COCATS 3: ACCF 2008 Recommendations for Training in Adult

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Journal of the American College of Cardiology Vol. 51, No. 3, 2008© 2008 by the American College of Cardiology Foundation ISSN 0735-1097/08/$34.00P

Task Forces

Task Force 1: Training in Clinical Cardiology

Kenneth L. Baughman, MD, FACC, ChairF. Daniel Duffy, MD, MACP (American Board of Internal Medicine Representative),Kim A. Eagle, MD, FACC, David P. Faxon, MD, FACC (Accreditation Council forGraduate Medical Education Representative), L. David Hillis, MD, FACC,Richard A. Lange, MD, FACC

ublished by Elsevier Inc.

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he training experience in clinical cardiology is fundamen-al to the development of the specialist in cardiovascularedicine. It should provide a broad exposure to acute and

hronic cardiovascular diseases, emphasizing accurate am-ulatory and bedside clinical diagnosis, appropriate use ofiagnostic studies, and integration of all data into a well-ommunicated consultation, with sensitivity to the uniqueeatures of each individual patient. Active participation inesearch projects will provide the trainee with furtherxperience in critical thinking and in evaluating the cardi-logy literature. The knowledge, skills, and experienceealized by this broad training are essential to providing aolid foundation in clinical cardiovascular medicine beforerainees focus on more specialized areas, which, for some,ay become the dominant feature of professional activity.ther goals should be to provide a broad clinical back-

round with an emphasis not only on pathophysiology,herapeutics, and prevention but also on the humanistic,oral, and ethical aspects of medicine. Although high levels

f skills in diagnostic and therapeutic techniques are essen-ial, the fundamental requirement for broad clinical insighteeded by the consultant in cardiovascular medicine shoulde emphasized.

eneral Aspects of Training

raining Institutions

rograms of training in cardiology must be accredited andffered only in university or university-affiliated institutionshat have a residency training program in internal medicinend in cardiovascular disease. The program should be fullyccredited by the Accreditation Council for Graduate Med-cal Education (ACGME) or the American Osteopathicssociation.

rerequisites for Training

raining in cardiology should almost always occur after suc-essful completion of postdoctoral education and training innternal medicine. One exception relates to medical residents
n the American Board of Internal Medicine (ABIM) Re- o
earch Pathway, which entails 2 years of internal medicineraining followed by 2 years of clinical training in a subspecialtynd 3 years of research training which includes an additional0% clinical training (www.abim.org).

bjectives of Training

he general principles enumerated in the institutional androgram requirements for residency education in internaledicine (1–4) are also applicable to training in cardiology.

See the World Wide Web site www.acgme.org for ongoingpdates of program requirements.) Cardiology trainingrograms must provide an intellectual environment forcquiring the knowledge, skills, clinical judgment, attitudes,nd values that are essential to cardiovascular medicineonsistent with the 6 core competencies delineated by theCGME (medical knowledge, patient care, interpersonal

nd communication skills, professionalism, practice andearning, and improvement and systems-based practice).undamental to this training is the provision of the bestossible care for each individual patient delivered in aompassionate manner. All physicians undergoing trainingn cardiology must have and maintain humanistic andthical attributes (1–7). The objectives of a training programn cardiology can be achieved only when the programeadership, supporting staff, faculty, and administration areully committed to the educational program and whenppropriate resources and facilities are present. Effectiveraduate education requires an appropriate balance betweencademic endeavors and clinical service. During training inardiology, faculty should encourage trainees to cultivate anttitude of scholarship and dedication to continuing educa-ion that will remain with them throughout their profes-ional careers. The development of a scholarly attitudencludes active participation in and completion of 1 or moreesearch projects supervised by faculty actively engaged inesearch, ideally followed by publication in critically re-iewed journals. These activities will provide additionalxperience in critical thinking and will help develop anttitude of scholarship and greater insight into the problemsf analyzing and reporting data and other observations
btained from patients. Critical thinking is also developed
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340 Baughman et al. JACC Vol. 51, No. 3, 2008ACCF COCATS 3 Training Statement: Task Force 1 January 22, 2008:339–48

n such educational activities as journal clubs, literatureeviews, use of the Internet for self-directed learning, andhe presentation of talks in seminars or conferences.

ole of the Specialist and Duration of Training

raining in cardiology must take into account the role thathe cardiovascular specialist is likely to play in the healthare delivery system of the future. As a consequence of theging of the population, the demand for cardiovascular careill increase. Cardiovascular specialists will have to serve as

xpert consultants and procedural specialists, and the train-ng must reflect this expanded role.

The rotations of fellows in training for cardiovascularisease must be determined by the curriculum that iseeded to permit fellows to develop requisite competen-ies, not by the needs of the training facility or theraining program faculty. The 3-year training programhould include a clinical core of 24 months with theollowing minimums: 1) 9 months in nonlaboratorylinical practice activities (e.g., cardiac consultation, in-atient cardiac care, intermediate acute care unit, chest painnit, coronary care unit, cardiothoracic/cardiovascular surgery,ongenital heart disease, heart failure/cardiac transplanta-ion, preventive cardiovascular medicine, cardiac rehabilita-ion, and vascular medicine); 2) 4 months in the cardiacatheterization laboratory; 3) 7 months in noninvasivemaging (echocardiography and Doppler [minimum 3

onths], noninvasive and peripheral vascular studies, anduclear cardiology techniques [minimum 2 months]) andardiovascular magnetic resonance and other techniquese.g., electron beam or fast helical computed tomography);) 2 months (in blocks or equivalent experience) in electro-ardiography, stress testing, and ambulatory electrocardiographic

Figure 1 COCATS 3-Year Cardiovascular Fellowship Level 1 Exp

This represents outpatient exposure at one-half day per week. Electrocardiogram,months. *Includes echocardiography, nuclear cardiology, cardiovascular magneticpreventive cardiovascular medicine.

onitoring; and 5) 2 months in arrhythmia management,ermanent pacemaker and implantable cardioverter-efibrillator management, and electrophysiology; 2 months inhe recognition and management of patients with peripheralascular disease. A continuing ambulatory care experiencehould be provided for at least one-half day per week through-ut the 3-year training program (Fig. 1). Trainees who elect toxtend their fellowship training to 4 years by performing 1dditional year of research may receive 1 month only of creditor clinical consultation training by extending their ambulatoryare experience for one-half day per week for at least 48 weeksuring that year. No other clinical curricular activities may beerformed during this time, and a maximum of 1 month ofredit is allowed regardless of duration of continuity outpatientlinical experience during research years. An option for fellowsndertaking 2 years of research training is to conduct aontinuity clinic every other week for the 2-year period. Thisould be equivalent to having a weekly clinic for 1 of the 2

esearch years. If a fellow moves to another institution for aear of research training as part of a 3-year fellowship program,comparable outpatient clinic experience can be undertaken at

he second institution.These time periods are considered to be the minimal time

equired to learn the indications, interpretative skills,nowledge of complications, risk/benefit, and cost/benefitf these procedures. This core 24-month training periodoes not qualify a trainee as a consultant in cardiovascularisease or as an expert in these technical procedures.xpertise in interventional cardiology, electrophysiology,eart failure/transplantation, and cardiovascular researchequire additional training beyond the standard 36-monthellowship.

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atory electrocardiogram, and exercise testing may be fulfilled in 24 to 36nce, and cardiovascular computed tomography. †May include cardiac failure and

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341JACC Vol. 51, No. 3, 2008 Baughman et al.January 22, 2008:339–48 ACCF COCATS 3 Training Statement: Task Force 1

The remaining year in the program should includeedicated research. In addition, trainees should be ex-osed to a curriculum throughout fellowship training thatncludes biostatistics, epidemiology, design and conductf research trials, and a critical review of the medicaliterature. The remaining months of training may includehe acquisition of more intensive training in specific areasf cardiovascular medicine or continued research. Train-es often require additional clinical training to be quali-ed to function properly as consultants in cardiovascularisease and as specialists in cardiology. This latter periodermits the trainees to obtain greater experience andupervised training in the clinical management of patientsith cardiovascular disease and to obtain additional

raining in the performance and application of particulariagnostic or therapeutic procedures. Trainees planningn academic career usually need additional researchraining (see Appendix 1). Vacation time, as well as timeor participation in professional meetings and confer-nces, will be allotted in a manner compatible withnstitutional policy. Vacation time will be taken propor-ionately during the clinical core and research electivexperience.

rogram Faculty

he program must be conducted under the auspices of arogram director who is highly competent in the specialtyf cardiovascular disease and fully committed to theraining of the cardiovascular specialist. The programirector must have experience as a faculty member in anctive and accredited cardiology residency program. Theirector of the cardiology training program must beertified by the ABIM Subspecialty Board on Cardiovas-ular Disease or possess appropriate educational qualifi-ations. The director should participate in scholarlyctivity (e.g., peer-reviewed publications, grants, andeview articles). The director is responsible for ensuringhe adequacy of the training facility, including supportesources for the provision of an education of highuality.There should be 1 full-time program faculty member

or every 1.5 trainees in the division (or section) ofardiology to guarantee close supervision of all traineesnd to allow for critical evaluation of the program and theompetence of the trainees. Each rotation and laboratoryhould have faculty members who supervise the fellows.t is essential that the cardiology program director devoteufficient time and effort to the graduate educationrogram and related activities. Cardiology program di-ectors must be full-time faculty members. The programirector must have the effective support of the institu-ion(s) where the training takes place to provide these
ducational attributes.
nvironment for Training inlinical Cardiology

nteraction With Other Disciplines

ardiology training programs must provide an intellectualnvironment for acquiring the knowledge, skills, clinicaludgment, and attitudes that are essential to the practice ofardiovascular medicine. Specialists in cardiovascular diseaseust interact with generalists and specialists in other areas

nd have knowledge of other specialties to provide excellentatient care. The ACGME requires at least 2 other sub-pecialty training programs in internal medicine and aesidency in internal medicine in order to enable theardiovascular disease trainee to collaborate with otherisciplines by providing consultations and participating ino-management of suitable patients. Close interaction withardiovascular/cardiothoracic surgery is of particular impor-ance. The overall program must provide advanced trainingo allow the physician to acquire expertise as a specialist andonsultant in cardiology.

elation to Training in Internal Medicine

ardiology training programs must provide the opportunityor cardiology trainees to maintain their skills in generalnternal medicine and in those aspects of cardiology thatelate to internal medicine. Therefore, the cardiology pro-ram must be closely related to the training program innternal medicine, and there must be carefully delineatedines of responsibility for the residents and staff in internal

edicine and the cardiology trainees. Trainees shouldaintain close working contact with residents and fellows in

ther areas, including surgery, critical care medicine, anes-hesia, radiology, pulmonary disease, pathology, pediatrics,nd neurology. When appropriate, expert faculty in theseisciplines should teach and supervise the trainees.

equired Training Program Resources

he program must have certain minimal resources, includ-ng the following:

1. There must be inpatient and outpatient facilities withan adequate number of patients of a wide age rangewith a broad variety of cardiovascular disorders. Train-ees must be supervised and evaluated on every rotationby qualified faculty members when they see patients inboth areas. Outpatient care must be carefully super-vised by faculty members.

2. The facility must provide laboratories for cardiac cath-eterization, electrocardiography, exercise and pharma-cologic stress testing, Doppler/echocardiography, am-bulatory ECG monitoring, and noninvasive peripheralvascular studies. There must be appropriate facilitiesfor cardiac catheterization, angiography, and hemody-namic assessment, with adequate numbers of patients
undergoing percutaneous interventional procedures

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(i.e., coronary angioplasty or stent placement), myo-cardial biopsy, and intra-aortic balloon placement (seethe Task Force 2, 3, and 4 reports).

3. Facilities for nuclear cardiology must be available,including ventricular function assessment, myocardialperfusion imaging, and studies of myocardial viability(see the Task Force 5 report).

4. There must be appropriate facilities for the manage-ment of patients with arrhythmias, including electro-physiologic testing, arrhythmia ablation, and signal-averaged electrocardiogram (ECG) and tilt-tabletesting, as well as the previous evaluation, implanta-tion, and assessment of patients with cardiac pacemak-ers and implantable antiarrhythmic devices and theirlong-term management (see the Task Force 6 report).

5. Facilities and faculty for training in cardiovascularresearch, including various basic science, clinical sci-ence, and population science modalities, are important(see the Task Force 7 report).

6. Modern intensive cardiac care facilities must be available.7. Facilities for cardiac and peripheral vascular surgery

and cardiovascular/cardiothoracic surgical intensivecare must be provided at the primary site of training.Close association with and participation in a cardio-vascular/cardiothoracic surgical program is an essentialcomponent of the cardiovascular training program.This must include active participation in the pre- andpost-operative management of patients with cardiovas-cular disease. Exposure to cardiac transplantation isstrongly recommended (see the Task Force 8 report).

8. Facilities and faculty must be involved in the diagnosis,therapy, and follow-up care of patients with congenitalheart disease (see the Task Force 9 report).

9. There must be appropriate facilities for the clinical andlaboratory assessment of patients with systemic hyper-tension and peripheral vascular disease (see the TaskForce 10 and 11 reports).

0. Facilities for assessment of cardiopulmonary and pul-monary function, cardiovascular radiography, andmagnetic resonance imaging and computed tomogra-phy must be available (see the Task Force 12 report).

1. Appropriate expertise and instruction in preventivecardiovascular medicine and risk-factor modification,including management of lipid disorders, must beprovided (see the Task Force 10 report).

2. There must be facilities for and faculty with knowledgeof cardiovascular pathology.

3. There must be facilities for and personnel and facultywith expertise in cardiac rehabilitation.

4. Other appropriate facilities and resources necessary toaccomplish the training must be provided, including acomprehensive medical library, facilities for continuingmedical education, and a curriculum that includesexperimental study design, statistics, and quality
assurance. n
raining Components

n educational clinical cardiovascular disease training pro-ram must have the following training objectives andharacteristics and must encompass the following areas.

raining in Patient Care and Management

n addition to the core clinical skills of internal medicine, allardiology trainees must be skilled in obtaining a history anderforming a complete cardiovascular physical examination.ll trainees must be familiar with the role of aging andsychogenic factors in the production of symptoms and themotional and physical responses of patients to cardiovas-ular disease. They must be familiar with the importance ofreventive care and rehabilitative aspects of the manage-ent of patients with known or potential cardiovascular

isease. The trainee should have considerable experiencecting as a consultant to other physicians and should haveirect, supervised patient care responsibility in proportion tois or her experience and qualifications. Extensive outpa-ient training is essential for learning the long-term coursef patients with chronic cardiovascular disease.

raining in Understanding, Diagnosis, Prevention,nd Treatment of Cardiovascular Disease

he trainee must become well educated in pathogenesis,athology, risk factors, natural history, diagnosis by history,hysical examination and laboratory methods, medical andurgical management, complications, and prevention ofardiovascular conditions including coronary artery disease,ypertension, hyperlipidemia, valvular heart disease, con-enital heart disease, cardiac arrhythmias, heart failure,ardiomyopathy, involvement of the cardiovascular systemy systemic disease, infective endocarditis, diseases of thereat vessels and peripheral blood vessels, diseases of theericardium, pulmonary heart disease, the interaction ofregnancy and cardiovascular disease, cardiovascular com-lications of chronic renal failure, traumatic heart disease,nd cardiac tumors and cardiovascular changes associatedith advancing age. Cardiology trainees must develop annderstanding of the various roles of collaboration, co-anagement, and consultation in the system-based care

f patients with complex comorbidity and cardiovascularisease.

raining in Intensive Care

he training must include at least 3 months of full-timexperience with patients undergoing intensive care for acuteardiovascular disorders and coronary care. This exposurehould include (but is not limited to) management of acuteoronary syndromes, ST-elevation myocardial infarction, car-iogenic shock, acute decompensated congestive heart failure,ymptomatic arrhythmias, hypertensive crisis, infective endo-arditis, aortic dissection, pericardial tamponade, and pulmo-
ary embolism. Appropriate use of hemodynamic monitoring;

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ntra-aortic balloon counterpulsation; and thrombolytic, per-utaneous, and surgical therapy should be emphasized. Inddition, because of the additional medical comorbidities thatcutely ill cardiovascular patients manifest, trainees should gaindditional expertise with airway and ventilator management,se of renal replacement therapy, and treatment of sepsis andther infectious complications.

raining in Ambulatory, Outpatient, andollow-Up Care

ontinued responsibility for principal care, co-managementith primary care physicians, and consultation outpatient

ardiovascular patient management must occupy at leastne-half day per week for 36 months. An ambulatoryontinuity clinic is essential for the duration of training.here should be exposure to a wide age range of patients,

rom adolescence through old age, with a spectrum ofardiovascular diagnoses, including post-operative patients,atients with congenital heart disease, and patients forvaluation and management related to pregnancy. Addi-ional ambulatory experience in specialty clinics or hospital-ased settings is desirable and may include participation iname-day diagnostic or therapeutic procedures.

raining in Electrocardiography

ll cardiovascular trainees must be skilled in the interpre-ation of ECGs. There must be appropriate review, audit,nd evaluation of their skills. All cardiology trainees must bekilled in the performance and interpretation of exerciseCG tests and ambulatory and signal-averaged ECGs, asescribed in the Task Force 2 report.

raining in the Cardiac Catheterization Laboratory

he trainee must have direct, supervised experience in aeneral adult cardiac catheterization laboratory that per-orms catheterizations of both the right and left sides of theeart. This initial experience in the cardiac catheterization

aboratory must emphasize the fundamentals of cardiovas-ular physiology as it relates to clinical disease, the analysisf hemodynamic records, and the interpretation of angio-raphic images. Such an experience must also emphasize theroblems in interpretation and analysis of such data and themportance of quality. All fellows must have adequateraining in the principles of radiation safety. The amount ofraining in the mechanical skills of cardiac catheterizationhat is necessary is addressed in the Task Force 3 report.he acquisition of advanced procedural skills is not therimary purpose of the initial exposure of the trainee to theardiac catheterization laboratory. All trainees must under-tand indications, risks, and benefits of interventional ther-peutic procedures, as described by the Task Force 3 report.

