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CARDIORESPIRATORY: Cardiovascular System

Index

• General Outcomes for the Cardiovascular System
• Hypertension (Priority 1)
• Angina (Priority 1)
• Acute Coronary Syndrome and Myocardial Infarction (Priority 1*)
• Arrythmias and Conduction Defects (Priority 1*)
• Acute Circulatory Failure and Shock (Priority 1*)
• Cardiorespiratory Arrest (Priority 1*)
• Vascular Disease in other sites including CVA (Priority 1 and 2)
• Infective Endocarditis (Priority 2*)
• Valvular Heart Disease (Priority 2)
• Atherosclerosis and Arteriosclerosis / Lipid Disorders (Priority 2)
• Acute and Chronic Limb Ischaemia / Peripheral Vascular Disease (Priority 2*) (See also Met 3A outcomes)
• Limb Ulceration and Gangrene (Priority 2) (See also Met 3A outcomes)
• Arterial Aneurysms (Priority 2*) (See also Met 3A outcomes)
• Pericardial Disease (Priority 3*)
• Myocardial Disease / Cardiomyopathy (Priority 3)
• Congenital Cardiovascular Disease (Priority 3)
• Rheumatic Fever and Rheumatic Heart Disease (Priority 3)
• Varicose Veins (Priority 3) (See also Met 3A outcomes)

• General Outcomes for the Cardiovascular System
  • Medical knowledge: ANATOMY (TD 8.1)
    • Development of the Cardiovascular System
      1. Describe the early development of the heart and vessels.
      2. Describe embryonic folding of the heart.
      3. Explain the importance of the endocardial cushions and the separation of the atria and ventricles.
      4. Describe fetal and neonatal circulation, and the adult derivatives of foetal vascular structures.
    • The Heart and Coronary Arteries
      1. Describe the mediastinum and its contents
      2. Identify the position in the heart of the sino-atrial and atrioventricular nodes. Describe the course of the atrioventricular bundle and its branches.
      3. Revise the gross anatomy of the heart and the great vessels. (CR2)
      4. Describe the surface anatomy of the heart, pericardium and great vessels.
      5. Understand the arrangement of the pericardium and the layers of the heart wall
      6. Relate myocardial infarction to the anatomy of the coronary circulation (CR2)
      7. Trace the flow of blood through the heart, identifying the major blood vessels and the chambers
      8. Identify the pericardium
      9. Describe the nervous innervation of the heart, and explain the anatomical basis of cardiac referred pain.
      10. Discuss the functional anatomy of the heart valves
      11. Learn the mechanisms of 3rd and 4th heart sounds and their clinical significance (CR3)
      12. Note the position of the heart and the great vessels in situ.
      13. Describe the importance of the fibrous skeleton of the heart as an attachment for valves and an electrical insulator.
      14. Know the surface markings of the heart (including apex and valves) and main vessels. (CR2)
      15. Understand the anatomy and perfusion of the coronary circulation
      16. Revise understanding of the cardiac myocyte and the blood supply to the myocardium.
      17. On the surface of the heart, identify the four chambers.
      18. Understand the effects of ischaemia on the myocardium.
      19. Identify the right and left coronary arteries and their major branches.
      20. Examine the coronary sinus and note its main tributaries.
      21. Identify the four valves of the heart; indicate which chambers they lie between and how they differ in their structure.
      22. Identify the nervous supply to the heart
    • The Mediastinum
      1. Identify the pleural cavities and the mediastinum
      2. Understand the divisions of the mediastinum and the structures that lie in each
      3. Identify the basic features of a mediastinal silhouette in a normal chest X-ray
    • Blood Vessels and Circulation of the Thorax
      1. Describe the three layers that typically form the wall of a blood vessel
      2. Distinguish among the types of blood vessels on the basis of their structure and function
      3. Identify the major arteries of the systemic and pulmonary circuits and the areas they serve.
      4. Explain the arterial supply to the thoracic wall and the lungs
      5. Describe the azygos system of venous drainage to the thorax
    • Circulation of the Shoulder, Arm and Hand
      1. Know the arterial supply to the upper limb (CR1, GEP/CO2)
      2. Describe the arterial supply to the upper limb
      3. Know the venous drainage of the upper limb (CR1, GEP/CO2)
    • Blood and the Circulatory System
      1. Describe the anatomy of blood and lymphatic vessels. (CR2)
      2. Revise the understanding of the anatomical characteristics and functions of different types of leukocytes and identify them in blood smears
      3. Be able to differentiate between erythrocytes found in normal blood smears and those indicative of anaemia.
      4. Understand the basic structure and function of bone marrow
      5. Be able to identify arteries and veins and relate the structure of their walls to their physiological function.
    • Lymphatic System
      1. Describe the anatomy of blood and lymphatic vessels. (CR2)
      2. Explain how lymph is formed and returned to the bloodstream. (CR2, GEP/CO2)
      3. Describe the form and function of the lymph nodes, tonsils, thymus and spleen. (CR2, GEP/CO2)
      4. Discuss the lymphatic drainage of the body and the anatomy of the major lymphatic ducts. (CR2, GEP/CO2)
    • Circulation of the lower limb and foot
      1. Know the arterial supply to the lower limb (CR1, GEP/CO2)
      2. Know the venous drainage of the lower limb (CR1, GEP/CO2)
  • Medical knowledge: PHYSIOLOGY (TD 8.2)
    • The Conducting System of the Heart and the ECG
      1. Describe the structural and functional properties of cardiac muscle, and explain how it differs from skeletal muscle
      2. Briefly explain the term 'functional syncytium' and the importance of coordinated contraction of cardiac muscle fibres.
