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Cardiology Fellowships: Investigator Track
Clinical
Training
 egarded as one of the most
comprehensive venues for training in clinical cardiovascular medicine,
the Cardiovascular Institute at Mount Sinai offers each fellow a full
exposure to both acute and longitudinal patient care across the entire
spectrum of health and disease. Comprehensive patient care derives from
a large staff of experienced cardiologists drawing upon the extensive
resources encompassed by allied programs in lipid management and clinical
nutrition, behavioral medicine, lifestyle interventions, vascular medicine,
hypertension, cardiac rhythm disturbances, cardiac failure and transplantation,
cardiovascular imaging. Fellows have traditionally gained exposure to
clinical cardiology through interactions with and supervision by the
full-time faculty and an experienced voluntary staff. The voluntary
staff includes many outstanding cardiologists in active clinical practice
who are eager to share their experience with fellows. For example, Dr.
José Meller, widely recognized as one of the nation’s leading
cardiology practitioners, holds weekly conferences to discuss management
of difficult or unusual cases. In addition to organized inpatient rotations
involving intensive care, consultative cardiology, and subspecialty
services, fellows participate in a comprehensive program of over 50
didactic conferences monthly, and conjoint rounds and care of patients
within the Divisions of Pediatric Cardiology and Vascular Surgery and
the Departments of Cardiothoracic Surgery and Geriatric and Adult Development.
Close working relationships such as these provide complete exposure
to the latest techniques for surgical management of coronary artery
disease, valvular heart disease, congenital heart disease, arrhythmias,
cardiomyopathy, peripheral vascular disease and cardiac transplantation.
Cardiac Catheterization Laboratory
The Cardiac Catheterization Laboratory at The Mount Sinai Hospital is
comprised of four fully equipped rooms for cineangiography (including
one biplane lab) with state of the art computerized hemodynamic monitoring
system, and a separate facility for myocardial biopsies. Presently,
the laboratory performs approximately 9,000 procedures per year, including
2400-2500 interventional procedures, which involve percutaneous transluminal
angioplasty, directional and rotational atherectomy, intracoronary stenting,
valvuloplasty, intracoronary brachytherapy, alcohol septal ablation,
and peripheral interventions. Approximately 25-30 procedures are performed
each day, including between 8-10 interventional procedures. Cath and
interventional procedures are expected to increase by about 15% each
year.
Presently, the faculty of the catheterization laboratory includes six
full-time attending physicians, three part-time attending physicians,
five interventional cardiology fellows, three or four other cardiology
fellows on rotatation in the laboratory, and two nurse practitioners.
During a typical training rotation in the catheterization laboratory,
fellows learn diagnostic angiography by working closely with an attending
cardiologist. Fellows typically perform all types of right-heart catheterizations
and actively participate in the left-heart procedures. The main educational
focus of this rotation is for fellows to gain an understanding of cardiac
hemodynamics and cineangiogram interpretation, while developing expertise
in the performance of procedures. A cardiology fellow is expected to
perform ª300 cath procedures during mean 3-year fellowship.
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Cardiac Catheterization Laboratory Research - Samin Sharma, M.D.,
Warren Sherman, M.D., Michael Kim, M.D., Annapoorna Kini, M.D., Pedro
Moreno, M.D.
Fellows are also encouraged to participate in the ongoing research
activities of the catheterization laboratory. Major research efforts
are focused on the pathophysiology and therapy of unstable angina. These
research endeavors primarily include interventional devices, including:
the determinants of thrombosis during angioplasty; mechanisms of the
early change in luminal diameter following interventional procedures;
and comparisons of angioplasty to atherectomy, trials of new stents,
IVUS guided stenting, shock trial, trials of new interventional devices,
trials of glycoprotein IIb/IIIa inhibitors, reduction in radiocontrast
nephropathy, and angiogenesis and myogenesis.
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The Phyllis and Lee Coffey Non-Invasive Area: Echocardiography Laboratory
The Echocardiography Laboratory at The Mount Sinai Hospital performs
approximately 25 to 30 echocardiograms per day, six of which are interventional
and/or
stress studies (pharmacological and exercise). Studies are done with
the latest and most sophisticated equipment (Acuson 128 XP, HP 2500
Sonos,
ATL HDI3000, Acuson Sequoia, omniplane transesophageal echocardiography)
and are performed with complete pulsed continuous wave and color Doppler
interrogation. Transesophageal echocardiography (TEE) is performed
by
fellows under the supervision of experienced attending echocardiographers.