raining in Echocardiography

ll trainees must participate in the performance of echo-ardiography and Doppler echocardiography and must un-
erstand the indications, risks, and benefits of transesoph- m
geal and stress echocardiography, as well as the principlesf evolving techniques, such as intravascular ultrasound.hose trainees who wish to perform these latter techniquesr to direct an echocardiography laboratory must havedditional training, as described in the Task Force 4 report.he duration of exposure or number of procedures to

chieve levels of training are outlined in the Task Force 4eport.

raining in Nuclear Cardiology

ll trainees should know the general principles, indications,isks, and benefits of nuclear cardiovascular procedures, suchs radionuclide ventriculography and myocardial perfusionnd viability assessment. All trainees must receive basicraining in radiation safety. Trainees need a minimum of 2onths of training; those who wish to practice nuclear

ardiology must have additional training, as described in theask Force 5 report.

raining in Other Advanced Imaging Techniques

ll trainees should be aware of and preferably directlyxposed to major evolving advanced imaging techniques.

raining in Cardiac Arrhythmia Device Management

ll trainees must understand the diagnosis and manage-ent of cardiac arrhythmias. Trainees should know the

ndications for cardiac arrhythmia devices and the principlesf management and follow-up of patients with implantedacemakers and antiarrhythmic devices, as described inhe Task Force 6 report. Participation in implantation isesirable.

raining in Electrophysiology

ll trainees must be skilled in the selection of patients forpecialized electrophysiologic studies, including arrhythmiablation. Those who wish to perform these procedureshould receive additional training, as described in the Taskorce 6 report.

raining in Cardiovascular Research

ll trainees should participate actively in research activities.rainees who anticipate a career in academic cardiology

hould have additional specialized training, as described inhe Task Force 7 report. All trainees should understandlinical study design, biostatistics, and how to critically readnd interpret the cardiovascular literature.

raining in Heart Failure and Heart Transplantation

ll trainees must understand the diagnosis and manage-ent of patients with heart failure and that of cardiac

ransplant recipients, as described in the Task Force 8eport.

raining in Congenital Heart Disease in the Adult

ll trainees must understand the diagnosis and manage-
ent of adult patients with and without surgical repair of

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ongenital heart disease, as described in the Task Force 9eport. Trainees must participate in the transition of care ofatients from pediatric to adult cardiologists.

raining in Preventive Cardiovascular Medicine

ll trainees should know the principles of preventive car-iovascular medicine, including vascular biology, genetics,pidemiology, biostatistics, clinical trials, outcomes re-earch, clinical pharmacology, behavior change, and multi-isciplinary care as described in the Task Force 10 report.pecific knowledge in the areas of hypertension, dyslipide-ia, thrombosis, smoking cessation, cardiac rehabilitation,

xercise physiology, nutrition, psychosocial issues, metabolicisorders, gender and racial issues, and aging is essential.deally, training should be undertaken in a 1-month (oronger) rotation. Those who will focus their clinical practicen preventive cardiovascular medicine should develop exper-ise in counseling for behavior change.

raining in Vascular Medicine

he trainee must develop sound knowledge of the clinicaleatures and treatment of vascular disease, demonstrate com-etence in obtaining the history and performing the physicalxamination of the arterial and venous systems, and becomenowledgeable in the interpretation and selection of patientsor noninvasive vascular tests and peripheral angiograms.

raining in Magnetic Resonance Imaging

amiliarity with the cardiovascular applications and inter-retations of magnetic resonance images is essential to theraining of a cardiovascular fellow. This imaging modalityas many existing uses and considerable potential in non-

nvasive diagnosis. The fellow should supplement this ex-erience with exposure to cardiovascular magnetic reso-ance (CMR) studies throughout the clinical trainingrogram. Those who wish to interpret CMR studies or whoesire advanced training must have additional training asesignated in the Task Force 12 report.

raining in Computed Tomography

omputed tomography (CT) is a rapidly evolving techniqueo evaluate cardiovascular anatomy and function. Clinicalpplications include noncontrast CT for coronary calcifica-ion, contrast CT to assess coronary anatomy and leftentricular function, and hybrid procedures combining CTith other noninvasive techniques. By the end of fellowship

he trainee should be expected to have participated in 50entored interpretations to achieve Level 1 competency.

ee the Task Force 13 report for details.

raining in Related Sciences

he training program should provide an opportunity forontinuing education in basic sciences, including thosespects of anatomy, physiology, pharmacology, pathology,enetics, biophysics, and biochemistry that are pertinent to
ardiology, particularly vascular biology, thrombosis, and
olecular biology. It is essential for trainees to acquire ahorough understanding of the normal physiology of theirculatory system, including the adaptation of the cardio-ascular system to exercise, stress, pregnancy, aging, andenal and pulmonary abnormalities, and trainees must beble to reliably interpret tests of renal and pulmonaryunction. Learning in pharmacology should recognize di-tary, renal, and hepatic function as well as geriatric influ-nce on drug therapy. Complementary medicine as it affectsraditional cardiovascular therapy should be included in theurriculum. The availability of educational programs iniostatistics, computer sciences, and biophysics is highlyesirable. Training in medical economics, health care sys-ems delivery, clinical decision making, preventive medicine,nd health care outcomes should also be available.

raining in Related Fields of Medicine

he trainee must gain knowledge and experience in a numberf related areas of medicine, including the following:

. Radiology: the interpretation of cardiovascular X-rayfilms, with particular reference to vascular structures andspecial cardiovascular radiologic procedures.

. Surgery: the risks and benefits of cardiothoracic andcardiovascular surgery and the rationale for the selectionof candidates for surgical treatment, as well as thenatural history and the pre- and post-operative manage-ment of patients with cardiovascular disease and variousco-morbid conditions.

. Anesthesia: close collaboration with anesthesia colleaguesin the pre- and post-operative management of patientswith cardiac disease for cardiac and noncardiac surgery,as well as cardiac procedures that require anesthesia(e.g., cardioversion).

. Pulmonary disease: a solid knowledge of basic pulmonaryphysiology in addition to the interpretation of pulmo-nary and cardiopulmonary function testing, blood gases,pulmonary angiography, and radiology lung scanningmethods, as well as experience with management ofpatients with acute pulmonary disease.

. Obstetrics: a solid knowledge of the inter-relations be-tween pregnancy and heart disease, together with expe-rience in the clinical management of patients with heartdisease who are pregnant, and safety of cardiovasculardrug use in pregnancy.

. Physiology: the physiology of the cardiovascular system,its response to exercise and stress, and the alterationsproduced by aging and disease.

. Pharmacology: the pharmacology and interactions ofcardiovascular drugs and drugs that affect cardiovascularfunction.

. Pathology: familiarity with the gross and microscopicpathology of all major forms of heart disease.

. Geriatrics: familiarity with the effects of aging on car-
diovascular disease and therapy.

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raining Through Conferences, Seminars, Review ofublished Reports, and Lectures

here must be regularly scheduled cardiology conferences,eminars, and reviews of published data. The participationf trainees in the planning and production of these confer-nces is expected. Attendance at medical grand rounds andultidisciplinary conferences is highly desirable, particularly

t conferences closely related to cardiovascular disease, suchs conferences on surgery, radiology, and pathology. Visit-ng professors should provide stimulation and at leastnformal evaluation and feedback to trainees and faculty.

eaching and Educational Experience

he trainee must participate directly in the teaching ofardiology to peers, internal medicine residents, and toeferring physicians and become familiar with the funda-ental principles of education, including skills in organiza-

ion of conferences, lectures, and teaching materials. Theeaching experience, often through weekly or more frequentore content conferences, must attempt to integrate basiciomedical information with the clinical aspects of cardiol-gy, including integration of clinical management princi-les. Trainees must be familiar with modern concepts ofducation and effective communication. They must beesponsible for teaching residents in internal medicine, asell as medical students, cardiology trainees, and alliedealth personnel, and for working collaboratively with otherealth care professionals. They must have regularly sched-led experiences in teaching and must be encouraged tottend and participate in national cardiology meetings.rainees must learn to prepare successfully, through self-study

nd participation in continuing education using various media,or certification, recertification, and credentialing.

pecial Procedural Areas

n specific procedural areas of cardiology, minimal trainings appropriate for physicians who do not plan to achievedditional qualifications in a given field. Conversely, thosehysicians who wish to become qualified in specialized areasequire additional training, as specified by the individualask forces. Trainees should log all appropriate procedures.

valuation and Documentation of Competence

he evaluation of trainees for both clinical and specializedechnical skills must be documented carefully. Cardiologyrogram directors must establish procedures for the regularvaluation of the clinical competence of cardiology trainees.his evaluation must include intellectual abilities, manual

kills, attitudes, and interpersonal relations, as well aspecific tasks of patient management, clinical skills (includ-ng decision-making skills), and the critical analysis of
linical situations. There must be provision for appropriate
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eedback of this information to the trainee at regularntervals. Records must be maintained of all evaluations andf the number and type of all laboratory procedures per-ormed by each trainee. The use of examinations (e.g., thedult Clinical Cardiology Self-Assessment Program

ACCSAP]) at the end of each year of training or uponompletion of each specialized area of training is stronglyncouraged.

Attainment of core competences (medical knowledge,atient care, interpersonal and communication skills, pro-essionalism, practice and learning and in applying therinciples of quality measurement and improvement in theirractice) must be documented. They should measure theirlinical performance and participate in practice-based learn-ng collaboratives, apply root-cause analysis to sentinelrrors, develop improvement plans, and participate in theuality improvement activities of the institution.

his is a revision of the 2002 document that was written byenneth L. Baughman, MD, FACC—Chair; Charles L.urry, MD, FACC; David C. Leach, MD (American Council

or Graduate Medical Education Representative); Prediman K.hah, MD, FACC; and Laura F. Wexler, MD, FACCAmerican Board of Internal Medicine Representative).

doi:10.1016/j.jacc.2007.11.009

ASK FORCE 1 REFERENCES

. Accreditation Council for Graduate Medical Education. Internal med-icine, program requirements for residency education in internal medi-cine. Available at: http://www.acgme.org/acWebsite/RRC_140/140_prIndex.asp. Accessed February 2, 2002.

. Accreditation Council for Graduate Medical Education. Policies andprocedures for subspecialties, policies and procedures for residencyeducation in the subspecialties of internal medicine. Available at:http://www.acgme.org/acWebsite/RRC_140/140_prIndex.asp. Ac-cessed February 2, 2002.

. Accreditation Council for Graduate Medical Education. Cardiovasculardisease, program requirements for residency education in cardiovasculardisease. Available at: http://www.acgme.org/acWebsite/RRC_140/140_prIndex.asp. Accessed February 2, 2002.

. Accreditation Council for Graduate Medical Education. Subspecialties,program requirements for residency education in the subspecialties ofinternal medicine. Available at: http://www.acgme.org/acWebsite/RRC_140/140_prIndex.asp. Accessed February 2, 2002.

. Benson JA, Blank LL, Frenkel EP, et al. Evaluation of humanisticqualities in the internist. Ann Intern Med 1983;99:720–4.

. Ad Hoc Committee on Medical Ethics, American College of Physi-cians. American College of Physicians Ethics Manual: part I: history ofmedical ethics, the physician and the patient, the physician’s relation-ship to other physicians, the physician and society. Ann Intern Med1984;101:129–37.

. Ad Hoc Committee on Medical Ethics, American College of Physi-cians. American College of Physicians Ethics Manual: part II: research,other ethical issues: recommended reading. Ann Intern Med 1984;101:263–74.

ey Words: ACCF Training Statement y COCATS 3 y clinicalardiology y training requirements.

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PPENDIX 1. SUMMARY OF TRAINING REQUIREMENTS

TaskForce Area Level

Minimal Number ofProcedures

Cumulative Durationof Training (Months)

Minimal Cumulative Numberof Procedures Comments

1 Clinical cardiology 1 36

2 Electrocardiography 12

3500*†3500

36 3500 *Can be taken throughoutthe training program.†The committeestrongly recommendsthat cardiologistsachieve Level 2 trainingin ECG interpretation.

Ambulatory monitoring 12

150*75

150225

*Can be taken throughoutthe training program.

Exercise testing 12

200*100

200300


3 Diagnosticcatheterization

12

100200

48

100300

Interventionalcatheterization

3 250 20 550

4 Echocardiography 1 (75/150) 3 75/150

2 (75/150) 6 150/300

3 (150/450) 12 300/750

5 Nuclear cardiology 1 100 cases 2 100 cases

2 300 cases 4 to 6 300� cases

3 600 cases 12 600� cases

6 Electrophysiology, pacing,and arrhythmias

1 20 2 10 temporary pacemakers10 D.C. cardioversions

2 100 6 100 pacemaker interrogation/reprogramming

3 300* prior procedure volumeduring Level 1 and 2training is cumulative andcounts towards overallnumbers recommended forLevel 3 training

12–24 150� EP cases75 ablations75� pacemaker/ICDs


7 Research 1 6–12‡ ‡Can be taken as part of9 months of requirednonlaboratory clinicalpractice rotation.

2 24

3 24–36

8 Heart failure andtransplantation

123

1‡§6

12

‡Can be taken as part of9 months of requirednonlaboratory clinicalpractice rotation.

§It is assumed that traineeswill obtain additionaltraining in heart failureand preventivecardiovascular medicinebeyond the 1-month coretraining as part of theexperience during otherclinical months, such asconsult services and CCU.

Continued on next page

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PPENDIX 1. CONTINUED



Cumulative Durationof Training (Months)

Minimal Cumulative Numberof Procedures Comments

9 Congenital heart disease 123

Core lectures‡1224

40 catheterizations300 TTE cases50 TEE cases


10 Preventive cardiovascularmedicine

123

1‡§6–12

12


§It is assumed thattrainees will obtainadditional training inpreventive cardiovascularmedicine beyond the1-month core training aspart of the experienceduring other clinicalmonths, such as consultservices and CCU.

11 Vascular medicine 1 2* *Can be taken throughoutthe training program.

Vascular medicinespecialist

Peripheral vascularintervention

2

3

475� noninvasive vascularcases�

100 diagnostic peripheralangiograms, 50 peripheralangioplasties/stents,10 peripheral thrombolyticinfusions/thrombectomy

12¶

12#

475� noninvasive vascularcases�

100 diagnostic peripheralangiograms, 50 peripheralangioplasties/stents, 10peripheral thrombolyticinfusions/thrombectomy

�The prerequisite for Level2 training is Level 1training in vascularmedicine.

¶In addition to all otherclinical requirements forLevel 2 training.

#The prerequisite for Level3 training includes Level1 training in vascularmedicine, and Level 1and Level 2 training indiagnostic cardiaccatheterization.Requirements for Level3 training in peripheralvascular interventioncan be fulfilled during a4th year of inter-ventional trainingfocused on peripheralvascular intervention orconcurrently withcardiac interventionaltraining.

12 Cardiovascular magneticresonance

123

1**3 to 6

12

25 cases150 cases300 cases

**Can be taken as part of7 months of noninvasiveimaging rotation.

13 Computed tomography 123

1**26

50 cases150 CTA cases300 CTA cases

**Can be taken as part of7 months of noninvasiveimaging rotation.

CU � coronary care unit; CTA � computed tomography angiography; D.C. � direct current; ECG � electrocardiogram; EP � electrophysiology; ICD � implantable cardioverter-defibrillator; TEE �

ransesophageal echocardiography; TTE � transthoracic echocardiography.

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348 Myerburg et al. JACC Vol. 51, No. 3, 2008ACCF COCATS 3 Training Statement: Task Force 2 January 22, 2008:348–54

PPENDIX 2. AUTHOR RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FOR TRAINING INDULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 1: TRAINING INLINICAL CARDIOLOGY

Name ConsultantResearch

GrantScientific Advisory

BoardSpeakers’

BureauSteering

CommitteeStockHolder Other

Dr. Kenneth L.Baughman

None None None None None None None

Dr. F. Daniel Duffy None None ● National Committeefor QualityAssurance

None None None ● American Board ofInternal MedicineEmployee

Dr. Kim A. Eagle None None None None None None None

Dr. David P. Faxon None None ● Johnson & Johnson ● Bristol-Myers Squibb● Sanofi

None ● Medical Technology None

Dr. L. David Hillis None None None None None None None

Dr. Richard A.Lange


his table represents the relationships of committee members with industry that were reported by the authors as relevant to this topic. It does not necessarily reflect relationships with industry at the timef publication.

PPENDIX 3. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FORRAINING IN ADULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 1:RAINING IN CLINICAL CARDIOLOGY

Name* Affiliation ConsultantResearch


BoardSpeakers’

BureauSteering


Dr. Rick A.Nishimura

● Official–Board of Trustees None None None None None None None

Dr. Chittur A.Sivaram

● Official–Board of Governors ● 3F Therapeutics None None None None None None

Dr. Laura F. Wexler ● Content–American Board ofInternal Medicine


his table represents the relationships of peer reviewers with industry that were reported by the authors as relevant to this topic. It does not necessarily reflect relationships with industry at the time ofublication.*Names are listed in alphabetical order with each category of review.