      3. Briefly describe the events of cardiac muscle cell contraction
      4. Briefly describe the events of cardiac muscle cell contraction. (CR1, GEP/CO2)
      5. Describe how the heart beat is generated
      6. Define the term 'pacemaker potential' and draw a labelled diagram of the pacemaker potential of a sino-atrial node cell. Briefly explain the reasons for the main potential changes. State the effects of sympathetic and parasympathetic input.
      7. Name the components of the conduction system of the heart, and trace the conduction pathway
      8. Draw a diagram of a normal electrocardiogram tracing; name the individual waves and intervals and indicate what each represents
      9. Name some abnormalities that can be detected on an ECG tracing
    • Sympathetic Nervous System and Circulation
      1. Describe the anatomy of the sympathetic nervous system with particular reference to the innervation of blood vessels
      2. Describe the transmitters used by the sympathetic nervous system
      3. Describe the role of the sympathetic nervous system in the control of blood pressure and cardiac output
      4. Describe the changes in the blood flow to muscle during exercise
      5. Describe how the sympathetic nervous system reacts after injury or haemorrhage
    • Blood Pressure
      1. Describe the physiological sensors and effectors for neuronal control of arterial blood pressure (GEP/CO2)
      2. Explain how the body controls blood volume.
      3. Describe the renin-angiotensin-aldosterone system and explain its role in blood pressure regulation (CR1, GEP/CO2)
      4. List common drugs which can be used to control hypertension and explain their mechanism of action (CR1, GEP/CO2)
      5. Describe the position and innervation of the aortic and carotid sinus baroreceptors, their central connections, and the role of the brainstem in the control of blood pressure (GEP/CO2)
      6. Describe the role of the vagus nerve and the sympathetic nervous system in the control of blood pressure (GEP/CO2)
      7. Describe the hormonal control of blood pressure
      8. Describe the renin-angiotensin-aldosterone system and explain its role in blood pressure regulation (CR1)
    • General Cardiovascular Physiology
      1. Describe the role of the vascular endothelium . (CR1)
      2. Discuss the changes that occur in the cardiorespiratory system during exercise, and how these may be compromised in cases of cardiorespiratory disease (CR2)
      3. Explain the role of nitric oxide in the coronary and skeletal arterioles
      4. Explain the role of nitric oxide in the coronary and skeletal arterioles (GEP/CO2)
      5. Explain the role of nitric oxide in exercise
      6. Explain the role of nitric oxide in exercise (GEP/CO2)
    • Smooth and Cardiac Muscle
      1. List the structures where smooth muscle is found (CR1, GEP/CO2)
      2. Describe the heterogeneity of smooth muscle and link to function (CR1, GEP/CO2)
      3. Describe the excitation - contraction coupling in smooth muscle and briefly contrast with cardiac and skeletal muscle (CR1, GEP/CO2)
      4. Explain briefly the electrophysiology of smooth muscle
      5. Describe how external factors may contract or relax smooth muscle (CR1, GEP/CO2)
      6. Describe the innervation of smooth muscle
    • Microcirculation and Oedema
      1. Draw a labelled diagram showing the anatomy of the microcirculation.
      2. Describe the three types of capillaries, continuous, fenestrated and discontinuous, with reference to their structure, distribution and function.
      3. Describe how the capillary permeability of lipid soluble molecules can be explained in terms of their oil:water partition coefficients.
      4. Describe how lipid insoluble molecules can move across the capillary endothelium.
      5. Draw a labelled diagram showing filtration and reabsorption of fluid along an average capillary.
      6. Explain how capillary pressure, plasma colloid osmotic pressure and interstitial colloid osmotic pressure can affect fluid movements between plasma, interstitium and lymph.
    • Haemodynamics
      1. Define the terms systolic and diastolic blood pressure, pulse pressure and mean blood pressure and state values for these in the normal healthy young adult
      2. Explain the relationships between cardiac output, peripheral resistance and blood pressure (CR1, GEP/CO2)
      3. Explain the concept of arterial compliance, and describe the relationship between pulse pressure, stroke volume and compliance (CR1, GEP/CO2)
      4. Know the importance of Poiseuille's Law relating vessel radius and resistance to flow, and the relevance of this to changes in pressure in the circulation (CR1)
      5. Be able to comment on the importance of Laplace's Law relating vessel radius and pressure, and how this relates to aneurysm formation. (GEP/CO2)
    • The Heart as a Pump
      1. Explain how the chambers of the heart and the heart valves cause blood to flow in sequence through the pulmonary and systemic circulations
      2. Define cardiac output and comment on how this is matched to demand
      3. Be able to draw a diagram of the pressure profiles in the left atrium, left ventricle and the aorta for a single cardiac cycle. Indicate the points at which the cardiac valves open and close, and the periods of iso-volumetric contraction and relaxation.
      4. Briefly describe the structure of the heart valves, and state what causes them to open and close
      5. State the reasons for the occurrence of the dichrotic notch of the aortic pressure pulse
      6. Draw the typical pressure / volume diagram for the heart and relate this to the difference phases of the cardiac cycle
      7. Outline the main processes ensuring adequate venous return to the heart.
  • Medical knowledge: BIOCHEMISTRY (inc. Metabolism) (TD 8.3)
    • Biochemistry - General
      1. Describe the properties of nitric oxide and its mechanism of synthesis in vascular endothelium
      2. Describe the properties of nitric oxide and its mechanism of synthesis in vascular endothelium (GEP/CO2)
      3. Understand the problem of the source of nitric oxide in exercising muscle
  • Medical knowledge: PATHOLOGY (TD 8.7)