A full-time cardiac nurse is assigned to the laboratory to assist with
TEE studies. The physician staff of the laboratory consists of two
full-time
and four part-time echocardiographers. The technical staff includes a
technical supervisor and four technologists. Fellows rotate through
the
laboratory as part of their first and third years of training and become
proficient in both the interpretation and performance of transthoracic
echocardiograms. Those desiring additional exposure to TEE, or other
specialized
ulrasound techniques, may spend additional time in the third year or
in a fourth year emphasizing echocardiography research.
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Echocardiography Laboratory - Vivian Abascal, M.D., Lori Croft,
M.D., Martin E. Goldman, M.D., Eric Stern, M.D., David Vorchheimer,
M.D.
Research in the Echocardiography Laboratory covers a broad range of
subjects including new, emerging technologies (3-dimensional echocardiography,
Doppler tissue imaging, high frequency imaging of coronary arteries
and atherosclerotic lesions), transesophageal echocardiographic evaluation
of left atrial appendage dysfunction and cardio-embolic risk, and multicenter
trials (V.O.T.E. = Value Of Transesophageal Echo, SPAF = Stroke Prevention
in Atrial Fibrillation, and CHF in the elderly). Three-dimensional echocardiography
is being used to evaluate right ventricular function and left ventricular
remodeling in various disease states. Opportunities in basic investigations
on the echogenicity of blood components and thrombus formation are also
available.
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The Phyllis and Lee Coffey Non-Invasive Area: Nuclear Cardiology
& Stress Laboratory
The Nuclear Cardiology and Stress Electrocardiography Laboratory performs
almost 4,000 noninvasive tests annually. includes exercise and pharmacological
stress tests, gated SPECT imaging with Tc99m sestamibi, Tc99m tetrofosmine
and Tl-201, gated blood pool studies at rest and during exercise. PET
cardiac imaging, both for perfusion and viability, is performed in conjunction
with Division of Nuclear Medicine. All Attendings in Nuclear Cardiology
are Board certified in Cardiovascular Diseases and in Nuclear Cardiology
or Nuclear Medicine. All Cardiology Fellows undergo Level I training.
Level II and Level III training (JACC 25, 1995, 1-34) are also available
by special arrangement. Fellows are encouraged to participate in clinical
research.
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Nuclear Cardiology Laboratory - Milena Henzlova, M.D., Josef
Machac, M.D, Lori Croft, M.D.
Opportunities are offered for both clinical and basic science research
projects, which include in vitro animal experiments. Major research
efforts in the laboratory include: investigations in the diagnostic
uses of new perfusion imaging agents, combined tomographic imaging of
wall motion and perfusion, myocardial blood flow reserve, diagnosis
of myocardial viability and ischemia using Thallium-201 and metabolic
PET imaging. Opportunities exists for laboratory and animal imaging
studies.
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Electrocardiography and Electrophysiology Section
The Electrocardiography (EKG) and Electrophysiology (EPS) Section provides
a variety of services throughout the hospital. The EKG area provides
electrocardiograms, signal averaged EKG's and 24-hour Holter monitors.
The EPS service provides electrophysiology studies, radiofrequency catheter
ablations, cardioversion, tilt-table tests, implantation of cardioverter
defibrillators and pacemakers including bi-ventricular devices (in collaboration
with cardiothoracic surgery); intraoperative mapping and cryoablation
(in collaboration with cardiothoracic surgery), an arrhythmia clinic,
and follow-up and consultation services. The staffing of this section
includes three full-time attendings and one part-time attending specializing
in pediatric electrophysiology and two dedicated EPS-Fellow. Other staffing
includes two dedicated EP nurses, a technician, and two clinical nurse
specialists. The program provides training in all aspects of clinical
electrophysiology, with the cardiology fellow on rotation assisting
on the consultative service and in all procedures in the EP laboratory
and in the operating room. The fellow also reviews EP intracardiac tracings,
signal- averaged tracings and EKG Holter tracings, attends clinic and
provides consultations to inpatients with rhythm disturbances.
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Electrophysiology Laboratory Research - J. Anthony Gomes, M.D.,
David Bharucha, M.D., Davendra Mehta, M.D.
