Coronary CT for Cardiology Fellows

The basics of cardiac CT imaging

My notes on coronary computerized tomography (CT).

Anatomy

  • Coronary artery segmentation
  • Normal coronary course
  • Normal anatomy on CT
  • Common anomalous coronary arteries
  • Common anomalous coronary arteries

Classification of anomalous coronary arteries

  1. Anomalies of:
    1. Origin (>LCX from right coronary sinus most common)
    2. Course
    3. Intrinsic anatomy
    4. Termination
  2. Hemodynamic consequence: non/significant
  3. Coronary fistula
  4. Complete myocardial bridging (>LAD most common)
  5. Association with higher risk of sudden cardiac death (SCD)

Normal Anatomy

  • A normal CTCA has a high negative predictive value (98– 100%) for excluding CAD
  • Indications for CTCA:
    • Low-to-intermediate risk patients with acute chest pain and non-diagnostic ECG and serum biomarkers
    • Low-to-intermediate probability of CAD and unable to exercise or with inconclusive functional test results

Malignant Anatomy: associated with chest pain, myocardial ischemia, or sudden cardiac death

  1. RCA arising from left sinus
  2. Left main coronary artery (LMCA) arising from right coronary sinus
  3. LMCA arising from the pulmonary artery

RCA arising from left side- generally better prognosis

  • Right coronary artery originating from the left coronary sinus. RCA in red, Left main coronary artery yellow. The proximal RCA's acute angle take off passes through the pulmonary trunk and aortic root causing moderate compression.
  • Myocardial bridging of the mid LAD
  • Pulmonary trunk level showing LMCA originating from pulmonary artery (red asterisk)
  • Aorta gives rise to RCA. Pulmonary artery gives rise to LMCA, now dilated
  • Again showing aorta gives rise to RCA. Pulmonary artery gives rise to LMCA, now dilated
  • Again showing aorta gives rise to RCA. Pulmonary artery gives rise to LMCA, now dilated
  • Anomalous left coronary from the pulmonary artery (ALPACA or Balnd-White-Garland syndrome)

Ischemic Cardiomyopathy (ICM)

High risk calcification features associated with higher event rates:

  • Low attenuation plaque: <30 Hounsfield units
  • Positive remodeling: lesion with vessel area >10% larger than a proximal normal reference site (remodeling index >1.1)
  • Napkin-ring sign: low-attenuation core surrounded by a rim-like area of higher attenuation (but less than 130 HU)
  • Spotty calcification: <3 mm length calcifications comprising <90°
  • CTA plaque phenotype features
  • CTA plaque phenotype features
  • CAD-RADS scoring and modifiers

Coronary artery calcium score (CACS) of 0

  • Asymptomatic, independent of Framingham risk score: very low risk of events (0.10% per year), safety window of at least 5 years
  • No benefit from aspirin for primary prevention
  • Patients with abnormal lipid profile but CACS 0 have little benefit from statin
  • Stable symptomatic patients with low-to-intermediate pretest likelihood of CAD, a CACS 0 can safely exclude flow-limiting coronary disease
  • CACS of 0
  • CACS of 0. Minimal calcium in the aortic root and aortic valve

Abnormal coronary artery calcium score (CACS)

  • Symptomatic patients with CACS> 400 are at high risk of events (>2% per year), independent of risk factors and functional tests.
  • CACS>1000, even if normal stress testing, have significantly higher risk of major adverse events
  • CACS 1832
  • Bicuspid AV with aortic dilation, and non-obstructive mixed plaque with evidence of positive remodeling`
  • pLAD, mLAD, dLAD in cross section
  • Obstructive CAD in LAD

Coronary Dissection

  • Linear low-density intraluminal image suggestive of focal dissection
  • Moderate ostial RCA stenosis. PRedominantly non-calcified eccentric lesion with low-attenuation core
  • Moderate ostial RCA stenosis. PRedominantly non-calcified eccentric lesion with low-attenuation core

LAD calcification

  • Calcified LAD with severe dLAD lesion
  • Severe focal, eccentric, predominantly non-calcified lesion in mid-to-distal LAD with low attenuation core, positive remodeling, and napkin ring sign

CTO of LCX with RCA collaterals in patient with discordant normal SPECT but abnormal ECG stress (2mm ST-depressions) sent for CTCA to evaluate coronary anatomy

  • Diffuse calcification of D1 and CTO of LCX

ECG Reference Guide For Medical Trainees

A quick reference guide for diagnostic ECG criteria with examples. Will continue to update regularly.


P-Wave Abnormalities

Right atrial enlargement (RAE)

  • 2 things help me remember RAE. First, the normal P-wave on an ECG typically represents the left atrium because the right atrium is typically smaller and it’s electrical current is typically hidden in the left atrium’s electrical signal. Second, the SA node sits in the right atrium. So when the right atrium gets enlarged we start to see it on the ECG. The P-wave gets BIGGER! I think of it similar to what we see in left ventricular hypertrophy. Typically, in a normal QRS complex we only see the left ventricle because it’s size and electrical signal is so much larger than the right atrium (similar to our atria). However, in LVH the left ventricle gets even larger. So the electrical signal it puts out is even bigger too. This is just like what happens in RAE. The right atrium is able to be seen in the P-wave which manifests with TALL P-waves. Thus, the diagnostic criterion are:
  • Inferior lead P-waves: >2.5 mm in height (tall positive P-wave because the SA node is superior in the heart so the electrical signal in the inferior leads, the direction the electrical impulse goes toward, will be larger in size)
  • >1.5mm in V1, V2
  • Clinically can be seen in RVH, COPD, pHTN > CHD >>tricuspid stenosis

Left atrial enlargement (LAE)

  • Back to our discussion about P-waves. In normal physiology the SA node in the right atrium fires and then the signal has to travel all the way over the left atrium. We already know that on normal ECG’s that the P-wave represents the left atrium. Thus, if the left atrium gets enlarged you will see LONGER P-waves because it will take more time for that signal to reach the entirety of the left atrium. Or at least that’s how I remember it in my head. Thus, for LAE think “1 box deep, 1 box wide”. If you can fit 1 small box inside the negatively deflected P-wave you should be thinking about LAE. The diagnostic criterion are:
  • Terminal portion V1 > 1mm deep, >40ms duration
  • Inferior leads: notched P-wave > 120ms

Biatrial enlargement (BAE)

You can also have both diagnostic criterion met for both left and right atrial enlargement. In these cases we simply call it biatrial enlargement. Here’s a quick and dirty reference for atrial enlargement:


Ventricular Hypertrophy

Left Ventricular Hypertrophy (LVH)

There are a LOT of criterion for LVH but the most frequent ones that I use in clinical practice are:

  • aVL >11 (Sokolow-Lyon ‘stand alone‘ criteria)
  • Cornell Criteria: R wave in avL + S wave in V3 > 28mm in men/> 20mm in women (Easy way to remember: CorneLL has 2 L’s, aVL has 1 L. Add them together to remember you use lead V3)
  • Sokolow-Lyon Criteria: S wave in V1 + R wave in V5 or V6 > 35mm
  • Delayed intrinsicoid deflection in V5, V6 >50ms (interestingly this is the only non-voltage criteria for LVH)

LVH can also have a ‘strain pattern’ with T-wave inversions (TWI) as seen in the ECG below.

LVH with strain pattern in I, II, V5, V6

Right Ventricular Hypertrophy (RVH)

  1. RAD: mean QRS axis ≥ 100 degrees
  2. Secondary ST-T segment changes (STD, TWI) in right precordial leads
  3. (R/S ratio in V1 > R/S ratio in V5, V6) or (R/S ration in V6 <1) or (R wave > 7mm in V1)

Clinically, Posterior MI can mimic RVH

  • Factors that favor RVH diagnosis: concomitant RAD, TWI in V1-V2
  • Factors that favor posterior MI: presence of inferior Q-waves

Combined Ventricular Hypertrophy

  • Exists when criteria for both isoloated LVH) and RVH are met
  • Should be suspected when criteria for LVH is present but QRS axis is > 90 degrees or criteria for right atrial enlargement exist
  • R/S ratio approximately equal to 1 in both V3 and V4 (Kutz-Wachtel phenomenon)
Diagnosis: Atrial flutter, LAD, LVH, RVH, iRBBB

Intraventricular Conduction

Left Bundle Branch Block (LBBB)

  1. QRS ≥120 ms
  2. Terminal S-wave in V1 (late forces of QRS should be negative)
  3. I, aVL, V5, V6: Broad notched or slurred R-wave. Occasional RS pattern in V5, V6 may be attributed to displaced transition of QRS complex)
  4. No Q-waves in I, V5, V6 but in aVL a narrow Q-wave may be present without myocardial pathology
  5. Delayed onset of intrinsicoid deflection >60 ms from beginning of QRS to peak of R-wave in V5, V6 but normal in V1-V3 when small initial R-wave can be discerned

Left Anterior Fascicular Block (LAFB)

  1. LAD (QRS axis between -45 to -90 degrees) and mean QRS duration < 120 ms
  2. qR complexes in I, aVL
  3. rS complexes in II, III, aVF
  4. Prolonged R wave peak time in aVL > 45ms (from beginning of QRS complex to peak of R wave)
  5. *Absence of other causes of marked LAD such as inferior MI or LVH

Note: The entire left bundle conduction system of the heart is made up of two fascicles, one anterior and one posterior. The left anterior fascicle supplies fibers to the anterior and lateral walls of the left ventricle. The above criteria of left anterior fascicular block do not apply to patients with congenital heart disease in whom left-axis deviation is present in infancy.

Left Anterior Fascicular Block (LAFB)

Left Posterior Fascicular Block (LPFB)

  1. RAD (QRS axis 90 to 180 degrees in adults) with mean QRS duration < 120 ms
  2. rS complexes in leads I and aVL
  3. qR complexes in leads II, III and aVF
  4. *Absence of other causes of right axis deviation including lateral MI, dextrocardia, or RVH

Note: The entire left bundle conduction system of the heart is made up of two fascicles, one anterior and one posterior. The left posterior fascicle is shorter and thicker than the left anterior, and receives dual blood supply from both the left and right coronary arteries. Multivessel coronary artery disease is the most common cause of left posterior fascicular block.

