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A CAUTIONARY TALE: A COMPARISON OF CONDENSED TEACHING STRATEGIES TO DEVELOP HAND-HELD CARDIAC ULTRASOUND SKILLS IN INTERNAL MEDICINE RESIDENTS
Abstracts METHODS:
Single center, single blinded randomized controlled trial of 39 low-risk patients 4 weeks to 6 months post ACS, EF > 40%, fully revascularized, were randomized to 12 to 18 weeks of 2-3 sessions/week (36 sessions total) of isocaloric MICET or HIIT on cycle ergometer. MICET protocol: 5 min warm-up at 30% maximal aerobic power (MAP) followed by 37 min at 60% MAP, followed by 5 min warm down at 30% MAP. HIIT included 3 sets of 10 minutes of repeated phases of 15 sec at 100 MAP alternating with 15 sec passive recovery. Warm up and cool down: 5 min at 30% MAP. MAP was determined using graded maximal cardiopulmonary exercise test (CPET) on cycle ergometer and continuous ECG and BP monitoring every 2 min. Metabolic and anthropometric profile, holter monitoring, as well as CPET was repeated before and after the intervention. RESULTS: 1 patient has yet to complete the intervention; complete data available for 35 patients (16 HIIT, 16 MICET). Baseline data is presented in Table 1. Significant improvement in VO2max was observed in both groups, with a greater increase seen in patients utilizing MICET (difference 102.4 46 vs 309.9 54 ml, p ¼ 0.011; 1.8 0.89 vs 3.5 0.84 ml/kg lean body mass difference, p¼0.018). No difference in respiratory exchange ratio at peak effort was observed (1.18 vs 1.16). No significant differences in systolic BP, weight, HRR, fasting lipids, glucose or insulin sensitivity were observed. No adverse events or ventricular arrhythmias were noted to be associated with exercise training. CONCLUSION: Both training modalities result in improvements in VO2max with greater effect in those using MICET. HIIT appears to be well tolerated in patients post ACS.
501 COMPARAISON OF HEART RATE RECOVERY AND PARASYMPATHETIC REACTIVATION PARAMETERS AFTER A MAXIMAL EXERCICE, A MODERATE-INTENSITY CONTINUOUS EXERCISE AND HIGH-INTENSITY INTERVAL EXERCISE IN YOUNG AND OLD HEALTY SUBJECTS AND STABLE CORONARY PATIENTS É Gagné, J Larouche, O Dupuy, A Nigam, M Juneau, T Guiraud, M Gayda
S313
of two phases. Few studies have used kinetic modeling for the characterization of the HRR in healthy subjects and CHD patients. Aging is associated with a slower HRR. Chronic training improves HRR and high intensity acute exercise is associated with a slower descrease of the HRR. CHD is associated with reduced HRR. Only one study used HRR to compare the types of exercise and found a decrease in PR during sprints and a high-intensity interval exercise (HIIE) in young males. However, no study has used the HRR to assess the PR after acute exerice of different natures (moderate-intensity continuous exercise (MICE) and HIIE). METHODS: Objectives: To investigate the effect of age and CHD on the HRR and on the PR parameters after a maximal exercise. To compare the HRR of the same subjects subsequently to a HIIE protocol versus MICE protocol of similar energy expenditure. 36 controls (16 young (YC) and 20 old (OC)) and 16 patients with stable CHD were recruited. Randomly, they did a cardiopulmonary exercice test (CPET), a MICE and a HIIE. The relative HRR (D bpm) was measured with a ECG (averaged every 5 s) for 5 min of recovery after de CPET, MICE and the HIIE. The asymptotic value of heart rate (a0) (in bpm) and the delta of the HRR at the end of exercise for t ¼ 5 (a1) (in bpm) were also determined. RESULTS: After the CPET, the HRR was significantly lower for CHD patients vs YC (from 180 to 300 s; P<0.05), for OC vs YC (from 240 to 300 s; P<0.05) and for CHD patients vs OC (210 s; P<0.05). YC’s a0 was superior vs OC and CHD patient’s data (p<0.05) and CHD patients a1’s was inferior to YC’s and OC’s (p<0.001). The HRR of the three groups was significantly higher at 5 and 10 s post HIIE vs MICE (p<0.05). CONCLUSION: Our results show that age and CHD could be associated to a diminished parasympathetic activity and/or a higher sympathetic activity after an MCGE, with a HRR that differs only after three minutes. In addition, HIIE could be responsible for a greater parasympathetic reactivation in the first second of the recuperation (10 s) vs the MICE for the CHD patients and the controls subjects.