    • Cardiac Failure and Pulmonary Oedema
      1. Describe symptoms and signs of left, right and biventricular cardiac failure (CR3)
      2. Be aware of new advancements in the treatment of heart failure (CR3)
    • Pathology of the Cardiovascular System - General
      1. Identify some of the anatomical features of common cardiac pathologies.
      2. Discuss and understand the pathological basis for atherosclerosis, myocardial infarction, mitral valve disease and aneurysm (CR2)
  • Medical knowledge: PHARMACOLOGY (TD 8.10)
    • General Outcomes for Cardiovascular Pharmacology
      1. Briefly describe how drugs may be used for treatment of hypertension and angina. (CR1)
      2. Describe the actions of the main groups of treatments used to prevent heart disease.
  • Medical knowledge: EPIDEMIOLOGY
    • Coronary Heart Disease (CHD)
      1. Discuss the burden of cardiovascular disease worldwide and in the UK.
  • Clinical skills: HISTORY (TD 13 a-b)
    • Examination of the Cardiovascular System
      1. Be confident in locating (via anatomical landmarks) and commenting on the strength of the following pulses: radial, brachial, carotid, popliteal, dorsalis pedis; posterior tibial (CR2)
      2. Be able to describe the rate and rhythm of the radial and carotid pulses (CR2)
      3. You should be able to take blood pressure competently on a normal person by first estimating the systolic pressure by palpation and then accurately measuring by auscultation. (CR2)
      4. You should be able to recognise the pulsation of the normal JVP and assess its vertical height above the manubrio-sternal angle. (CR2)
      5. You should be able to accurately locate the normal apex beat, and report on its location by standard anatomical landmarks. (CR2)
      6. You should be able to auscultate the normal heart, and time the heart sounds with the pulse in your assessment of the cardiac cycle. (CR2)
      7. You should be confident in recognising the first and second heart sounds, the systolic and diastolic spaces, by timing the cardiac cycle against a central pulse. (CR2)
      8. You should be aware of the four main areas to auscultate, and the use of the bell and diaphragm of the stethoscope. (CR2)
      9. You should be starting to put together your assessment of the pulse, peripheral pulses, blood pressure and cardiac examination to form an examination of the cardiovascular system. (CR2)
  • Clinical skills: PLANNING AND INTERPRETING INVESTIGATIONS (TD 14 c-d)
    • Electrocardiograph (ECG)
      1. Set up and record a 12 lead ECG from a normal subject
      2. State which measurements should be made from an ECG trace and how to make them
      3. Perform basic rhythm analysis from an ECG
      4. Recognise the following rhythm disturbances: PAC, atrial flutter, PVC.
      5. Perform basic conduction analysis from an ECG
    • Cardiovascular Investigations - General
      1. You should have an understanding of the 12-lead ECG, including lead placement and general principles behind what it assesses. (CR2)
    • Cardiovascular Imaging
      1. Understand the efficacy of cardiac imaging techniques, e.g. echocardiography, coronary angiography. (CR2)
      2. Identify the basic features of a normal mediastinal silhouette and the basic features of cardiac pathologies in chest X-rays (CR2)
  • Clinical skills: MAKING A DIAGNOSIS and CLINICAL JUDGEMENT (TD 14 e-f)
    • General Outcomes for Cardiovascular Diagnosis
      1. carry out ankle brachial pressure index measurement (MET3A)
  • Clinical skills: DIAGNOSTIC PROCEDURES (TD 18 a)
    • ECG Monitoring and Interpretation
      1. Describe or demonstrate the recording of a 6 lead ECG using standard and augmented limb leads.
      2. Relate the P-wave, QRS complex and T-wave of the lead II ECG to the sequence of depolarization and repolarization of the atria and ventricles of the heart.
      3. Explain why the shape of the ECG varies between the 6 leads.
      4. Describe the relationship between the heart sounds and the ECG and relate both the mechanical events of the cardiac cycle.
    • Pulse and Respiration Measurements
      1. Be able to describe the rate and rhythm of the radial and carotid pulses (CR2)
      2. You should be able to accurately locate the normal apex beat, and report on its location by standard anatomical landmarks. (CR2)
      3. You should be able to auscultate the normal heart, and time the heart sounds with the pulse in your assessment of the cardiac cycle. (CR2)
      4. You should be aware of the four main areas to auscultate, and the use of the bell and diaphragm of the stethoscope. (CR2)
    • Blood Pressure
      1. You should be able to take blood pressure competently on a normal person by first estimating the systolic pressure by palpation and then accurately measuring by auscultation. (CR2)
      2. You should be able to recognise the pulsation of the normal JVP and assess its vertical height above the manubrio-sternal angle. (CR2)
  • Clinical skills: PRESCRIBING DRUGS SAFELY AND EFFECTIVELY (TD 17 a-h)
    • Pharmacological Therapy - Cardiovascular Disorders (General)
      1. Apply the ‘brains and aims’ algorithm to prescribing for those with heart problems
      2. Explain how to integrate treatments in management of heart disease.
      3. Define heart failure and describe its treatment. (CR1)
      4. Discuss key influences on prescribing for patients with heart disease
      5. Discuss drug safety issues and the basis for safe prescribing
  • Clinical skills: EVIDENCE BASED MEDICINE
    • Evidence Based Medicine - General
      1. Explain the economics of prescribing and the importance of evidence-based medicines.
• Hypertension (Priority 1)
  • General
    1. Learn the patho-physiology of atherosclerosis and other mechanisms of hypertension (CR3)
    2. Define hypertension (essential and secondary) and learn British Hypertension Society targets for blood pressure control (CR3)
    3. Describe symptoms and signs of hypertension (CR3)
    4. Learn secondary causes of hypertension and give symptoms and signs that may be found in each condition (CR3)
    5. Explain how these control systems could malfunction to produce hypertension, and the problems caused by hypertension.
    6. Learn about the associated cardiovascular risk factors that should be looked for in patients with hypertension (CR3)
    7. Describe the relevant investigations to look for causes and complications of hypertension (CR3)
    8. List the common types of drugs used to control hypertension.
    9. Discuss the non-pharmacological management of cardiovascular risk factors (CR3)
    10. Advise patients with hypertension on the risks and benefits of drugs and non-therapeutic treatment options. (CR3)
    11. Learn those classes of drugs that can be used to control blood pressure and describe the mechanism of action, place in therapy and major side effects of each. (CR3)
    12. List SIX classes of drugs that can be used to control blood pressure and describe their mechanism of action, place in therapy and major side effects.