Right Bundle Branch Block (RBBB)

  1. QRS ≥ 120 ms
  2. V1, V2: RSR’ with secondary R-wave usually wider than initial R-wave
  3. Minority of patients may have a wide and often notched R wave pattern in lead V1 and/or V2
  4. S wave duration > than R wave or > 40 ms in leads I and V6
  5. Normal R peak time in leads V5 and V6 but > 50 ms in lead V1

Of the above criteria, the first 3 should be present to make the diagnosis. When a pure dominant R wave with or without a notch is present in V1, the 4th criteria should be satisfied

ECG Right Bundle Branch Block RBBB 5

Incomplete Right Bundle Branch Block (iRBBB)

  1. Same criteria for RBBB but QRS < 120ms but > 100ms

Non-specific inter-ventricular conduction delay

  1. QRS ≥ 110 ms
  2. Specific criteria for RBBB, LBBB not met

Quick and dirty reference to compare LBBB and RBBB:

Bundle Branch Block : Mnemonic | Epomedicine

Atrial Rhythms

Sinus Rhythm

In medical school we are taught this incorrectly. The correct way to tell that a P-wave is of sinus origin is that they are:

  1. Upright in the inferior leads (remember the sinus node is in the right atrium so the electrical wave will go from the top down and thus be positive inferiorly)
  2. Biphasic in V1
  3. Axis between 0 to 75 degrees (i.e. upright in the inferior leads)

The number of P-waves before every QRS complex is irrelevant. You can have sinus rhythm but be in complete heart block. Or have sinus rhythm but have second degree type I or type II heart block. Generally however they should have the same morphology. A single P-wave with a different morphology can indicate a premature atrial complex (PAC) but if you have multiple different P-wave morphologies then you might be dealing with wandering atrial pacemaker (WAP) or multifocal atrial tachycardia (MAT). I think of WAP and MAT as the same rhythm across a spectrum ranging from a normal heart rate (WAP) to a fast heart rate (MAT).

Sinus Arrhythmia

Diagnostic criteria:

  • Normal P wave axis (0 to 75 degrees; i.e. upright in leads I and II)
  • P-P interval varies by > 10% or 0.16 seconds

tl;dr normal sinus P-waves (as above) but P-P interval varies by >10% or 160ms (4 little boxes). ECG intervals can vary with respiration but they shouldn’t vary by more than 10%. Often incidental without major clinical significance

High Yield Board Review Notes for Cardiovascular Disease Fellowship

The following are iterative notes that I take while studying for my general cardiology, echocardiography, and nuclear cardiology board exams. Making them public so I can access them on the go and help out anyone else looking for similar information.


Valvular Heart Disease

Aortic Insufficiency/Regurgitation (AI/AR)

Severe AI, indications for surgery

  1. Asymptomatic: EF ≤55%
  2. Asymptomatic: EF >55% + LVESD >50mm or LVESDi >25mm/m2
  3. Asymptomatic: EF >55% with progressive decline in EF to low-normal (55-60%) with LVEDd >65mm
  4. Symptomatic
  5. Other concurrent cardiac/aortic surgery

  • Severe AI surgical indications
  • Accurate measurements
  • Severe AI via echo
  • Chronic sever eaortic regurgitation (AI/AR) symptom progression
  • Severe AI: survival and LV function
  • Severe AI: survival and NYHA class

Aortic Stenosis

  • Prostehtic AV algorithm

Low-Flow Low-Gradient AS (LF-LG AS)

  • LFLG algorithm 2

Bicuspid Aortic Valve

  • Bicuspid AV algorithm
  • Frequency of bicuspid anatomy
  • Screening guidelines
  • Bicuspid AV imaging surveillance guidelines
  • Bicuspid aortic valve surgical intervention guideline recomendations

Surgical indications for dilated aortic root/ascending aorta

Aorta sizeIndicationClass recomendation
≥ 5.5 cmRisk factors for dissection (FH, growth rate >0.5cm/year, bicuspid AV)I
> 5.0 cmRisk factors and low surgical risk <4% (FH of dissection, growth 3-5mm/year, aortic coarctation, small stature)IIa
> 5.0 cmLow risk, experienced surgeon, expert centerIIa
> 4.5 cmBicuspid AV planning for surgical AVR for AS/AIIIa

*Aortic root measured at sinus of Valsalva

ACC Guideline: Aortic Surgery for Bicuspid AV

Mitral Regurgitation

  • Simplified asymptomatic severe primary MR algorithm
  • Primary mitral regurgitation (MR) algorithm
  • Qualitative and quantitative MR by echocardiography (TTE)
  • Mitral valve anatomy
  • Etiologies of chronic mitral regurgitation (MR)- acute and chronic
  • Pathophysiology of acute and chronic MR
  • Qualitative assessment of MR
  • Clinical workflow for diagnosis and management of MR
  • MR algorithm
  • Qualitative and quantitative MR by echocardiography (TTE)
  • Medical therapy for chronic MR
  • Surgical interventions for asymptomatic chronic primary MR
  • Surgical interventions for asymptomatic chronic primary MR
  • Surgical interventions for asymptomatic chronic primary MR
  • Transcatheter edge-to-edge repair (TEER) for severe primary MR

Mitral valve prolapse and flail

Carpentier Classification of MR

  • Type 1: normal leaflet mobility (primary: endocarditis, perforation, clefts; secondary: dilated annulus)
  • Type 2: excessive leaflet mobility (prolapse, flail)
  • Type 3: restricted leaflet motion
    • 3a: in systole and diastole (Fibrosis of subvalvular apparatus: rheumatic, radiation, drug-induced injury, inflammatory conditions)
    • 3b: only in systole (Leaflet or chordal tethering: ICM, NICM causing LV dilation)

Mitral Valve Regurgitation Review Article

Chronic MR Algorithms

  • Qualitative and Quantitative Assessment of MR severity by echo
  • Recommended Treatment of severe secondary MR
  • Severe MR Algorithm
  • Recommended Treatment of severe secondary MR
  • Algorithm for Eligibility of Transcatheter Edge-to-Edge Repair (TTER) in severe MR
  • Semiquantitative parameters in MR
  • Quantitative measures for severe MR by PISA png
  • Pulsed Doppler Volumetric Quantification of severe MR
  • Indications for exercise stress testing in MR
  • Routine monitoring of MR via echo
  • MR treatment algorithm

Indications for TTE, TEE in MR

  1. Initial evaluation if suspicious for MV disease or MVP
  2. Initial evaluation of known ur suspected MR
  3. Annual evaluation in severe MR
  4. Reevaluation of MR with change in clinical status
  5. TEE to determine mechanism of MR and suitability of valve repair
  6. *Inappropriate: routine evaluation of MVP with (1) no or mild MR and (2) no change in clinical status

Mitral Valve Prolapse (MVP)

Arrhythmic MVP

  • Non-invasive markers associated with sudden cardiac death (SCD) despite not having severe MR
  • High density of PVCs, inferior TWI, spiked systolic high-velocity signal on echo (Pickelhaube sign), myocardial/papillary scar on MRI
  • Pickelhaube sign: peak systolic lateral mitral annular velocity ≥16 cm/s. More likely to have malignant arrythmia in those with myxomatous bileaflet MVP (‘B’ in image below)
Non-invasive markers associated with SCD in MVP

Acute Severe MR

  • Rapid equalization of pressure across LA/LV may only cause a short, unimpressive murmur (may only appear as mild MR)
  • *Suspect in acute heart failure with normal LV systolic function
  • *Suspect in decreased LVOT VTI despite hyperdynamic LV EF (suggestive of low forward flow- consistent with severe MR)

Mitral Stenosis

  • Stages of mitral stenosis (MS)
  • Stages of mitral stenosis (MS)
  • Wilkins Score for rheumatic mitral stenosis (MS)
  • Mitral stenosis (MS) pressure half-time
  • Mitral stenosis (MS) pressure half-time 2
  • Mitral stenosis (MS) mean gradient (MG)
  • Mitral stenosis (MS) PISA
  • Continuity equation for mitral stenosis (MS)
  • Mitral valve area via LHC
  • Gorlin formula: mitral valve area via LHC
Typical appearance of rheumatic mitral stenosis

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease


Invasive Hemodynamics Review


Classic Valvular Murmurs

LesionTimingQualityRadiationSeverity
ASCrescendo-decrescendo

Gap between S1, murmur, and S2
Harsh, noisy
MRHolosystolic through S2

Starts with S1 through S2
Blowing, high pitchedAnterior prolapse/flail: axilla, left intrascapular area

Posterior: anteriorly along aortic outflow in left parasternal area (can be confused with SEM)
Weak correlation between intensity and severity

S3: increase in diastolic flow across MV orifice during rapid filling phase  

Increased P2 intensity: pHTN   Enlarged, displaced LV impulse: LV dilation
Post PVCMR changes little: high gradient between LA/LV in SR and post-PVC*AS murmur increases post-PVC as SV after PVC is greater (more flow)  
MVPEarly, mid-systolic click ➡️ systolic murmur±High pitched, ‘whoop’ sound Maneuvers on click and murmur:
– ⬇️ LV volume/preload (Valsalva, squat to stand): murmur/click occur earlier in systole
– ⬆️ LV afterload (squatting): murmur/click occur later in systole
Severe MVP: holosystolic murmur 
Differentiating AS from MR

Prosthetic Valves

Prosthetic Aortic Valves

Pressure recovery: due to small aorta causing falsely elevated mean gradient readings and thus low AVA

Prosthetic Valve Thrombosis

Prosthetic Valve Guidelines from JASE (Journal of American Society of Echocardiography)


Heart Failure

Non-Ischemic Cardiomyopathy (NICM)

2022 AHA/ACC/HFSA Guidelines

Abnormalities in Hepatic Vein Flow on Doppler

Amyloidosis

Diagnostic algorithm for diagnosis of amyloidosis

Figure 2.
99mTechnetium-pyrophosphate imaging for transthyretin cardiac amyloidosis

Treatment for ATTR amyloidosis

Medical therapies for amyloid

  • Tafamadis: amyloidosis but not NYHA IV
  • Patisiran: for ‘papa’- familial amyloid neuropathy

Pulmonary Hypertension (pHTN)

Peak TR jet velocity (m/s)Presence of other echo ‘PH Signs’TTE probability of pHTN
≤2.8 or not measurableNoLow
≤2.8 or not measurableYesIntermediate
2.9-3.4NoIntermediate
2.9-3.4YesHigh
>3.4Not requiredHigh

Echo Findings in Pulmonary Hypertension (pHTN)

VentriclesPulmonary ArteryIVC, RA
RV/LV basal diameter ratio >1RVOT acceleration time (AT) <105ms ±midsystolic notchingIVC >21mm, <50% inspiratory collapse with sniff (or <20% with quiet inspiration)
IVS flatteningEarly diastolic PI velocity >2.2m/sRA size >18cm2 at end-systole
PA diameter >25mm

Chagas Cardiomyopathy

Hypertrophic Cardiomyopathy (HCM)

Surgical options and complicationsSeptal myectomy –> LBBB
Alcohol septal ablation —> RBBB
DysopyramideQT-prolongation
Physical exam maneuversLouder murmur with Valsalva (decreased preload)Softer murmur with hand grip
High risk features for SCD1. First degree relative SCD
2. IVSd ≥30mm (IIa indication: ICD for primary prevention)
3. Unexplained syncope in past 6 months
4. LV apical aneurysm
5. EF <50%
6. NSVT: children (IIa), adults (IIb)
7. Extensive LGE on CMR (IIb)
8. Exercise induced NSVT or abnormal BP response to (drop ≥20mmHg) + high risk features (IIa- it is IIb if no high risk features)
HCM family screening in 1st degree relatives

Echo following septal myectomy for HCM with edge-to-edge (Alfieri) repair of the mitral valve

  • Anterior and posterior leaflets are sutured together in the mid portion giving the typical appearance of a double-orifice mitral valve
  • The color jet that can be seen on the septal wall represents flow from a coronary-LV fistula, a common benign finding after septal myectomy procedures
  • May lead to functional mitral stenosis (MS) requiring surgical interventions following edge-to-edge repair