Task Force 2: Training in Electrocardiography,Ambulatory Electrocardiography, and Exercise Testing

Robert J. Myerburg, MD, FACC, ChairBernard R. Chaitman, MD, FACC, Gordon A. Ewy, MD, FACC, Michael S. Lauer, MD, FACC

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lectrocardiography

mportance

lectrocardiography is the most commonly used diagnosticest in cardiology. Properly interpreted, it contributes sig-ificantly to the diagnosis and management of patients with
ardiac disorders. Importantly, it is essential to the diagnosis e
f cardiac arrhythmias and the acute myocardial ischemicyndromes. These 2 conditions account for the majority ofardiac catastrophes. It is appropriately used as a screeningest in many circumstances.

oal of Training

lthough every physician should have a basic knowledge of
lectrocardiography, and the general internist should have

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349JACC Vol. 51, No. 3, 2008 Myerburg et al.January 22, 2008:348–54 ACCF COCATS 3 Training Statement: Task Force 2

ore advanced knowledge than most others, the subspecial-st in cardiology should be familiar with nearly all clinicallyncountered patterns of depolarization and repolarizationnd of arrhythmias. The trainee should understand clinicalmplications, sensitivity, and specificity of the test, andhould be able to identify normal variants. The traineehould have sufficient basic knowledge to understand thehysiologic mechanisms for arrhythmias and electrocardio-raphic waveforms rather than to simply recognize patterns.he recognition and understanding of the basis for the

tems included in Appendix 1 of this task force report areinimum requirements for each trainee.The trainee should also be familiar with the instrumen-

ation necessary to acquire, process, and store electrocardio-rams (ECGs), in both analog and digital format. Therainee should understand the effect of acquisition rates andlter settings, as well as recognize electronic artifacts. Therainee should be able to accurately measure basic ECGntervals in both analog and digital systems.

raining

n essential feature of training is to interpret a large numberf ECGs and to review all interpretations with experiencedaculty. The committee recommends that all traineeschieve Level 2 training in ECG interpretation. Thisecessitates interpreting 3500 ECGs over 24 to 36 monthsTable 1). These should be documented individually. Thisay be accomplished by 1 or more training periods assigned

pecifically for interpretation of ECGs, or it may be anxperience provided in a continuing manner. The experi-nce should include clinical correlation in patients in inten-ive care units, emergency rooms, and pacemaker/efibrillation clinics. The ECG should be integrated withhe clinical problem. Formal courses and correlative confer-nces in electrocardiography are strongly recommended. Inddition, guidelines for the role of electrocardiography inlinical practice should be thoroughly understood, reviewed,nd followed (1).

ummary of Training Requirements in Electrocardiography, Ambula

Table 1 Summary of Training Requirements in Electrocardiogra



Cumof Tr

2 Electrocardiography 1 3500*†

2 3500

Ambulatory monitoring 1 150*

2 75

Exercise testing 1 200*

2 100

CG � electrocardiogram.

n-Training Evaluation

he trainee must become familiar with the indications forlectrocardiography and electrophysiologic studies. Simi-arly, the trainee should be familiar with the principles ofntracardiac electrophysiologic studies, their indications,ontraindications, sensitivity, and specificity (see the Taskorce 6 report). The trainee should be evaluated on anngoing basis by responsible faculty to determine that therainee has integrated these knowledge bases. Because ofariability in training in electrocardiography and to doc-ment the trainee’s proficiency, an in-training examina-ion in electrocardiography should be used and imple-ented by each training program. The Adult Clinicalardiology Self-Assessment Program (ACCSAP) con-

ains a self-assessment examination in electrocardiogra-hy, which is available on a national basis and is useful fordentifying knowledge areas of specific weakness andevels of proficiency.

mbulatory ECG Monitoring

mportance

bservation and documentation of cardiac rhythm duringaily activities, as well as the relation of the rhythmisturbances to patient symptoms, are important factors forlinical decision making. Major indications for ambulatoryCG monitoring include the following: detection of or

uling out of rhythm disturbances as a cause of symptoms;etection and assessment of arrhythmias believed to bessociated with an increased risk for cardiovascular events;he identification and accurate interpretation of ambulatoryT-T wave changes occurring throughout a diurnal timeeriod; assessment of efficacy of antiarrhythmic and anti-

schemic therapy; and investigation of the effects of therapeuticevices (e.g., pacemakers and implantable cardioverter-efibrillator).

lectrocardiography, and Exercise Testing

Ambulatory Electrocardiography, and Exercise Testing

e Duration(Months)

Minimal Cumulative Numberof Cases Comments

3500 *Can be taken throughout thetraining program.†The committee stronglyrecommends thatcardiologists achieve Level2 training in ECGinterpretation.

6

150 *Can be taken throughout thetraining program.

225

200 *Can be taken throughout thetraining program.

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oal of Training

he technology is not perfect, and multiple methods ofecording and analysis are currently in use. The traineehould understand the differences between continuous andntermittent recordings and the advantages and disadvan-ages of each and should have a basic knowledge of thearious methods used for arrhythmia and ST-segmentetection, classification, and analysis. The trainee shouldnderstand the potential pitfalls inherent in each method.n addition, the trainee should have current knowledgebout what may represent a “normal” finding for various ageroups during sleeping and waking hours and what shoulde considered “abnormal,” realizing that the clinical signif-cance of some findings on ambulatory monitoring is stillnresolved.

tructure of Training

he trainee should participate in interpretation sessionsith a staff cardiologist knowledgeable in the indications for

he test, the techniques of recording, and the clinicalignificance and correlations of findings. It is recommendedhat the trainee interpret a minimum of 150 ambulatoryCG recordings over 24 to 36 months. Ideally, the trainee

hould be exposed to both full-disclosure (complete print-ut) and computer-assisted systems so that the advantages,isadvantages, and cost of each may be understood. Inddition, transtelephonic and event-recorder devices arencreasingly used on an adjunct basis for prolonged ambu-atory electrocardiography. Knowledge of their indicationsnd limitations must also be gained, preferably from struc-ured training in ambulatory electrocardiography that per-its interaction of the trainee with an experienced cardio-

ascular technician and ambulatory ECG instrumentationnd review of interpreted records with the attending cardi-logist with specific expertise in ambulatory electrocardiog-aphy. Such training will provide knowledge to satisfylinical competence in ambulatory electrocardiography asndicated by the American College of Cardiology (ACC)/merican Heart Association (AHA)/American College ofhysicians–American Society of Internal Medicine (ACP–SIN) Task Force on Clinical Competence (1).Level 2 trainees will interpret a minimum of 75 additional

ecordings over 12 months (a total of 225 recordings over 36onths). Such recordings or other provided material should

nclude all forms of artifact, pacemaker, and implantableardioverter-defibrillator patterns, heart rate variabilitytudies, repolarization abnormalities (e.g., QT or T wavelternans), and applications of the signal-averaged ECG.uch trainees will demonstrate knowledge of the operationnd limitations of a variety of types of ambulatory ECGnstrumentation. Additional ECG interpretation of in-ospital telemetry ECGs is required. This may range fromto 8 s of real-time printout strips to 72 h of full-disclosureata. Such ECG data often augment standard and ambu-

atory electrocardiography. Trainees will be experienced in s

he interpretation and limitations, since knowledge at thisevel also supports the objectives of Level 2 training inlectrophysiology, pacing, and arrhythmia management (seehe Task Force 6 report).

n-Training Evaluation

ecause of the large number of different rhythm patternseen during routine clinical ambulatory ECG recordingsnd the many technologic approaches, it may not be possibleo assess adequately a trainee’s expertise in ambulatorylectrocardiography by a uniform, written examination.hus, the trainee must be given the responsibility for initial

nterpretation of all phases of the ambulatory ECG study.he trainee should provide a detailed interpretation and

eview it with the attending cardiologist responsible andxperienced in ambulatory electrocardiography. This at-ending cardiologist is responsible for the evaluation andocumentation of a trainee’s progress and skills.

volving New Applications

ong-term ambulatory electrocardiography continues tovolve with regard to QT measurements and heart rateariability studies. These measurements provide insight intoentricular repolarization changes and the autonomic ner-ous system (sympathetic and parasympathetic) over ex-ended periods of ambulatory electrocardiography. Traineeshould be cognizant of these developments and follow theirvolution and clinical application.

xercise Testing

mportance

xercise testing is an important physiologic procedure usedo elicit cardiovascular abnormalities not present at rest ando determine adequacy of cardiac function. These tests arealuable clinical procedures used to assess patients withuspected or proven cardiovascular disease. Exercise testings used primarily to estimate prognosis, determine func-ional capacity, provide a diagnostic estimate of the likeli-ood and extent of coronary disease, and determine theffects of therapy. Exercise electrocardiography is also com-ined with ancillary techniques such as radionuclide imag-ng, echocardiography, or metabolic gas analysis to enhancehe information content of the test in selected patients.

oal of Training

he trainee should become proficient at performing botheart rate-limited and maximal or near-maximal treadmillxercise tests and should have the opportunity to learnlternative exercise testing techniques. The training pro-ram should provide the opportunity for the trainee toecome knowledgeable in exercise physiology and patho-hysiology. The trainee should also be taught the essentialsf exercise testing, such as skin preparation, electrode
election and application, choice of exercise testing proto-

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ols, blood pressure monitoring during exercise, and mon-toring of the patient for adverse signs or symptoms. Therainee should be thoroughly familiar with evidence-basedndications and contraindications to exercise testing. Therainee must become proficient in the interpretation ofommonly used measurements available from the exerciseest. These include the onset and offset of ischemic ST-egment depression and the distinction between normalariants and abnormal patterns, exercise-induced cardiacrrhythmias, magnitude and slope of ST-segment depres-ion or elevation, ST/heart rate indexes, exertional hypo-ension, chronotropic incompetence, heart rate recovery,nd hemodynamic measurements such as maximum exerciseeart rate, systolic blood pressure, and double product. Therainee should become proficient in integrating the data,nderstanding the reasons for stopping exercise, and estab-ishing diagnostic accuracy (sensitivity and specificity) andrognostic importance of the procedure in different clinicalettings as described in the ACC/AHA guidelines forxercise testing (2). This training will provide knowledge toatisfy clinical competence in exercise testing, as indicatedy the ACC/AHA/ACP–ASIN Task Force on Clinicalompetence.

tructure of Training and In-Training Evaluation

he training of a fellow in cardiology should include at leastmonths, or the equivalent, of active participation in a fully

quipped exercise testing laboratory, during which time theellow should perform a minimum of 200 exercise testseviewed by faculty. This experience can be obtained con-urrently with training in an exercise imaging laboratory asart of the training requirements in nuclear cardiology orchocardiography. Level 1 trainees will gain proficiency inhe standard exercise test and its interpretation (minimumxperience 200 tests), to include pharmacologic testingdipyridamole, adenosine, and dobutamine), whereas Leveltrainees (additional 100 tests) will become experienced in

dvanced forms of exercise testing, which include arrhyth-ia evaluation, ventilatory gas studies, pulmonary function

esting as part of cardiopulmonary stress testing, stresschocardiographic techniques, and nuclear cardiology (seehe Task Force 4 and 5 reports).

The laboratory should be engaged in the performance ofxercise tests on a regular basis that involve a broadpectrum of both inpatients and outpatients with a variety ofnown and suspected cardiac disorders. The training pro-ram should be structured so that the trainee is guided inhe laboratory by a specially trained exercise professionalntil the trainee has become proficient at conducting andonitoring exercise tests under a variety of clinical circum-

tances. The trainee must be given the responsibility fornitial interpretation of all phases of the exercise study,roviding a detailed interpretation, and reviewing it withhe attending cardiologist responsible and experienced in
xercise testing. The faculty physician should assess and
ocument the trainee’s progress on a regular basis, includingechnical performance and ability to interpret results.

his is a revision of the 2002 document that was written byobert J. Myerburg, MD, FACC—Chair; Bernard R. Chait-an, MD, FACC; Gordon A. Ewy, MD, FACC; and Melvin. Scheinman, MD, FACC.

doi:10.1016/j.jacc.2007.11.010


. Kadish AH, Buxton AE, Kennedy HL, et al. ACC/AHA clinicalcompetence statement on electrocardiography and ambulatory electro-cardiography: a report of the ACC/AHA/ACP-ASIM Task Force onClinical Competence (ACC/AHA Committee to Develop a ClinicalCompetence Statement on Electrocardiography and Ambulatory Elec-trocardiography). J Am Coll Cardiol 2001;38:2091–100.

. Rodgers GP, Ayanian JZ, Balady G, et al. American College ofCardiology/American Heart Association Clinical Competence state-ment on stress testing: a report of the American College of Cardiology/American Heart Association/American College of Physicians—American Society of Internal Medicine Task Force on ClinicalCompetence. J Am Coll Cardiol 2000;36:1441–53.

ey Words: ACCF Training Statement y COCATS 3 y

lectrocardiogram y electrocardiography y ambulatorylectrocardiography y exercise testing.

PPENDIX 1: ELECTROCARDIOGRAPHIC KNOWLEDGE BASE AND

NTERPRETATION

natomy and Electrophysiology

1. Anatomy of the specialized conducting system (sino-atrial node, atrioventricular node, His bundle, bundlebranches), concept of the trifascicular conductionsystem

2. Spread of excitation in the ventricles3. Difference between unipolar and bipolar leads4. Einthoven triangle; frontal and horizontal lead refer-

ence system5. Vectorial concepts6. Significance of a positive and negative deflection in

relation to lead axis7. Relation between electrical and mechanical activity

echnique and the Normal ECG

8. Effect of improper electrode placement (limb andprecordial)

9. Effect of muscle tremor10. Effect of poor frequency response of the equipment11. Effect of uneven paper transport12. Measurement of PR, QRS, QT, normal values/rate

correction of QT interval13. Normal ranges of axis in the frontal plane14. Effect of age, weight, and body build on the axis in

the frontal plane, as well as specific ECG diagnoses(i.e., left ventricular hypertrophy, left ventricular hy-pertrophy, and strain)

15. Normal QRS/T angle

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16. Differential diagnosis of normal ST-T, T-wave vari-ants (e.g., “juvenile” pattern and early repolarizationsyndrome)

rrhythmias: General Concepts

17. Reentry, automaticity, triggered activity18. Aberration (various mechanisms)19. Capture and fusion complexes20. Escape (passive, accelerated) complexes or rhythms:

atrial, junctional, and ventricular21. Interpolated premature beat22. Parasystole (atrial, junctional, ventricular), modulated

parasystole23. Vulnerability24. Exit block25. Reciprocation26. Concealed conduction27. Supernormality

rrhythmias: Recognition

inoatrial Rhythm

28. Sinus tachycardia29. Sinus bradycardia30. Sinus arrhythmia31. Sinoatrial arrest32. Sinoatrial block

trial Rhythms

33. Atrial premature complexes (conducted, noncon-ducted)

34. Atrial tachycardia (ectopic)35. Atrial tachycardia with atrioventricular block36. Atrial fibrillation37. Atrial flutter (typical and atypical forms)38. Multifocal atrial tachycardia39. Wandering atrial pacemaker-multifocal atrial rhythm

trioventricular Node (Junctional)

40. Premature junctional complexes41. Atrioventricular node re-entrant tachycardia (com-

mon and uncommon type)42. Nonparoxysmal junctional tachycardia-accelerated

junctional rhythm43. Atrioventricular re-entrant or circus movement

tachycardia with an accessory pathway44. Escape complex or escape rhythm

entricular

45. Ventricular ectopic complexes46. Accelerated idioventricular rhythm47. Ventricular tachycardia: uniform (monomorphic),

multiform (pleomorphic or polymorphic), sustained,nonsustained, bidirectional, and torsades de pointes

48. Ventricular flutter, ventricular fibrillation
49. Ventriculoatrial conduction
50. Ventricular escape or idioventricular rhythm

trioventricular Dissociation Due To:

51. Slowing of dominant pacemaker52. Acceleration of subsidiary pacemaker53. Above with depression of atrioventricular conduction54. Third-degree atrioventricular block55. Isorhythmic atrioventricular dissociation

trioventricular Block

56. First degree57. Second degree; 2:1, Mobitz type I (Wenckebach),

Mobitz type II, high-degree atrioventricular block58. Third-degree atrioventricular block (complete)59. Significance of wide versus normal QRS complex

aveform Abnormality

bnormalities of Repolarization (Concept of Primary andecondary ST-T Wave Change); Abnormalities of U Wave;entricular Hypertrophy

60. Left ventricular hypertrophy: criteria for left ventric-ular hypertrophy; specificity and sensitivity of criteria

61. Right ventricular hypertrophy: criteria for right ven-tricular hypertrophy; sensitivity and specificity of thecriteria

62. Biventricular hypertrophy63. Electrical alternans

trial Abnormalities

64. Criteria for left atrial abnormality65. Criteria for right atrial abnormality66. Biatrial abnormality67. Clinical significance of atrial abnormalities

ntraventricular Conduction Disturbances

68. Anatomic and electrophysiologic basis for intraven-tricular conduction defects

69. Criteria for incomplete and complete left bundle-branch block

70. Criteria for the diagnosis of incomplete and completeright bundle-branch block

71. Criteria for left anterior and posterior fascicular blocks72. Concept of combined bundle and fascicular blocks73. Indeterminate intraventricular conduction defects74. Diagnosis and classification of pre-excitation syn-

dromes (e.g., Wolff-Parkinson-White syndrome)

yocardial Ischemia and Infarction

75. Transient ischemia and injury76. Normal Q waves77. Abnormal Q waves not associated with infarction78. Differential diagnosis of tall R wave in right precor-

dial leads79. Theoretical basis of ECG changes in acute myocar-

dial infarction (Q, ST-T waves)

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80. Time course of ST-segment changes in acute myo-cardial infarction

81. Diagnosis of myocardial infarction (without Q waves)82. ST-segment changes in conditions other than myo-

cardial infarction83. Localization of myocardial infarction84. QRS residuals of old myocardial infarction85. Reliability of QRS and ST-segment changes of myo-

cardial infarction in previously abnormal ECG: intra-ventricular conduction defects; ventricular hypertrophy