    13. Understands the associated cardiovascular risk factors that should be looked for in patients with hypertension
    14. Discuss the control of blood pressure and plasma cholesterol
  • Acute management of a hypertensive emergency
    1. Learn the definition of accelerated hypertension (CR3)
    2. Learn about the pathology of target organ damage caused by accelerated hypertension (CR3)
    3. Discuss the principles of emergency blood pressure control in hypertension (CR3)
• Angina (Priority 1)
  • Angina - General
    1. Learn patho-physiology of atherosclerosis and explain how this leads to angina (CR3)
    2. Identify a patient with ischaemic heart disease (CR3)
    3. Describe symptoms and signs of angina (CR3)
    4. Learn about differential diagnosis for retrosternal chest pain (CR3)
    5. Learn about risk factors for the development of atheroma and outline how each should be controlled in a patient with angina (CR3)
    6. Describe investigations that can be used to confirm the diagnosis of angina (CR3)
    7. Learn those classes of drugs used for angina and describe the mechanism of action, place in therapy (i.e. whether they reduce the risk of a CV event or just control the symptoms) and major side effects of each (CR3)
    8. Explain to a patient how to take sublingual GTN spray in the event of chest pain (CR3)
    9. Learn about the indications for referral of a patient with angina to a specialist cardiology service (CR3)
    10. Prescribe for a patient with ischaemic heart disease with a view to improving prognosis
    11. Distinguish between the terms chronic stable angina and acute coronary syndrome
    12. Plan how to improve one’s own skills in diagnosing and managing a person with angina.
    13. Explain what determines oxygen demand and supply in the heart “cardiac economics”; describe how treatment alters this oxygen balance
    14. List the priorities in the management of a person with angina.
  • Angina - Acute Management
    1. Define unstable angina and the risk of progression of this to myocardial infarction (CR3)
    2. Describe symptoms and signs of unstable angina (CR3)
    3. Learn the investigations that should be performed in a patient with unstable angina and describe the expected findings (CR3)
    4. Describe the management of unstable angina (CR3)
    5. Give mechanism(s) of action and major side effects of drugs used in unstable angina (CR3)
    6. Learn the indications for urgent cardiological intervention (CR3)
  • Angina - Coronary Intervention
    1. Describe the processes of coronary angiography, angioplasty and stenting to a patient (CR3)
    2. Learn the complications of these procedures and discuss their prevention and management (CR3)
    3. Discuss indications for coronary artery bypass surgery (CR3)
    4. Describe some details about the process of putting a patient onto cardiopulmonary bypass (CR3)
    5. Learn the common complications of cardiopulmonary bypass and explain why these occur (CR3)
    6. Describe the process of coronary artery bypass and the risk of complications to a patient (CR3)
• Acute Coronary Syndrome and Myocardial Infarction (Priority 1*)
  • Coronary Syndrome & Myocardial Infarction - General
    1. Learn the coronary circulation, particularly the vascular supply to various myocardial regions
    2. Learn the coronary circulation, particularly the vascular supply to various myocardial regions
    3. Learn the basic anatomy of the heart (CR3)
    4. Explain how an ECG can be used to determine the site of myocardial infarction and indicate which vessel is occluded (CR3)
    5. Learn the ECG changes (including evolutional changes) in Acute Coronary Syndrome.
    6. Identify a patient with ischaemic heart disease (CR3)
    7. Learn the ECG changes (including evolutional changes) in Acute Coronary Syndrome. (CR3)
    8. Explain how and why complications may differ between anterior and inferior MI
    9. Describe the changes in cardiac enzymes including troponin and creatinine kinase that occur from hours to weeks following MI (CR3)
    10. Explain how and why complications may differ between anterior and inferior myocardial infarction (CR3)
    11. Describe symptoms and signs of complications of MI including a) arrhythmias and b) cardiac failure (CR3)
    12. Learn the drugs which are proven to improve prognosis / survival following MI and give evidence supporting their use including number need to be treated (NNT) values (CR3)
    13. Organise the long term care of a patient with ischaemic heart disease (CR3)
    14. Advise patients with ischaemic heart disease on non therapeutic methods of improving their condition (CR3)
    15. Prescribe for a patient with ischaemic heart disease with a view to improving prognosis (CR3)
    16. Evaluate the most appropriate treatment for patients with ischaemic heart disease (CR3)
    17. Advise patients with ischaemic heart disease on the risks and benefits of drugs and non therapeutic treatment options. (CR3)