Coronary Artery Disease

Guidelines/Review Articles

CABG (coronary artery bypass graft) Guidelines

UA/NSTEMI

  • TIMI risk score for UA/NSTEMI: predicts all-cause mortality, new/recurrent MI, severe recurrent ischemia requiring urgent revascularization through 14 days
  • GRACE score for UA/NSTEMI: predicts in-hospital mortality and death or MI
  • Risk stratification into ischemia guided, immediate invasive

NSTEMI: Early invasive strategy (within 24 hours) if:

  1. Elevated troponin
  2. Dynamic ST-changes
  3. Recurrent angina
  4. EF <40%
  5. Recent PCI
  6. Prior CABG
  7. DM
  8. Intermediate/high risk score (GRACE >140)

ACS Medications and Anti-Platelet Agents

NTg and PDE5i interaction

  • NTg contraindicated 24 hours of last use of sildenafil (Viagra, Revatio)
  • NTg cointraindicated 48 hours of last use of tadalafil (Cialis)

Coronary Microvascular Dysfunction

  • Coronary flow reserve (CFR) <2.5 indicative of microvascular disease in the absence of obstructive epicardial CAD
  • Treatment: ± beta blockers, CCB but not definitive guideline

Coronary Flow Reserve

  • iFR ≤0.89 or FFR <0.8

STEMI

  • RCA vs. LCX: STE III >II indicates RCA

Spontaneous Coronary Artery Dissection

  • Risk factors: fibromuscular dysplasia (FMD), postpartum status, multiparity, connective tissue disorders, systemic inflammatory conditions, and hormonal therapy
  • FMD screening: screen for extracoronary disease from brain to pelvis with CTA or contrast-enhanced MRA for aneurysms, dissections, and other areas of FMD
  • Renal aneurysms: treat when >2cm
  • Renal stenosis: balloon angioplasty > stenting. Stent reserved for procedural complications (i.e. dissection)


General Cardiology

Guideline Indications

TreatmentIndication
EntrestoHFrEF (≤40%) and NYHA II, III
IvabridineHFrEF (≤35%) at max tolerated dose of bb in SR with HR ≥70bpm
IV iron sucrose or ferric carboxymaltoseNYHA II, III and at least 1 of the following: 1. Ferritin <100 ng/mL2. Ferritin 100-299 ng/mL but iron sat <20%
PatisiranFamilial amyloid neuropathy
ICD, primary prevention1. EF ≤35%, NYHA II, III due to N/ICM
2. EF ≤30%, NYHA I, II, III
CRT indications1. LBBB with QRS ≥150 msec
2. EF ≤35%
3. NYHA II, III or ambulatory type IV
4. Already on GDMT
(LOE A for NYHA class III, IV and LOE B for NYHA class II)

ICD Indications

EFNYHAEtiologyClass Indication
≤35%II-IIIN/ICMI
≤35%INICMIIb
≤30%IICMI
≤40%Inducible VT/VF on EPSICMI
>55%Inducible VT/VF on EPS with extensive scarring on PET/MRIBrugadaIIb
>55%Inducible VT/VF on EPS with extensive scarring on PET/MRISarcoidIIa

Hypertension (HTN)

TypeDefinition
Resistent HTN≥130/80 on 3 meds for ≥ 1 month
Refractory HTNNot adequately controlled on 5 meds
PseudoresistentWhite coat HTN
MaskedNormal in office, high at home

Genetics

MutationAssociated Disease
Lamin A/CSkeletal muscle dystrophies
Notch 1Bicuspid AV, early AV calcification
T-box 5Holt-Oram syndrome (abnormal thumbs, ASD, VSD, HCM, conduction disease)
FBN1Fibrillin-1. 90% AD for Marfan syndrome
COL3A1Collagen- Ehlers-Danlos syndrome

Long QT-Syndromes

SyndromeGeneFunctional EffectAssociationInheritance
LQTS 1KCNQ1⬇️ IKSSwimmingAD; AR, ~30-35%
LQTS 2KCNH2⬇️ IKRStartleAD, ~25-30%
LQTS 3SCN5A⬆️ INASleepAD, ~5-10%
JLNS 1, 2KCNQ1, KCNE1⬇️ IKRDeafnessAR, very rare

Genetic Screening

  • Start with index family member with unknown or uncertain patterns (athletes with LVH or apical hypertrophy)
  • Idiopathic dilated cardiomyopathy without known mutation in family: first degree relatives TTE q3-5 years

Physical Exam

MurmurLesionLocation Best Heard
Fixed split S2ASD 
Single 2nd heart soundTOF 
Absent A2AS 
Absent P2Pulmonary stenosis 
Loud P2pHTN 
Worsens with ValsalvaHOCM (decreased preload) 
Diastolic murmur?Subaortic membrane 
Early systolic clickBicuspid AV (stiff but mobile)Left 2nd IC space, apex
Mid-systolic clickMVPLeft lower sternal border
Diastolic opening snapMS (and diastolic rumble)Left lower sternal border in LLD position

JVD Physical Exam Findings

DiagnosisJVD Finding
Constrictive pericarditisProminent Y descent, ±prominent X descent
TamponadeProminent X descent, absent Y descent
RV infarctionAbsent X and Y descent
VT, CHBVariable size A-waves (‘cannon A-wave’)

Vascular Diseases

Abdominal Aortic Aneurysm (AAA)

Society for Vascular Surgery recommendations, surveillance intervals for asymptomatic AAA:

  1. >2.5 cm but <3.0 cm, rescreen after 10 years
  2. 3.0-3.9, repeat imaging every 3 years
  3. 4.0-4.9, repeat imaging in 12 months
  4. 5.0-5.4, repeat imaging in 6 months

Indications for elective repair of an asymptomatic AAA include:

  1. >2.5 cm but ≤5.5 cm
  2. rapid expansion
  3. AAA associated with peripheral arterial aneurysms or peripheral artery disease.

May-Thurner Syndrome

PathophysiologyAnatomical variant: right common iliac artery overlies and compresses the left common iliac vein against lumbar spine
Risk factorsLeft lower DVT
Scoliosis
Female sex
OCP use or recent pregnancy
Left lower extremity swelling in absence of DVT
Clinical presentationYoung adult woman with left leg swelling and DVT
Diagnostic testMagnetic resonance venography of the pelvis
References
1. Peters M, Syed RK, Katz M, et al. May-Thurner syndrome: a not so uncommon cause of a common condition. Proc (Bayl Univ Med Cent) 2012;25:231-3.
2. Baglin T, Gray E, Greaves M, et al.; British Committee for Standards in Haematology. Clinical guidelines for testing for heritable thrombophilia. Br J Haematol 2010;149:209-20.
3. Society for Vascular Medicine. Five Things Physicians and Patients Should Question (Choosing Wisely website). 2015. Available at: http://www.choosingwisely.org/wp-content/uploads/2015/02/SVM-Choosing-Wisely-List.pdf. Accessed 03/22/2019.
May-Thurner Syndrome

Electrophysiology (EP)

CRT Indications

Antiarrhythmic Medications

*DFT: defibrillator threshold
SyndromeGeneMiscellaneous
ARVCPKP-2Plakophillin-2Intracellular calcium signaling abnormality
ARVCDSPDesmoglein-2Intracellular calcium signaling abnormality
ARVCDSC2Desmocollin-2Intracellular calcium signaling abnormality
ARVCJUPPlakoglobinIntracellular calcium signaling abnormality
MarfanFBN1Fibrillin-1Associated with aortic aneurysm, dissection
Ehlers-DanlosCOL3A1Collagen type 3, a1Associated with aortic aneurysm, dissection
Loeys-DietzTGFB1, 2Transforming growth factorAssociated with aortic aneurysm, dissection
CPVT1RYR-2Ryanodine receptorAD (>70% of cases, intracellular Ca-signaling)
CPVT2CASQ2CalsequestrinAR inheritence
LQTS1KCNQ1K current IKsbb (nadalol > propanalol)
***Associated with SCD while swimming
LQTS2KCNH2K current IKrK-supplementation (IIb rec)
LQTS3SCN5Aalpha-unit of INa±Mexilitine (IIb rec)
GAIN of function mutation
BrugadaSCN5ALOSS of function mutation
Hereditary PAHBMPR-2Bone morphogenic protein receptorAssociated with >70% of inherited pulmonary arterial HTN
DCMLamin A/C± skeletal muscle dystrophy
T-box5Holt-Oram (hand heart, ASD)
Notch 1Bicuspid AV, premature AV calcification
Genetic mutations associated cardiac conditions
Cardiac Genetics Chart

Supraventricular Tachycardia (SVT)

  • Focal AT- ongoing treatment options

Early Afterdepolarization (EAD) and Delayed Afterdepolarization (DAD)

Localizing VT Origin: LVOT vs. RVOT

  • Step 1: V1
    • LBBB: anterior to posterior- RVOT
    • RBBB: posterior to anterior- LVOT
  • Step 2: concordance
    • Positive: originates near base
    • Negative: originates near apex
  • LVOT VT
  • RVOT VT
  • RVOT: later R-wave transition (≥V3)
  • LVOT: earlier R-wave transition, LBBB, inferior axis

Bidirectional Ventricular Tachycardia (aka CPVT or catecholaminergic polymorphic VT)

  • Also known as Familial polymorphic VT
  • Inheritance: RyR2 gene mutation is AD, CASQ2 gene mutation is AR
  • Treatment: Nadolol (non-selective β1 and β2 agonist)
  • Dose: 0.8 mg/kg of nadolol ~ 1 mg/kg of metoprolol SR
  • Flecainide also used (ask EP)
Source: Leren, I., Saberniak, J., Majid, E., Haland, T., Edvardsen, T., & Haugaa, K. (2016). Nadolol decreases the incidence and severity of ventricular arrhythmias during exercise stress testing compared with β1-selective β-blockers in patients with catecholaminergic polymorphic ventricular tachycardia. Heart Rhythm13(2), 433-440. doi: 10.1016/j.hrthm.2015.09.029

2:1 AV Block

AV nodeHPS
Type of BlockMobitz I >> Mobitz IIMobitz II > Mobitz I
Conducted QRSNarrow (unless preexisting BBB)Wide (except intra-His block)
Escape rhythmReliable (narrow QRS)Unreliable (wide QRS)
PR on conducted beatsLongNormal
*Carotid sinus pressure Block worsensBlok improves
*Exercise/atropineImproves blockBlock worsens
Characteristics to identify site of block in 2:1 AVB

Stroke (CVA) Management

Blood Pressure

  1. If tPA used: BP should be lowered <180/110 prior to tPA administration
  2. After tPA: <180/105 for at least 24 hours post-tPA
  3. No tPA: only treat if >220/120
  4. Can treat if no tPA plus other reason to treat (Aortic dissection, pre/eclampsia, unstable CAD, acute HF)