86. Overall assessment of serial ECGs as to the proba-bility of acute myocardial infarction

acemaker

87. Fixed-rate pacemaker88. Atrial pacing89. Ventricular demand pacing90. Atrial triggered ventricular pacing91. Atrioventricular dual pacing92. Malfunctioning: demand acting as fixed rate; failure

to sense; slowing of rate; acceleration of rate; failureto capture; failure to pace (inappropriate inhibition)

xercise ECG Test

93. Criteria for a positive response94. Significance of an abnormal baseline ECG; effect of

drugs; effect of pre-excitation95. Significance of heart rate and blood pressure response

(normal and abnormal)96. Sensitivity: false-negative (incidence and principal

causes)97. Specificity: false-positive (incidence and principal

causes)98. Significance of magnitude of ST-segment changes99. Normal responses to maximum exercise testing00. Exercise-induced rapid versus slow upsloping ST-

segment depression01. Exercise-induced minor versus abnormal horizontal

or downsloping ST-segment depression02. Exercise-induced ST-segment elevation in noninfarct-

related versus infarct-related leads03. Exercise-induced intraventricular conduction dis-

turbance04. Exercise-induced ventricular and supraventricular

arrhythmias05. Exercise-induced hypertensive or hypotensive

response 1

06. Sensitivity, specificity, and predictive accuracy inclinical patient subsets

07. Identification of chronotropic incompetence or accel-erated ventricular response

08. Utility of peak exercise capacity, ECG, hemodynamicresponse, and exercise-induced symptoms

09. Noncoronary causes of exercise-induced ST-segmentdepression

10. Exercise parameters that indicate adverse prognosis ormultivessel coronary disease

11. Indications and contraindications for exercise testing12. Exercise testing with ventilatory gas analysis13. Exercise testing in special groups: women, asymp-

tomatic subjects, post-revascularization patients,post-myocardial infarction or acute coronary syn-drome patients

14. Evaluation of valvular heart disease15. Evaluation of cardiac arrhythmias16. Interpretation of exercise test results in subjects with

resting ST-segment depression, left ventricular hy-pertrophy, Wolff-Parkinson-White syndrome, pace-makers, or cardiomyopathy

linical Diagnoses (Selected)

17. Hyperkalemia18. Hypokalemia19. Hypercalcemia20. Hypocalcemia21. Long-QT syndromes (congenital and acquired)22. Atrial septal defect, secundum23. Atrial septal defect, primum24. Dextrocardia25. Mitral stenosis26. Chronic obstructive pulmonary disease27. Acute cor pulmonale28. Pericardial effusion29. Acute pericarditis30. Hypertrophic cardiomyopathy31. Central nervous system disorder32. Myxedema33. Hypothermia34. Sick sinus syndrome35. Digitalis effect or toxicity36. Effects of other drugs (e.g., tricyclic or antiarrhythmic

agents)
37. Possible proarrhythmic effects

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PPENDIX 2. AUTHOR RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FOR TRAINING INDULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 2: TRAINING INLECTROCARDIOGRAPHY, AMBULATORY ELECTROCARDIOGRAPHY, AND EXERCISE TESTING



BoardSpeakers’

BureauSteering

Committee Stock Holder Other

Dr. Bernard R.Chaitman

● CV Therapeutics● Merck

● Berlex● CV Therapeutics● Pfizer

● CV Therapeutics● GE Healthcare

● Pfizer None None None

Dr. Gordon A. Ewy None None None ● AstraZeneca● Kos Pharmaceuticals● Merck● Pfizer● Schering-PloughPharmaceuticals

● Wyeth Pharmaceuticals

None None None

Dr. Michael S. Lauer None None None None None None None

Dr. Robert J.Myerburg

● Procter & Gamble● ReliantPharmaceuticals

None None ● Guidant● Procter & Gamble● Reliant Pharmaceuticals

None None ● Guidant(IndependentPanel onDeviceMalfunction)


PPENDIX 3. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FORRAINING IN ADULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 2:RAINING IN ELECTROCARDIOGRAPHY, AMBULATORY ELECTROCARDIOGRAPHY, AND EXERCISE TESTING

Name Affiliation ConsultantResearch


BoardSpeakers’

BureauSteering


Dr. Gordon L. Fung ● Official–Board ofGovernors

None None None ● AstraZeneca● CV Therapeutics● GlaxoSmithKline● Merck● Novartis● Pfizer

None None None

Dr. Richard J. Kovacs ● Official–Board ofGovernors

● Biosignals● Eli Lilly● Oxford● Xenoplast

None None ● CV Therapeutics None None None

Dr. Rick A. Nishimura ● Official–Board ofTrustees


his table represents the relationships of peer reviewers with industry that were reported by the authors as relevant to this topic. It does not necessarily reflect relationships with industry at the time ofublication.

B

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355JACC Vol. 51, No. 3, 2008 Jacobs et al.January 22, 2008:355–61 ACCF COCATS 3 Training Statement: Task Force 3

Task Force 3: Training in Diagnostic andInterventional Cardiac CatheterizationEndorsed by the Society for Cardiovascular Angiography and Interventions

Alice K. Jacobs, MD, FACC, ChairJoseph D. Babb, MD, FACC (Society for Cardiovascular Angiography and Interventions Representative),John W. Hirshfeld, JR, MD, FACC, David R. Holmes, JR, MD, FACC

Unudahpdaitiodi

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ackground

ince the second edition of Task Force 3 of the Americanollege of Cardiology (ACC) Core Cardiology Trainingymposium (COCATS) guidelines was published (1), bothhe cognitive knowledge and technical skill required of thenvasive and interventional cardiologist have continued torow. Concomitantly, the role of the cardiac catheterizationaboratory in trainee education and as a clinical care facilityontinues to evolve. The cardiac catheterization laboratoryerves as both a diagnostic and therapeutic facility. It has anmportant diagnostic role in the evaluation and managementf all types of heart disease: coronary, valvular, congenital,nd primary myocardial. This role includes invasive hemo-ynamic measurements and angiographic delineation ofardiovascular anatomy and pathology. The informationerived from these studies has a complementary overlapith that derived from other diagnostic modalities such as

chocardiography, computed tomography (CT), and mag-etic resonance imaging (MRI). This relationship has valueoth in enhancing diagnostic accuracy and in fostering thenderstanding of cardiovascular physiology, pathology, andathophysiology. The widespread use of echocardiographyn addition to the growing use of cardiovascular magneticesonance (CMR) and CT angiography has also changedhe practice of invasive and interventional cardiology. Pa-ients with diagnostic echocardiographic hemodynamic as-essment of valvular or myocardial/pericardial disease maye referred for diagnostic coronary angiography only. How-ver, patients in whom the echocardiographic findings areonflicting are still referred to the catheterization laboratoryor hemodynamic assessment; these patients are often ex-eedingly complex. Thus, somewhat paradoxically in thisra of enhanced noninvasive imaging, the understandingnd proper performance of detailed hemodynamic evalua-ion in such patients is of even greater importance.

The therapeutic role of the cardiac catheterization laboratoryontinues to increase as interventional cardiology procedures
re applied to increasingly complex and critically ill patients. m
rgent catheterization and percutaneous revascularization areow considered to be the standard of care for patients withnstable coronary ischemic syndromes, ST-elevation myocar-ial infarction, and cardiogenic shock. Furthermore, newdjunctive pharmacologic regimens and interventional devicesave emerged. In addition, many noncoronary therapeuticrocedures including percutaneous closure of atrial septalefects and patent foramen ovale, valve repair or replacement,nd septal artery ablation are currently in various stages ofnvestigation and are likely to significantly expand the scope ofhe field of interventional cardiology. This evolution hasncreased the cognitive and technical knowledge base requiredf invasive and interventional cardiologists. Consequently, thisocument revises and updates the standards for training in

nvasive cardiology.The American Board of Internal Medicine (ABIM)

rovides an added qualification certifying examination innterventional cardiology, and the Residency Review Com-

ittee of the American Council for Graduate Medicalducation (ACGME) has a formal accreditation mecha-ism for interventional cardiology training programs. Theecommendations in this document are consistent with theequirements of the ABIM and the ACGME. In 1999, theCC published a training statement on recommendations

or the structure of an optimal adult interventional cardiol-gy training program (2), and the recommendations areummarized in this document.

rogram Accreditation

raining in diagnostic cardiac catheterization (Levels 1 and 2)ust occur within a cardiology training program that is fully

ccredited by the ACGME. If the program does not includen accredited training program in interventional cardiology,xposure to an active interventional cardiology program shoulde provided. Training in interventional cardiology (Level 3)ust occur within an ACGME-accredited program. All in-

erventional cardiology training programs in the United States
ust satisfy the basic standards developed by the ACGME

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356 Jacobs et al. JACC Vol. 51, No. 3, 2008ACCF COCATS 3 Training Statement: Task Force 3 January 22, 2008:355–61

nd must be accredited by the ACGME for candidates to beligible for the clinical interventional cardiology certificate ofdded qualification of the ABIM. The ACGME standardsepresent the qualifying requirements. This document endorseshe ACGME standards for program accreditation and makesdditional recommendations over and above those standards.

rogram Goals

he ultimate goal of a cardiac catheterization trainingrogram is to teach the requisite cognitive and technicalnowledge of invasive cardiology. This includes indicationsnd contraindications for the procedures, pre- and post-rocedure care, management of complications, and analysisnd interpretation of the hemodynamic and angiographicata. The cardiac catheterization laboratory provides alatform for the teaching of the core knowledge bases ofardiac anatomy, pathology, physiology, and pathophysiol-gy that should be possessed by all cardiologists whether orot they perform invasive cardiovascular procedures. Inddition, it is the facility that provides training in the basicntravascular catheter insertion and manipulation skillseeded to care for cardiac patients in critical care environ-ents. The trainee’s overall professional goals determine the

equisite knowledge and skill set to be acquired. In general,rainees may be divided into 3 broad groups with differingraining requirements:

Level 1—Trainees who will practice noninvasive cardi-ology and whose invasive activities will be confined tocritical care unit procedures. However, this level willprovide training in the indications for the procedureand in the accurate interpretation of data obtained inthe catheterization laboratory.

Level 2—Trainees who will practice diagnostic but notinterventional cardiac catheterization.

Level 3—Trainees who will practice diagnostic andinterventional cardiac catheterization.

Each level has specific goals for training that build onach other and which are detailed in the following text. Allardiologists should have Level 1 knowledge and skills.

rogram Structure

aculty

aculty should be full-time, experienced, and committed tohe teaching program. Exposure to multiple faculty mentorsubstantially enhances the quality of a training experience.he faculty should consist of a program director, key

aculty, and other associated faculty. An optimal programhould have a minimum of 3 key faculty members, one ofhom is the program director and each of whom maintains
minimum procedural volume of 150 diagnostic catheter- v
zation procedures per year and devotes at least 20 h pereek to the program. Associated faculty may have varying

evels of commitment and involvement in the program.

rogram Director

he program director for the invasive cardiology curriculumhould be certified in cardiovascular medicine by the ABIMnd should be recognized as an expert in cardiac catheter-zation. Preferably, the program director will have com-leted his or her training at least 5 years previously and wille a full-time faculty member of the overall cardiovascularraining program and committed to medical education andeaching. If the program also provides training in interven-ional cardiology, the program director must be board-ertified in interventional cardiology and should have aareer experience of at least 5 years after completion ofraining, including an aggregate experience of 1000 coro-ary interventional procedures. The program directorhould be responsible for the invasive teaching curriculumnd overall teaching program in addition to trainee evalua-ion. If the program director is the director of the catheter-zation laboratory, this individual should also be responsibleor the administration of the laboratory, quality assurance,nd radiation safety.

ther Key Faculty

ey faculty members should be certified in cardiovascularedicine by the ABIM and have expertise in all aspects of

iagnostic procedures, including the evaluation of coronary,alvular, congenital, and cardiomyopathic disease, andhould be familiar with complex hemodynamics in patientsith all types of heart disease. The program faculty should

nclude individuals with expertise in the performance ofyocardial biopsies, trans-septal catheterization, and the

nterpretation and performance of intracoronary ultrasoundnd intracoronary physiologic assessment (Doppler cor-nary flow and intracoronary pressure measurement),lthough each member need not have expertise in everyrea. If the program also provides training in interven-ional cardiology, its faculty must satisfy the requirementsor accreditation in interventional cardiology by theCGME (http://www.acgme.org/acWebsite/RRC_140/

40_prIndex.asp) and the requirements outlined in thereviously published ACC training statement (2). Ideally, innstitutions where patient volume is adequate, the programhould include faculty who possess skills in advanced inter-entional cardiovascular techniques such as patent foramenvale and atrial septal defect closure, septal ablation forypertrophic obstructive cardiomyopathy, and balloon val-uloplasty. In addition, ideally the program should includeaculty with expertise in peripheral vascular disease.

acilities and Environment

ll training facilities must be equipped and staffed tounction in accordance with the ACC/Society for Cardio-
ascular Angiography and Interventions clinical expert con-


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ensus document on cardiac catheterization laboratory stan-ards (3).

-Ray Imaging Equipment

he cardiac catheterization laboratory must generate highuality X-ray digital images during diagnostic and interven-ional catheterization procedures. The laboratory must haveccess to the support personnel needed to ensure that imageuality is optimal and that radiation exposure to patientsnd staff is minimized.

emodynamic Monitoring and Recording Equipment

he facility must have high-quality physiologic monitoringnd recording equipment to permit the accurate assessmentf complex hemodynamic conditions. The presence ofquipment for assessment of coronary physiology such asractional flow reserve, Doppler coronary velocity, andoronary anatomy such as intravascular ultrasound andntracardiac echocardiography (the latter for programs per-orming percutaneous treatment of structural heart disease),s strongly recommended.

ncillary Support Capabilities

he program must have on-site access to all core cardiologyervices, including a cardiac critical care facility, echocardi-graphy, stress testing with nuclear imaging, and electro-hysiologic testing. Required on-site support services fornterventional cardiology training include cardiac surgery,nesthesia, vascular and interventional radiology, vascularurgery, nephrology, and hematology.

rogram Activity Level and Patient Mix

evel 1 and Level 2 training require comprehensive expo-ure to the full variety of cardiovascular disorders andlinical procedures. This is important not only to provideirect hands-on training experience but also to provide theequisite material for clinical conferences. In addition toxperience with the many manifestations of coronary arteryisease, all trainees should also acquire experience in theemodynamic assessment, evaluation, and management ofatients with valvular, myocardial, and congenital heartisease. Level 3 training requires exposure to the fullpectrum of cardiac ischemic syndromes and noncoronaryeart disease (2) to provide comprehensive experience in thecope of interventional cardiology procedures and to main-ain faculty expertise.

ummary of Training Requirements in Diagnostic and Interventiona

Table 1 Summary of Training Requirements in Diagnostic and I


M

3 Diagnostic catheterization 1

2

Interventional catheterization 3 2

uration of Training

evel 1 (Minimum of 4 Months)

evel 1 training requires a minimum of 4 months ofxperience in the cardiac catheterization laboratory. Duringhis period, a trainee should participate in a minimum of00 diagnostic cardiac catheterization procedures over aeriod of 2 to 3 years (Table 1). Only one Level 1 traineeay claim credit for participation in a given procedure. An

ssential part of this training is the instruction in evaluatingemodynamic data and reading cardiac and coronary angio-raphic studies, and the trainee should acquire Level 1ognitive knowledge (see Training Program Curriculum).

evel 2 (Minimum of 8 Months Over a 3-Year Period)

evel 2 training requires a minimum of 8 months (over theourse of 3 years) in the cardiac catheterization laboratorynd participation in the performance (under direct supervi-ion) of a minimum of 300 diagnostic cardiac catheteriza-ion procedures (Table 1). Only one Level 2 trainee maylaim credit for participation in a given procedure. Duringhis period, the trainee should acquire Level 2 cognitivenowledge (see Training Program Curriculum).

evel 3

evel 3 training must be performed during a fourth year ofellowship dedicated primarily to cardiovascular interven-ional training (2). During this period, the trainee shouldarticipate in a minimum of 250 coronary procedures (Table) (with each patient counting as 1 procedure regardless ofhe number of interventions) in addition to other noncoro-ary interventional procedures and acquire Level 3 cognitivenowledge (2).

onduct of Training

he nature of a trainee’s participation in a given procedureill vary depending on the procedure’s complexity and the

rainee’s experience level. Requisite participation in a pro-edure includes the following elements:

. Pre-procedural evaluation to assess appropriateness and toplan procedure strategy. Before the procedure, it is ex-pected that the trainee will review the patient’s medicalrecord and obtain a confirmatory history and physicalexamination, with specific attention given to factorsknown to increase the risk of the procedure, such asvascular disease, renal failure, history of contrast reac-tion, congestive heart failure, anemia, active infection,

diac Catheterization

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Number ofedures

Cumulative Duration ofTraining (Months)

Minimal CumulativeNumber of Cases

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and conditions known to increase the risk of bleeding.The trainee should also obtain informed consent anddocument a pre-procedural note that includes indica-tions for the procedure, risks of the procedure, andalternatives to the procedure.

. Performance of the procedure by the trainee at a levelappropriate to experience, always (at all levels) under thedirect supervision of a program faculty member. Level 1trainees will begin in a mostly observational role andassume greater participation as experience is gained.Level 2 trainees will assume progressive responsibilityfor the conduct of diagnostic procedures as they acquireskills. Highly experienced Level 2 (or Level 3) traineesmay collaborate in a procedure with Level 1 traineesunder the direct supervision of a program faculty mem-ber. In this circumstance, both Level 1 and Level 2 (orLevel 3) trainees may claim credit for participation inthe procedure. Level 3 trainees will assume progressiveresponsibility for the performance of interventionalprocedures as they acquire skills.

. Participation in the analysis of the hemodynamic andangiographic data obtained during the procedure and prep-aration of the procedure report.