    18. Describe the role of cardiac rehabilitation in recovery from ACS (CR3)
    19. Have awareness of the spectrum of myocardial injury: from acute coronary syndromes to frank myocardial infarction
    20. Define the surfaces of the heart and relate myocardial infarctions to the anatomy of the coronary circulation.
    21. List the causes of myocardial ischaemia and infarction. (CR2)
    22. Describe the changes in the coronary arteries that lead to myocardial ischaemia and infarction. (CR2)
    23. Describe the pathological changes that occur in a heart undergoing infarction (CR2)
  • Coronary Syndrome & Myocardial Infarction - Acute Management
    1. Describe the pathogenesis of an acute MI (CR3)
    2. Describe the symptoms and signs of acute MI (CR3)
    3. Describe the emergency investigations to confirm the diagnosis of MI (CR3)
    4. Describe the criteria for the diagnosis of myocardial infarction (CR3)
    5. Describe the immediate management of a patient with myocardial infarction (CR3)
    6. Describe the mechanism of action, role in therapy and major side effects of aspirin, other anti-platelet therapies, diamorphine and oxygen in acute MI (CR3)
    7. Learn the role of primary coronary intervention (PCI) as an emergency therapy (CR3)
    8. Learn the role of thrombolysis in MI (CR3)
    9. Describe mechanism of actions, indications and contraindications and major side effects of thrombolytic agents (CR3)
    10. Learn about the indications, pros and cons on the use of Primary Coronary Intervention (PCI) versus thrombolysis (CR3)
    11. Define "arrival-to-ECG" and "door-to-needle" times for suspected MI and explain why these are important (CR3)
    12. Give indications for urgent cardiological referral in MI (CR3)
    13. List the complications of myocardial infarction (CR2)
• Arrythmias and Conduction Defects (Priority 1*)
  • Arrhythmias and Conduction Defects - General
    1. Learn about cardiac cycle and cardiac electrophysiology and learn how this relates to the ECG waveform.
    2. Learn about cardiac cycle and cardiac electrophysiology and learn how this relates to the ECG waveform (CR3)
    3. Identify common arrhythmias on an ECG (CR3)
    4. Using history (symptoms), signs and ECG findings be able to diagnose and distinguish between e) peri-arrest f) ventricular fibrillation g) supraventricular tachycardia, h) 1st, 2nd and 3rd degree heart block
    5. Using history (symptoms), signs and ECG findings be able to diagnose and distinguish between the following: cardiac arrest; atrial flutter and atrial fibrillation (AF); respiratory arrest; ventricular tachycardia; pulse; Peri-arrest; ventricular fibrillation; supraventricular tachycardia; 1st, 2nd & 3rd degree heart block (CR3)
    6. Describe the symptoms by a patient experiencing cardiac arrhythmias
    7. Learn how to distinguish between neurological and cardiological causes of collapse
    8. List cardiological causes of collapse.
    9. Learn cardiological causes of collapse (CR3)
    10. Learn the causes of each type of pathological tachycardia and bradycardia (CR3)
    11. Learn about the ECG changes in common electrolyte disturbances, particularly potassium abnormalities.
    12. Describe how abnormalities of cardiac electrophysiology lead to the arrhythmias listed above (CR3)
  • Arrhythmias and Conduction Defects: Management
    1. Describe other investigations that should be performed in patients with suspected arrhythmias including 24 hour cardiac monitoring and investigation of underlying causes
    2. Describe the mechanism and speed of onset of action, place in therapy and major side effects of adenosine, digoxin, amiodarone, verapamil, beta blockers, lignocaine, flecainide, magnesium and atropine.
    3. Explain the role of anticoagulation in cardiac arrhythmias, particularly in atrial fibrillation
    4. Know how to manage a patient with a cardiac arrest in line with current UK Resuscitation Council Guidelines
    5. Describe the relevant investigations that should be performed in patients with suspected arrhythmias including 24 hour cardiac monitoring and investigation of underlying causes (CR3)
    6. Describe the mechanism and speed of onset of action, place in therapy and major side effects of adenosine, digoxin, amiodarone, verapamil, beta blockers, lignocaine, flecainide, magnesium and atropine. (CR3)
    7. Learn the role of anticoagulation in cardiac arrhythmias, particularly in atrial fibrillation (CR3, CR3)
    8. Discuss indications for "electrical treatment" of arrhythmias (cardioversion, pacemaker and ablation) and describe how each procedure is done (CR3)
    9. Describe methods that can be used to reduce recurrence of arrhythmias including treatment of underlying cause, drug treatment and radiofrequency ablation (CR3)
    10. Summarise the management of arrhythmias listed including termination of arrhythmias, control of heart rate and prevention of recurrence (CR3)
    11. Know how to manage a patient with a cardiac arrest in line with the current UK Resuscitation Council Guidelines
• Acute Circulatory Failure and Shock (Priority 1*)
  • General Outcomes for Acute Circulatory Failure and Shock
    1. Learn about the mechanisms of shock (CR3)
    2. Describe how hypovolaemia, cardiac failure or obstruction (cardiac tamponade, pulmonary embolism), sepsis and anaphylaxis can each cause shock (CR3)
    3. Describe how clinical examination can be used to distinguish between the causes of shock listed (CR3)
    4. Describe how central venous pressure measurement can be used to give an indication of the cause of shock (CR3)
    5. Learn to distinguish between bronchial and �cardiac asthma�
    6. Describe how a patient in shock should be monitored and managed (CR3)
    7. Explain the patho-physiological consequences / complications of shock (CR3)
    8. Outline the measures that should be taken to prevent these complications of shock (CR3)
  • Cardiogenic Shock
    1. Learn the causes of cardiogenic shock (CR3)
    2. Describe how preload, cardiac contractility and after load could be optimised to maximise cardiac function (CR3)