Research interests in this area include atrial flutter-fibrillation,
risk assessment in Atrial fibrillation utilizing signal processing techniques,
ablative techniques in pulmonary vein ablation for atrial fibrillation,
risk assessment of post-myocardial infarction patients, ventricular
arrhythmias in cardiac sarcoidosis and right ventricular dysplasia,
signal-averaged electrocardiography and clinical trials related to investigational
antiarrhythmic drugs and implantable cardioverter defibrillators and
dual site pacemakers. Basic research in cellular electrophysiology is
conducted in the laboratories of Drs. Diomedes Logothetis and Maria
Diverse.
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Frieda and Milton F. Rosenthal Coronary Care Unit Coronary Care
Unit - David Vorchheimer, M.D.
The Coronary Care Unit (CCU) is a state-of-the-art 14 bed facility.
Approximately 1200 patients are admitted each year to the CCU with a
range of cardiac problems, including acute myocardial infarction/unstable
angina, decompensated heart failure (including patients awaiting heart
transplant), and complex arrhythmias. Included in the unit is a treatment
room equipped for the insertion of Swan-Ganz catheters and temporary
pacemakers. The facility provides for patients on balloon pumps, multiple
intravenous medications and arrhythmia monitoring. The CCU is staffed
by a cardiology fellow, three senior medical residents, three medical
interns and an outstanding nursing staff. Two attending cardiologists
make teaching rounds in the CCU with the medical staff.
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Heart Failure and Cardiac Transplantation Program - Alan Gass,
M.D. (Director, Transplant Cardiology)
The Heart Failure and Cardiac Transplant Programs are integrated areas
of clinical care and research. Patients referred to the Heart Failure
Program receive a full cardiac evaluation and optimization of their
medical regimen. A heart failure evaluation customarily includes exercise
testing with metabolic cart as well as a hemodynamic assessment. Patients
are often eligible to participate in one of the on-going trials of the
Heart Failure Program. Current research studies encompass novel uses
of beta-blockers in heart failure, investigational oral inotropic agents,
the role of anticoagulation in heart failure, anemia and heart failure,
and biventricular pacemakers for heart failure
Patients in the Heart Failure Program are also candidates for cardiac
transplantation. The Cardiac Transplant Program is an active, integrated
component of the Heart Failure Program and provides both clinical and
research training in the management of heart failure transplant patients.
Research in the Cardiac Transplant Program encompasses both the basic
science laboratories and clinical research. Among the investigations
in exercise capacity that are being investigated are changes in the
peripheral vasculature in patients pre- and post-transplant.
Current basic science research includes regulation of calcium channels
in heart failure, the development of animal models to study gene regulation
during heart failure and the use of antiproliferative drugs to prevent
accelerated atherosclerosis and rejection after transplant. Clinical
research now involves markers for rejection, protocols for myocarditis,
immunosuppressive protocols, use of left ventricular device systems
in heart failure and prevention of allograft arteriopathy.
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Joseph H. Hazen Ambulatory Cardiac Care Center - Ira Nash, M.D.
The Joseph H. Hazen Ambulatory Cardiac Care Center an integrated environment
for comprehensive outpatient cardiovascular care. The site of both faculty
practice and longitudinal care of patients by cardiology fellows, the
10,000 square foot facility accommodates nearly 20,000 visits each year.
Ancillary staff includes nurse practitioners, nurse clinicians, medical
assistants and technologists, social worker, nutritionists, and an exercise
physiologist. An extensive array of lifestyle oriented prevention services
is available through a large staff of specialized personnel in the affiliated
Behavioral Medicine, Cardiac Health and Rehabilitation programs.
The modern suite of offices includes patient reception, consultation
and examination facilities equipped with computers that provide access
to the cardiology information system network, the Enterprise Data Repository,
allowing access to test results, clinical data, and the networks of
The Mount Sinai Hospital and Mount Sinai School of Medicine and library.
Fellows are assigned to one session (four hours) weekly for the entire
three years of training. The program in ambulatory care is structured
as a firm-oriented consultative cardiology practice, in which fellows
evaluate all newly referred cases and provide ongoing care under the
supervision of preceptors from the full-time attending staff. Specialized
programs are directed at the evaluation and management of hypertension,
hyperlipidemia, congestive heart failure, cardiac rhythm disturbances,
genetic diseases and peripheral vascular disorders.