. Active involvement in post-procedural management both inand out of the catheterization laboratory. After the pro-cedure, a preliminary catheterization report or noteshould be placed in the patient’s file. The trainee shouldmonitor the patient’s status and be available to respondto any adverse reactions or complications that may arise,such as hypotension, vascular complications, heart fail-ure, renal failure, bleeding, or myocardial ischemia. Apost-procedural note should be completed before hos-pital discharge. If a complication occurs, the traineeshould participate in the follow-up and management ofthe complication.

raining Program Curriculum

he trainee should possess the cognitive knowledge andechnical skills detailed in the following text.

nowledge Base

evel 1 Cognitive Knowledge

1. Understand coronary anatomy, its variations, and con-genital abnormalities

2. Understand coronary physiology3. Understand cardiac hemodynamics, including the

measurement and interpretation of pressure, flow,resistance, and cardiac output. Understand ventricularand myocardial mechanics and the determinants ofcardiovascular performance

4. Interpret hemodynamic findings in a variety of cardiacconditions, including various forms of myocardial dis-
ease, pericardial disease, valvular stenosis and regurgi-
tation, congenital heart disease, and pulmonary vascu-lar disease. Understand how to differentiate thehemodynamics of constrictive pericarditis from restric-tive cardiomyopathy

5. Understand the relationship between hemodynamicassessment as determined by invasive measurementsand echocardiography in addition to other noninvasivemodalities

6. Understand the indications and contraindications forcardiac catheterization and coronary intervention

7. Understand the complications of the procedure andtheir management, such as hypotension, acute myocar-dial ischemia, congestive heart failure, renal failure,contrast reactions, retroperitoneal bleeding, cardiactamponade, vascular problems, arrhythmias, and stroke

8. Select the optimal treatment modality, including med-ical therapy, percutaneous coronary and noncoronaryintervention, or surgical therapy, with understandingof the indications for and risks of each revasculariza-tion strategy

9. Understand the indications for and complications oftemporary transvenous pacing

0. Understand the indications for and complications ofpericardiocentesis and recognize tamponade physiology

1. Understand the indications for and complications ofother laboratory procedures, such as endomyocardialbiopsy, intra-aortic balloon counterpulsation, and re-trieval of foreign bodies

2. Understand basic principles of X-ray imaging, radia-tion protection, and radiation safety

3. Understand the anatomy of and methods to accesscardiac chambers and coronary arteries via the femoral,brachial, and radial access sites

4. Interpret diagnostic coronary angiograms and appreci-ate the interface with noninvasive techniques of coro-nary imaging

5. Interpret ventricular, atrial, and aortic angiography anddetermine left ventricular ejection fraction

6. Understand the indications for and complications ofcontrast agents, the risk of contrast nephropathy, and therisks and benefits of various renal protective regimens

7. Understand the indications for and complications ofdrugs commonly used for invasive procedures, such asunfractionated heparin, low-molecular-weight hepa-rin, glycoprotein IIb/IIIa receptor antagonists andother antiplatelet drugs, direct thrombin inhibitors,vasopressors, vasodilators, and fibrinolytic and antiar-rhythmic agents

8. Understand the indications for and the mechanisms ofaction of mechanical circulatory support devices

9. Understand the indications for and complications ofvascular closure devices

evel 1 Technical Skills

. Perform percutaneous vascular access from the femoral
artery and vein and subclavian or internal jugular vein

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. Perform right heart catheterization using a balloonflotation catheter

. Perform temporary right ventricular pacemaker insertion

. Perform left heart catheterization and coronary angiog-raphy of native arteries (using standard views) and leftventriculography under supervision

evel 2 Cognitive Knowledge

. All Level 1 items

. Understand radiologic imaging, including design andoperation of X-ray cineradiographic units, digital imag-ing and storage, radiation physics, factors influencingimage quality, radiation quality assurance, and physiol-ogy of X-ray contrast media

. Understand the basic operation of physiologic recorders,pressure transducers, oximeters, and oxygen consump-tion measurement equipment

. Understand coronary physiology using techniques suchas Doppler flow and fractional flow reserve

. Understand the indications for and methods of per-forming trans-septal catheterization

. Acquire knowledge of peripheral vascular anatomy andunderstand the indications and complications of periph-eral vascular angiography

evel 2 Technical Skills

1. All Level 1 items2. Perform vascular access from the femoral, radial, or

brachial route3. Perform left heart catheterization and coronary an-

giography, as well as visualization of venous bypass andinternal mammary and radial artery grafts

4. Perform angiography of the cardiac chambers (inaddition to the left ventricle) and aorta

5. Perform intra-aortic balloon insertion and operate aballoon pump

6. Perform cardiac catheterization in common types ofvalvular, adult congenital, and cardiomyopathic heartdisease

7. Perform pericardiocentesis, preferably under echocar-diographic guidance

8. Perform right ventricular endomyocardial biopsy9. Perform vascular closure device insertion0. Perform aortography and femoral artery angiography

evel 3 Cognitive Knowledge and Technical Skills

he trainee should possess the cognitive knowledge andechnical skills outlined in the previously published ACCraining statement (2). In addition, the trainee shouldcquire knowledge about trans-septal catheterization, per-utaneous management of access site complications, andanagement of other complications of including but not

imited to coronary perforation, no reflow (and its preven-ion), and stent thrombosis. The trainee should obtain aore experience in balloon angioplasty, intracoronary stents,
therectomy techniques, distal (and proximal) protection g
evices, intravascular ultrasound, and measurement of frac-ional flow reserve. Familiarity with noncoronary (periph-ral) angiography and intervention should be encouraged.

onferences

evels 1 and 2

ll trainees must attend a regular cardiac catheterizationonference. This may be a combined medical/surgical con-erence. The conference must present hemodynamic andngiographic data that are discussed in context with history,hysical examination, and noninvasive findings. Indications,omplications, and management strategies should also beiscussed. It is particularly important that the Level 1 and 2urriculum focus on teaching hemodynamics, cardiovascularhysiology, and the pathophysiology of the major cardio-ascular disorders. In this role, it is important that theardiac catheterization program establish a close liaison withther noninvasive diagnostic laboratories, particularly thechocardiography laboratory. The educational programhould emphasize the relationships between the findingsrovided by the different diagnostic modalities in order toreate a clear picture of the physiology and pathophysiologyf the various cardiovascular disorders. A regular morbiditynd mortality conference, either as part of the cardiacatheterization conference or as a separate conference, islso required.

evel 3

he interventional cardiology training program should con-uct a regularly scheduled clinical interventional cardiologyonference at least weekly (2) and journal club at leastonthly.

esearch

ll trainees should be exposed to the principles of researchnd to research conducted in the cardiac catheterizationaboratory. For those who plan to perform independentatheterization and angiography, it is desirable that theyctively participate in the research and attend researchonferences that discuss such studies. Those planning aareer in interventional cardiology must participate in re-earch, either during their 3-year fellowship training oruring their subsequent interventional training.

rainee Evaluation

rainee evaluation involves 3 components: cognitive, tech-ical, and documentary. Case selection and pre-, intra-, andost-procedural care and judgment must be evaluated invery trainee. Facilities that foster the trainee’s involvementn the continuum of care (outpatient or inpatient) fromre-procedural assessment to post-procedural follow-up areequired. In every trainee, interpretive skills that relate tossessment of complex hemodynamics, coronary angio-
raphic images, and physiologic studies must also be eval-

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ated. Quality of clinical follow-up, reliability, interactionith other physicians, patients, and laboratory support staff,

nd the initiative and ability to make independent, appro-riate decisions are to be considered. The individual mustave knowledge of the specific equipment to be used in eachrocedure, including X-ray contrast, diagnostic catheters,nd potential closure devices. Assessment of technical per-ormance is also a requirement. This is best done by directversight during procedures of actual handling of equip-ent and devices, by assessment of the interaction of the

rainee with the device and specific anatomy being treated,nd by procedural complication rate. The competence of allardiology trainees in cardiac catheterization should beocumented by both the cardiovascular program directornd the program director of the cardiac catheterizationaboratory. All procedures performed by the trainee must beocumented electronically or in a logbook.Responsibility for trainee evaluation resides with the

atheterization laboratory program director, who performshe assessment of the success of the trainee’s progress inollaboration with the other program faculty. The overallvaluation includes rigorous compilation of trainee experi-nce and assessment of the trainee’s cognitive knowledge,echnical skill, and clinical and procedural judgment. Eval-
ative feedback, verbal and written, to the trainee on a
Kc

i-annual basis during the training period is vital to directhe trainee’s progress.

his is a revision of the April 2002 document that was writteny Alice K. Jacobs, MD, FACC—Chair; David P. Faxon,

D, FACC; John W. Hirshfeld, Jr., MD, FACC; and David. Holmes, Jr., MD, FACC.

doi:10.1016/j.jacc.2007.11.011


. Jacobs AK, Faxon DP, Hirshfeld JW Jr., Holmes DR. Training indiagnostic cardiac catheterization and interventional cardiology. ACCrevised recommendations for training in adult cardiovascular medicinecore cardiology training II (COCATS 2). J Am Coll Cardiol 2002;39:1242–3.

. Hirshfeld JW Jr., Banas JS Jr., Brundage BH, et al. American Collegeof Cardiology training statement on recommendations for the structureof an optimal adult interventional cardiology training program: a reportof the American College of Cardiology Task Force on Clinical ExpertConsensus Documents. J Am Coll Cardiol 1999;34:2141–7.

. Bashore TM, Bates ER, Berger PB, et al. American College ofCardiology/Society for Cardiac Angiography and Interventions clinicalexpert consensus document on cardiac catheterization laboratory stan-dards: a report of the American College of Cardiology Task Force onClinical Expert Consensus Documents. J Am Coll Cardiol 2001;37:2170–214.

ey Words: ACCF Training Statement y COCATS 3 y diagnosticardiac catheterization y interventional cardiac catheterization.

PPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FOR TRAINING INDULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 3: TRAINING INIAGNOSTIC AND INTERVENTIONAL CARDIAC CATHETERIZATION



BoardSpeakers’

BureauSteering


Dr. Joseph D. Babb None None None None None ● General Electric None

Dr. John W.Hirshfeld, Jr.

None ● GE Healthcare ● BraccoDiagnostics

None None None None

Dr. David R.Holmes, Jr.


Dr. Alice K. Jacobs None None None None None None ● Wyeth Pharmaceuticals—spouse’s employer


ATT

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361JACC Vol. 51, No. 3, 2008 Ryan et al.January 22, 2008:361–7 ACCF COCATS 3 Training Statement: Task Force 4

PPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FORRAINING IN ADULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 3:RAINING IN DIAGNOSTIC AND INTERVENTIONAL CARDIAC CATHETERIZATION



BoardSpeakers’

BureauSteering



● Official–Board ofTrustees


Dr. Jeffrey J.Cavendish

● Official–Board ofGovernors


Dr. Jorge Gaspar ● Official–Board ofGovernors


Dr. Matthew R.Wolff



Dr. Jose G. Diez ● Content–CardiacCatheterizationCommittee

● Sanofi-Aventis None None ● Sanofi-Aventis None None None

Dr. Leonard S.Dreifus

● Content–ElectrophsyiologyCommittee

● Merck● WyethPharmaceuticals

None None None None None None

Dr. Mazen Abu-Fadel

● Content–CardiacCatheterizationCommittee


Dr. James J.Ferguson



Dr. DebabrataMukherjee



Dr. CharanjitSingh Rihal

● Content–PreventionCommittee

● Cordis ● CardiacDimensions

None None None None None

Dr. Thoralf M.Sundt



his table represents the relationships of peer reviewers with industry that were reported by the authors as relevant to this topic. It does not necessarily reflect relationships with industry at the time ofublication. *Names are listed in alphabetical order within each category of review.

Task Force 4: Training in EchocardiographyEndorsed by the American Society of Echocardiography

Thomas Ryan, MD, FACC, ChairWilliam F. Armstrong, MD, FACC, Bijoy K. Khandheria, MD, FACC (American Society ofEchocardiography Representative)

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chocardiography is currently the most widely used imag-ng technique for assessing cardiovascular anatomy andunction. Clinical application of ultrasound encompasses

-mode, two-dimensional (2D), pulsed, and continuous-ave Doppler and color-flow imaging. Echocardiography,

ike invasive catheterization, provides information concern-ng cardiovascular anatomy, function (i.e., ejection fraction),
emodynamic variables (i.e., gradient or pressure), and flow f
isturbances by means of pulsed, continuous-wave, andolor-flow Doppler imaging. Today, an echocardiographyaboratory can appropriately be called an ultrasound imagingnd hemodynamic laboratory.

Fellowship training in echocardiography should includenstruction in the basic aspects of ultrasound, but only thoseellows who go beyond the basic level are trained sufficiently
or independent interpretation of echocardiographic studies.

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362 Ryan et al. JACC Vol. 51, No. 3, 2008ACCF COCATS 3 Training Statement: Task Force 4 January 22, 2008:361–7

very trainee should be educated in the physical principlesnd instrumentation of ultrasound and in cardiovascularnatomy, physiology, and pathophysiology, both with re-ard to the cardiovascular system in general and in relationo the echocardiogram in particular. Trainees at all levelshould be required to perform the echocardiographic andoppler examination to integrate their understanding of

hree-dimensional (3D) cardiac anatomy. Trainees shoulde encouraged to correlate the findings from the echocar-iographic and Doppler examination with the results ofther imaging modalities and physical examination. Therainee should master the relation between the results of thechocardiographic examination and findings of other car-iovascular tests, such as catheterization, angiography, andlectrophysiology. Exposure to computer sciences and bio-ngineering may also be beneficial. The trainee should alsoaster the relation between the results of the echocardio-

raphic examination and surgical and medical managementf the patient.Every cardiology fellow should be exposed to and

amiliar with the technical performance, interpretation,trengths, and limitations of 2D echocardiographic/oppler technology and its multiple clinical applications.

t is recognized that ultrasound is an evolving technology,xperiencing continued improvement, with an expandingist of clinical indications.

For appropriate use of this technology, it is possible toefine 3 levels of expertise (Table 1). All cardiologists mustttain at least the first level of expertise. This entailsnderstanding the basic principles, indications, applications,nd technical limitations of echocardiography and the in-errelation of this technique with other diagnostic methods.his level will not qualify a trainee to perform echocardi-graphy or to interpret echocardiograms independently.he second level of training in echocardiography shouldrovide the knowledge and experience necessary to performnd interpret resting transthoracic M-mode, 2D, andoppler examinations in adults independently under the

upervision of a laboratory director. An exposure to orraining in special echocardiographic procedures such asransthoracic echocardiography (TTE) and stress echocar-iography can be undertaken as described later in thiseport. Gaining experience in the appropriate use of contrastnd the emerging field of 3D echocardiography should alsoe a part of fellowship training. A third level of expertiseould enable the trainee to direct an echocardiography

ummary of Training Requirements for Echocardiography

Table 1 Summary of Training Requirements for Echocardiograp

LevelDuration of

Training (Months)Cumulative Duration of

Training (Months)

1 3 3

2 3 6

3 6 12

Exposure to TEE and other special procedures. †Completion of Level 2 and additional special training nAdd’l � additional; TEE � transesophageal echocardiography; TTE � transthoracic echocardiography.

aboratory and to gain additional expertise in various specialltrasound procedures (i.e., transesophageal, stress, andntraoperative procedures). Requirements for optimal train-ng for these 3 levels differ and are addressed separately.

eneral Standards

raining in echocardiography should be integrated closelyith the educational experience in cardiovascular catheter-

zation and intervention, other noninvasive imaging modal-ties, surgery, and pathology. The echocardiographic labo-atory in which training of cardiology fellows is undertakenhould be under the direct supervision of a full-timeualified director (or directors) who has achieved Level 3raining (1,2). The training center should be a full-serviceaboratory that provides all modalities of echocardiography,ncluding transthoracic, ambulatory, and intraoperativeransesophageal echocardiography (TEE) and stress (exer-ise, pharmacologic, or both) echocardiography. Echocar-iographic/Doppler examination in children or adults withongenital heart disease requires specific training at cardi-logy centers experienced in the management of theseatients. Specific requirements for examination of pediatricatients have been published elsewhere (3–5). Traininguidelines in the present document are primarily directed torainees performing echocardiographic examinations indult patients with acquired and congenital heart disease. Aully trained (Level 3) director of a laboratory shouldupervise the fellowship training program in echocardiog-aphy (1,2). Participation of additional full- or part-timeaculty is highly desirable because of the multiple applica-ions of echocardiography (i.e., transesophageal, stress, con-rast, intraoperative, intravascular, 3D, and congenital).

The echocardiographic examination is an operator-ependent procedure in which it is possible to introduceonfounding artifacts or omit data of diagnostic importance.ccordingly, the echocardiographic examination is interac-

ive and requires the instantaneous recognition of normalariants and specific diagnostic findings to obtain an optimaltudy. Therefore, fellowship training in echocardiographyust emphasize the ability to perform a hands-on exami-

ation independently with on-line interpretation of results.ands-on training is important, not so much to develop

rue technical expertise but rather as a valuable aid to learnomographic cardiac anatomy, integrate planar views into a

inimal No. of TTEExams Performed

Minimal No. of TTEExams Interpreted

TEE and SpecialProcedures

75 150 Yes*

150 (75 Add’l) 300 (150 Add’l) Yes†

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D framework, and understand the distinction betweeneliable and unreliable data. The trainee should developufficient technical facility to use an echocardiographicnstrument to answer common clinical questions. To helpith this training, availability of highly skilled cardiac

onographers with broad experience in the performance ofhe echocardiographic examination is desirable.

ontent of the Training Program

chocardiography plays an important role in the diagnosisnd treatment of a wide variety of acquired and congenitalardiac disorders in a diverse group of patients. Accordingly,t is highly desirable that any laboratory in which cardiologyellows undertake echocardiographic training provide expo-ure to the entire spectrum of acquired and congenital heartiseases in patients of varying ages and both genders (6).enerally, such a laboratory should conform to continuing

uality improvement guidelines (7) and perform at least000 echocardiographic studies per year, to give the fellown appropriate variety of experience.