    3. Describe the mechanism of action, place in therapy and major side effects of adrenaline, noradrenaline, dopamine and dobutamine (CR3)
    4. Learn about the prognosis of cardiogenic shock (CR3)
• Cardiorespiratory Arrest (Priority 1*)
  • General Outcomes for Cardiorespiratory Arrest
    1. Learn how to recognise cardiorespiratory arrest (CR3)
    2. Learn UK resuscitation council (UK) guidelines in cardio-respiratory arrest. (CR3)
    3. Know how to perform basic life support including a) assessment and maintenance of the airway; b) respiratory support; c) cardiac massage (CR3)
    4. Explain the role and details about the cardiac arrest team and describe how to contact them (CR3)
    5. Explain the importance of rapid defibrillation in a patient with VF or pulseless VT (CR3)
    6. Demonstrate the positioning of defibrillator gel pads and safe use of a defibrillator (CR3)
    7. Describe the mechanism of action and role of adrenaline, lignocaine, amiodarone and magnesium in the management of a cardiac arrest (CR3)
    8. Describe how you would administer defibrillation to a patient in ventricular fibrillation (CR3)
    9. Learn about the reversible causes of a cardiorespiratory arrest and explain how you would look for and correct these rapidly (CR3)
    10. Describe the prognosis of a patient in hospital who has a cardio-respiratory arrest and explain how underlying illnesses (acute and chronic), such as cancer influences this prognosis (CR3)
    11. Explain why the cardiac arrest team is NOT called for all patients that have cardiorespiratory arrest. (CR3)
    12. Discuss how the decision not to call the arrest team is made and describe how the patient and their family should be involved in this process (CR3)
• Vascular Disease in other sites including CVA (Priority 1 and 2)
  • Carotid Stenosis
    1. Learn the patho-physiology of atherosclerosis (CR3, CR3)
    2. Describe symptoms and signs of carotid stenosis (CR3)
    3. Describe investigations that can be used to diagnose carotid stenosis (CR3)
    4. Discuss the main indications for end-arterectomy in patient with carotid stenosis (CR3)
  • Renal Vascular Disease
    1. Describe symptoms and signs of renal artery stenosis (CR3)
    2. Learn the different pathological types of renal artery stenosis and describe people who might typically be affected by each (CR3)
    3. Describe investigations that can be used to confirm the diagnosis of renal artery stenosis (CR3)
    4. Outline the management of renal artery stenosis (CR3)
    5. Explain why ACE Inhibitors are contra-indicated in patients with renal artery stenosis (CR3)
    6. Describe measures you would take to ensure ACE inhibitors are used safely in a patient with possible vascular disease (CR3)
  • Mesenteric Ischaemia
    1. Learn the common symptoms and signs of mesenteric ischaemia
    2. Explain how blood supply to the bowel may be compromised and how this might present acutely/chronically (CR3)
    3. Learn the management of mesenteric ischaemia (CR3)
  • Cerebro-Vascular Disease (Inc CVA)
    1. Identify a patient with cerebro-vascular accident
    2. Describe the symptoms and signs associated with stroke and its complications (CR3)
    3. Know the general mechanisms which cause cerebral vascular disease (CR3)
    4. Describe the role of aspirin, other anti-platelet drugs, thrombolysis and anticoagulation in the treatment of stroke (CR3)
    5. Demonstrate examination of the relevant neurological system following stroke (CR3)
    6. Know the medical management of transient ischaemic attacks (TIA) and completed stroke (CR3)
    7. Know about the rehabilitation of patients with completed stroke (CR3)
    8. Demonstrate competency in use of an ophthalmoscope to recognise retinal vascular abnormalities (CR3)
    9. Outline the management options in primary care for a patient who has residual disabililty following stroke (CR3)
    10. Describe the importance of appropriate disease treatment and life style changes in stroke prevention (CR3)
• Infective Endocarditis (Priority 2*)
  • General Outcomes for Infective Endocarditis
    1. Describe the signs and symptoms of infective endocarditis (CR3)
    2. Give a differential diagnosis for an unexplained fever (CR3)
    3. Learn about the organisms that cause infective endocarditis and explain how cardiac infection with each may be acquired (CR3)
    4. Describe the pathogenesis of infective endocarditis and its complications (CR3)
    5. Explain how the diagnosis of infective endocarditis is made and describe the role of investigations including blood cultures and echocardiography in this process (CR3)
    6. Learn about the antibiotics effective against each organism that commonly causes infective endocarditis and describe the mechanism of action, place in therapy and major side effects of each (CR3)
    7. Learn NICE guidelines on antibiotic prophylaxis for endocarditis (CR3)
    8. Give indications for the surgical treatment of infective endocarditis and discuss the timing of surgery in patients with this condtion (CR3)
    9. Be able to define minimum inhibitory concentration (MIC), minimal bactericidal concentration (MBC) and antimicrobial synergy (CR3)
    10. Be able to explain why liaison between the microbiologist, cardiologist and cardiac surgeon is important (CR3)
    11. Be able to list host factors predisposing to the development of endocarditis (CR3)
    12. Be able to list the common bacterial causes of endocarditis in people with normal valves, abnormal native valves and prosthetic valves (CR3)
    13. Discuss the link between rheumatic fever and infective endocarditis (CR3)
    14. Infective endocarditis: organisms, valves, guidelines for choosing antimicrobial (CSP3)
• Valvular Heart Disease (Priority 2)
  • General Outcomes for Valvular Heart Disease
    1. Learn the anatomy of the heart and the structure of the semi-lunar and AV valves (CR3)
    2. Explain the cardiac cycle, particularly the valvular functions during this cycle (CR3)
    3. Explain how the first and second heart sounds are generated and relate these to the cardiac cycle and valve openings and closures (CR3)