Canadian Cardiovascular Society (CCS) Highlighted Poster EDUCATION HIGHLIGHTED POSTER SESSION Monday, October 27, 2014 502 A CAUTIONARY TALE: A COMPARISON OF CONDENSED TEACHING STRATEGIES TO DEVELOP HAND-HELD CARDIAC ULTRASOUND SKILLS IN INTERNAL MEDICINE RESIDENTS
Montréal, Québec
JS Wilkinson, W Barake, C Smith, A Thakrar, AM Johri
BACKGROUND:
Kingston, Ontario
Heart rate recovery (HRR) is used to study the parasympathetic reactivation (PR). During recovery, there is a decrease in heart rate resulting in a mono exponential function
BACKGROUND:
Advances in ultrasound technology have allowed for hand-held cardiac ultrasound (HHCU) units that
S314
fit comfortably into a physician’s lab coat. Recently, studies to educate both medical students and internal medicine residents have shown promising results. The optimal duration and methodology for teaching HHCU skills has not been established. Our objective was to assess the effectiveness of two condensed educational programs occurring over a single clinical rotation to teach internal medicine residents diagnostic and technical skills of HHCU. METHODS: Over a one-year period, internal medicine residents were recruited during their cardiology ward rotation into a single-centre, non-blinded, randomized trial. The two condensed teaching strategies were: a conventional ward-based program and a technology driven (simulation-based) strategy. In the conventional group, residents were given one hour of ward-based teaching for a total of 4 sessions. Residents in the technology arm of the study also completed 4 teaching sessions, but used only an online module-based education program and a virtual trainer (CAE Healthcare, Québec). Outcomes were evaluated using both a). An OSCE to evaluate interpretation ability (assessing both Type I and Type II error rates) and b). Demonstration of HHCU acquisition skills graded by two Level-III echocardiographers. RESULTS: Twenty-four internal medicine residents were recruited (13 in the conventional and 11 in the technology arm). Characteristics and baseline ability to interpret HHCU images were similar. After teaching, the conventional group had a significant relative increase in the ability to make a singular correct diagnosis (156%, p<0.001). In the technology arm, making a singular correct diagnosis increased 169% from baseline (p¼0.001). Interpretation skill was not significantly different between groups (Table 1). Both groups, however, significantly increased their falsepositive rate (type II error), from 30% to 44% (p¼0.079) and from 29% to 45% (p¼0.008). Lastly, diagnostic quality ultrasound images were more likely to be acquired from participants in the conventional ward-based program (53.8%) than in the technology-driven group (13.6%, p¼0.006). CONCLUSION: Our findings suggest that HHCU interpretation and acquisition skills improve following both a conventional ward-based and technology-driven approach. However, our study emphasizes the important limitations of simulation-based teaching of HHCU skills since acquisition skill was superior following conventional ward-based teaching. Lastly, we detected a significant increase in the false positive rate following both teaching programs. This suggests that a short duration of training may not be sufficient for HHCU to be performed in a safe and appropriate manner.