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Hypertension - Clive Rosendorff, M.D.,Ph.D., Acting Director
The Hypertension section offers an integrated clinical and research
approach to the understanding of hypertensive disorders. Opportunities
exist for a comprehensive one-year training period in hypertension.
This program offers advanced training in the pathophysiology, diagnosis
and treatment of essential and secondary forms of hypertension. Experience
is enhanced by an active consultative practice on the wards, emergency
room, clinic, and faculty practice. There are weekly seminars reviewing
recent research findings.
The research in this section is supported by several NIH grants. It
focuses on the following areas. 1) The use of home and ambulatory blood
pressure monitoring as a research and clinical tool, 2) The clinical
significance of white coat and masked hypertension; 3) Adherence with
medication and blood pressure control; 4) sleep-disordered breathing
and hypertension; stress and hypertension; and 5) The molecular biology
of hypertension (In a study funded by the American Heart Association,
in collaboration with the National Cancer Institute, we are principal
investigators on a unique national data set for the study of genes related
to hypertension).
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Vascular Medicine - Jeffrey W. Olin, D.O., Director
The Clinical Vascular Medicine Program offers clinical and research
training in all aspects of peripheral vascular disease. Clinical training
emphasizes:
- The natural history, epidemiology, diagnosis, and treatment of arterial,
venous and lymphatic diseases.
- Arterial and venous thromboemRisk factor modification: hypertension,
lipids, and diabetes.bolic disorders and hypercoagulable states
- Risk factor modification: hypertension, lipids, and diabetes.
- Medical management of the vascular surgical patient.
- Swollen legs, leg ulcers, leg pain
- Inflammatory and rare vascular diseases such as vasculitis, fibromuscular
dysplasia, popliteal artery entrapment, cystic adventitial disease
- Aneurysms
- Atheroembolism
- Peripheral arterial disease, cerebrovascular disease and stroke,
and renovascular disease.
- Endovascular treatment of vascular diseases
- Imaging modalities for vascular disease
- Vascular diagnostic laboratory
Cardiovascular fellows are exposed to a core curriculum of didatic
topics related to vascular medicine as well as clinical experience in
ambulatory care, hospital consultation and the noninvasive vascular
laboratory. Electives rotations are available for more intensive training.
Two interdisciplinary conferences are held each week in which specialists
in vascular medicine, vascular surgery, and interventional radiology
participate. One is devoted to imaging and case management and the other
to a didactic core curriculum. This is an opportunity for true collaboration
among individuals with different specialties involved in the care of
vascular patients.
Research efforts include clinical trials in peripheral arterial disease,
venous thromboembolic disease, renal artery disease, therapeutic angiogenesis
for claudication and critical limb ischemia and research in vascular
ultrasound. Fellows are encouraged to participate in the vascular medicine
research initiative. Translational research with other members of the
Cardiovascular Institute will be available on an individual basis.
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Clinical Trials - Jonathan L. Halperin, M.D., David A. Vorchheimer,
M.D., Maryann McLaughlin, M.D., Jeffrey W. Olin, D.O.
Mount Sinai investigators have participated in countless clinical trials
(GUSTO, PURSUIT, CAPRIE, AFFIRM, SHOCK, MOST, ROSTER, and TEAM, to name
just a few) and have served in leadership roles as members of the steering
committees for many others, such as the Assessment of Cardioversion
Using Transesophageal Echocardiography (ACUTE), Warfarin vs Aspirin
for Patients with Reduced Cardiac Ejection Fraction (WARCEF), Warfarin
vs. Aspirin for Stroke due to Intracranial Arterial Disease (WASID)
trials. More importantly, Mount Sinai has served as the scientific organizational
hub of several of the largest, most influential multicenter clinical
trials, including the Stroke Prevention in Atrial Fibrillation (SPAF),
the Coumadin Aspirin Re-infarction Study (CARS), Stroke Prevention using
an Oral Direct Thrombin Inhibitor in Patients with Atrial Fibrillation
(SPORTIF), Future Revascularization Evaluation in Diabetic patients:
Optimal management of Multivessel disease (FREEDOM), and Systemic Immune
Modulation Therapy In Patients Peripheral Arterial Disease and Intermittent
Claudication (SIMPADICO). In addition to gaining experience in the conduct
and execution of such trials, opportunities for fellows to design and
carry out individual investigations typically involve sub-studies or
secondary analyses that form the basis for hypothesis generation and
the development of pilot studies for new trials.