Although numbers of studies and time intervals of train-ng are given as guidelines, these numbers are less importanthan depth of understanding and quality of the clinicalxperience. The number of echocardiographic studies inhich the trainee participates is less important to the qualityf the experience than the mix of patients and the range ofiseases and pathology that he or she encounters. Theriteria described herein are similar to those in otherublications on this topic (1,2,8–11). If the case mixvailable for the trainee is skewed, additional numbers ofases beyond the criteria quoted herein may be required tochieve a broad spectrum of experience (12). It is recom-ended that fellows keep a logbook documenting their

nvolvement in echocardiographic studies.To provide acceptable fellowship training in echocardi-

graphy, a laboratory must have equipment with the capa-ility for comprehensive TTE and TEE, including-mode and 2D imaging, pulsed and continuous-waveoppler echocardiography, and color-flow imaging. In this

egard, 3D echocardiography is becoming increasingly prev-lent and should be available in most modern trainingnvironments. The ability to complete adequate training inchocardiography will depend on the background and abil-ties of the trainee, as well as the effectiveness of thenstructor and laboratory. The current trend to introducehe fundamental principles, indications, applications, andimitations of echocardiography into the education of med-cal students and residents is encouraged and will facilitateubsequent mastery of this discipline. The components andequirements of the 3 levels of training in clinical echocar-iography are summarized in Table 1 and described in detail
n the following text. o
evel 1 Training (3 Months, at Least5 Examinations Personally Performed,50 Examinations Interpreted)

he first, or introductory, level requires 3 months ofull-time training or its equivalent devoted to an under-tanding of functional anatomy and physiology in relation tohe echocardiographic examination. During this time, therainee should participate in the interpretation of a mini-um of 150 complete (M-mode, 2D, and Doppler) exam-

nations and personally perform 75 of these studies. Thesenitial training activities should take place under the super-ision of the laboratory director, designated faculty, andardiac sonographers. The Level 1 trainee should be able toecognize common cardiovascular pathologic entities. Dur-ng Level 1 training, some initial exposure to TEE andther special procedures may be appropriate. However, fullompetence in these areas requires additional training. Nother clinical or service responsibility, other than requiredutpatient clinic and routine night call duties, should bexpected of the trainee during his or her 3 months of Leveltraining.

evel 2 Training (3 Months ofdditional Training, at Least5 Additional Examinations Personallyerformed, at Least 150 Additionalxaminations Interpreted)

uring Level 2 training, emphasis should be placed on theariety, quality, and completeness of studies, on quantifica-ion in diagnostic studies, and on correlation with otheriagnostic and clinical results in a broad range of clinicalroblems. To accomplish this, the fellow should devote andditional 3 months, or the equivalent, of full-time training,nterpreting a minimum of 150 additional (300 total)omplete ultrasound imaging and Doppler hemodynamicxaminations. Of these, at least 75 (150 total) should beerformed by the trainee under appropriate supervision.he fellow who has accomplished Level 2 training shoulde able to perform an echocardiographic and Doppler studyhat is diagnostic, complete, and quantitatively accurate.ompetence at this level implies that the trainee is suffi-

iently experienced to interpret the TTE examination ac-urately and independently. Continued exposure to specialchocardiographic procedures such as TEE, 3D, and stresschocardiography is appropriate during Level 2 training.owever, to become fully competent to perform these

echniques independently, the completion of Level 2 train-ng and the supervised performance of the required number
f special studies are necessary.

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evel 3 Training (6 Months ofdditional Training, at Least50 Additional Examinations Personallyerformed, at Least 450 Additionalxaminations Interpreted)

or a trainee desiring to direct an echocardiographic labo-atory (Level 3), an additional 6 months (total of 12 monthsf training) devoted to echocardiography is required. Tottain Level 3, the trainee should interpret a minimum of50 additional complete imaging and hemodynamic studiesa total of 750 studies) and personally perform an additional50 examinations (a total of 300) in a patient population inhich a broad spectrum of adult acquired and congenitaleart disease is present. The laboratory should conform toontinuing quality improvement guidelines (8) and ideallyerform at least 2000 echocardiographic studies per year toive the fellow an appropriate variety of experience. At theiscretion of the director, increasing independence in inter-retation and overreading of echocardiographic studies cane implemented. Level 3 training should also includexposure to administrative aspects of running an echocar-iographic laboratory and documented experience in echo-ardiographic research, as well as understanding of new andvolving ultrasound technologies and applications of echo-ardiography. To complete Level 3, the trainee should fulfillll of the previously described requirements and developompetence in performing and interpreting special procedures,uch as TEE, 3D, stress, and contrast echocardiography.

raining in Multiple Imaging Modalities

he recent emergence of other noninvasive imaging modal-ties, especially cardiovascular magnetic resonance and com-uted tomography angiography, is having a profound im-act on the practice of cardiology and the fellowshipraining experience. The cardiovascular medicine specialists increasingly expected to provide expertise in 2 or more ofhe imaging techniques. It is understandable, then, thatrainees will desire the opportunity to gain exposure toultiple imaging modalities during their fellowship experi-

nce. To the degree possible, the training program shouldtrive to meet these needs by offering a “multimodality”maging experience. This might include an appreciation forach technique’s uses and clinical indications, strengths andimitations, safety issues, and the guidelines and appropri-teness criteria, when available.

raining for Physicians in Practice

t should be recognized how difficult it is to recreate thereadth and intensity of a training fellowship once an
ndividual has assumed the full-time responsibilities of a i
ractice setting. It may be possible to obtain the equivalencef Level 1 or 2 training outside the usual fellowship trackhrough assiduous self-study, ongoing visits to trainingaboratories, and participation in continuing medical edu-ation. Key aspects of the training experience, however, maye impossible to replicate outside the fellowship environ-ent. For the practicing physician interested in obtaining

quivalent training, it is recommended that a mentoringelationship be established with a training laboratoryhereby the physician works under the aegis of a Level-trained echocardiographer. In this situation, the numbersf cases required to achieve each level of training are similaro those listed in Table 1.

ltrasound Special Procedures

pecial procedures include but are not limited to exercisend pharmacologic stress, TEE (including intraoperativeEE), epicardial and epivascular echocardiography, intra-

ascular echocardiography, intracardiac echocardiography,ontrast echocardiography, echocardiography during inter-entional procedures (myocardial biopsy, pericardiocentesis,itral balloon valvulotomy, or device closure of septal

efects), and TTE in patients with complex congenitaleart disease. Exposure to these procedures may beginuring Level 1 training, but competence requires comple-ion of Level 2 and additional specialized training asescribed in the following text. These examinations requirepecial expertise, involve the management of high-riskatients, and often entail the performance of invasiveltrasound procedures in ways that cannot be repeatedeadily if the initial study is not diagnostic. As with anychocardiographic technique, adequate training in specialltrasound procedures is dependent on a full understandingf the principles, indications, applications, and technicalimitations of these techniques. There is a certainrocedure-specific learning curve to these advanced studies13–15), which are best learned under the close supervisionf a fully qualified expert in the particular ultrasoundpplication. These more detailed procedures can only beearned by affiliation with a high-volume reference labora-ory with adequate ongoing volumes in each of theseodalities, under the tutelage of a designated physician-

nstructor who performs and interprets a large number ofhese special procedures annually (7,8). Specific recommen-ations for the various procedures are presented in theollowing text.

ransesophageal Echocardiography

ransesophageal echocardiography is best learned in aigh-volume laboratory that performs at least 500 TEEtudies per year. Although the technical expertise needed toerform TEE may be acquired in a lower-volume setting,he lower number of pathologic cases typically encountered
n low-volume laboratories limits the trainee’s exposure to

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ritical and unusual abnormalities that are uniquely identi-ed by TEE. Minimum training in TEE requires 25sophageal intubations and 50 supervised diagnostic studiesefore independent interpretation (8). However, in manynstances, this level of expertise will be inadequate to exposehe trainee to the full range of pathologies encountered inhe clinical practice of TEE. Therefore, continued trainingnder the supervision of a more experienced operator for andditional 50 studies is highly recommended. For mostardiology training programs, initiation of the process ofearning TEE should be undertaken only after completionf Level 1 training; exposure to TEE during Level 1raining is appropriate in some situations and laboratories.or full competence and independence in TEE procedures,dditional special training is necessary. Competence in TEElso requires knowledge of and experience in the adminis-ration of conscious sedation.

tress Echocardiography

or exercise and pharmacologic stress echocardiography,articipation in a sufficient number (greater than or equal to00) of supervised interpretations is the minimum require-ent for the independent interpretation of stress echocar-

iograms (13,14). Exposure to stress echocardiography mayegin during Level 1 training; however, because of the highevel of difficulty in interpreting segmental wall-motionbnormalities in stress echocardiography, achieving basicompetence in this area is an objective of Level 2 trainingnd ideally entails supervised interpretations of far morehan 100 stress echocardiography studies. For competencend independence in stress echocardiography, additionalraining beyond Level 2 is recommended. In addition toupervised interpretation, the training experience shouldnclude involvement in the selection of patients for therocedure; a thorough understanding of the advantages,

imitations, and risks of each of the procedures; and mon-toring of the actual stress test.

ntracardiac and Intravascular Ultrasound

ntravascular ultrasound is a specialized procedure that isost often performed in conjunction with catheterization.his requires close collaboration with the interventional

ardiologist to ensure proper interpretation of all availablemaging data. Because the interpretation of these studies hashe potential for immediate and significant impact onatient management, communication among involved par-ies is critical. Performance and interpretation of intravas-ular ultrasound requires specific training in this techniquerom a standpoint of both acquisition and interpretationhat can be obtained only through dedicated training in aigh-volume intravascular/catheterization setting. Intracar-iac echocardiography is a newly developed ultrasound toolor which there are no specific pre-existing training guide-ines. This procedure should be learned during or after Level

training in echocardiography, and the requisite skills can s

e obtained only in a reference laboratory in which thisxamination is performed on a routine basis.

ntraoperative Transesophageal Echocardiography

ntraoperative TEE requires background and experience inoutine TEE followed by additional specific experience in theperating room evaluating patients undergoing a variety ofardiac procedures. Experience in the operating room is re-uired before independent performance of intraoperative echo-ardiography, and this training should involve the monitoringf patients undergoing routine coronary bypass surgery, as wells the study of patients during valve replacement and repairrocedures (15–17). This entails an understanding of andxperience with the processes of cardiac surgery, cardiopulmo-ary bypass, and intraoperative changes in hemodynamics ashey are assessed with echocardiography. Guidelines for train-ng in intraoperative TEE have been developed and published18). For basic training, a minimum of 150 complete exami-ations under appropriate supervision are required, of which at

east 50 should be personally performed, interpreted, andeported. This level of experience is necessary for independentiagnostic expertise in this field. For advanced training, it isecommended that 300 complete examinations be undertaken,f which at least 150 are personally performed.

Intraoperative echocardiography is an area in which diag-ostic conclusions have the potential for immediate majorhanges in patient management and outcome. A Level-trained echocardiographer needs to be a locus of knowledgeith expertise in intraoperative echocardiography and mayeed to provide guidance and consultation to colleagues innesthesia or surgery. Intraoperative monitoring of congenitaleart disease procedures requires specific training that is bestcquired in a pediatric training laboratory (16).

ontrast Echocardiography

ontrast echocardiography is a broad and evolving disci-line. For simple applications, such as saline contrastnjections to detect right-to-left shunts, it is appropriate toearn during Level 1 training in echocardiography. Cur-ently available contrast agents allow left ventricular cavitypacification and can be helpful for identification of endo-ardial borders. Knowledge of contrast physics and addi-ional experience in this technique should be part of Level 2raining. The individual completing Level 2 training shouldave the requisite skills to perform and interpret contrast-nhanced echocardiograms. Contrast echocardiography forhis purpose is a technology- and machine-specific study.hus, the trainee should have obtained special training in

he instrumentation required for acquisition of high-qualityontrast echocardiograms. Participation in a sufficient num-er (greater than or equal to 20) of supervised interpreta-ions of contrast echocardiograms for left ventricular cavitypacification for endocardial border detection is the mini-um requirement for independent interpretation.Contrast echocardiography to assess myocardial perfusion is

till in evolution and remains a complex technology-dependent

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xamination. The skills required for appropriate performancend interpretation of myocardial contrast echocardiographyan be obtained only by association with a high-volumeaboratory actively engaged in this technique. The individualho wishes to obtain training in myocardial contrast echocar-iography must have a firm understanding of the physics and

nstrumentation technology needed to detect microbubblesithin the coronary microcirculation and an understanding of

he limitations of this technique. This can be obtained only bydvanced training (within or beyond Level 3) in high-volumeeference laboratories actively engaged in this procedure.

D Echocardiography

hree-dimensional echocardiography has emerged as alinically relevant, although technically complex, modality.s the technology continues to evolve, it will likely play an

ncreasingly prominent role in echocardiographic diagnosis.eginning in Level 2, the trainee should be exposed to 3Dchocardiography, primarily to understand its growing roleithin the broader echocardiographic armamentarium. Inrder to develop true expertise in the instrumentation andechniques required for the acquisition and interpretation ofD echocardiograms, Level 3 training is necessary.

valuation of Proficiency

valuation of competence is an integral and critical part ofhe educational process in echocardiography for a cardiologyellow. Optimal evaluation may be accomplished by directbservation of the ability of the trainee to perform andnterpret the echocardiographic examination or may takehe form of a practical or written examination, or both. It isecommended that such observational evaluation be done ondaily basis by the director of the laboratory or his or her

ssociates and that it involve both hands-on and readingessions. Evaluation of the competence of a cardiologyellow in echocardiography should be the responsibility ofhe director of the echocardiographic training laboratorynd the director of the cardiology training program.

In addition, objective examinations have been created by theational Board of Echocardiography for physicians who want

o test and demonstrate their proficiency in both generalchocardiography and intraoperative echocardiography. Somehird-party payers have already begun to propose limitingayment for echocardiographic services to those physiciansith documented evidence of proficiency. Hence, it is recom-ended that all physicians who want to confirm their profi-

iency should strongly consider preparing for and taking theppropriate National Board of Echocardiography examination.

his is a revision of the March 2002 document that was writteny Thomas Ryan, MD, FACC—Chair; William F. Arm-trong, MD, FACC; Alan S. Pearlman, MD, FACC; and

illiam J. Stewart, MD, FACC.
doi:10.1016/j.jacc.2007.11.012 t

1. DeMaria AN, Crawford MH, Feigenbaum H, Popp RL, Tajik AJ.17th Bethesda conference: adult cardiology training: Task Force IV:training in echocardiography. J Am Coll Cardiol 1986;7:1207–8.

2. Pearlman AS, Gardin JM, Martin RP, et al. Guidelines for optimalphysician training in echocardiography: recommendations of theAmerican Society of Echocardiography Committee for PhysicianTraining in Echocardiography. Am J Cardiol 1987;60:158–63.

3. Meyer RA, Hagler D, Huhta J, Smallhorn J, Snider R, Williams R.Guidelines for physician training in pediatric echocardiography: rec-ommendations of the Society of Pediatric Echocardiography Commit-tee on Physician Training. Am J Cardiol 1987;60:164–5.

4. Meyer RA, Hagler D, Huhta J, et al. Guidelines for physician trainingin fetal echocardiography: recommendations of the Society of PediatricEchocardiography Committee on Physician Training. J Am SocEchocardiogr 1990;3:1–3.

5. Fyfe DA, Ritter SB, Snider AR, et al. Guidelines for transesophagealechocardiography in children. J Am Soc Echocardiogr 1992;5:640–4.

6. Cheitlin MD, Armstrong WF, Aurigemma GP, et al. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardi-ography: Summary article: A report of the American College ofCardiology/American Heart Association Task Force on PracticeGuidelines (ACC/AHA/ASE Committee to Update the 1997 Guide-lines for the Clinical Application of Echocardiography. Circulation2003;108:1146–62.

7. Recommendations for continuous quality improvement in echocardi-ography: American Society of Echocardiography. J Am Soc Echocar-diogr 1995;8:S1–28.

8. Pearlman AS, Gardin JM, Martin RP, et al. Guidelines for physiciantraining in transesophageal echocardiography: recommendations of theAmerican Society of Echocardiography Committee for PhysicianTraining in Echocardiography. J Am Soc Echocardiogr 1992;5:187–94.

9. Parmley WW. Changing requirements for training in cardiovasculardiseases. J Am Coll Cardiol 1993;22:1548.

0. Education and Training Subcommittee of the British Society ofEchocardiography. Training in echocardiography. Br Heart J 1994;71:2–5.

1. Popp RL, Winters WL Jr. Clinical competence in adult echocardiog-raphy: a statement for physicians from the ACP/ACC/AHA TaskForce on Clinical Privileges in Cardiology. J Am Coll Cardiol1990;15:1465–8.

2. Eisenberg MJ, Rice S, Schiller NB. Guidelines for physician trainingin advanced cardiac procedures: the importance of case mix. J Am CollCardiol 1994;23:1723–5.

3. Popp R, Agatston A, Armstrong W, et al. Recommendations fortraining in performance and interpretation of stress echocardiogra-phy: Committee on Physician Training and Education of theAmerican Society of Echocardiography. J Am Soc Echocardiogr1998;11:95– 6.

4. Picano E, Lattanzi F, Orlandini A, Marini C, L’Abbate A. Stressechocardiography and the human factor: the importance of beingexpert. J Am Coll Cardiol 1991;17:666–9.