Canadian Journal of Cardiology Volume 30 2014
503 COMPETENCY-BASED EDUCATION IN CARDIOLOGY: IS IT TIME? E Yu, P Nair, M Sibbald, P Dorian Toronto, Ontario BACKGROUND:
Mastering the basic skills required to practice cardiology is becoming harder as the curriculum expands with more emphasis on non-medical expert roles, increasing work hour restrictions and technologic growth in the field with the advent of newer modalities for investigation of cardiac disease. Recent observations from formal assessments at end of training have suggested that competency and proficiency in skills such as ECG and echocardiographic interpretation may be suboptimal. The purpose of this study is to identify whether residents perceive gaps in training, and whether current training models provide residents with the requisite tools to function as an independent consultant. METHODS: We surveyed current and recent graduates of adult cardiology training programs in Canada, between academic years 2010-2014, using a survey administered by the Canadian Cardiovascular Society. A total of 425 surveys were sent via email, and 110 responses were received. Demographics of respondents were as follows: male gender 73%; training program located in Eastern Canada 67%; training program size: small (1-9 residents): 10%; medium (10-19 residents) 56%; and large (>20 residents) 34%. Procedural and diagnostic test interpretation and performance by residents were recorded; as well as the optimum number residents believed were important in their training. The resident’s self rated level of competency and proficiency in performance and interpretation were also recorded. RESULTS: The residents’ self-report of procedural and diagnostic testing volumes as well as their perceived minimum exposure to achieve competency and proficiency are presented in the following table. Graduating residents and recent graduates rated their level of competency and proficiency high or extremely high for: cardioversion (71%); pericardiocentesis (62%); right heart catheterization (57%); temporary transvenous pacemaker (58%); echocardiographic interpretation (52%); ECG interpretation (47%) and exercise stress test interpretation (42%). Areas where the greatest percentage of graduating residents and recent graduates rated their competency and proficiency as poor to low included: pacemakers and devices interpretation (24%); myocardial perfusion image interpretation (31%); and holter monitor interpretation (24%). CONCLUSION: Areas that received low ratings of perceived competency and proficiency in performance directly correlates with the amount of dedicated time allocated for training in these domains. Given the identification of such potential gaps in knowledge, current traditional Methods of cardiology training should be reassessed.
Single center, single blinded randomized controlled trial of 39 low-risk patients 4 weeks to 6 months post ACS, EF > 40%, fully revascularized, were randomized to 12 to 18 weeks of 2-3 sessions/week (36 sessions total) of isocaloric MICET or HIIT on cycle ergometer. MICET protocol: 5 min warm-up at 30% maximal aerobic power (MAP) followed by 37 min at 60% MAP, followed by 5 min warm down at 30% MAP. HIIT included 3 sets of 10 minutes of repeated phases of 15 sec at 100 MAP alternating with 15 sec passive recovery. Warm up and cool down: 5 min at 30% MAP. MAP was determined using graded maximal cardiopulmonary exercise test (CPET) on cycle ergometer and continuous ECG and BP monitoring every 2 min. Metabolic and anthropometric profile, holter monitoring, as well as CPET was repeated before and after the intervention. RESULTS: 1 patient has yet to complete the intervention; complete data available for 35 patients (16 HIIT, 16 MICET). Baseline data is presented in Table 1. Significant improvement in VO2max was observed in both groups, with a greater increase seen in patients utilizing MICET (difference 102.4 46 vs 309.9 54 ml, p ¼ 0.011; 1.8 0.89 vs 3.5 0.84 ml/kg lean body mass difference, p¼0.018). No difference in respiratory exchange ratio at peak effort was observed (1.18 vs 1.16). No significant differences in systolic BP, weight, HRR, fasting lipids, glucose or insulin sensitivity were observed. No adverse events or ventricular arrhythmias were noted to be associated with exercise training. CONCLUSION: Both training modalities result in improvements in VO2max with greater effect in those using MICET. HIIT appears to be well tolerated in patients post ACS.
