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Cardiology curriculum standards (Adult Internal Medicine)

Knowledge guides

LG 18: Heart failure

Key presentations and conditions

Advanced Trainees will have a comprehensive depth of knowledge of these presentations and conditions.

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Less common or more complex presentations and conditions

Advanced Trainees will understand these presentations and conditions.

Advanced Trainees will understand the resources that should be used to help manage patients with these presentations and conditions.

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Epidemiology, pathophysiology, and clinical sciences

Advanced Trainees will have a comprehensive depth of knowledge of the principles of the foundational sciences.

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Investigations, procedures, and clinical assessment tools

Advanced Trainees will know the scientific foundation of each investigation and procedure, including relevant anatomy and physiology. They will be able to interpret the reported results of each investigation or procedure.

Advanced Trainees will know how to explain the investigation or procedure to patients, families, and carers, and be able to explain procedural risk and obtain informed consent where applicable.

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Important specific issues

Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis and management and integrate these into care.

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Presentations
  • Arrhythmia (palpitations, syncope)
  • Cachexia
  • Dizziness
  • Dyspnoea
  • Fatigue/Lethargy
  • Oedema
  • Orthopnoea
  • Reduced exercise tolerance
  • Tachycardia
Conditions
  • Cardiomyopathy:
    • acquired
      • myocarditis
      • peripartum
      • stress-induced
      • tachycardia-induced
    • genetic
      • arrhythmogenic (ACM)
      • hypertrophic (HCM)
    • mixed
      • dilated
      • restrictive
    • primary
  • Heart failure syndromes/ phenotypes:
    • diabetes/diabetic myopathy
    • mid-range EF(HFmrEF)
    • preserved ejection fraction (HFpEF)
    • recovered EF (HFrecEF)
    • reduced EF (HFrEF)

For each presentation and condition, Advanced Trainees will know how to:

Synthesise
  • recognise the clinical presentation
  • identify relevant epidemiology, prevalence, pathophysiology, and clinical science
  • take a comprehensive clinical history
  • conduct an appropriate examination
  • establish a differential diagnosis
  • plan and arrange appropriate investigations
  • consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
  • provide evidence-based management
  • prescribe therapies tailored to patients' needs and conditions
  • recognise potential complications of disease and its management, and initiate preventative strategies
  • involve multidisciplinary teams
Consider other factors
  • identify individual and social factors and the impact of these on diagnosis and management
Presentations
  • Deep vein thrombosis (DVT)
  • Gastrointestinal:
    • hepatic congestion and dysfunction
    • malabsorption
  • Musculoskeletal:
    • muscle wasting
  • Peripheral embolism
  • Pulmonary embolism (PE)
  • Stroke
  • Sudden death
Conditions
  • Athlete's heart
  • Drug-induced cardiomyopathy, chemotherapy, or immunotherapy
  • Infiltrative cardiomyopathies (e.g., amyloid)
  • Inherited cardiomyopathies:
    • arrhythmogenic (e.g. arrhythmogenic right ventricular dysplasia/ cardiomyopathy [ARVD/C])
    • infiltrative (some) (e.g. hereditary TTR cardiac amyloid, Fabry disease)
    • left ventricular noncompaction cardiomyopathy (LVNC)
  • Post-vaccine or infective pericarditis and myocarditis (e.g. COVID-19 myocarditis)

For each presentation and condition, Advanced Trainees will know how to:

Synthesise
  • recognise the clinical presentation
  • identify relevant epidemiology, prevalence, pathophysiology, and clinical science
  • take a comprehensive clinical history
  • conduct an appropriate examination
  • establish a differential diagnosis
  • plan and arrange appropriate investigations
  • consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
  • provide evidence-based management
  • prescribe therapies tailored to patients' needs and conditions
  • recognise potential complications of disease and its management, and initiate preventative strategies
  • involve multidisciplinary teams
Consider other factors
  • identify individual and social factors and the impact of these on diagnosis and management
  • Cardiomyopathy:
    • describe genetic basis for cardiomyopathies, including hypertrophic cardiomyopathy
    • pathogenesis, natural history, and prognosis of cardiomyopathy
  • Define heart failure, appreciating different classification systems based on clinical, morphological, and functional characteristics of the patient
  • Differentiate between pathologic versus physiologic remodelling of the heart
  • Understand different subgroups of heart failure classified by ejection fraction
  • Understand the epidemiology of heart failure, including incidence, prevalence, risk factors, natural history, and prognosis
General management
  • Management of underlying causes and associated conditions, including:
    • arrhythmias/conduction system
    • cardiomyopathy
    • diabetes mellitus
    • hypertension
    • ischaemic heart disease
    • other associated conditions
    • valvular
  • Monitoring of heart failure (serological, imaging, symptom-based)
    • Non-pharmacological therapies
      • Cardiac rehabilitation
      • Device-based therapies
        • left ventricular assist device (LVAD)
      • Transplant
      • Volume and sodium management
    • Pharmacologic therapies
      • Acute heart failure:
        • inotropes
        • vasopressors
      • Beta-blockers
      • Digoxin
      • Diuretic therapy
      • Ivabradine
      • Mineralocorticoid antagonist
      • Renin-angiotensin system inhibitors:
        • angiotensin II receptor blockers (ARB)
        • angiotensin converting enzyme inhibitors (ACE)
        • angiotensin receptor-neprilysin inhibitors (ARNI)
      • SGLT2 inhibitors
Investigations
  • Blood tests, including plasma markers and markers of perfusion (renal/hepatic)
  • Cardiac catheterisation
  • Cardiac CT
  • Cardiac MRI
  • Chest x-ray
  • Electrocardiogram (ECG)
  • Echocardiogram, including stress, transoesophageal (TOE), transthoracic (TTE), especially evaluation of systolic and diastolic dysfunction
  • Genetic testing
  • Myocardial biopsy
  • Positron emission tomography (FDG) (e.g. for sarcoidosis)
  • Technetium pyrophosphate (TC-PYP) scan
Procedures
  • Cardiac transplantation (know indications for)
  • Devices:
    • defibrillators (know different types and indications for)
    • pacemakers (know different types and indications for)
General management considerations
  • Goals of therapy
  • Impact of comorbidities on diagnosis and management
  • Individual patient clinical indications to determine patients’ needs and the most appropriate approach to investigations and care
  • Patient demographics, including geographic location, socioeconomic status, ethnicity, and cultural background, and the considerations when managing and following up these patients (e.g. travel from rural to metropolitan areas)
  • The timing of decisions and risks for the individual patient
Specific management considerations
  • Advanced care, including referral to palliative care for patients with advanced heart failure to support discussion of treatment goals
  • Management of heart failure in the community, including refractory heart failure
  • Shared decision making (particularly for complex treatments options such as ICD, mechanical circulatory support, and transplantation)
  • Sleep apnoea management
  • Understand the implications of having a cardiomyopathy on quality of life, prognosis, and planning (e.g. pregnancy, competitive sport)