CHA2DS2-VASc

  • 2 points: age ≥ 75 years and history of stroke/TIA/thromboembolism

Contraindications (CI) to tPA

AbsoluteRelative
History of hemorrhagic stroke or stroke unknown originTIA in prior 6 months
CVA within previous 6 monthsOral anticoagulation
CNS neoplasmPregnancy or first post-partum week
Major trauma, surgery, or head injury in past 3 weeksNon-compressible puncture site
Bleeding diathesisTraumatic resuscitation
Active bleedingRefractory HTN (sBP > 180)
Advanced liver disease
Infective endocarditis
Active peptic ulcer

Pulmonary Embolism


Cardiac Oncology

  • Dexrazoxane: prevent anthracycline-induced cardiotoxocity
  • Anthracycline cardiotoxicity: risk if >250mg/m2

Congenital Heart Disease (CHD)

D-Loop Transposition of the Great Arteries (D-TGA)

  • Atrio-ventricular concordance and ventricular arterial discordance
  • 2nd most common cyanotic congenital lesion (#1 is ToF)
  • Associated defects: VSD (~40%), pulmonic stenosis (PS), coronary artery anomalies
  • D-TGA anatomy
  • D-TGA Surgical Corrections
  • D-TGA surgical correction complications
  • Complications of arterial switch
  • Event free survival following atrial switch
  • Apical 4 chamber view showing anterior transposed aortic valve with posterior pulmonary valve behind it

Complications Following D-TGA Surgical Correction: Arterial Switch (Mustard/Senning Procedure)

  1. Arrhythmia: sinus node dysfunction, frequent SVT
  2. Systemic RV: 25% develop heart failure in their 30’s
  3. Tricuspid regurgitation (TR): functional due to annular dilation

Complications Following D-TGA Surgical Correction: Atrial Switch

  1. Supravalvular AS, pulmonic stenosis (AS), PPS (pulmonary artery stenosis)
  2. Coronary stenosis at re-implantation site
  3. Branch pulmonary artery stenosis
  4. Neo-aortic dilation and AI

L-TDA (or congenitally corrected-TGA)

  • Double-discordance (RA to LV to PA, LA to RV to aortia)
  • Non-cyanotic
  • Treat severe TR like severe MR in normal patients
  • Complications: TR, RV dysfunction, CHB (complete heart block)
  • L-TDA (ccTGA)
  • Complications of L-TGA


Biostats

TermDefinitionExample
Relative risk reduction (RRR)Rate in treatment/rate in placebo10%/20%=0.5
Absolute risk reduction (ARR)(Rate in placebo)-(rate in treatment)20%-10%=10% or 0.1
Number needed to treat (NNT)1/(ARR)1/(0.1)=10 so treat 10 patients over 2 years to prevent 1 event
Example: over a 2 year period therapy A has an event rate of 10% and placebo has an event rate of 20%

Echocardiography

Physics

Speed of sound propagation through tissue: 1540 m/s

Mitral Valve Leaflets on TEE

MV Leaflets on TEE

Stress Testing

Duke Treadmill Score= minutes of exercise – (5 x mm of ST-depression) – (4 x anginal index)

  • Anginal index: 0 for no angina, 1 for non-limiting angina, 2 for having to stop exercise due to angina
  • Positive score is good. Possible to get a negative score
  • Score ≤ -11 is high risk (79% survival at 5 years), -10 to +4 is medium risk (95% survival at 5 years) ≥5 is low risk (99% 5 year survival)
  • Consider LHC for high risk patients (≤ -11)

Nuclear Cardiology

Occupational Dose Limits

1 Rem = 0.01 Sv (international standard unit)

LocationRemSv
Whole body (organs)5 Rem0.05 Sv
Skin50 Rem0.5 Sv
Lens of eye15 Rem0.15 Sv
Pregnant workers
(Over gestation period)
500 mRem5 mSv
Fetus
(non-occupational worker)
500 mRem5 mSv
General public100 mRem1 mSv

Shielding

Alpha particles

Particle typeShield requirement
Alpha particlesSheet of paper
Beta particlesPlastic/clothing
Gamma raysInches/feet of concrete or lead

Common artifacts

  • LBBB: anterior septum (occurs least frequently with NM stress)

Abnormal TID (~1.36, exercise ≥1.29) with normal perfusion: special considerations

  1. HTN with LVH
  2. Difference in HR between rest and stress
  3. Technical difficulties in image acquisition

Echo Cheat Sheet For First Year Cardiology Fellows

When my co-fellow and started our cardiology fellowship we wish we had an echocardiography reference value cheat sheet. So we decide to make one for our new first year fellows! Our hope is that by having all of the reference values organized in one easily accessible place online that we can ease any new cardiology fellow into their new role. Instead of making it a Word document or PDF we wanted to share it with any other fellows who may find this useful. We will continue to update it with useful educational links, images, and videos over time. *Please only use this as a reference. The most reliable sources of information are ASE guideliens*

Echocardiography Reference Values

Normal Values for Aorta via 2D echo (Indexed to BSA)

Normal intervalIndexed interval
Aortic annulus20-31 mm12-14 mm/m2
Sinus of Valsalva29-45 mm15-20 mm/m2
Sinotubular junction22-36 mm13-17 mm/m2
Ascending aorta22-36 mm13-17 mm/m2
Aortic arch22-36 mm
Descending aorta20-30 mm

Aortic annulusSinus of ValsalvaSinotubular junctionAscending aortaAortic arch
AgeMenWomenMenWomenMenWomenMenWomenMenWomen
<3011.4 ± 1.211.4 ± 1.115.3 ± 1.815.5 ± 1.512.7 ± 2.313.5 ± 1.414.3 ± 1.615.1 ± 1.610.1 ± 1.310.7 ± 1.0
30-3911.4 ± 1.111.7 ± 1.015.7 ± 1.316.5 ± 1.613.3 ± 1.314.3 ± 1.514.5 ± 1.416.4 ± 1.810.8 ± 1.311.6 ± 1.6
40-4911.5 ± 0.911.7 ± 1.016.6 ± 1.516.8 ± 1.414.1 ± 1.514.6 ± 1.215.5 ± 1.516.4 ± 1.411.3 ± 1.311.5 ± 1.2
50-5911.5 ± 0.912.0 ± 0.916.8 ± 1.717.9 ± 1.614.1 ± 1.515.7 ± 1.316.2 ± 1.618.0 ± 1.411.3 ± 1.212.7 ± 1.1
60-6912.1 ± 1.011.7 ± 1.117.8 ± 1.617.5 ± 1.715.1 ± 1.614.7 ± 1.617.3 ± 1.717.6 ± 1.712.0 ± 1.112.5 ± 1.4
>7012.0 ± 1.011.6 ± 1.118.1 ± 1.718.2 ± 1.914.7 ± 1.615.5 ± 2.017.5 ± 1.418.2 ± 3.312.2 ± 1.312.7 ± 1.2
All11.6 ± 1.011.7 ± 1.016.6 ± 1.817.0 ± 1.913.9 ± 1.814.7 ± 1.715.7 ± 1.816.9 ± 2.311.2 ± 1.411.9 ± 1.5
Aortic Root Dimensions

Aortic Regurgitation

Primary Parameters
MildModerateSevere
Vena contracta (cm)< 0.30.3 – 0.6> 0.6
PHT (ms) – CW doppler> 500200-500< 200
Diast flow rev – PW desc AortaIf present, early diastolicEarly diastolicHolodiastolic
Primary Parameters

Quantification of Jet
MildModerateSevere
Jet-width / LVOT-width< 0.250.25 – 0.64> 0.64
Jet-area / LVOT-area< 0.050.05 – 0.59> 0.59

Qualitative Parameters
MildModerateSevere
Jet areaSmallVariableLarge if central, variable if eccentric
Coaptation defectMildModerateSevere
CW-profileWeakViableDense
LA sizeNormalNormal or enlargedEnlarged
LV sizeNormalNormal or enlargedEnlarged

PISA Parameters
MildModerateSevere
EROA (cm2)< 0.10.1 – 0.29≥ 0.30
Regurgitant volume (ml/beat)< 3030 – 59≥ 60
Regurgitant fraction (%)< 3030 – 49≥ 50

Aortic Stenosis

Disease Defining Parameters
MildModerateSevere
Valve area (cm2)> 1.51.0 – 1.5< 1.0
Indexed valve area (cm2/ m2)> 0.850.6 – 0.85< 0.6
Measured Parameters
MildModerateSevere
Mean gradient (mmHg)< 2020 – 40> 40
Peak gradient (mmHg)< 3535 – 65> 65
Peak velocity (m/s)2.6 – 2.93.0 – 4.0> 4.0
Dimensionless index (LVOT/AV)> 0.50.5 – 0.25< 0.25

Bioprosthetic Aortic Valve Stenosis

EOA (effective orifice area) index
  • Mild PPM: EOA ⩽ 0.85 cm2/m2
  • Moderate PPM: EOA 0.65–0.85 cm2/m2
  • Severe PPM: EOA < 0.65 cm2/m2
Practice Questions | Echocardiographic Evaluation of Aortic Valve Prosthesis
Prosthesis‐patient mismatch: definition, clinical impact, and prevention

Visual Assessment of LV RWMA 

Type of motionDefinitionWall Motion Score
Normal Normal thickening (>30% thickening end-systole to end-diastole)1
Hypokinesia Reduced thickening (10-30%)2
Akinesia Markedly reduced thickening (<10%)3
Dyskinesia Paradoxical thinning and/or outward motion during systole4
Aneurysmal Diastolic deformation5

LV Dimension and Volume

LV Dimension
 Women Men 
 Normal Mild Moderate Severe Normal Mild Moderate Severe 
Diastolic diameter 3.9-5.3 5.4-5.7 5.8-6.1 >6.2 4.2-5.9 6.0-6.3 6.4-6.8 >6.9 
Diastolic diameter/BSA cm/m22.4-3.2 3.3-3.4 3.5-3.7 >3.8 2.2-3.1 3.2-3.4 3.5-3.6 >3.7 

LV Volume
 Women Men 
 Normal Mild Moderate Severe Normal Mild Moderate Severe 
Diastolic volume, mL 56-104 105-117 118-130 >131 67-155 156-178 179-201 >201 
Diastolic volume/BSA mL/m235-75 78-86 87-96 >97 35-75 76-86 87-96 >97 
Systolic volume, mL 19-49 50-59 60-69 >70 22-58 59-70 72-83 >83 
Systolic volume/BSA 12-30 31-36 37-42 >43 12-30 31-36 37-42 >43 

LV Ejection Fraction (EF %)

Women Men 
Normal Mild Mod Severe Normal Mild Mod Severe 
54-74 41-53 30-40 <30 52-72 41-51 30-40 <30 

Right Ventricle Dilation

Base (RVD1)> 42mm
Mid (RVD2)> 35mm
Longitudinal dimension (RVD3)> 86mm
RV focused apical 4 chamber
PLAX Distal RVOT (left side)> 30 mm
PSAX Proximal RVOT (middle)> 35 mm
PSAX Proximal RVOT (right side)> 27 mm

RV dimensions
 Normal Dilated Moderate Severely 
RV diameter (RVD 1) 2.0-2.8 2.9-3.3 3.4-3.8 ≥3.9 
RV diameter (RVD 2) 2.7-3.3 3.4-3.7 3.8-4.1 ≥4.2 
Base-to-apex length 7.1-7.9 8.0-8.5 8.6-9.1 ≥9.2 