5. Savage RM, Licina MG, Koch CG, et al. Educational program forintraoperative transesophageal echocardiography. Anesth Analg 1995;81:399–403.

6. Ungerleider RM, Greeley WJ, Kanter RJ, Kisslo JA. The learningcurve for intraoperative echocardiography during congenital heartsurgery. Ann Thorac Surg 1992;54:691–6.

7. Practice guidelines for perioperative transesophageal echocardiog-raphy: a report by the American Society of Anesthesiologists andthe Society of Cardiovascular Anesthesiologists Task Force onTransesophageal Echocardiography. Anesthesiology 1996;84:986 –1006.

8. Cahalan MK, Stewart W, Pearlman AS, et al. American Society ofEchocardiography and Society of Cardiovascular AnesthesiologistsTask Force Guidelines for Training in Perioperative Echocardiogra-phy. J Am Soc Echocardiogr 2002:15:647–52.


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PPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FOR TRAININGN ADULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 4:RAINING IN ECHOCARDIOGRAPHY



BoardSpeakers’

BureauSteering


Dr. William F.Armstrong

● St. Jude Medical● Wyeth Pharmaceuticals

None None None None None ● WyethPharmaceuticals(legal consultant)

Dr. Bijoy K.Khandheria


Dr. Thomas Ryan None None None None None None None


PPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FORRAINING IN ADULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 4:RAINING IN ECHOCARDIOGRAPHY

Name* Affiliation Consultant Research GrantScientific Advisory

BoardSpeakers’

BureauSteering


Dr. David J.Clardy

● Official–Boardof Governors


Dr. BibianaCujec


● AstraZeneca● Biovail● GE Healthcare● Philips

None None None None ● GlaxoSmithKline● Johnson &Johnson

None

Dr. MonicaEscarzaga



Dr. GordonL. Fung


None None None ● AstraZeneca● CV Therapeutics● GlaxoSmithKline● Merck● Novartis● Pfizer

None None None


● Official–Boardof Trustees




● 3FTherapeutics


Dr. ArthurJ. Labovitz

● Organizational–AmericanSociety ofEchocardiography

None ● BoehringerIngelheim

● Integrium● Sanofi-Synthelabo

None ● Baxter None None None

Susan E.Wiegers



his table represents the relationships of peer reviewers with industry that were reported by the authors as relevant to this topic. It does not necessarily reflect relationships with industry at the time ofublication. *Names are listed in alphabetical order with each category of review.

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368 Cerqueira et al. JACC Vol. 51, No. 3, 2008ACCF COCATS 3 Training Statement: Task Force 5 January 22, 2008:368–74

Task Force 5: Training in Nuclear CardiologyEndorsed by the American Society of Nuclear Cardiology

Manuel D. Cerqueira, MD, FACC, ChairDaniel S. Berman, MD, FACC, Marcelo F. Di Carli, MD, FACC,Heinrich R. Schelbert, MD, PHD, FACC, Frans J. Th. Wackers, MD, PHD, FACC,Kim Allan Williams, MD, FACC (American Society of Nuclear Cardiology Representative)

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raining in Nuclear Cardiology

uclear cardiology (Table 1) provides important diagnosticnd prognostic information that is an essential part of thenowledge base required of the well-trained cardiologist forptimal management of the cardiovascular patient. Trainingf fellows in nuclear cardiology is divided into 3 levels:*

General (Level 1, 2 months): Makes trainee conversantwith the field of nuclear cardiology for application ingeneral clinical management of cardiovascular patients.Specialized (Level 2, 4, to 6 months): Provides trainee withspecial expertise to practice clinical nuclear cardiology.†

he recommendations of this Joint Task Force, made up of representatives of themerican College of Cardiology Foundation (ACCF) and the American Society ofuclear Cardiology (ASNC), have been approved by the governing bodies of theCCF and ASNC in October 2007.*The issues of ongoing clinical competence and training or retraining of practicing

ardiologists are beyond the scope of this document. The Certification Board ofuclear Cardiology (CBNC) was established jointly by the American College ofardiology and ASNC and assesses knowledge and mastery in the areas of radiation

afety and the technical and clinical performance of nuclear cardiology procedures. Fordditional information, contact CBNC at 19562 Club House Road, Montgomeryillage, MD 20886; http://www.cbnc.org.†Level 2 and Level 3 training meet eligibility criteria for taking the Certification

oard of Nuclear Cardiology examination and Nuclear Regulatory CommissionNRC) training and experience requirements to become an authorized user. TheRC establishes federal policy with regard to the medical use of nuclear reactor

yproduct materials. Currently, there are 33 states that have applied and beenpproved by the NRC to self-regulate the use of radioactive materials, so calledAgreement States.” The other 17 states and the District of Columbia are regulatedy the federal policy. There is variation within the Agreement States in the trainingnd experience requirements for physicians applying to become authorized users ofadioactive materials for diagnostic testing. The NRC requires only that thegreement State requirements be as stringent as the federal NRC policy, but statesave the authority to make the requirements more stringent. Some states require areater number of total hours for the didactic, classroom, and laboratory experience inadiation safety. Other states have restricted the acceptable programs or institutionshere such training hours may be acquired. Given this variability in training and

xperience requirements within the U.S., trainees are advised to contact the NRC andhe Agreement States where they may seek to become authorized users of radioactiveaterials for the current rules and requirements. For details contact the Agreement

tates Homepage at http://www.hsrd.ornl.gov/nrc/home.html. Click on Directorynd then click on Directory of Agreement States and Non-Agreement State Directors

pnd State Liaison Officers. This will provide information on contacting the individualtates and getting the specific licensure requirements.

Advanced (Level 3, 1 year): Provides advanced trainingsufficient to pursue an academic career or direct a nuclearcardiology laboratory.†

eneral Cardiology Training Background

o have an adequate understanding of the clinical applica-ions of nuclear cardiology and to perform tests safely, theardiology trainee must acquire knowledge and proficiencyn the following areas of general cardiology:

. Coronary angiography and physiology

. Cardiac physiology and pathophysiology

. Rest and exercise electrocardiography

. Exercise physiology

. Pharmacology of standard cardiovascular drugs

. Cardiopulmonary resuscitation and treatment of othercardiac emergencies

. Pharmacology and physiology of commonly used stressagents, such as dipyridamole, adenosine, and dobutamine

. Clinical outcomes assessment

verview of Nuclear Cardiology Training

raining in nuclear cardiology at all levels should provide annderstanding of the indications and appropriate use ofpecific nuclear cardiology tests, the safe use of radionu-lides, basics of instrumentation and image processing,ethods of quality control, image interpretation, integra-

ion of risk factors, clinical symptoms and stress testing, andhe appropriate application of the resultant diagnostic in-ormation for clinical management. The depth of under-tanding will vary with each of the 3 levels of training.raining in nuclear cardiology is best acquired in Accredi-

ation Council for Graduate Medical Education (ACGME)-pproved training programs in cardiology, nuclear medicine,r radiology. An exception to this ACGME requirement ishe didactic and laboratory training in radiation safety andadioisotope handling that may be provided by qualified
hysicians/scientists in a non-ACGME program when such
http://www.cbnc.org

http://www.hsrd.ornl.gov/nrc/home.html

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program is not available as part of the clinical ACGMEraining program. For laboratories that provide training toardiology fellows, accreditation by the Intersocietal Com-ission for Accreditation of Nuclear Laboratories

ICANL) is also recommended.Nuclear cardiology training consists of the components

hown in Table 2. Didactic, clinical case experience, andands-on training hours require documentation in a log-ook, having the trainee’s name appear on the clinical reportr having some other specific record. The hours need to beonitored and verified by the nuclear cardiology training

receptor. For the advanced trainee, specialized training andesearch can be derived as part of an established program inither cardiology or a division of nuclear medicine. Theerson(s) responsible for the didactic, clinical, and hands-onraining and experience are responsible for evaluating theompetence of the trainee in nuclear cardiology uponompletion of the program. This can be accomplished bybserving the daily performance of the fellow, a formalesting procedure, or both. The preceptor for Level 2 orevel 3 should be an authorized user recognized by theuclear Regulatory Commission (NRC) or an Agreementtate, have Level 3 (or the equivalent) training in nuclearardiology, and preferably be certified by the Certificationoard of Nuclear Cardiology (CBNC).

idactic Program

ectures and self-study. This component consists ofectures on the basic aspects of nuclear cardiology and

lassification of Nuclear Cardiology Procedures

Table 1 Classification of Nuclear Cardiology Procedures

1. Standard nuclear cardiology proceduresa. Myocardial perfusion imaging

i. SPECT with technetium-99m agents and/or thallium-201, with or withouii. PET with rubidium-82 and/or nitrogen-13 ammoniaiii. Planar with technetium-99m agents and/or thallium-201iv. ECG gating of perfusion images for assessment of global and regional vv. Imaging protocolsvi. Stress protocols

1. Exercise stress2. Pharmacologic stress

vii. Viability assessment including reinjection and delayed imaging of thalliub. Equilibrium radionuclide angiocardiography and/or “first-pass” radionuclide ac. Qualitative and quantitative methods of image display and analysis

2. Less commonly used nuclear cardiology proceduresa. Combined myocardial perfusion imaging with cardiac CT for attenuation corrb. Equilibrium radionuclide angiocardiography and/or “first-pass” radionuclide ac. Metabolic imaging using single-photon and/or positron-emitting radionuclided. Myocardial infarct imaginge. Cardiac shunt studies

T � computed tomography; ECG � electrocardiogram; PET � positron emission tomography; SP

uclear Cardiology Training Components

Table 2 Nuclear Cardiology Training Components

1. Didactic programa. Lectures and self-studyb. Radiation safety

2. Interpretation of clinical cases3. Hands-on experience

a. Clinical cases

sb. Radiation safety

arallel self-study material consisting of reading andiewing cases on video or CD-ROM. The lectures andeading should provide the fellow with an understandingf the clinical applications of nuclear cardiology, includ-ng imaging with positron-emitting radionuclides andomputed tomography (CT) hybrid systems includingingle-photon emission computed tomography (SPECT)/CTnd positron emission tomography (PET)/CT. The mate-ial covered should include radiopharmaceuticals, radiationhysics instrumentation, nuclear cardiology diagnostic testsnd procedures/protocols, general cardiology as it relates tomage interpretation, risk stratification, myocardial perfu-ion imaging, ventricular function imaging, and assessmentf myocardial viability. Specificity, sensitivity, diagnosticccuracy, utility in assessing prognoses and interventions,osts, indications, and pitfalls in interpretation and clinicalpplication must be emphasized for each patient subset.

This program may be scheduled over a 12- to 24-montheriod, concurrent with other fellowship assignments. Some ofhe information can be effectively transmitted as part of aeekly noninvasive or invasive cardiology conference withresentation and discussion of nuclear cardiology image data.adiation safety. The second component of the didacticrogram should provide the fellow with an understanding ofadiation safety as it relates to patient selection and admin-stration of radiopharmaceuticals and utilization of CTystems. Fellows seeking Level 2 or Level 3 training willequire greater in-depth knowledge as well as hands-onractical experience. These requirements are detailed forach level of training.

nterpretation of Clinical Cases

uring training, fellows should actively participate in dailyuclear cardiology study interpretation under the directionf a qualified preceptor in nuclear cardiology. For all studiesn which angiographic or hemodynamic data are available,

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ardiology studies. Although experience in all aspects ofuclear cardiology is recommended, some procedures mayot be available—or may be performed in low volume—inome training programs. Under such circumstances, andequate background for general fellowship training can beatisfied with appropriate reading or review of case files.raining in nuclear cardiology needs to include extensive

xperience with the standard nuclear cardiology proceduresnd as much exposure as possible with the less commonlyerformed procedures. The training program needs to provideteaching file consisting of perfusion and ventricular function

tudies with angiographic documentation of disease.

ands-On Experience

linical cases. Fellows should have hands-on supervisedxperience in an appropriate number of the standard pro-edures (e.g., myocardial perfusion imaging and radionu-lide angiography) and as many of the less commonlyerformed procedures as possible. Such experience shouldnclude pre-test patient evaluation; radiopharmaceuticalreparation—measuring the dose, administration, and ex-erience with relevant radionuclide generators; operationnd quality control of planar and SPECT gamma camerand PET and CT systems; setup of the imaging computer;tilization of ECG gating; performing treadmill, bicycle,nd pharmacologic stress testing techniques; processing theata for display; interpreting the study; and generating alinical report. Complete nuclear cardiology studies shoulde performed under the supervision of qualified personnel.adiation safety. Fellows need to be familiar with radia-

ion biology and the regulations governing the use ofadioactive materials and ionizing radiation for performingiagnostic nuclear cardiology and hybrid CT studies. Thisnowledge includes details for protecting patients, theublic, and the user from the effects of radiation.

eneral Training—Level 1Minimum of 2 Months)

he trainee is exposed to the fundamentals of nuclearardiology for a minimum period of 2 months duringraining. This 2-month experience provides familiarity withuclear cardiology technology and its clinical applications inhe general clinical practice of adult cardiology, but it is notufficient for the specific practice of nuclear cardiology. The

components of training include a didactic program thatncludes lectures, self-study, radiation safety and regula-ions, interpretation of nuclear cardiology studies, andands-on experience.

idactic Program

ectures and self-study. This component consists of lec-ures on the basic aspects of nuclear cardiology and parallelelf-study material consisting of reading and viewing case
les. The material presented should integrate the role of t
uclear cardiology into total patient management. Suchnformation can be included within a weekly noninvasive ornvasive cardiology conference, with presentation and dis-ussion of nuclear cardiology image data as part of diagnos-ic and therapeutic management.

nowledge and appreciation of radiation safety. Theidactic program should include reading and practical ex-erience with the effects of radiation and provide the fellowith an understanding of radiation safety as it relates toatient selection and administration of radiopharmaceuti-als and utilization of CT systems.

nterpretation of Nuclear Cardiology Studies

uring the 2-month rotation, fellows should actively par-icipate in daily nuclear cardiology study interpretationminimum of 100 cases). Experience in all the areas listed inable 1 is recommended. If some procedures are not

vailable or are performed in low volume, an adequateackground for general fellowship training can be satisfiedy appropriate reading or review of case files. The teachingle should consist of perfusion and ventricular functiontudies with angiographic/cardiac catheterization documen-ation of disease.

ands-On Experience

ellows should perform complete nuclear cardiology studieslongside a qualified technologist or other qualified labora-ory personnel. They should, under supervision, observe andarticipate in a large number of the standard procedures ands many of the less commonly performed procedures asossible. Fellows should have experience in the practicalspects of radiation safety associated with performing clin-cal patient studies.

pecialized Training—Level 2Minimum of 4 Months)

ellows who wish to practice the specialty of nuclearardiology are required to have at least 4 months of training.evel 2 training includes a minimum of 700 h of radiation

afety experience in nuclear cardiology. There needs to beidactic, clinical study interpretation, and hands-on involve-ent in clinical cases. In training programs with a high

olume of procedures, clinical experience may be acquired ins short a period as 4 months. In programs with a lowerolume of procedures, a total of 6 months of clinicalxperience will be necessary to achieve Level 2 competency.he additional training required of Level 2 trainees is to

nhance their clinical skills, knowledge, and hands-onxperience in radiation safety and qualify them to becomeuthorized users of radioactive materials in accordance with
he regulations of the NRC and/or the Agreement States.†

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idactic

ectures and self-study. The didactic training shouldnclude in-depth details of all aspects of the proceduresisted in Table 1. This program may be scheduled over a 12-o 24-month period concurrent and integrated with otherellowship assignments.

adiation safety. Classroom and laboratory training needso include extensive review of radiation physics and instru-entation, radiation protection, mathematics pertaining to

he use and measurement of radioactivity, chemistry ofyproduct material for medical use, radiation biology, theffects of ionizing radiation, and radiopharmaceuticals.here should be a thorough review of regulations dealingith radiation safety for the use of radiopharmaceuticals and

onizing radiation. This experience should total a minimumf 100 cases and be separately documented.

nterpretation of Clinical Cases

ellows should participate in the interpretation of all nuclearardiology imaging data for the 4- to 6-month trainingeriod. It is imperative that the fellows have experience inorrelating catheterization or CT angiographic data withadionuclide-derived data for a minimum of 30 patients. Aeaching conference in which the fellow presents the clinicalaterial and nuclear cardiology results is an appropriate

orum for such experience. A total of 300 cases should benterpreted under preceptor supervision, from direct patienttudies (Table 3).

ands-On Experience

linical cases. Fellows acquiring Level 2 training shouldave hands-on supervised experience with a minimum of 35atients: 25 patients with myocardial perfusion imaging and0 patients with radionuclide angiography. Such experiencehould include pre-test patient evaluation; radiopharmaceu-ical preparation (including experience with relevant radio-uclide generators and CT systems); performance of studiesith and without attenuation correction; administration of

he dosage, calibration, and setup of the gamma camera andT system; setup of the imaging computer; processing theata for display; interpretation of the studies; and generatinglinical reports.adiation safety work experience. This experience should

otal 620 h and be acquired during training in the clinicalnvironment where radioactive materials are being used andnder the supervision of an authorized user who meets theummary of Training Requirementsor Nuclear Cardiology

Table 3 Summary of Training Requirementsfor Nuclear Cardiology

LevelMinimum Duration of

Training (Months)Total No. of

Examinations

1 2 100*

2 4–6 300*

3 12 600*

A minimum of 35 cases with hands-on experience must be performed and interpreted underupervision.