    4. Discuss the causes and symptoms of mitral stenosis and regurgitation
    5. Explain the management of the patient with mitral valve disease.
    6. Describe the structure of heart valves (CR2)
    7. Recognise the first and second heart sounds on cardiac auscultation and identify systolic and diastolic murmurs (CR3)
    8. Discuss the structural changes that occur in valvular heart disease and how function is affected. (CR2)
    9. Be able to describe the haemodynamic consequences of atrial and ventricular septal defects (CR3)
    10. Discuss briefly pulmonary and tricuspid valve disease.
    11. Describe the anatomy and physiology of normal heart valves.
    12. Discuss the causes and symptoms of aortic stenosis and regurgitation.
  • Systolic Murmurs
    1. Describe symptoms and signs of aortic stenosis, aortic sclerosis, mitral regurgitation, tricuspid regurgitation and pulmonary stenosis (CR3)
    2. Distinguish between the causes of systolic murmurs using characteristics of the murmur (site, radiation, character, pitch) and associated clinical features, mainly to differentiate ejection systolic murmur of aortic stenosis, aortic sclerosis, mitral regurgitation, tricuspid regurgitation and pulmonary stenosis from that of pan systolic murmur. (CR3)
  • Diastolic Murmurs
    1. Describe symptoms and signs of aortic/pulmonary regurgitation and mitral stenosis (CR3)
    2. Distinguish between the causes of diastolic murmurs using characteristics of the murmur (site, radiation, character, pitch) and associated clinical features (CR3)
    3. Learn the causes of aortic regurgitation and mitral stenosis; describe the pathological effect that each type of valve lesion has on the heart and circulation (CR3)
    4. Learn about ECG findings expected in patients with these cardiac valve defects (CR3)
    5. Discuss the management of a patient with a cardiac valve defect including a) treatment of the underlying cause b) prevention of complications, c) valve replacement surgery (CR3)
    6. Describe different types of prosthetic heart valve that may be used to replace defective valves and discuss the advantages and disadvantages of each (CR3)
• Atherosclerosis and Arteriosclerosis / Lipid Disorders (Priority 2)
  • Atherosclerosis and Arteriosclerosis - General
    1. Describe the development of atherosclerosis (CR2)
    2. Recognise the complications of atherosclerosis (CR2)
    3. Learn basic biochemistry about lipids, particularly chylomicrons, cholesterol, VLDL, HDL (CR3)
    4. Describe the clinical symptoms and signs of coronary artery disease and their association with underlying pathology. (CR2)
    5. Describe the prevention and treatment strategies for coronary artery disease, with particular attention paid to the mechanism of action of drugs. (CR2)
    6. Describe the relationship between lipoprotein concentrations, atheroma and cardiovascular risk (CR3)
    7. Identify common locations for atherosclerotic lesions and the consequences of these. (CR2)
    8. Describe clinical features and investigations of hyperlipidaemia (CR3)
    9. Describe the management of hyperlipidaemia including diet, exercise and drugs (CR3)
    10. Describe primary and secondary prevention of hyperlipidaemia and benefits (CR3)
    11. Learn about commonly prescribed drugs in hyperlipidaemia (CR3)
    12. Describe the role of screening for hyperlipidaemia (CR3)
    13. Discuss the control of blood pressure and plasma cholesterol
• Acute and Chronic Limb Ischaemia / Peripheral Vascular Disease (Priority 2*) (See also Met 3A outcomes)
  • General Outcomes for Limb Ischaemia / PVD
    1. Describe the symptoms and signs of chronic limb ischaemia (CR3)
    2. Learn about the differential diagnosis for calf pain (CR3)
    3. Describe the pathogenesis of peripheral vascular disease (CR3)
    4. Learn the risk factors for the development of peripheral vascular disease and describe how each of these can be looked for and controlled (CR3)
    5. Describe the investigations that should be performed to determine the presence and severity of peripheral vascular disease, including ABPI and duplex Doppler (CR3)
    6. Counsel a patient on improving symptoms, slowing progression and preventing complications of peripheral vascular disease (CR3)
    7. Give indications for percutaneous transluminal angioplasty and arterial reconstruction surgery (CR3, MET3A)
    8. Describe percutaneous transluminal angioplasty and arterial reconstruction surgery to a patient, including risk of complications (CR3)
    9. Discuss indications for limb amputation (CR3)
    10. Describe types and the process of limb amputation and list possible complications (CR3)
    11. Discuss rehabilitation for patients following limb amputation and list mobility aids available (CR3)
    12. Explain the options available for pain control and palliative support in a patient with intractable limb ischaemia (CR3)
  • Acute Limb Ischaemia
    1. Describe the symptoms and signs of acute limb ischaemia (CR3)
    2. Discuss mechanisms which may lead to the development of acute limb ischaemia (CR3)
    3. Describe the nature and timing of pathological changes that will occur in an acutely ischaemic limb if the ischaemia is not relieved (CR3)
    4. Describe the emergency investigation of a patient with acute limb ischaemia (CR3)
    5. Recognise the urgency of management of the acutely ischaemic limb (CR3)
    6. Discuss the options available for emergency management of acute limb ischaemia including anticoagulation, thrombolysis, angioplasty and embolectomy (CR3)
• Limb Ulceration and Gangrene (Priority 2) (See also Met 3A outcomes)
  • General Outcomes for Limb Ulceration and Gangrene
    1. List the causes of chronic leg ulcers and describe the different appearances (CR3)
  • Limb Ulceration
    1. Compare and contrast the presentation of venous and arterial leg ulcers (CR3)
    2. Describe the pathogenesis of ischaemic, venous and diabetic ulcers (CR3)
    3. Describe the features of decubitus ulcers (pressure sores) (CR3)
    4. Describe the risk factors for decubitus ulcers (CR3)
    5. Describe measures for the primary and secondary prevention of leg ulcers (CR3)
    6. Learn the investigations that should be performed in patients with leg ulcers and explain how these will help with patient management (CR3)