RV diameter
 Normal Mild Moderate Severely 
Above aortic valve 2.0-2.8 2.9-3.3 3.4-3.8 ≥3.9 
Above pulmonic valve 2.7-3.3 3.4-3.7 3.8-4.1 ≥4.2 

PA diameter
 Normal Mild Moderate Severe
Below pulmonic valve 1.5-2.1 2.2-2.5 2.6-2.9 ≥3.0 

RV size and function
 Normal Mild Moderate Severe
RV diastolic area, cm2 11-28 29-32 33-37 ≥38 
RV systolic area, cm2 7.5-16 17-19 20-22 ≥23 
RV fractional area change, % 32-60 25-31 18-24 ≤17 

Left Atrial Size and Volumes

Atrial dimensions
 Women Men 
 Normal Mild Mod Severe Normal Mild Mod Severe 
LA diameter 2.7-3.8 3.9-4.2 4.3-4.6 ≥47 3.0-4.0 4.1-4.6 4.7-5.2 ≥5.3 
LA diameter/BSA 1.5-2.3 2.4-2.6 2.7-2.9 ≥3.0 1.5-2.3 2.4-2.6 2.7-2.9 ≥3.0 
RA minor axis, cm 2.9-4.5 4.6-4.9 5.0-5.4 ≥5.5 2.9-4.5 4.6-4.9 5.0-5.4 ≥5.5 
RA minor-axis/BSA (cm/m21.7-2.5 2.6-2.8 2.9-3.1 ≥3.2 1.7-2.5 2.6-2.8 2.9-3.1 ≥3.2 

LA area (cm2)
Women Men 
Normal Mild ModSevere Normal Mild ModSevere 
<20 20-30 30-40 >40 <20 20-30 30-40 >40 

Atrial volumes
 Women Men 
 Normal Mild ModSevere Normal Mild ModSevere 
LA volume 22-52 53-62 63-72 ≥73 18-58 59-68 69-78 ≥79 
LA volume/BSA 22±6 29-33 34-39 ≥40 22±6 29-33 34-39 ≥40 

Mitral Regurgitation

Primary parameters
 Mild ModSevere 
Vena Contracta <0.3 0.3-0.69 ≥0.7 
EROA (cm2) <0.2 0.2-0.39 ≥0.4 
Jet size <4 cm2 or <20% of atrial size 4-10cm 2 or 20-40% of atrial size >10cm 2 or >40% of atrial size 
Jet orientation Central Variable Eccentric 
Pulmonary vein flow S-dominant Reduced S-wave Systolic flow reversal 

Qualitative parameters
 Mild Mod Severe 
Mitral valve apparatus Normal-mildly abnormal Often abnormal Abnormal, possibly flail 
CW-profile Weak Variable Dense 
Shape CW-profile Parabolic Variable Early peak, triantriangular 
LA sizeNormalNormal or dilatedDilated

Additional PISA-parameters
     Mild Mod Severe 
Regurgitation volume (mL/beat) <30 30-59 ≥60 
Regurgitation volume (EROA x TV)   
Regurgitation fraction (%) <30 30-49 ≥50 
PW-doppler A-dominant Variable High E values 

Miscellaneous parameters
    Mild Moderate Severe 
PW-doppler A-dominant Variable High E values 

Mitral Stenosis

Primary parameters
   Mild Mod Severe 
Valve area>1.5cm21.5-1.0m2<1.0cm2
Mean gradient<5mmHg5-10mmHg>10mmHg
PAP<30 mmHg30-50>50

Pulmonary Regurgitation

 MildModSevere
Pulmonary valve morphologyNormalNormal/abnormalAbnormal
Density CW-dopplerWeak, slow decalVariableDense, steep deceleration, early termination of diastolic flow
Jet width color DopplerSmall, <10 mm length, narrow originVariableLarge, wide origin
Ratio pulmonic to aortic flowNormalVariableSignificantly increased

Pulmonary Stenosis

 MildModSevere
Peak velocity (m/s)<33-4>4
Peak gradient (mmHg)<3636-64>64

Tricuspid Regurgitation

 MildModSevere
PISA radius<0.60.6-0.9>0.9
Vena contracta (cm_Not defined<0.7>0.7
Liver vein flowS-dominantReduced S-waveSystolic flow reversal, jet reaching liver vein

Additional Quantitative Parameters
 Mild Moderate Severe 
Jet size<5 cm25-10 cm2>10 cm2
IVC size<2.1cm, compressibleIn between>2.1cm, not compressible
 
Additional Qualitative Parameters 
 Mild Moderate Severe 
Coaptation defectMildModSevere
RV sizeNormalNorma/enlargedEnlarged
RA sizeNormalNormal/enlargedEnlarged
CW-profile tricuspid regurgitationWeak VariableDense
Shape CW-profile TRParabolicVariableEarly peak, triangular

Tricuspid Stenosis

Mean PG≥ 5 mmHg
Valve area ≤ 1cm2
VTI of TV inflow>60cm
Pressure half time≥190 ms
RASeverely enlarged
IVCElnarged

Pulmonary Artery Pressure

 RA pressure
IVC <2.1cm, >50% sniff3 mmHg
All others or if not visualized8 mmHg
>2.1cm, sniff <50%15 mmHg

Pulmonary HTN (pHTN)

Mild30-50 mmHg
Moderate51-65 mmHg
Severe> 65mmHg

LV Region Identification

Diastolic Function

Mitral Valve Leaflets on TEE

https://thoracickey.com/role-of-transesophageal-echocardiography-in-mitral-valve-repair/

Useful Websites

Hahnemann University Hospital Closure Saga Continues: ex-residents & fellows likely forced to purchase their own tail end medical malpractice insurance

In June I completed my three year internal medicine residency at Hahnemann University Hospital/Drexel University College of Medicine. In July the hospital, recently sold to new owners, shut its doors.

I wasn’t impacted directly. However active residents and fellows, including first year residents starting the first month of training who moved their lives and families, were forced to find new residency programs. Our program leadership were incredibly supportive and helped these residents and fellows find new hospitals to finish their training. We thought it was in the rear view. It was stressful but it was over. We got out. Turns out that was just chapter one.

Last week our Program Director (PD) informed us that the current owners of the hospital would likely not be covering our tail end medical malpractice insurance. It will likely cost a few hundred to a few thousand dollars depending on the duration of malpractice needed. It can be much more expensive for other fields like OB/GYN or emergency medicine. You can see the full email sent from our PD in my tweet below.

You might be wondering how this is legal given it is detailed in our contract that they have to cover tail end malpractice insurance. Well, it isn’t but they’re doing it anyway. You also might be wondering what tail end medical malpractice insurance is and until a week ago I didn’t know either as I detailed in my Instagram post below.

View this post on Instagram

The #HahnemannClosure saga continues 😡 Remember Hahnemann? It was that teaching hospital that closed its doors and orphaned over 400 residents and fellows this past July. Well, this week we learned that the owners of the hospital plan to break their contractual obligations and force us to pay for tail end malpractice insurance ▪️ You might be wondering ‘what’s tail end malpractice insurance’ and to be honest until this week I had no idea! It’s basically malpractice for when you no longer work at a hospital to cover you in case you are named in a lawsuit ▪️ Wanna know why I didn’t know what it was till this week? BECAUSE RESIDENTS AND FELLOWS AREN’T SUPPOSED TO BUY THEIR OWN MALPRACTICE INSURANCE. This is unheard of and can cost thousands of dollars for each individual. Or we can go uninsured and risk litigation where we can potentially lose a whole lot more. Not to mention attorney fees😡 ▪️ #HahnemannClosure has already impacted a population of doctors in training that have been through enough adversity and a decade’s worth of stress. And I haven’t really been impacted much until now. And now. I. Am. Pissed. 😡😡 ▪️ So what can you do to help? Send me funny cat videos. Just kidding (but not really) 1️⃣ If you live in Philly, contact your congressman. This should never happen again. It shouldn’t even be a question of if it’s possible. It should be outright illegal. No resident or fellow should ever have to be in doubt of their future because of the possibility of having to buy their own malpractice insurance while in training 2️⃣ Spread the word. I’m thankful that I was interviewed by @whyy and even @zdoggmd made a video about us! Unfortunately though we need more help. Maybe if enough people yell someone will hear us. So if you know anyone who can help spread the word please share the #HahnemannClosureSaga story and send them my way. Because enough is enough. 🎤drop.

A post shared by Marc Katz, MD (@kittykatzmd) on

I spoke with Whyy Philadelphia who went into further detail in the article below. They were also able to speak with Dr. Aizenberg, Hahnemann’s venerable former Internal medicine program director.


Former Hahnemann residents and fellows impacted by this are organizing. In the meantime, we await a final ruling to decide our fate. Unfortunately as Dr. Aizenberg outlined in his email it doesn’t look like the situation will result in a favorable ruling for former Hahnemann residents. Even if a decision is made to have our former employer follow through with their obligations outlined in our contracts it won’t happen for quite some time down the line. This leaves residents to foot the bill. Yet another out of pocket expense that many can’t afford and further stress on an already heavily burdened group of doctors in training.

A broken healthcare system failed the patients of Philadelphia and now continue to fail it’s doctors. One of my favorite social media doctors, ZDoggMD spoke about Hahnemann in one of his most recent video posts, below.

ZDoggMD on continued Hahnemann closure issues

Many people have pointed for assistance or guidance from medical residency training oversight boards like the ACGME. Unfortunately this likely won’t be a quick fix with a linear projection. At this time we have not been told of any further developing communication from them or any other medical boards.

Ultimately I’m thankful that I got lucky. I was on vacation during the last week of residency when I found out Hahnemann was closing it’s doors. This is the first time I’m directly impacted by its closure. For many of my colleagues from Hahnemann however this is yet another impediment to their future.

Current third year residents need to find jobs and can be uniquely impacted by this issue. You need tail end malpractice insurance to work. I am no expert in malpractice or physician contracts but I’m told that some hospitals simply won’t hire you if you don’t have it. They’re going to be forced to buy it. Others are seeking fellowship positions and this issue will certainly carry on with them wherever they match. I hope that fellowship programs view ex-Hahnemann residents like I do- with respect and admiration for not just persevering through these challenges but thriving despite them.

Some of my prior colleagues and I didn’t always see eye-to-eye. It happens when you have, shall we say, a ‘strong personality’. But to my ex-Hahnemann colleagues I promise to continue to advocate for you and use my platform to spread awareness of this developing situation. We share a common bond and unfortunately we are the last group of residents that will ever know the meaning and depth behind the phrase ‘welcome to Hahnemann’.

People wonder why the medical field is going through an epidemic of professional burnout. This developing story embodies the issue. We are viewed as expendable and nothing more than part of the bottom line and treated like it. Not all hospital systems run like this and I hope that this will become an exception to the rule but only time will tell.

So what can you do to help? Share this story. First comes awareness. Next comes action.

