Curriculum Overview

Our academic year is divided into 13 four-week blocks. An example of a typical first year fellow’s schedule is shown below. All fellows have two research blocks each year. However, fellows in the T-32 research program have 6 blocks of research during the first clinical year. The second year is very similar to the first year, but usually with only 2 months of consults, 1 month of heart failure and additional echo and cath lab time. Third year fellows have at least 2 months of imaging (CT and MRI) with the option to achieve COCATS level 2 and elective time in addition to research time.

Call Overview

Call is covered by first and second year fellows. Overnight call in our fellowship program is on a 24 hour or 24+4 hour (weekends) system. Call on Monday through Friday nights begins at 5 p.m. and lasts until 8 a.m. the following morning. Saturday and Sunday call begins at 8 a.m. and lasts until 8 a.m. the following morning. On Saturday and Sunday mornings, the post-call fellow rounds with either the CV-ICU or cardiology floor team and is finished no later than 11 a.m. We have recently implemented a change to post-call days during the week; the post-call fellow is relieved of all duties at noon on the post-call day and their pager is handed off to a fellow on a consult rotation. Additionally, the post-call fellow does not have afternoon clinic. This has been particularly well received by everyone.

Each rotation provides an opportunity for the fellow to be exposed to a variety of clinical settings, consult services and labs. The clinical training is balanced by research opportunities, in addition to clinical rotations.

Cardiology Continuity Clinic

Each fellow is assigned a weekly, half-day outpatient clinic in which he or she is the primary cardiologist. 1 to 3 new patients and 3 to 5 established patients are seen per session. An attending cardiologist is assigned as the preceptor to whom all patients are presented for discussion and formulation of diagnostic and therapeutic plans.

Wake Forest Cardiology clinic sites include:

• Country Club Road* (Winston-Salem)
• Janeway Tower* (Winston-Salem, Main Campus)
• Davie Medical Center
• Elkin, NC
• High Point, NC
• Lexington, NC
• Wilkesboro, NC

*Fellow clinic locations

Educational purpose: To master the diagnosis, evaluation and treatment of all common cardiovascular disorders in the ambulatory setting.

Inpatient Cardiovascular Medicine Service

Each fellow will rotate through the inpatient service for a total of three months as a first- and second-year fellow. The educational content of this rotation reflects the pathology encountered in a large tertiary hospital with both referral cases and cases admitted directly from the emergency room.

Pathology includes:

• Coronary artery disease
• Valvular heart disease
• Congenital heart disease
• Cardiac arrhythmias
• Heart failure
• Infective endocarditis
• Peripheral vascular disease
• Pericardial disease
• Pulmonary heart disease

Educational purpose: To learn how to diagnose and care for a wide variety of cardiac diseases seen on a general cardiology inpatient service.

CV-ICU

Third-year fellows rotate through the CV-ICU for a total of 2 to 3 months during their third year. This rotation is driven by several parallel educational experiences:

• Direct patient care
• Review of diagnostic studies
• Performing bedside procedures
• Mentoring house staff and medical students

Educational purpose: To master the evaluation and management of cardiovascular critical care issues in the CV-ICU. Fellows are provided with the cognitive and technical skills necessary to achieve Level 2 (COCATS II).

Cardiac Catheterization Laboratory

Wake Forest Baptist’s cardiac catheterization laboratory specializes in diagnostic and therapeutic interventions for patients with conditions that include:

• Coronary artery disease
• Peripheral vascular disease
• Valvular heart disease
• Structural heart disease interventions (includes ASD, PFO and TAVR)
• Advanced heart failure and cardiac transplantation
• Pulmonary Embolism

We take pride in our high clinical volumes. In 2022, our catheterization lab performed over 3,300 diagnostic catheterizations, approximately 1,700 PCI and mechanical support device insertions, and over 400 structural interventions (TAVR, MitraClip, PFO/ASD closure, left atrial appendage closure). We perform cutting-edge interventional procedures including catheter-directed therapies for pulmonary embolism, aortic interventions and Angiovac for endocarditis. The general fellow spends approximately 6 to 7 total months on this rotation during the fellowship and is expected to have performed over 400 diagnostic catheterizations during that time. The fellow receives training on the performance, interpretation and indications of all aspects of invasive cardiology, including:

• Right and left heart catheterization
• Ventriculography
• Coronary angiography
• Interpretation of hemodynamic recordings
• Endomyocardial biopsy
• Pericardiocentesis
• Peripheral angiography
• Acute mechanical circulatory support
• Percutaneous coronary interventional techniques

Educational purpose: To provide the fellow with the technical and cognitive skills necessary to achieve COCATS level II in invasive cardiology.

Echocardiography Laboratory

Each fellow spends 6 to 8 months in the echocardiography lab, where over 33,000 transthoracic and over 1,300 transesophageal echocardiography studies were performed in 2022. This rotation provides intensive exposure to the performance and interpretation of:

• Transthoracic echocardiography
• Doppler echocardiography
• Transesophageal echocardiography
• Stress echocardiography
• Tissue Doppler imaging
• Strain imaging
• 3-D echocardiography
• Contrast echocardiography
• Congenital echocardiography

First year fellows spend most of their time in the echocardiography lab performing and interpreting transthoracic echocardiograms, working with skilled sonographers and faculty. During the second year, the fellow spends increasing amounts of time with more advanced procedures, such as TEE and stress echocardiography, while reading studies with faculty. A third year fellow is expected to have developed the skills expected of an independent echocardiographer and further hone advanced imaging skills such as structural TEE in support of interventional procedures such as MitraClip and TAVR. By the end of fellowship, a fellow will have personally performed over 150 and interpreted 600-1000 transthoracic examinations, interpreted more than 150 stress echocardiography studies and performed over 150 TEE examinations under faculty supervision. Because we do not have an advanced imaging fellow, the general fellows perform a high volume of TEEs.