    7. Discuss the treatment options for a patient with chronic leg ulcers including a) management of the underlying cause b) dressings and bandaging and c) skin grafting (CR3)
    8. Describe the role of the multidisciplinary team in the prevention and treatment of pressure sores (CR3)
  • Gangrene
    1. Learn the types of gangrene e.g. wet, dry, gas, Fournier’s scrotal gangrene and explain the pathogenesis and appearance of each and outline its management (CR3)
    2. Explain how you would recognise gangrene clinically (CR3)
    3. Describe the gangrene associated with chronic ischaemia (CR3)
    4. Describe the management of each type of gangrene (CR3)
    5. Describe how skin ulceration can be prevented (CR3)
• Arterial Aneurysms (Priority 2*) (See also Met 3A outcomes)
  • General
    1. Describe how arterial aneurysms develop and give common anatomical sites at which they occur (CR3)
    2. Explain the difference between true and false aneurysms (CR3)
    3. Describe symptoms and signs of an aortic aneurysm (CR3)
    4. Describe the potential complications of aneurysms (CR3)
    5. Describe investigations that can be used to diagnose and monitor an aortic aneurysm (CR3)
    6. Explain the difference between an open and endovascular repair (CR3)
    7. Know the indications for surgical intervention in aortic aneurysm disease (CR3)
    8. Describe the potential complications of aortic aneurysm surgery including mortality figures for elective and emergency aneurysm surgery (CR3)
    9. Give a differential diagnosis for an epigastric mass (CR3)
    10. Learn the risk factors for arterial aneurysm and describe how these should be assessed and controlled (CR3)
    11. Describe complications of arterial surgery and explain how these should be managed (CR3)
  • Acute Management
    1. Describe the symptoms and signs of a patient presenting with a leak or rupture of an aneurysm of : a) the abdominal aorta; b) the thoracic aorta (CR3, MET3A)
    2. Describe the emergency management of a patient presenting with a leaking or ruptured aortic aneurysm (CR3, MET3A)
• Pericardial Disease (Priority 3*)
  • General Outcomes for Pericardial Disease
    1. Describe the characteristics of pain caused by pericardial inflammation (CR3)
    2. Describe the clinical signs and causes of pericarditis, pericardial effusion and constrictive pericarditis/cardiac tamponade (CR3)
    3. Describe the ECG changes expected in a patient with acute pericarditis and explain how these differ from the changes seen with an MI (CR3)
    4. Understand the ECG and echocardiography findings in patients with pericardial effusion and constrictive pericarditis/cardiac tamponade (CR3)
    5. Describe the management of acute pericarditis (CR3)
    6. Outline the use of pericardiocentesis and surgery in the diagnosis and treatment of patients with pericardial effusion or constriction (CR3)
• Myocardial Disease / Cardiomyopathy (Priority 3)
  • Myocardial
    1. Describe symptoms and signs of myocarditis (CR3)
    2. Learn the major causes of myocarditis (CR3)
    3. Explain how the diagnosis of myocarditis can by confirmed by investigation (CR3)
  • Cardiomyopathy
    1. Define cardiomyopathy and know the types of cardiomyopathy (CR2)
    2. Know the constraints that different cardiomyopathies pose on haemodynamics (CR2)
    3. Know the current criteria that govern the classification of cardiomyopathies (CR2)
    4. Define cardiomyopathy and learn the types of cardiomyopathy (CR3)
    5. Describe symptoms and signs of dilated, hypertrophic and restrictive cardiomyopathy and explain why these differ between types (CR3)
    6. Give causes of dilated, hypertrophic and restrictive cardiomyopathy (CR3)
    7. Discuss the advantages and disadvantages of screening in families with cardiomyopathy (CR3)
    8. Describe the management options for patients with dilated, hypertrophic and restrictive cardiomyopathies (CR3)
    9. Outline the main pathological features of cardiomyopathy (CR3)
• Congenital Cardiovascular Disease (Priority 3)
  • General Outcomes for Congenital Cardiovascular Disease
    1. Describe symptoms and clinical signs of the cardiac malformations: atrial and ventricular septal defects, patent ductus arteriosus, Fallot’s tetralogy, coarctation of the aorta (CR3)
    2. Give a differential diagnosis for central cyanosis (CR3)
    3. Learn the factors that cause congenital heart disease (CR3)
    4. Describe the pathology and cardiac consequences of these cardiac malformations (CR3)
    5. Define and explain the Eisenmenger reaction / syndrome and explain why this worsens prognosis (CR3)
    6. Know the complications of congenital heart disease and explain how these may be prevented (CR3)
    7. Describe investigations that can be used to confirm the diagnosis of congenital heart disease (CR3)
    8. Discuss the role and timing of surgery in the management of congenital cardiac disease (CR3)
    9. Discuss the particular difficulties that may be faced by adolescents and young adults with chronic cardiac disease (CR3)
• Rheumatic Fever and Rheumatic Heart Disease (Priority 3)
  • General
    1. Describe symptoms and signs of rheumatic fever (CR3)
    2. Describe how the Duckett-Jones criteria are used to make the diagnosis of rheumatic fever (CR3)
    3. Explain how Group A streptococcal pharyngeal infection can lead to heart, skin, joint and CNS involvement and describe the pathological changes in these tissues. (CR3)
    4. Describe investigations that can contribute to the diagnosis of rheumatic fever (CR3)
    5. Discuss the management of rheumatic fever including the choice of antibiotics for streptococcal infection (CR3)
    6. Discuss the cardiac complications of rheumatic fever (CR3)
    7. Discuss the epidemiology of rheumatic fever in the UK and worldwide (CR3)
• Varicose Veins (Priority 3) (See also Met 3A outcomes)
  • General
    1. Describe the symptoms and signs associated with varicose veins and their complications (CR3)
    2. Demonstrate examination of varicose veins including distribution, communication with deep veins and complications (CR3)
    3. Discuss the pathophysiology of varicose veins (CR3)
    4. Give risk factors for the development of varicose veins (CR3)
    5. Outline the management options for a patient with varicose veins including indications for surgery (CR3)
    6. Describe the surgical options for treatment of varicose veins to a patient (CR3)

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