YouTube Channel

I just started a new YouTube channel! My first three videos are on Caribbean med schools, why I chose to pursue an internal medicine residency, and how to get a cardiology fellowship and become a cardiologist in the US. Watch them below and be sure to subscribe! The next videos coming out will be patient centered about heart health!





How To Match Into Gastroenterology Fellowship

I’m excited to share my next interview. Keerthi Shah was a senior resident at my residency program and is now a first year gastroenterology fellow at Hahnemann University Hospital/Drexel University College of Medicine.


Thanks for letting me pick your brain Keerthi. Can you tell my followers a little bit about yourself?

I would love to! I’m a PGY-4 or a first year Gastroenterology (GI) Fellow at Drexel University College of Medicine.

I grew up in Georgia most of my life. I went to Georgia Technology for undergrad and then Philadelphia College of Osteopathic Medicine for medical school (the GA campus). When I’m not practicing medicine I love to dance and travel. I’ve been learning, teaching and performing kuchipudi, an indian artform, since I was 7!

I’ll start off with another softball question and take you back to your residency days. Why did you go into medicine?

I was always pretty sure that I wanted to do medicine and then specialize. Combining patient histories with objective data to figure out the diagnosis was like a puzzle. I liked that kind of challenge. In addition, having such a broad knowledge base prepares you for any future fellowship.

Did you always know that you wanted to go into GI?

No! I was between nephrology and gastroenterology when I started residency. These two fields are worlds apart!

The biggest reason I found my way to GI is the procedures. There is such a satisfying feeling about working with your hands and learning a new technical skill. Even during my time in medicine, I enjoyed placing central lines and performing paracentesis. I knew the learning curve would be very steep, but I was ready for that challenge!

To be extra sure of this path I spent months exploring gastroenterology and hepatology, both inpatient and outpatient. All this time just made me more sure and excited.

GI fellowship is three years. What are the subspecialties in GI and how long are they?

There are 5 main subspecialities in GI: (1) motility and functional GI disease, (2) Inflammatory Bowel Disease, (3) advanced endoscopy, (4) nutrition/obesity and (5) hepatology/transplant hepatology. You can choose to do an extra year or you can attend symposia and workshops to build those skills. You essentially don’t have to do the extra year to be able to practice most of those subspecialities. The only exception is advanced endoscopy and trnsplant hepatology which is 2 years and 1 year respectively.

Do you think you will stay as a general gastroenterologist or do you plan on pursuing a subspecialty?

I’m fortunate to be at a program that exposes fellows to subspecialities. Honestly, I’m just enjoying learning about every area of GI. Motility, nutrition, and IBD are areas of focus that I’ve particularly enjoyed. For right now though, I plan to stay general gastroenterology.

I remember you telling me about a pretty alarming turn of events during interview season that almost left you without a fellowship. What happened and what lesson should fellowship applicants take away from it?

I’ll start out saying I’m an osteopathic physician. When I was applying, I applied to both MD and DO programs. Some of the DO programs are still outside of the match process. I interviewed and got accepted at one program. After a lot of thought, I accepted the position and cancelled the rest of my interviews. A couple days before the match, the program contacted me saying they could no longer give me the position because of internal issues. I scrambled to get interviews back. Luckily everything worked out and I matched at my home program. Needless to say, this was a stressful couple of days! The moral of the story is to not cancel anything till the contract is signed.

Gastroenterology is one of the most competitive internal medicine fellowships. What are the most important aspects of a GI fellowship application?

Great letters of recommendation, which stems from good mentorship, are the most important part of your fellowship application. Take the time to get to know the GI attendings at your home program. Work in the inpatient and outpatient clinics.. Get letters from these physicians! Their names are known in the GI community and getting a great recommendation will go a long way.

Research is a must for competitive fellowships like gastroenterology; however quality is valued over quantity. Programs like to see that you took a project to completion from conception to poster/oral presentations and eventually to publication.

Lastly, work hard! People will notice your hustle and that will make your LOR’s even better.

What research did you do during residency?

My first project was assessing quality of life (QOL) in transplant recipients and the use of group experiences to improve QOL. I was fortunate to be able to present this at an international conference and very recently published in Pediatric Transplantation Journal.

I did mostly hepatology research because my first mentor at Drexel was Dr. Santiago Munoz. The two notable projects were addressing etiology and prevention of hyponatremia in cirrhosis at an inner city hospital and expanding inclusion criteria for Obeticholic Acid in Primary Biliary Cirrhosis. Both projects were presented at GI conferences.

From there I expanded to gastroenterology. I worked with our Motility focused attending on evaluating Dysynergic Defecation with 3D High Resolution Anorectal Manometry.

Did you do any quality improvement projects?  

I did one quality improvement project analyzing and improving night float and nursing communication using cell phones and text paging. The current pager system is such an archaic interface for communication. Our hospital is now transitioning to a phone based night float system.

What general advice do you have for prospective residents who want to pursue gastroenterology?

Spend time getting to know the GI program at your hospital. Work with them inpatient and outpatient. Do research with them.

The hardest part of fellowship is the volume of consults and learning a new technical skill. Hard work and a good attitude will go a long way.

You recently started a blog. Tell me about it. What’s your vision for your blog?

I recently started this blog initially to answer questions from my friends and family. I wanted to be able to provide them with answers that were based on up to date literature.

Our interactions with patients in the clinic are so brief. In 15 minutes, we are expected to take a history, diagnose, and treat. This leaves patients’ with a lot of questions and they seek their answers on social media. I wanted to be a part of the social media dialogue. I also wanted this to be my way of supplementing abbreviated clinic time to explain gastroenterology topics to patients in an effective way.

Where can my followers find you on Instagram? What can the expect to see?

@digestivedoc

In a nutshell, my Instagram is a combination of 3 things: GI, travel and friends/family. When it comes to gastroenterology I hope to perpetuate evidence based information as well as tips and tricks for aspiring GI fellows.

What’s the weirdest question people ask you after they find out you’re a GI fellow?

Honestly nothing weird! People ask me a lot of questions regarding their bowel movements. I think the strangest part of being a fellow is the number of pictures of stool I have on my phone.

How much poop is too much poop?

Well, everyone’s “normal” is different! Too much poop for you might be someone’s normal! The number of times you go isn’t as important as the consistency of your bowel movements. If you’re having 3 or more loose/watery Bristol 5-6 bowel movements, we need to talk!

Why do you get the day after drinking diarrhea?

Acute alcohol consumption inhibits absorption of nutrients and fluids. this stimulates secretion of water and electrolytes. effect of alcohol on CNS increases colonic motility and transit time. This prevents absorption of water in the large intestine. If you are drinking sugary mixed drinks, you might be drinking sugar substitutes, which causes osmotic diarrhea.

A patient recently asked me about constipation. What are some common home remedies patients can try?

Constipation affects so many people and results in many hospital admissions. Some things people can do at home include exercise, fiber supplementation, answer nature’s call, and improve your stooling posture. Osteopathic Manipulative Medicine (OMM) can also be helpful. Check out my blog post for more details!


Thank you so much for sharing some insight into the world of gastroenterology Keerthi. As always be sure to subscribe below so you don’t miss out on the next post!





Should You Attend A Caribbean Medical School?

The most frequently asked question that I receive from students from around the world is ‘should I apply to a Caribbean medical school?’. There are plenty of blog posts on the internet that provide advise without objective evidence. So before I give you my unfiltered opinion I want to first present the cold hard facts surrounding the topic as well as some information that is not common knowledge to many pre-med students, most individuals outside of medicine, and future Caribbean graduates. My hope is to arm you with data so that you can make an informed decision about applying to Caribbean medical schools and how best to prepare yourself for success when attending a Caribbean medical school. Before jumping into the benefits and drawbacks of these programs let’s first take a step back and look at the journey of becoming a doctor in the United States.


Part I: Becoming a doctor in the United States

‘What do you call someone who graduates at the bottom of their class in medical school? Unemployed.

In order to apply to medical school in the United States you are required, at a minimum, to have completed your pre-med requisite courses which include one year of biology, one year of physics, one year of english, and two years of chemistry (usually general and organic chemistry). Many medical schools are also now requiring molecular genetics and biochemistry. For school specific requirements you can check out the Medical School Admission Requirement website. On top of your pre-med course requirements most American medical schools require a stellar MCAT score, extracurricular activities inside and outside of the medical field, and shadowing experiences of some sort. For the sake of brevity this blog post will not cover the lengthy topic of how to get into medical school.

There are two types of medical schools in the United States- allopathic and osteopathic. Students who graduate from allopathic medical schools earn an ‘M.D.’ which stands for ‘medical doctor‘ and students who graduate from osteopathic medical schools are a ‘D.O.‘ which stands for ‘doctor of osteopathic medicine’. There are differences between the two in certain aspects of their training and the standardized tests they have to take but in clinical practice they are quite synonymous and are otherwise both ‘doctors’ in every modern sense of the word.

In general, medical school in the United States is four years. This includes both MD and DO programs. However to make matters slightly more complicated there are also many medical schools that offer dual MD/PhD programs (generally speaking these are 7 year programs) as well some schools that offer or even require an additional year of research. Other medical schools also offer dual degrees. Some schools offer an MBA or MPH alongside their medical degree. So generally speaking medical school is a four year process but clearly there are exceptions to the rule if you choose to pursue a different path.

After graduating from medical school you are now a doctor, in name at least. In the United States you cannot practice medicine independently without completing residency training. This is worth repeating. In the United States you cannot practice medicine independently without completing residency training. This is the crux of issue regarding Caribbean medical schools. Acceptance into medical school ≠ a job. Acceptance into medical school guarantees you two fancy letters at the end of your name but without landing a residency position you will never practice medicine as a physician. In the remainder of this post I will explain that, based on prior residency match data and from personal experience, by attending a Caribbean medical school you put yourself at a distinct and intrinsic disadvantage in your ability to obtain a residency position in the United States compared with graduates from stateside MD and DO medical schools.


Part II: The Match

‘Like speed-dating but worse’

If we are going to understand why Caribbean medical graduates are at a disadvantage historically compared to American medical graduates we have to first understand the National Resident Matching Program (NRMP), or ‘the match’. 

Near the end of the third year of medical school students begin applying for residency. The program known as ERAS, or the electronic residency application system, is the online application students use to apply. It is a common application that almost every residency program uses and makes applying for residency simpler. After uploading your application and appropriate paperwork all you have to do, generally speaking, is click which school you want to apply to.

After the application deadline passes residency programs begin downloading applications. Many programs have hard cut offs. For instance, some programs require you to have a step score above a certain value and if your score is not up to par then your application simply won’t be looked at. Next the residency program picks who to send interview invitations to. Interview season generally lasts 3-4 months from October to January but varies from specialty to specialty. After interview season concludes both students and programs must submit ‘rank lists’. Rank lists are exactly what they sound like. Applicants rank which programs, from the ones they interviewed with, that they want to go to with their most highly sought after program at number 1 and then rank each subsequent program down the line. Programs do the same with applicants. Eventually a computer system attempts to ‘match’ students and programs together to make the best possible fit based on each respective applicant and programs choices. The following video is the best one that I could find that explains this quite complex process as succinctly as possible.

On the Monday of ‘match week’ applicants find out if they have matched or not. They find out where they matched on Friday. The reason for this is that if a student does not match they can participate in the SOAP, or supplemental offer and acceptance program. This is a second chance to try and match into a residency position that went unfilled. More information on the SOAP can be seen at The NRMP website.

This is why medical students ‘match’ into residency spots. It isn’t as simple as a job application. And Caribbean medical students match into residency at a far lower rate compared to their stateside colleagues.


Chapter 3: Raw Data

‘Without data you’re just another person with an opinion’

So now that we kind of understand what it means to ‘match’ into residency let’s finally take a look at the raw data from the 2018 main residency match. The NRMP data is widely available and I encourage you to take a look yourself here. The data describes Caribbean graduates with the term ‘international medical graduates’ or an ‘IMG’. These are further split into two categories: US citizen IMG and non-US citizen IMG. So if you are a US citizen and went to a Caribbean medical school then you are considered a US IMG.

In 2018 there were 37,103 active applicants and 30,232 first year and 2,935 second year residency positions. The following are the match rates for each type of applicant:

  • US allopathic graduates (MD’s): 94.3%
  • US osteopathic graduates (DO’s): 81.7%
  • US IMG: 57.1% 
  • Non-US IMG: 56.1%

If you only remember one thing from this post then this should be it. Only 57.1% of US IMG’s, or people like me who are US citizen Caribbean medical graduates, match into residency positions versus 94.3% of US allopathic grads and 81.7% of US osteopathic grads. This is terrifying! Imaging going through four years of medical school, accumulate a crushing amount of debt, only to end up without a job or the ability to practice as a physician (check out prior interview posts with individuals who went through that exact experience).

An interesting graph from the NRMP data shows that not every specialty ranks equally.

This graphic shows that the specialty in which the highest percentage of US IMG’s were able to match into was pediatrics at 69.8% of applicants matching while psychiatry on the other hand was the most difficult specialty for US IMG’s to match into at 30%.

So why do Caribbean graduates have a greater difficulty matching? Let’s take a look at NRMP data from a survey of program directors. This survey is also widely available and I encourage you to analyze it yourself here. The survey was sent to 209 program directors (PD’s) and 78 responded, or 37.3%.

The data shows each individual factor that program directors find important when they choose applicants to interview and rank for residency. As you can see below the USMLE step 1 score, based on this data, is by far the most important factor for choosing applicants to interview.

So a strong STEP 1 or COMLEX 1 score gets your foot in the door but it does not necessarily get you the job. Now let’s use the data from pediatric program directors (PD’s) for the next few graphs. This next graph shows the most important factors that pediatric PD’s felt were the most important factors when ranking applicants.

This graph clearly shows that the more important component of how medical students are ranked on a program’s rank order list is how an applicant interacts with residents and faculty on interview day. Again, a strong USMLE step 1 score seems to be of critical importance in helping get an applicant’s foot in the door but how they interacted on interview day earns medical students the opportunity to walk through it. Of note, each specialty seems to vary slightly in what they rank as most to least important but grossly these trends seem consistent across the board.

The issue however is that getting a stellar USMLE step 1 score isn’t the only obstacle when it comes to matching into residency for Caribbean medical students. At the end of the day all medical students learn the same science but not all medical students have access to the same residency programs.

The same survey of pediatric PD’s (and the same specialty that in 2018 had the highest successful match rate from US IMG’s) shows that some program’s won’t even consider an applicant if they graduated from a Caribbean medical school. The graph below shows that out of the PD’s who responded to the survey only 67% of them typically even interview US IMG’s.

Broken down even more we see that an even smaller percentage of programs will ‘often’ interview and rank candidates from Caribbean medical schools. This is another huge point that you should take away from this blog post.

Again, the match rate for US IMG’s in 2018 was 57.1% versus 94.3% and 81.7% match rate for allopathic and osteopathic grads respectively. I believe that part of that intrinsic disadvantage is that some residency programs simply won’t touch Caribbean medical school graduates. You simply can’t get a job if they won’t interview you for it.

Another unfortunate aspect of being a Caribbean graduate is that it seems to impact the fellowship match too, although to a lesser degree compared to the residency match. If we take a look at the results of the 2019 fellowship match data we can see a clear trend that does not favor Caribbean graduates. The following are the match rates for fellowships in 2019:

  • US allopathic graduates (MD’s): 89.4%
  • US osteopathic graduates (DO’s): 78.9%
  • US IMG: 68.5% 
  • Non-US IMG: 71.4%

For the sake of brevity I won’t delve too much into this data because the fellowship match is a little bit more complicated and not so clear cut. I’m not certain as to why Caribbean medical graduates have a tougher time matching into fellowships but I am certain that some fellowship programs won’t touch a Caribbean graduate just like how some residency programs don’t.


Chapter 4: Informed Consent

‘Without consent surgery would be considered assault’

In medicine before we perform any test or procedure we are required to get informed consent from our patient. Informed consent is the concept of understanding all of the possible consequences with full knowledge of the possible risks and benefits of said procedure. I think the same should be true about applying to Caribbean medical schools and after getting through all of that data I think we’re closer to fully understanding the implications of attending a Caribbean medical school.

Don’t get me wrong, I’m not trying to scare you away from applying. I graduated from a Caribbean medical school, matched into an internal medicine residency program, and successfully matched into a cardiovascular disease fellowship. There are plenty of success stories that originate in the Caribbean and I’ve interviewed nearly a dozen of my colleagues who matched into competitive specialties like emergency medicine and surgery. But Caribbean medical schools aren’t for everyone and you should understand that before you sign up or apply.


Chapter 5: The Caribbean Stigma

‘Some stereotypes originate in truth but are exaggerated by myth’

There is a common misconception in the pre-med community about the ‘Caribbean stigma’. This myth that there would be a doctor or nurse in the hospital you are rotating in that would choose not to work with you because of where you went to medical school. Or that Caribbean medical students are not as qualified as their stateside counterparts. Unfortunately the stigma is steeped in truth.

Caribbean medical students go to the Caribbean because they could not get into a US MD or DO program. That’s why I went to Ross University. I applied to 36 medical schools and Ross University was the only one that accepted me. Caribbean medical schools typically have lower standards and thus not every medical student makes it to graduation. I could not find the statistics on the attrition rate from stateside or Caribbean medical schools but I can speak from experience.

Out of the 440 students who started with me in my first semester of medical school only 76% advanced to their second semester. Although this is only one anecdotal piece of evidence and shouldn’t be used to grossly generalize against all Caribbean schools it does in fact happen. Furthermore, the fact that some Caribbean medical schools are for profit organizations is worrying to me and further underlines the fact that they accept too many students who otherwise wouldn’t be accepted into stateside medical schools. Not to mention that medical school in the Caribbean is just as expensive as medical school in the US. So if you are unable to secure a residency position you will be left with massive loans and a hard road ahead to paying them off.

So although the ‘Caribbean stigma’ exists when applying to and while attending medical school once you make to the hospital nobody cares where you went to med school. In the hospital I’ve met incredibly passionate, intelligent, and competent medical students, residents, fellows, and attending physicians from both Caribbean and allopathic and osteopathic medical schools. I’ve also met terribly incompetent individuals from Caribbean, allopathic, osteopathic medical schools too. Just because you attended a certain medical school doesn’t make you a better or worse doctor. Sure, it certainly impacts your ability to match into residency but there isn’t a single nurse, physician assistant, or doctor out there who will treat you any better or worse just because of what med school you went to.


Chapter 6: The Life of a Caribbean Medical Student

‘It doesn’t really matter where go to medical school because it’s always 72 and fluorescent in the library’

I won’t delve into the specifics of each individual Caribbean medical school and this list is not exhaustive but each of these schools share many similarities with the majority of Caribbean medical schools. In general when you go to a Caribbean med school only the first two years are spent ‘on the island’, or in the actual Caribbean. These first two years are spent in the traditional classroom where we are taught the same basic sciences that allopathic and osteopathic med students learn in preparation for USMLE step 1. It’s really not that bad. I enjoyed my time on the island. I remember being stressed out before my first major exam so I took a stroll on the beach to relax. After leaving the island most medical students rotate in hospitals across the US that each respective medical school has affiliations with. I rotated in hospitals in New York and Florida.


Chapter 7: The End Game

Measure twice, cut once

Your first choice should be to get into a US allopathic or osteopathic program. People who are not accepted at first often work on improving their weak spots in their resumé or work while they study to retake the MCAT. Often students will work a few years, do research,  get various master’s degrees, or do a post-baccalaureate degree. Others, like me, don’t want to wait and choose to attend a Caribbean medical school instead. 

This is a viable option for certain students but it might not be the right fit for everyone. Some residency specialties, like neurosurgery, orthopedic surgery, ophthalmology, otolaryngology, plastic surgery, urology, and dermatology, are some of the most competitive medical specialties that exist. Even US graduates often have difficultly earning these residency positions (my osteopathic colleague took three attempts to match into derm and he was a PhD too!). By attending a Caribbean medical school you are again giving yourself another uphill battle to fight. So if your heart is truly set on one of these specialties understand that although it is not impossible to match as a US IMG it will make it increasingly more difficult to do so. That being said, if you know you want to go into primary care fields like internal medicine, family medicine, or pediatrics then a Caribbean medical school might be the right fit for you. Again many residency, and fellowship, programs simply won’t look at you because you are a US IMG. So you might not be able to go to an ivy league internal medicine residency or fellowship program but you certainly can still become a doctor.

The ironic part of all of this is that in order to be a good doctor at the end of the day it really doesn’t matter where you went to medical school or what you got on your USMLE step 1 (as this blog post points out). In residency nobody care what your test scores were and when you are an attending your patients won’t care that you went to an ivy league school if you aren’t compassionate, kind, caring, or intelligent. And yet if you don’t do well on your exams, especially coming from the Caribbean, you hurt your chances of ever being able to treat future patients. Whether you like it or not this is the current status quo. So if you go to the Caribbean be ready to work hard, crush your step exams, and get great letters of recommendation.


I hope this post helped uncover some of the hidden curriculum of medical school and residency and didn’t scare you away from applying to Caribbean medical schools. Ross University was the only medical school I was accepted to and they gave me the opportunity to pursue my dream of becoming a physician. It’s up to you to make the best decision for your future career and then make the most of that opportunity. Hopefully now you can do so with confidence and informed consent.

You can also check out my YouTube video on the topic below:

Drop me any follow up questions that you may have below and be sure to subscribe so you don’t miss my next post!

How To Match Into a Hematology & Oncology Fellowship

Joel Alcid is a third year internal medicine resident finishing up his final year of residency at Hahnemann University Hospital/Drexel University College of Medicine. Next year he will be starting his fellowship training in hematology and oncology. I sat down with him to learn more about how he earned this monumental achievement and tips for medical students and residents who are interested in pursuing a heme/onc fellowship too

Thanks for letting me pick your brain Joel. Can you tell my followers a little bit about yourself?

Thank you for this opportunity. I am happy to share my thoughts and provide some guidance for those who are interested in pursuing a career in hematology/oncology. But first here are some fun facts about me

  • I am Filipino-American
  • Born and raised in North Jersey
  • Attended the University of Hartford and majored in respiratory therapy (yes, I originally thought of pulmonary/critical care prior to med school)
  • Attended the American University of Antigua for medical school
  • I’m a huge boxing fan, my favorite boxer is of course…Manny Pacquiao
  • I currently train at James Shuler’s Gym in West PhillyI recently got married in August of this year in Riviera Maya, Mexico

Did you always know you wanted to pursue hematology and oncology (heme/onc) fellowship? What about it attracted you?Yes. I knew since my third year of medical school that I wanted to pursue a career in hematology/oncology. I was always interested in the variety of pathology within the field, especially the cancer aspect. During my fourth year of medical school I was fortunate enough to do a one-on-one sub-internship rotation with an attending in his private practice. I had the chance to gain firsthand experience of what a career in heme/onc would be like. The diversity and complexity of the cases I was seeing on a daily basis attracted me to this specialty. From a patient with recurrent invasive ductal carcinoma who had developed metastasis to bone to a patient with a skin lesion that was diagnosed as mantle cell lymphoma.

Another aspect of the field that I developed immense respect towards during my rotation was the chance to support patients through their emotional struggles. Close patient contact and forming relationships with the patients is an important aspect of medicine in which I really enjoy and I feel the doctor-patient relationship seems especially important when the battle against cancer is shared over many years and often through multiple phases of progression and response. It’s definitely an exciting time to go into heme/onc as there are many new up and coming treatments along with endless ongoing clinical trials.

Do a lot of subspecialties in heme/onc exist? Are they traditionally additional years of dedicated fellowship training?

Great question. Those who are pursuing a career in academics tend to specialize in one area of hematology or oncology such as only treating breast or lung cancer for example. Most academic centers have faculty members for each type of cancer. Just like internal medicine, it is difficult to “know everything” and I think that’s why some are heading into the direction of just focusing on one type of cancer. A sub-specialist in an academic setting will generally spend most of their time geared towards research, clinical trials, teaching and maybe 1 or 2 days of clinic. How it typically works is you would either tailor your practice towards your specific interest or look for an opening in your area of interest which will usually be in an academic center.

For those who want to pursue a career in bone marrow transplant, additional fellowship training is required. Bone marrow transplant is an advanced fellowship which is an additional year after completing the initial 3 years of heme/onc. There are some non ACGME accredited 1 year fellowships available at top cancer centers like MD Anderson for leukemia, lymphoma, and myeloma.

Do you plan on pursuing a subspecialty?

Although I have an interest in solid tumors I will not be pursuing any subspecialty. The variety of pathology is what attracted me to this field so I would like to be a “generalist” and treat all types of cancer. If I only focused on breast or lung for example I would definitely miss seeing patients with myeloma, pancreatic, prostate, or even gynecologic cancers. My career goal is to go into private group practice and treat a variety of malignancies.

Every specialty is becoming more and more competitive to match into. Can you share with us some data on what your fellowship application looked like?

I definitely agree that most specialties continue to become more competitive each year. Here are some data for hem/onc from the 2018 NRMP fellowship match data

  • 553 spots with 760 total applicants
  • 73 % matched, 27% went unmatched
    • US allopathic grads: 327 matched, 62 unmatched
    • US IMG’s (like Caribbean med grads): 36 matched, 48 unmatched
    • Non US IMGs: 142 matched, 95 unmatched
    • Osteopathic: 34 matched, 15 unmatched

Below are the details on the statistics from the NRMP match data. You can see the average USMLE step scores for matched and unmatched applicants from US medical schools, IMG’s, international medical graduates, and osteopathic graduates. For instance, the average USMLE step 1 score of US, IMG, and international matched grads respectively were 239, 237, and 242.

What research did you work on during residency? Was that below, above, or an average amount of research for someone applying to heme/onc?

Research is a major component of the fellowship application (especially compared to residency). Research can be any abstracts, poster presentations, publications, or quality improvement projects. Anytime I would see a patient with a rare malignancy I would look it up to see if there have been any case reports published and if only a few have been reported, then I would use that opportunity to write up my own case report. I was taking care of a patient with a primary DLBCL (diffuse large B-cell lymphoma) of the cervix and primary pulmonary angiosarcoma (both extremely rare) and took the opportunity to write them up. They were both accepted for publication in an online oncology journal and have been presented as poster presentations at several meetings. I also worked on a case series with a gynecologic oncologist comparing patients with low grade serous ovarian cancer that was also published in an online oncology journal.

As far as poster presentations, I was able to present some of my abstracts at several meetings including the Lymphoma and Myeloma International meeting in NYC, the American College of Physicians Southeastern PA chapter meeting, the Drexel Discovery Research Day and our departments own internal medicine annual research day. I also presented an overview of the treatment guidelines for autoimmune hemolytic anemia at the Drexel Hematology journal club.

Here are some data regarding research from the 2018 NRMP fellowship match. For US allopathic grads, the average research (abstracts, presentations and publications) was 9.1 for matched and 8 for unmatched. US IMGs had 12.5 for matched and 4.5 for unmatched. Non US IMG had 16.5 matched and 9.6 unmatched. Based on this data, the more research you have, the safer you are to match. Bottom line..find time for research!!

Did you complete any quality improvement projects?

I worked on a quality improvement project with 3 other residents who were also going into heme/onc. We decided to evaluate blood transfusion utilization and cost analysis at Hahnemann University Hospital. We conducted a retrospective chart review of packed red blood cell transfusions administered at Hahnemann University Hospital during the month of May 2017. Data collected included pre-transfusion hemoglobin level, quantity of units transfused, post-transfusion hemoglobin level, the patient’s primary service, and level of care. One hundred and fifty-three charts were reviewed across all specialties and units. Twenty-one               percent of blood transfusions in this period, representing 41 units of packed RBC, were determined to be inappropriately administered. Based on the figures from the ASH 2008 study, the estimated patient costs of these inappropriately administered units may be as high as $140,753. Our conclusion was that the number of blood transfusions administered during the period under review that did not follow the AABB guidelines was substantial. Stricter adherence to established evidence-based guidelines for red blood cell transfusions could represent a significant cost-saving measure.

What advice do you have for medical students interested in pursuing heme/onc?

For medical students who know they want to pursue hem/onc…more power to you! To make yourself a competitive applicant for residency, you must do well on USMLE step 1 and step 2 CK. Lower than average scores can hurt you in the long run and yes they still matter for fellowship. I would recommend setting up 1 or 2 heme/onc electives during your 4th year so you can get an idea of what it’s like to be an oncologist. Try to rotate at the outpatient clinic, as heme/onc is primarily an outpatient specialty. An inpatient or consult elective would be a misrepresentation of what the specialty is truly like.

When rotating on a hem/onc elective try to attend all of the conferences such as tumor boards and ask if you can even present a case. Feel free to ask the fellows and attendings questions on what their daily routine is like. Remember, to become a hematologist/oncologist, you must first get accepted into an internal medicine residency. So work hard and ace those boards!

What advice do you have for residents who are interested in pursuing heme/onc?

For residents interested in pursuing heme/onc, I would make sure the attendings and fellows know you’re interested from the beginning. Try to do as many rotations as you can whether it be the inpatient service, consults or outpatient clinic. The more they see you around, the more they will see that you are truly interested. I know not all residency programs will have an in-house fellowship or not have any available heme/onc rotations so I recommend scheduling an away rotation at program that has a heme/onc fellowship. This can be an “audition rotation” and might be beneficial in the long run (letters, connections, etc). 

Also try to join any heme/onc interest groups and if there are none then perhaps create one! This will definitely look good on the CV.

As mentioned above, research is a vital component of the fellowship application. Try to get started early (as early as first half of intern year). Some projects will take time and you want to make sure you have enough to put on your CV come application time (towards the end of PGY-2). Ask around if any ongoing projects are available for you to join. Senior residents and fellows are good resources to ask.

Ask for letters in advance (anywhere from January-April) depending on the size of the residency program. Internal medicine program directors have to write a letter for every resident applying for fellowship so make sure to notify them early so they have ample amount of time.

How many programs did you apply to, interview at, and rank?

Hem/onc gets more competitive every year. I thought I had a decent application (also reviewed by current fellows and attendings) but I was surprised with the response I received from programs. I applied broadly to around 80 programs and only received 6 interview invites. I ranked all 6 programs and I’m thankful that I matched. I heard the safe number of interviews to have to increase your chance of matching is around 6-10 but that is variable. Some have matched with fewer and some didn’t match with 10 or even more.

I will training at East Carolina University/Vidant Medical Center in Greenville, NC. I am definitely excited for this opportunity but will miss my family and friends in Philadelphia/New Jersey.

If you had to be a component of plasma what would you be?

Hmm…I would probably be the globulins..since they are important for immune system and help protect against bacteria and viruses. I can put the boxing training to use!

If any of my readers have a follow up question where can they find you?

My instagram is @joelal_md and my email is joelalcidmd@gmail.com . Please feel free to contact me with any questions

How To Find Research in Medical School and Residency

One of the most frustrating aspects of medical school and residency is the hidden curriculum. The stuff you kind of just figure out along the way and wish you knew from the beginning. One part of the hidden curriculum of medical school and residency is research. Here are my tips on how to successfully get published.

 

First off, why bother doing research?

If you are a medical student it will make you stand out when applying to residency and if you are a resident applying for certain fellowships it might as well be mandatory. So the first reason is for your resumé. The second reason is that research forces you to learn a topic more extensively than you normally would otherwise. That’s my favorite reason to get involved in research. You end up learning so much more compared to just reading topics and doing practice questions. Additionally, you also learn to

 

 

Find a topic or field that interests you

The only thing worse than doing research is doing research on a topic or in a field that bores you. That’s why all of my research is in cardiology. So find a research project in a medical specialty or disease process that you find interesting.

 

 

Find a mentor

Okay, so I’ve sold you on the idea of doing research. Next, you found a field that interests you. But how do you just start a research project? The best way to approach finding a research project is approaching someone who is already doing research in that field or specialty. As a medical student, I asked the cardiologist I was working with if he knew of any interesting research going on in the cardiology department. He put me in touch with the right people who pointed me in the right direction. Ultimately, I got two publications out of the experience and learned a lot about cardiac magnetic resonance imaging.

Fast forward to residency and some of the best advise I’ve received has been from my senior residents and fellows. These are people who have already done what you want to accomplish. They are probably the most valuable resources you’ve got so use them! Better yet, get involved in their research projects to get your feet wet.

Additionally, don’t forget your co-residents or medical students. Some of my close friends and colleagues are doing amazing research and their tenacity to publish their work inspires me to get on my grind. They are another valuable resource. Some of my colleagues who already have a few research projects under their belt know the system and how to maneuver it. So don’t be shy or too proud and ask your successful colleagues how they did it.

 

 

Be curious

If you don’t understand something then ask! Be curious about medicine and uncover the reasoning behind clinical decision making. As much as we know about the human body there is still so much that we don’t understand and your questions on rounds one day might be the beginning of your research project.

 


 

What did I miss? What tips do you have to help medical students and residents get published? Comment below and don’t forget to subscribe so you don’t miss my next blog post!