501 COMPARAISON OF HEART RATE RECOVERY AND PARASYMPATHETIC REACTIVATION PARAMETERS AFTER A MAXIMAL EXERCICE, A MODERATE-INTENSITY CONTINUOUS EXERCISE AND HIGH-INTENSITY INTERVAL EXERCISE IN YOUNG AND OLD HEALTY SUBJECTS AND STABLE CORONARY PATIENTS É Gagné, J Larouche, O Dupuy, A Nigam, M Juneau, T Guiraud, M Gayda
S313
of two phases. Few studies have used kinetic modeling for the characterization of the HRR in healthy subjects and CHD patients. Aging is associated with a slower HRR. Chronic training improves HRR and high intensity acute exercise is associated with a slower descrease of the HRR. CHD is associated with reduced HRR. Only one study used HRR to compare the types of exercise and found a decrease in PR during sprints and a high-intensity interval exercise (HIIE) in young males. However, no study has used the HRR to assess the PR after acute exerice of different natures (moderate-intensity continuous exercise (MICE) and HIIE). METHODS: Objectives: To investigate the effect of age and CHD on the HRR and on the PR parameters after a maximal exercise. To compare the HRR of the same subjects subsequently to a HIIE protocol versus MICE protocol of similar energy expenditure. 36 controls (16 young (YC) and 20 old (OC)) and 16 patients with stable CHD were recruited. Randomly, they did a cardiopulmonary exercice test (CPET), a MICE and a HIIE. The relative HRR (D bpm) was measured with a ECG (averaged every 5 s) for 5 min of recovery after de CPET, MICE and the HIIE. The asymptotic value of heart rate (a0) (in bpm) and the delta of the HRR at the end of exercise for t ¼ 5 (a1) (in bpm) were also determined. RESULTS: After the CPET, the HRR was significantly lower for CHD patients vs YC (from 180 to 300 s; P<0.05), for OC vs YC (from 240 to 300 s; P<0.05) and for CHD patients vs OC (210 s; P<0.05). YC’s a0 was superior vs OC and CHD patient’s data (p<0.05) and CHD patients a1’s was inferior to YC’s and OC’s (p<0.001). The HRR of the three groups was significantly higher at 5 and 10 s post HIIE vs MICE (p<0.05). CONCLUSION: Our results show that age and CHD could be associated to a diminished parasympathetic activity and/or a higher sympathetic activity after an MCGE, with a HRR that differs only after three minutes. In addition, HIIE could be responsible for a greater parasympathetic reactivation in the first second of the recuperation (10 s) vs the MICE for the CHD patients and the controls subjects.
Canadian Cardiovascular Society (CCS) Highlighted Poster EDUCATION HIGHLIGHTED POSTER SESSION Monday, October 27, 2014 502 A CAUTIONARY TALE: A COMPARISON OF CONDENSED TEACHING STRATEGIES TO DEVELOP HAND-HELD CARDIAC ULTRASOUND SKILLS IN INTERNAL MEDICINE RESIDENTS
Montréal, Québec
JS Wilkinson, W Barake, C Smith, A Thakrar, AM Johri
BACKGROUND:
Kingston, Ontario
Heart rate recovery (HRR) is used to study the parasympathetic reactivation (PR). During recovery, there is a decrease in heart rate resulting in a mono exponential function
BACKGROUND:
Advances in ultrasound technology have allowed for hand-held cardiac ultrasound (HHCU) units that
S314
fit comfortably into a physician’s lab coat. Recently, studies to educate both medical students and internal medicine residents have shown promising results. The optimal duration and methodology for teaching HHCU skills has not been established. Our objective was to assess the effectiveness of two condensed educational programs occurring over a single clinical rotation to teach internal medicine residents diagnostic and technical skills of HHCU. METHODS: Over a one-year period, internal medicine residents were recruited during their cardiology ward rotation into a single-centre, non-blinded, randomized trial. The two condensed teaching strategies were: a conventional ward-based program and a technology driven (simulation-based) strategy. In the conventional group, residents were given one hour of ward-based teaching for a total of 4 sessions. Residents in the technology arm of the study also completed 4 teaching sessions, but used only an online module-based education program and a virtual trainer (CAE Healthcare, Québec). Outcomes were evaluated using both a). An OSCE to evaluate interpretation ability (assessing both Type I and Type II error rates) and b). Demonstration of HHCU