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Outcomes Research and Clinical Practice Evaluation - Ira S. Nash,
M.D. and Maryann McLaughlin, M.D.
Several projects are underway to assess and improve clinical practices
and patient outcomes in Cardiovascular Medicine. In close collaboration
with the Department of Health Policy, we developed evidence-based guidelines
for the acute hospital care of patients with acute myocardial infarction.
Application of these guidelines form the basis of clinical quality improvement
initiatives encompassing not only The Mount Sinai Medical Center, but
also the Mount Sinai Health System of affiliated institutions and medical
practices throughout the New York metropolitan area. Other areas of
active investigation include the assessment and improvement of lipid
management in patients undergoing coronary revascularization, the evaluation
of functional status following percutaneous coronary revascularization,
the impact of physician specialty and payor status on clinical outcomes
in patients with cardiovascular disease and the development of new strategies
to maximize functional independence in elderly people with heart failure.
In collaboration with the Department of Emergency Medicine, studies
focus on characterizing, developing treatment strategies for, and assessing
the outcomes of patients undergoing evaluation of chest pain. A recently
awarded grant establishes an infrastructure to monitor the quality of
routine inpatient and outpatient cardiovascular care and evaluate aggregate
outcomes against emerging benchmarks.
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The Cardiac Rehabilitation Program - Ira Nash, M.D.
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Integrative and Behavioral Cardiology Program - D Phil, Bill Gerin
Ph.D., Lynn Clemow Ph.D.
This novel program focuses on the ways in which behavior and lifestyles
affect cardiovascular disease, and how they can be modified to prevent
and treat it. The program is evidence-based, and includes research,
clinical practice, and educational programs. It has an interdisciplinary
approach, and includes physicians, psychologists, epidemiologists, nurses,
and dietitians.
The treatment arm includes individual and group sessions in stress
management, smoking cessation, weight control, and meditation. Educational
programs focus on both patients and health care providers. Fellows are
instructed in topics such as giving brief smoking counseling, recognizing
depression (a major risk factor for heart disease), and diagnosing and
treating panic disorder (a common and often unrecognized cause of non-cardiac
chest pain and other symptoms).
The research arm includes a variety of studies (mostly funded by NIH,
and including a Program Project Grant). These include:
- A study of the relationships between psychosocial factors and the
diurnal rhythm of blood pressure in black and white normotensive and
hypertensive patients, done in collaboration with Harlem Hospital
and the Sleep lab at NYU.
- A worksite-based study (The Cornell Worksite Study) of the effects
of occupational stress on 24 hour blood pressure and cardiovascular
disease. Measurements made over 3-4 year intervals include echocardiograms,
carotid ultrasound, and a variety of psychometric tests.
- A study of the determinants of white coat hypertension. Measurements
include measurement of blood pressure made in the clinic, using self-monitoring,
and 24 hour monitoring.
- We are one of 6 national sites for the Sleep Heart Health Study,
a prospective multi-center study of the relationships between sleep-disordered
breathing and cardiovascular disease. The main outcome variables are
cardiovascular morbid events.
- A study of the associations between major depressive disorder and
an altered circadian rhythm. Subjects are studied on the CRC with
polysomnography, 24 hour blood pressure and heart rate monitoring,
and blood sampling. Outcome variables include blood pressure control,
heart rate variability (HRV), and platelet reactivity.
There are also several interventional studies.
- We are investigating the use of a telephone-linked home blood pressure
monitoring system and telephone-based nurse case management to improve
the compliance of patients with uncontrolled hypertension. Both medication
adherence and blood pressure control are major outcomes .
- We are collaborating with Dr. Mark Chassin’s group in a Program
Project entitled Improving the Delivery of Effective Care to Minorities,
which is also directed at minority groups with uncontrolled hypertension.
- A study of the effects of an inexpensive brief behavioral intervention
(expressive writing) on ambulatory blood pressure in treated hypertensive
patients.
- A study of the effects of behavioral therapy for depression in hypertensives.
- A clinical trial of an omega-3 fatty acid supplement on blood lipids
and blood pressure.
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