stress tests under supervision during the course of the fellowship.

Imaging

Fellows will learn the safe handling of radioisotopes, ALARA principles, and learn the proper administration of radioisotopes for diagnostic procedures, as well as equipment quality control (QC) and image processing. It is anticipated that fellows will have experience in administration of at least 500 doses of single photon tracers during the fellowship. Advanced Imaging fellows also learn to operate the rubidium generator and to perform QC on the generator and the PET scanner. Fellows will also observe QC and operation of the CT scanner and MR scanner, including acquisition and processing.

Interpretation

Fellows will be instructed in the interpretation of myocardial perfusion scans for both diagnosis of coronary artery disease and viability assessment, radionuclide ventriculograms, gated perfusion imaging, and PET scans for both perfusion and metabolism. Fellows will read at least 500 scans during training under direct attending supervision. Fellows will also interpret coronary calcium studies, coronary CTA, and cardiac MR studies with attending physicians. The COCATS level of training for clinical fellows in CT and MR is level I. For Advanced Imaging fellows, higher levels of training may achieved on an individual basis.

RESPONSIBILITIES

The fellow will be responsible for obtaining a directed history and physical examination of patients presenting to the lab; for determining the suitability of the ordered test; and for medically clearing the patient for the test. The fellow will present the patient to the attending physician and then perform the study under the direct supervision of the attending. After completion of the stress test, the fellow will analyze the hemodynamic and ECG response and review them with the attending physician. The fellow is responsible for filling out all paperwork on each patient including the database entry form. The fellow will participate in scan interpretations for all patients stressed in the laboratory on that day. When assigned to the PET suite, the fellow helps with the administration of rubidium, and learns how to manage blood glucose levels in diabetic and non-diabetic patients prior to administration of FDG. The fellow interprets the PET scans with the PET attending physician. When assigned to CT/MRI the fellow reports to the CT suite and helps with obtaining clinical history, learns how to administer beta blockers to achieve optimal HR for coronary CTA, and spends times with technologists in processing the data and with the CT attending physicians in interpreting the images. Several half days per week, he/she spends time in adult and pediatric MRI suites under supervision of the attending physician of the day. All fellows must compete a radiation safety course before starting in the laboratory.

CONFERENCES

Fellows are expected to attend Cardiology Grand Rounds (Tuesday mornings 8-9 am) and other scheduled cardiology conferences during the week. Additional relevant conferences include times reserved for a core curriculum in cardiac imaging in the daily 8 AM clinical fellows conference schedule, including a once-monthly interesting case review and a once monthly combined imaging case conference (PET, CTA, and MRI).

REFERENCES

Stress Testing

1. Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, Mark DB, McCallister BD, Mooss AN, O’Reilly MG, Winters WL Jr. ACC/AHA 2002 guideline update for exercise testing: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). Available at: http://www.acc.org/clinical/guidelines/exercise/dirIndex.htm.

2. Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, Fleisher LA, Froehlich JB, Gusberg RJ, Leppo JA, Ryan T, Schlant RC,Winters WL Jr. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). 2002. American College of Cardiology Web site. Available at: http://www.acc.org/clinical/guidelines/perio/dirIndex.htm.

Imaging

1. DePuey EG (ed.). Imaging guidelines for nuclear cardiology procedures: a report of the American Society of Nuclear Cardiology Quality Assurance Committee. Journal of Nuclear Cardiology 2006; 13: e21-e171. Available at: http://www.asnc.org/section_73.cfm.

2. Klocke FJ, Baird MG, Bateman TM, Berman DS, Carabello BA, Cerqueira MD, DeMaria AN, Kennedy JW, Lorell BH, Messer JV, O’Gara PT, Russell RO Jr., St. John Sutton MG, Udelson JE, Verani MS, Williams KA. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for

the Clinical Use of Radionuclide Imaging). (2003). American College of Cardiology Web Site. Available at: http://www.acc.org/clinical/guidelines/radio/rni_fulltext.pdf.

3. Brindis RG, Douglas PS, Hendel RC, Peterson ED, Wolk MJ, Allen JM, Patel MR, Raskin IE. ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): a

report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology. J Am Coll Cardiol 2005;46:1587– 605. Available at: http://www.acc.org/qualityandscience/clinical/pdfs/SPECTMPIACPubFile.pdf.

4. Hesse B, Tägil K, Cuocolo A, Anagnostopoulos C, Bardiés M, Bax J, Bengel F, Busemann Sokole E, Davies G, Dondi M, Edenbrandt L, Franken P, Kjaer A, Knuuti J, Lassmann M, Ljungberg M, Marcassa C, Marie PY, McKiddie F, O’Connor M, Prvulovich E, Underwood R and vanEck-Smit B. EANM/ESC procedural guidelines for myocardial perfusion imaging in nuclear cardiology. European Journal of Nuclear Medicine and Molecular Imaging 2005; 32: 855-897. Available at: http://www.springerlink.com/content/rx414l46p0865014/fulltext.pdf.

5. Hendel RC, Patel MR, Kramer CM, Poon M. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a report of the American College of Cardiology Foundation/American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology. J Am Coll Cardiol 2006;48:1475–97. Available at: http://content.onlinejacc.org/cgi/reprint/48/7/1475.

6. Budoff MJ, Achenbach S, Blumenthal RS, Carr JJ, Goldin JG, Greenland P, Guerci AD, Lima, JAC, Rader DJ, Rubin GD, Shaw LJ, Wiegers SE. Assessment of Coronary Artery Disease by Cardiac Computed Tomography: A scientific statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology. Circulation. 2006;114:1761-1791. Available at: http://circ.ahajournals.org/cgi/reprint/114/16/1761.

7. American Heart Association Writing Group on Myocardial Segmentation and Registration for Cardiac Imaging: Cerqueira MD, Weissman NJ, Dilsizian V, Jacobs AK, Kaul S, Laskey WK, Pennell DJ, Rumberger JA, Ryan T, Verani MS. Standardized Myocardial Segmentation and Nomenclature for Tomographic Imaging of the Heart. A statement for healthcare professionals from the cardiac imaging committee of the council on clinical cardiology of the American Heart Association. Circulation 2002;105:539-542. Available at: http://circ.ahajournals.org/cgi/reprint/105/4/539.

Training

1. Beller GA, Bonow RO, Fuster V. ACCF 2006 Update for Training in Adult Cardiovascular Medicine (Focused Update of the 2002 COCATS 2 Training Statement): a report of the American College of Cardiology/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training. J Am Coll Cardiol 2006;47:893–920. Available at: http://www.acc.org/qualityandscience/clinical/competence/nuclear/COCATSfinal.pdf.

2. Rodgers GP, Ayanian JZ, Balady G, Beasley JW, Brown KA, Gervino EV, Paridon S, Quinones M, Schlant RC. American College of Cardiology/American Heart Association clinical competence statement on stress testing. J Am Coll Cardiol 2000;36:1441–53. Available at: http://www.acc.org/qualityandscience/clinical/competence/stress/stresstest.pdf.

3. Budoff MJ, Cohen MC, Garcia MJ, Hodgson JMcB, Hundley WG, Lima AC, Manning WJ, Pohost GM, Raggi PM, Rodgers GP, Rumberger JA, Taylor AJ. ACC/AHA clinical competence statement on cardiac imaging with computed tomography and magnetic resonance: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence (ACC/AHA Committee on CV Tomography). J Am Coll Cardiol 2005;46:383–402. Available at: http://www.acc.org/qualityandscience/clinical/competence/imaging/index.pdf.