acquisition skills graded by two Level-III echocardiographers. RESULTS: Twenty-four internal medicine residents were recruited (13 in the conventional and 11 in the technology arm). Characteristics and baseline ability to interpret HHCU images were similar. After teaching, the conventional group had a significant relative increase in the ability to make a singular correct diagnosis (156%, p<0.001). In the technology arm, making a singular correct diagnosis increased 169% from baseline (p¼0.001). Interpretation skill was not significantly different between groups (Table 1). Both groups, however, significantly increased their falsepositive rate (type II error), from 30% to 44% (p¼0.079) and from 29% to 45% (p¼0.008). Lastly, diagnostic quality ultrasound images were more likely to be acquired from participants in the conventional ward-based program (53.8%) than in the technology-driven group (13.6%, p¼0.006). CONCLUSION: Our findings suggest that HHCU interpretation and acquisition skills improve following both a conventional ward-based and technology-driven approach. However, our study emphasizes the important limitations of simulation-based teaching of HHCU skills since acquisition skill was superior following conventional ward-based teaching. Lastly, we detected a significant increase in the false positive rate following both teaching programs. This suggests that a short duration of training may not be sufficient for HHCU to be performed in a safe and appropriate manner.
Canadian Journal of Cardiology Volume 30 2014
503 COMPETENCY-BASED EDUCATION IN CARDIOLOGY: IS IT TIME? E Yu, P Nair, M Sibbald, P Dorian Toronto, Ontario BACKGROUND:
Mastering the basic skills required to practice cardiology is becoming harder as the curriculum expands with more emphasis on non-medical expert roles, increasing work hour restrictions and technologic growth in the field with the advent of newer modalities for investigation of cardiac disease. Recent observations from formal assessments at end of training have suggested that competency and proficiency in skills such as ECG and echocardiographic interpretation may be suboptimal. The purpose of this study is to identify whether residents perceive gaps in training, and whether current training models provide residents with the requisite tools to function as an independent consultant. METHODS: We surveyed current and recent graduates of adult cardiology training programs in Canada, between academic years 2010-2014, using a survey administered by the Canadian Cardiovascular Society. A total of 425 surveys were sent via email, and 110 responses were received. Demographics of respondents were as follows: male gender 73%; training program located in Eastern Canada 67%; training program size: small (1-9 residents): 10%; medium (10-19 residents) 56%; and large (>20 residents) 34%. Procedural and diagnostic test interpretation and performance by residents were recorded; as well as the optimum number residents believed were important in their training. The resident’s self rated level of competency and proficiency in performance and interpretation were also recorded. RESULTS: The residents’ self-report of procedural and diagnostic testing volumes as well as their perceived minimum exposure to achieve competency and proficiency are presented in the following table. Graduating residents and recent graduates rated their level of competency and proficiency high or extremely high for: cardioversion (71%); pericardiocentesis (62%); right heart catheterization (57%); temporary transvenous pacemaker (58%); echocardiographic interpretation (52%); ECG interpretation (47%) and exercise stress test interpretation (42%). Areas where the greatest percentage of graduating residents and recent graduates rated their competency and proficiency as poor to low included: pacemakers and devices interpretation (24%); myocardial perfusion image interpretation (31%); and holter monitor interpretation (24%). CONCLUSION: Areas that received low ratings of perceived competency and proficiency in performance directly correlates with the amount of dedicated time allocated for training in these domains. Given the identification of such potential gaps in knowledge, current traditional Methods of cardiology training should be reassessed.