Educational purpose: To master the understanding and performance of transthoracic, transesophageal and stress echocardiography in a system of graduated responsibility meeting COCATS Level II requirements for echocardiography and preparing the fellow to sit for echocardiography boards if desired.

Imaging (Nuclear Cardiology/CT/MRI)

Fellows will have 5 to 7 months of supervised training in cardiovascular imaging, which will include CT and MRI at Atrium Health Wake Forest Baptist Medical Center, as well as nuclear cardiology training at the VA Medical Centers in Kernersville and Salisbury, NC. Our program is one of the few programs that enables fellows to achieve COCATS level II CT training within a two-year training span. Beginning with the 2023 graduating class, the fellowship gives the opportunity for fellows to achieve COCATS level II in CT, so that fellows pursuing Interventional and EP fellowships can graduate with level II training if so desired.

Fellows participate in:

• Pretest patient evaluation
• Supervision of the study
• Data processing and analysis
• Study interpretation
• Clinical report generation

Nuclear: In addition to Cadmium Zinc Telluride (CZT) cameras, most systems are equipped with CT attenuation, including both VA locations. At the main campus, myocardial PET perfusion is also available. Fellows typically meet their requirements within 3 to 4 months at the VA. Didactic lectures are given by both VA faculty and Dr. Madigan from the Wake Forest Cardiology section.

Cardiac CT: At Wake Forest Baptist, we use both Dual Source 128- slice FLASH (Siemens) and 256 row Revolution (GE) systems. These systems have access to multiple image processing software programs (GE AW server, Siemens Syngo Via, TeraRecon). Remote access is also available. Fractional Flow Reserve (FFR) CT will be available beginning Fall 2023.

Cardiac MRI: A Siemens 1.5T scanner is available with an entire package of T2/T1 mapping sequences. Image processing systems include Circle and Webpax. A research agreement with Siemens is in process and access to dark blood sequences along with improved delayed enhancement sequences in patients with implanted devices will soon be available.

Educational purpose: To understand the indications for specific imaging modalities, the safe use of radionuclides, basics of instrumentation, image processing, methods of quality control, image interpretation, integration of risk factors and clinical symptoms, and the appropriate application of the resultant diagnostic information for clinical management. Fellows will have the opportunity to achieve Level 2 in nuclear and MRI.

Research

Cardiology fellows will select a project by identifying an interest and will then select a faculty mentor. There are 6 months of protected research time during the fellowship. Fellows will present their research at the Cardiovascular Medicine Research Conference in the spring. Please see our “Research and Academics” page for further details.

General Cardiology Consults

Each fellow will spend two to three months on the consultation service during the first and second years of their fellowship. This rotation is designed to provide the fellow with comprehensive training in the assessment of:

• Patient symptoms
• Physical examination findings
• Selection and interpretation of appropriate tests
• Development of rational management strategies for inpatients

Educational purpose: To provide fellows with the technical and cognitive skills that are required to achieve independence in the clinical assessment and appropriate management of patients whose primary problem is non-cardiac, but in whom cardiac issues have been identified.

Arrhythmia Consults/Electrophysiology

General cardiology fellows will spend 2 to 3 months on the Arrhythmia Consult Service. Fellows evaluate and treat patients with a wide variety of arrhythmia/EP pathology, including diagnosis and treatment of atrial and ventricular arrhythmias, need for temporary and permanent pacing, ICDs, cardiac resynchronization therapy and much more. Fellows are also invited to participate in EP lab procedures. During the 2022 fiscal year, our EP lab implanted over 700 pacemakers and ICDs, performed over 160 laser lead extractions and performed approximately 1,150 ablations (SVT, VT/PVC, and atrial fibrillation). 

Educational purpose: To learn the indications for temporary and permanent pacing, participate in the evaluation and programming of pacemakers and defibrillators, learn the indications for and limitations of electrophysiology studies, and learn the appropriate use of pharmacologic and non-pharmacologic treatments of arrhythmias. 

Advanced Heart Failure/VAD/Transplant

Fellows on this service will assist in management of a wide variety of patients including those with LVAD, cardiac transplantation, percutaneous mechanical support, cardiogenic shock, inotropic therapy, adult congenital heart disease, cardiac amyloid and pulmonary hypertension. We work closely with cardiac surgery and critical care anesthesia to ensure optimal multidisciplinary care for these complex patients. The fellow will also participate in didactic sessions and VAD/Transplant selection committee meetings.

Educational Purpose: To acquire skills in the medical management of patients with advanced heart failure and cardiogenic shock. The fellow will have the appropriate training to become a competitive applicant to match for an advanced fellowship in heart failure and transplant cardiology.

VA Rotation

Fellows spend time at the Kernersville, NC, VA Health Care Center and the Salisbury, NC, VA Medical Center during their first and second years. The Kernersville VA Health Care Center is a unique VA facility. In addition to having an active outpatient cardiology clinic, this location has an outpatient cardiac catheterization laboratory, an EP lab, and a busy device clinic in addition to facilities for echocardiography, exercise stress testing and nuclear stress testing. At the VA Kernersville location, cardiology fellows will perform and interpret nuclear cardiology studies. Additionally, the fellow will assist with consults in the clinic and participate in outpatient diagnostic cardiac catheterization procedures, TEE and cardioversions. At the VA Salisbury location, fellows will perform and interpret nuclear cardiology studies as noted above.

Kernersville VA Weekly Schedule:

Electives:

Fellows are welcome to allocate an elective during their third year to develop proficiency in specific skills, such as EP lab or additional imaging.

Volumes in each subsection: