C3.5 R2: Prepare and deliver educational seminar to nurses, physicians or other allied health care members

For my cardiology rotation, I prepared and delivered my first nursing in-service on vasopressors and inotropes in cardiogenic shock. I was fortunate to have my preceptor review my handout and help me prepare for my in-service, as well as, to have a great group of nurses attend the in-service! 🙂

Areas I did well on:

  • Slowed down my pace and provided time for the audience to absorb the information presented, as well as, ask and answer questions. There were times where I got nervous and quickened my pace, but I was able to pick up on those moments and slow down my pace.
  • Incorporated visuals and asked questions to the audience in order to engage and reinforce understanding of the material

Areas to improve on and do for future in-services:

  • Conveying relevant information in a manner that is easy for the audience to absorb and giving my audience key points to take away (e.g. incorporating possible cases or situations, explaining key concepts clearly and providing memory aids)
    • For future in-services, I will:
      • ask my target audience about what they would want to know more about or would like a reference handout on, as well as, the sorts of experiences they have had regarding the topic.
      • Incorporate learning objectives and an outline of the in-service so that the audience is aware of the purpose and flow of the presentation
      • Draw commonalities and provide memory aids
      • making sure I define duration (e.g. short-term), pay attention to the units I use and include references
  • Paying attention to my audience and their body language, as well as, the environment that I am presenting at in order to assess if I am projecting my voice loud enough.
  • Being more comfortable and practicing different ways of presenting. This was my first time presenting with a whiteboard and it was a challenging but great learning experience to have to juggle writing on the whiteboard and connecting with the audience, all while trying to keep myself on track with the presentation. At times, I got nervous and lost where I was in my presentation and had to rely on my handout to get me back on track.
    • For my future in-services, I will:
      • trial out different ways to present information in a clear, neat and organized manner
      • Practice, practice, practice! If time allows, I will at least try to record my voice and reflect on the delivery of my next in-service
  • Even if I may not have time to go over it during the in-service, I will incorporate things that would be important for the nursing staff to have as a quick reference on the handout (e.g. common dosing of medications)

My handout: cardiogenic-shock_nursing-inservice_audience

C3.5 R3(d): Prepare and Facilitate a journal club to pharmacists

For my cardiology rotation, my journal club was on the newly published: Pioneer AF-PCI.

Areas I improved on:

  • Going at an easy to follow pace and leaving enough time/pauses for the audience to absorb information and join in the discussion has been something that I had difficulty with in my previous journal clubs. For this journal club, I was able to slow my pace down and turn the discussion to the group every once in a while to help keep the discussion going.
  • In order to help facilitate discussion, I had prepared questions which I think helped the audience reflect on the information presented on the handout and its implications
    • Another question I could have asked is if the audience agreed with the bottom line before I discussed my opinion on the bottom line, and what kinds of patients the audience would apply this trial on.

Areas to improve on:

  • Continue to work on highlighting pertinent information from the handout, and letting the audience know if we are deviating from the order presented on the handout
  • Especially during the second half, I was reiterating certain points over and over (e.g. one of the limitations of the trial). Another area to improve on is being concise and figuring out and preparing different ways to present the information in advance.
  • Continue to develop my critical appraisal skills and understanding the implications of the study’s design
    • E.g. for this trial: understanding the implications for having a multi-arm study design
  • My handout was very text-heavy and busy. I will continue to work on the spacing of my handout. So far, I have trialed different ways to present each of my journal club and for this journal club, I had attempted to follow the “Rxfiles” style. However, in my attempt to fit everything on two pages, there were certain portions of my handout that were difficult to follow.
  • When preparing for future journal clubs, doing the following:
    • If adherence to the study drug was reported, understand how adherence was measured in the trial
    • Familiarize myself with the protocol under the supplementary appendix and identify any differences between the protocol and the final design/results
    • Understanding and being able to concisely explain the potential implications of the differences in the baseline characteristics of the different treatment arms
    • Be familiar with other guidelines (e.g. European Guidelines for this particular journal club topic), assess the evidence behind their recommendations and rationalize the differences between those recommendations and our local guidelines and current practice
    • Similarly to my preceptor, providing ~ 2 weeks for people to read the trial

My handout: pioneer-af_audience


Reflections – Cardiology

This was by far one of my favorite rotations in residency! Herb and the interdisciplinary team at SMH were amazing and incredibly supportive throughout my rotation. When discussing my patients, Herb would write out my patients’ medical conditions, medications and history on a board. This definitely made it a lot easier to draw connections between the progress in hospital and their medications.

During this rotation, I feel that I have gained a stronger understanding of various cardiac conditions, as well as, the evidence and key landmark trials. Aside from my objectives, other things I was able to improve on are identifying patient-specific goals, presentation skills, patient interviewing and chart documentation. These are things I can definitely still work on but with the help of Herb, I feel more confident in these areas and will continue to work on them in my future rotations/practice. Additionally, during this rotation,  Herb taught me how to perform physical assessments and learn how to interpret them. It was definitely exciting to be actually performing these assessments on real patients, instead of lab simulators! While a little daunting at first, making sure I did physical assessments whenever I had the opportunity to helped increase my comfort level and enhanced my ability to see my patient as a whole. All in all, this was a fantastic rotation and I will definitely aim to keep using the skills I have gained in future rotations! 🙂


Treatment of Hypertension in Patients 80 years of Age or Older (2008)

Design: Double-blinded, placebo-controlled RCT

  • Intention-to-Treat Analysis
P N = 3845
SBP > 160mmHg
I Indapamide 1.5mg SR daily
* If needed to target BP of 150/80mmHg, perindopril 2 or 4mg daily was added
C Placebo
* If needed to target BP of 150/80mmHg, placebo daily was added
O Primary endpoint: fatal or non-fatal stroke

Secondary endpoints: death from any cause, death from cardiovascular causes, death from cardiac causes, death from stroke


  • Active treatment: 83.6 + 3.2 yo vs. Placebo: 83.5 + 3.1 yo
  • BP:
    While sitting: 173/90.8
    While standing: 168/88.6
  • Orthostatic hypotension: ~32%
  • HR: 74.5 + 9
  • Cardiac history:
    • CVD ~11.5-12%
    • HTN: 90%
    • Antihypertensive treatment: 64-65%
    • Stroke 6.8%
    • MI: 3.1%
    • HF: 2.9%


  • Median duration of f/u: 1.8 years
    • Active-treatment:
      25.8% indapamide alone, 23.9% + perindopril 2mg, 49.5% + perindopril 4mg
  • Surrogate markers:
    • Drop in sitting BP:
      Placebo: 14.5+18.5mmHg/6.8+10.5mmHg
      Active treatment: 29.5+15.4mmHg/12.9+9.5mmHg
    • Drop in standing BP:
      Placebo: 13.6+18.9mmHg/7.0+10.9mmHg
      Active treatment: 28.3+16.5mmHg/12.4+10.3mmH
  • Primary endpoint: 30% reduction in the rate (-1 to 51%, P = 0.06)
    • NNT = 11 strokes per 1000 patients treated for 2 years (0-21)
  • Death: 21% reduction in the rate (4-35, P = 0.02)
    • Cardiac-caused death NSS
  • Fatal stroke: 39% reduction in the rate (1-62, P = 0.05)
  • Fatal or non-fatal heart failure: 64% reduction (42-78, P<0.001)
  • Cardiovascular event (death from CV causes or stroke, MI or HF):
    34% reduction (18-47%, P < 0.001)

    • NSS for MI
    • SS for death from stroke (P = 0.06, crosses 1), death from CV causes (P = 0.06, crosses 1) and HF


  • NSS in potassium levels, uric acid, glucose, or creatinine
  • Serious ADRs: Placebo (448/1912) vs. Active Tx (358/1933), P = 0.001

CHEP Guidelines:

  • In the very elderly (> 80 yo), SBP < 150mmHg (Grade C)
  • HYVET: BP reduced to 144/77mmHg (15/6.1mmHg lower than placebo group)
    • data safety and monitoring board stopped trial early due to SS efficacy outcomes

Take-away points:

  • ?Restriction to background therapy (more serious ADRs in placebo)
  • HYVET did not study other BP targets – ?benefit vs risk ratio of lower BP targets in this patient population
  • Targeting BP of 150/80 (50% reached target in HYVET after 2 years) with diuretic + ACEI in > 80 yo: SS for reduction in stroke (P=0.06, crosses 1), death from stroke, CV death (P = 0.06, crosses 1), heart failure
    (NSS for MI)

    • Patient population: majority did not have CVD, MI, HF, stroke or orthostatic hypotension – patient population studied was relatively healthy; therefore, results may not be applicable to the general elderly population
  • Safety: tolerability of SBP lowering in higher risk + frailer patients?


Comparison of Dopamine and Norepinephrine in the Treatment of Shock (2010)

Design: Multicenter, RCT

P N = 1679
I Dopamine
*If BP could not be maintained with a dose of 20ug/kg of body weight for dopamine, open label NE, epinephrine or vasopressin could be added
C Norepinephrine
*If BP could not be maintained with a dose of 0.19ug/kg of body weight for NE, open label NE, epinephrine or vasopressin could be added
O Primary outcome: rate of death at 28 days

  • NSS for rate of death
  • Sub-group analysis: dopamine associated with increased rate of death at 28 days among cardiogenic shock, but not septic or hypovolemic shock


  • More arrhythmic events among the patients treated with dopamine
    (24.1% vs. 12.4%, p<0.001)

Take-away points:

  • In cardiogenic shock, norepinephrine is associated with less death at 28 days than dopamine


Warfarin, Aspirin or Both after Myocardial Infarction (2002)

Design: Multicenter, open-label RCT

 P  < 75 yo, hospitalized for AMI (i.e. SECONDARY prevention)

Excluded: indication or CI for study drugs, malignancy, poor compliance

Mean duration of observation: 4 years

  • Warfarin (target INR 2.8-4.2)
  • ASA 75mg daily + Warfarin (target INR 2-2.5)
  •  ASA 160mg daily
 O Primary outcome: composite of death, non-fatal reinfarction, or thromboembolic cerebral stroke

  • Intention to treat analysis

Versus ASA alone

  • RR for warfarin + ASA: 29% (P = 0.001), NNT = 67
  • RR for warfarin alone: 19% (P = 0.03), NNT = 100
  • NSS in mortality (benefit with non-fatal reinfarction and TE stroke)
    • TE stroke for combination + warfarin alone ~ same (Rate ratio: 0.52)
    • Benefit for reinfarction for combination > warfarin alone
      (Rate ratio: 0.56 for combination vs. 0.74 for warfarin alone)


  • NNH for 1 major bleeding episode:
    • 250 for warfarin + ASA
    • 200 for warfarin alone

Take-away points:

  • Main benefit of warfarin + ASA or warfarin alone over ASA for secondary prevention for MI is the:
    Prevention of non-fatal reinfarction and TE stroke

    • No SS difference in mortality
  • But…comes with increased bleeding
    • Increased major bleeding with combination + warfarin > ASA
      • 4 times as many major bleeding
    • Increased minor bleeding with combination


D: Randomized, double-blind, placebo-controlled trial (1997)

P N = 6800, HF and LVEF < 45%, NSR
302 clinical centers in US and CanadaExcluded: afib/flutter, cardiac surgery or PCI within previous 4 weeks or need for cardiac surgery or PCI in near future
I Digoxin
C Placebo
O Efficacy:

  • NSS for death
  • Hospitalizations for worsening HF – RR: 0.72 (0.66-0.79, p<0.001)
  • Subgroup analysis: high risk patients – those with lower EF or enlarged hearts and those in NYHA III or IV – benefit appeared greater


  • Most common reasons for suspected digoxin toxicity: ventricular fibrillation or tachycardia, supraventricular arrhythmia, 2nd or 3rd degree AV block

**Retrospective Analysis: Relationship of serum digoxin concentration to mortality and morbidity in the DIG trial** (2005):

For women:

  • 0.5-0.9ng/mL: Beneficial effect of digoxin on morbidity and no excess mortality
  • > 1.2ng/mL (= 1.5 nmol/L): Risk for mortality was greater than placebo

**Association of serum digoxin concentration and outcomes in patients with heart failure (2003): Post-hoc analysis of the DIG trial

For men:

  • 0.5-0.8ng/mL: associated with reduction in mortality
  • 0.9-1.1ng/mL: not associated with reduction in mortality
  • > 1.2ng/mL (= 1.5 nmol/L): higher mortality in men

Take-home messages:

  • Efficacy of digoxin in heart failure:
    • Reducing risk for hospitalizations for worsening HF
  • Monitor digoxin trough levels (30min prior to dose)
    • Levels should at least be 8-12 hours after dose
    • CCS AF guidelines: maximum trough digoxin serum concentration: 1.5 nmol/L
      • DIG trial suggests that > 1.5 nmol/L associated with greater mortality in HF
    • CCS compendium for HF
      • Digoxin trough level in HF patients with severe renal dysfunction: <1nmol/L
      • If rapid deterioration in renal fx, hold digoxin and R/A when stable
      • Role of digoxin: in patients who are in SR + moderate to severe symptoms, despite optimized HF therapy → relieve symptoms + reduce hospitalizations
  • Concurrent atrial fibrillation:
    • Digoxin – target HR of <100bpm
    • Not as effective as controlling HR vs BB or CCBs during exercise
      – should not be used as monotherapy for active patients
    • CCS guidelines for atrial fibrillation:
      If used for treating patients with concomitant LV systolic dysfunction, its use should be dictated by the recommendations of the CCS HF Clinical Guidelines

1.0ng/mL = 1.3 mmol/L – associated with increased mortality in HF

Learning Objectives – Cardiology

I will be heading to Surrey Memorial Hospital for my Cardiology rotation. The following are my learning objectives:

  1. Describe the pathophysiology, fundamental diagnostics, medications and non-drug measures, management and monitoring for STEMI, NSTEACS, Ischemic Heart Disease, Heart Failure, Atrial fibrillation, Ventricular arrhythmias, Valvular heart disease, Hypertension/Hypertensive Crisis, Dyslipidemias
    1. Compare and contrast available antiplatelet agents for management of ACS
    2. List the different types of valvular dysfunction and the appropriate management for each of them
    3. Develop an approach to assessing and managing patients with HFrEF and HFpEF (including assessing need for ACEI, BB, MRAs, diuretics and risk factor modification, and monitoring parameters)
  2. Improve on my ability to perform physical assessments to monitor my patients’ cardiac conditions and efficacy/safety of cardiac medications
    1. Perform at least 1 physical assessment per week
  3. Improve on my knowledge of important landmark trials in cardiology and my ability to effectively apply the PICO and results of landmark trials to my patients
    1. Use evidence to identify the medications’ roles of therapy (i.e. goals of therapy), compare and contrast different therapeutic alternatives, and to justify and defend my recommendations
  4. Improve on my ability to prepare and deliver presentations in an organized and easy-to-follow manner
    1. With a focus on slowing down my pace of delivery

If possible, I would also like to complete the following procedure log (s):

  • C3.5 R2: Prepare and deliver educational seminar to nurses, physicians or other allied health care members

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