RC requirements of Part 35.290 or Part 35.290(c)(ii)(G)nd Part 35.390 or the equivalent Agreement State require-ents, and must include:

a. Ordering, receiving, and unpacking radioactive materialssafely and performing the related radiation surveys;

b. Performing quality control procedures on instrumentsused to determine the activity of dosages and per-forming checks for proper operation of survey meters;

c. Calculating, measuring, and safely preparing patient orhuman research subject dosages;

d. Using administrative controls to prevent a medical eventinvolving the use of unsealed byproduct material;

e. Using procedures to safely contain spilled radioactivematerial and using proper decontamination procedures;

f. Administering dosages of radioactive material to pa-tients or human research subjects; and

g. Eluting generator systems appropriate for preparationof radioactive drugs for imaging and localizationstudies, measuring and testing the eluate for radionu-clide purity, and processing the eluate with reagentkits to prepare labeled radioactive drugs.

dditional Experience

he training program for Level 2 must also provide expe-ience in computer methods for analysis. This shouldnclude perfusion and functional data derived from thalliumr technetium agents and ejection fraction and regional wallotion measurements from radionuclide angiographic studies.

dvanced Training—Level 3Minimum of 1 Year)

or fellows planning an academic career in nuclear cardiol-gy or a career directing a clinical nuclear cardiologyaboratory, an extended program is required. This may beart of the standard 3-year cardiology fellowship. In addi-ion to the recommended program for Level 2, the Level 3rogram should include advanced quality control of nuclearardiology studies and active participation and responsibilityn ongoing laboratory or clinical research. In parallel witharticipation in a research program, the trainee shouldarticipate in clinical imaging activities for the total trainingeriod of 12 months, to include supervised interpretativexperience in a minimum of 600 cases. Hands-on experi-nce should be similar to, or greater than, that required forevel 2 training. The fellow should be trained in most of the

ollowing areas:

Qualitative interpretation of standard nuclear cardiologystudies, including SPECT and/or PET myocardial perfu-sion imaging, ECG-gated perfusion studies, attenuation-
corrected studies, gated-equilibrium studies, “first-pass,”

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and any of the less commonly performed proceduresavailable at the institutionQuantitative analysis of SPECT and/or PET myocardialperfusion and/or metabolic studiesQuantitative radionuclide angiographic and gated-myocardial perfusion analyses, including measurement ofglobal and regional ventricular functionSPECT and/or PET perfusion acquisition, reconstruc-tion, and displayECG-gated SPECT and/or perfusion acquisition, anal-ysis, and display of functional dataImaging of positron-emitting tracers using dedicatedPET systems or hybrid PET/CT systems

The requirements for Level 1 to 3 training in nuclearardiology are summarized in Table 3.

pecific Training in Cardiac Imaging ofositron-Emitting Radionuclides

ardiac PET and PET/CT imaging of positron-emittingadionuclides are part of nuclear cardiology. An increasingumber of nuclear laboratories have access to both conven-ional SPECT and PET imaging. For institutions that haveositron-imaging devices, training guidelines are appropri-te. Training in this particular imaging technology shouldo hand-in-hand and may be concurrent with training inonventional nuclear cardiology. Such training should in-lude those aspects that are unique or specific to the imagingf positron-emitting radionuclides. Depending on the de-ired level of expertise, training in cardiac PET and imagingith positron-emitting radionuclides should include knowl-

dge of substrate metabolism in the normal and diseasedeart; knowledge of positron-emitting tracers for bloodow, metabolism and neuronal activity, medical cyclotrons,adioisotope production, and radiotracer synthesis; andrinciples of tracer kinetics and their in vivo application forhe noninvasive measurements of regional, metabolic, andunctional processes. The training should also include thehysics of positron decay, aspects of imaging instrumenta-ion specific to the imaging of positron emitters and the usef CT, production of radiopharmaceutical agents, qualityontrol, handling of ultra-short life radioisotopes, appropri-te radiation protection and safety, and regulatory aspects.

Consistent with the training guidelines for general nu-lear cardiology, training should be divided into 3 classes.

eneral Training (2 Months)

his level is for cardiology fellows who are associated withn institution where PET and/or PET/CT devices arevailable and who wish to become conversant with cardiacositron imaging. Training should therefore be the same asor Level 1 training in nuclear cardiology but should includespects specific to cardiac positron imaging. The additional
roficiency to be acquired by physician trainees includes
ackground in substrate metabolism, patient standardiza-ion and problems related to diabetes mellitus and lipidisorders, positron-emitting tracers of flow and metabolism,nd technical aspects of positron and CT imaging. Aidactic program should include the interpretation of car-iac PET studies of myocardial blood flow and substrateetabolism, the interpretation of studies combining

PECT for evaluation of blood flow with PET for evalua-ion of metabolism, the evaluation of diagnostic accuracynd cost-effectiveness of viability assessment of coronaryrtery disease detection, and the understanding of radiationafety as specifically related to positron emitters. Hands-onxperience should include supervised observation and inter-retation of cardiac studies performed with positron-mitting radionuclides and PET and PET/CT imagingevices.

pecialized Training (Minimum of 4 Months)

his level of training is for fellows who wish to perform andnterpret cardiac PET or positron imaging studies in addi-ion to nuclear cardiology. This training should include allevel 1 and Level 2 training in nuclear cardiology (4 to 6onths) as well as general training for cardiac PET andET/CT. Specific aspects of training for PET and for usingositron-emitting radionuclides should include radiationosimetry, radiation protection and safety, dose calibration,hysical decay rates of radioisotopes, handling of large dosesf high-energy radioactive materials of short physical half-ives, quality assurance procedures, and NRC safety andecord-keeping requirements. This level of training requiresirect patient experience with a minimum of 40 patienttudies of myocardial perfusion, metabolism, or both.

dvanced Training (Minimum 1 Year)

his level of training is intended for fellows planning ancademic career in cardiac PET or who wish to direct alinical cardiac PET laboratory. Similar to Level 3 trainingn nuclear cardiology, this training should include activearticipation in laboratory and clinical research in parallelith clinical activities.In addition to the requirements for general and special-

zed cardiac PET training (including standard nuclearardiology training, as previously described), advancedraining should include the following:

. Basic principles of cyclotrons, isotope production, ra-diosynthesis, tracer kinetic principles and models, car-diac innervation and receptors, and methods for quan-tifying regional myocardial blood flow and substratemetabolism.

. Imaging instrumentation including dedicated PET sys-tems, hybrid PET/CT systems and SPECT-like positronimaging devices with high-energy photon collimators orcoincidence detection. Image acquisition and processing
to include review of sinograms, errors in image recon-

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struction, correction routines for photon attenuation,and patient misalignment.

. Tissue kinetics of positron-emitting tracers; in vivoapplication of tracer kinetic principles; tracer kineticmodels, generation of tissue time–activity curves, andcomputer-assisted calculation of region of functionalprocesses of the myocardium.

. Computer-assisted data manipulation, quantitative im-age analysis, and image display.

ybrid Computed Tomography Imaging

ybrid imaging devices combining PET or SPECT withT are playing an increasing role in the field of cardiac

maging. Currently, nearly all PET scanners are sold asET/CT devices, and SPECT/CT machines are nowvailable from most manufacturers. As these devices becomeore widely disseminated, it will be important that training

uidelines for their use be developed both for fellows inraining and cardiologists already in practice. The applica-ions of hybrid imaging in cardiology include the use of CTcanning to provide robust attenuation correction ofPECT or PET and to assess coronary calcium as a markerf coronary atherosclerosis. Even these noncontrast appli-ations of hybrid imaging will require additional training
eyond that required for CT alone. With CT coronary e
alcium and SPECT or PET perfusion assessments, addi-ional training will be needed regarding discordant results.

ith contrast injection, high resolution CT coronary an-iography can be combined with rest/stress assessments ofyocardial perfusion provided by PET and SPECT, allow-

ng functional assessment of the anatomic findings. Thepecifics of the training required in hybrid imaging areeyond the scope of this document; nonetheless, thoseuclear cardiology training programs that are equipped toerform hybrid imaging should incorporate training in thiseld in their programs. Training should include the physicsf hybrid systems, CT attenuation correction, principles andpplication of CT coronary calcium assessment, and prin-iples and application of CT coronary angiography.

his is an update of the 2006 document that was writteny Manuel D. Cerqueira, MD, FACC—Chair; Daniel. Berman, MD, FACC; Marcelo F. Di Carli, MD,ACC; Heinrich R. Schelbert, MD, PhD, FACC; Frans

. Th. Wackers, MD, PhD, FACC; and Kim Allan Wil-iams, MD, FACC (American Society of Nuclear Cardiologyepresentative).

doi:10.1016/j.jacc.2007.11.013

ey Words: ACCF Training Statement y COCATS 3 y nuclearardiology y electrocardiograph y computed tomography y positron
mission tomography y single-photon emission computed tomography.
PPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FOR TRAINING INDULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 5: TRAINING INUCLEAR CARDIOLOGY



BoardSpeakers’

BureauSteering


Dr. Daniel S.Berman

● Tyco-Mallinckrodt ● Astellas● Bristol-Myers Squibb● GE Healthcare

● Spectrum Dynamics None None ● SpectrumDynamics

● Cedars-SinaiMedical Center(Softwareroyalties)

Dr. Manuel D.Cerqueira

None ● GE Healthcare ● Bristol-Myers Squibb● CV Therapeutics

● Astellas● Bristol-Myers Squibb● CV Therapeutics● GE Healthcare● Mallinckrodt

None None None

Dr. Marcelo F. DiCarli

● Bracco● Bristol-MyersSquibb Imaging

● GE Healthcare

● Astellas● Bracco● Bristol-Myers SquibbImaging

● GE Healthcare

● Bracco● Bristol-Myers SquibbImaging

● GE Healthcare

● Astellas● Bracco● GE Healthcare

None None None

Dr. Heinrich R.Schelbert


Dr. Frans J. Th.Wackers

● Acusphere● GE Healthcare

● Acusphere● Astellas● Bristol-Myers Squibb● GE Healthcare

● KingPharmaceuticals

None None None None

Dr. Kim AllanWilliams


● Bristol-Myers Squibb● CV Therapeutics● GE Healthcare

● Bristol-Myers Squibb● GE Healthcare

● Astellas● GE Healthcare

None None None

his table represents the relationships of committee members with industry that were reported by the authors as relevant to this topic. It does not necessarily reflect relationships with industry at the time

f publication.

ATT

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374 Naccarelli et al. JACC Vol. 51, No. 3, 2008ACCF COCATS 3 Training Statement: Task Force 6 January 22, 2008:374–80

PPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FORRAINING IN ADULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 5:RAINING IN NUCLEAR CARDIOLOGY



BoardSpeakers’

BureauSteering


Dr. David J.Clardy






Dr. James A.Arrighi

● Organizational–AmericanSociety of NuclearCardiology


Dr. Myron CraigGerson



his table represents the relationships of peer reviewers with industry that were reported by the authors as relevant to this topic. It does not necessarily reflect relationships with industry at the time of
ublication. *Names are listed in alphabetical order with each category of review.
Task Force 6: Training in SpecializedElectrophysiology, Cardiac Pacing,and Arrhythmia ManagementEndorsed by the Heart Rhythm Society

Gerald V. Naccarelli, MD, FACC, FHRS, ChairJamie B. Conti, MD, FACC, FHRS, John P. DiMarco, MD, PHD, FACC, FHRS,Cynthia M. Tracy, MD, FACC, FHRS (Heart Rhythm Society Representative)

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linical cardiac electrophysiology and cardiac pacing haveerged into a common cardiac subspecialty discipline. Com-

lex cardiac arrhythmias are managed by physicians withpecial expertise in cardiac electrophysiology, the use of cardiacmplantable electrical devices (CIEDs), and the application ofther interventional ablative techniques and pharmacologicreatments. Cardiac implantable electronic devices is a termsed to encompass implantable cardioverter-defibrillatorsICDs), pacemakers, cardiac resynchronization therapyCRT) devices, implantable hemodynamic monitorsIHMs), and implantable loop recorders (ILRs). For pur-oses of this document, IHMs and ILRs, while legitimatelyonsidered CIEDs, are excluded, and implantation numbersor these should not be considered as satisfying minimumraining requirements.

The current Task Force is charged with updating previouslyublished adult clinical cardiac electrophysiology traininguidelines (1–4) based on changes in the cardiac electrophys-ology field since the last revision (4). The number of proce-ures recommended for each level is a consensus based on
ublished guidelines and competency statements and assumes m
raining by an appropriately trained mentor and documenta-ion of satisfactory completion of such training by the programirector. The number of procedures and duration of trainingre summarized in Tables 1 and 2.

eneral Standards and Environment

acilities and Faculty

hree organizations—the American College of CardiologyACC), the American Heart Association (AHA), and the

eart Rhythm Society (HRS)—have addressed trainingequirements and guidelines for permanent pacemaker se-ection, implantation, and follow-up (5,6); guidelines for themplantation and follow-up of ICDs in cardiovascularractice (7,8); guidelines for training in catheter ablationrocedures (9,10); and teaching objectives for fellowshiprograms in clinical electrophysiology (11,12). The trainingecommendations for these 3 organizations are congruentnd address new technologies, faculty, and facility require-
ents, as well as practice. It is strongly recommended that

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375JACC Vol. 51, No. 3, 2008 Naccarelli et al.January 22, 2008:374–80 ACCF COCATS 3 Training Statement: Task Force 6

rainees who desire admission to the American Board ofnternal Medicine (ABIM) examination for certification inardiovascular diseases and those who seek admission to thelinical cardiac electrophysiology (CCEP) examination forertification of added qualifications in CCEP be certain tobtain specific requirements from the ABIM (13,14).The cardiac arrhythmia aspects of a cardiology training

rogram should meet the published recommendations andequirements regarding facilities and faculty (9,10). In orderor trainees to be eligible for admission to the CCEPxamination of the ABIM, training must take place in anccreditation Council for Graduate Medical Education

ACGME)-approved training program (13). The intensityf training and the required teaching resources may varyccording to the level of training provided. Facilities shoulde adequate to ensure a safe, sterile, and effective environ-ent for invasive electrophysiologic studies and implanta-

ion of arrhythmia control devices. Faculty should includepecialists who are skilled in the medical and surgical aspectsf pacing and electrophysiology. In addition, faculty shoulde knowledgeable about the risks to the patient and toedical personnel from radiation exposure. Faculty respon-

ible for training must be board certified in CCEP orossess equivalent qualifications. In addition, there must beminimum of 2 key clinical CCEP faculty members,

ardiac Arrhythmia and Electrophysiology Curriculum Training Sum

Table 1 Cardiac Arrhythmia and Electrophysiology Curriculum T

Level Curriculum/Skills

1 Cardiac arrhythmia and electrophysiology core 2 motra

2 Advanced noninvasive arrhythmiamanagement

6 mo

3 Clinical invasive cardiac electrophysiology(meets the American Board of InternalMedicine CCEP Examination requirements)

1–2 y

CEP � Clinical Cardiac Electrophysiology; CIED � cardiac implantable electrical device.

ore Cardiac Arrhythmia and Electrophysiologyurriculum Training

Table 2 Core Cardiac Arrhythmia and ElectrophysiologyCurriculum Training

Level Minimal Number of ProceduresCumulative Durationof Training (Months)

1 10 temporary pacemakers10 cardioversions

2

2 100 CIED interrogations/programming 6

3 150� EP cases 12–24

75 ablations

30–50 atrial fibrillation ablations

10� trans-septal procedures

75 CIEDs (25 ICD, 25 dual-chamberdevices, 25 CRT devices)

30 CIED revisions/replacements

200 CIED interrogations/programming(100 ICDs, 100 pacemakers)

AIED � cardiac implantable electrical device; CRT � cardiac resynchronization therapy; EP �

lectrophysiology; ICD � implantable cardioverter-defibrillator.

ncluding the program director. In programs with a total ofore than 2 residents enrolled, a ratio of such faculty to

esidents of at least 1:1 must be maintained (13).

evels of Training

evel 1

ithin the cardiology core training program, Level 1hould comprise at least 2 months of CCEP rotationesigned for cardiology trainees to acquire knowledge andxperience in the diagnosis and management of brady-rrhythmias and tachyarrhythmias. Level 1 trainees stilleed to meet the requirements necessary for proper training

n electrocardiography. Every cardiology trainee shouldearn the indications for and limitations of electrophysi-logic studies, the ability to interpret intracardiac recordingsuch as AH, HV intervals and basic activation sequencesuring tachycardia, differentiation of a supraventricular andentricular tachycardia, and the use of antitachycardia pac-ng to terminate tachyarrhythmias. Level 1 trainees shouldearn the proper use of antiarrhythmic agents, includingrug interactions and proarrhythmic potential. In addition,evel 1 trainees should learn the appropriate indications foratheter ablation procedures. The Level 1 trainee should bexposed to noninvasive and invasive techniques related tohe diagnosis and management of patients with cardiacrrhythmias that include ambulatory electrocardiographiconitoring (see the Task Force 2 recommendations), event

ecorders, ILRs, exercise testing for arrhythmia assessment,ilt-table testing, invasive electrophysiologic studies, andmplantation of cardiac arrhythmia control devices. Thelectrocardiographic manifestations of arrhythmias shoulde taught on a regular basis during formal electrocardiogramECG) conferences. Additional experience in heart rhythmisorders and clinical correlations can be obtained fromidactic sessions and conferences; however, they must beupplemented by rotation on an arrhythmia consultationervice, during which time the trainee should gain first-handxperience as a consultant in arrhythmia management.

ng Summary

e Requirement Optional Training in Device Implantation

n addition to Task Force 2equirements)

No

Yes: In addition to 6 months of noninvasiveemphasis, another 6 months for a totalof 12 months is required for pacemakerimplantation training

2–24 months) Yes: A total of 1 year beyond the 3-yearcardiology training program is required.If surgical aspects of CIED implantationare desired, a total of 12 months willneed to be devoted to this discipline.

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xposure to cardiac and noncardiac surgical procedures aremportant components of the arrhythmia core training.

The Level 1 cardiology trainee’s experience should alsonclude learning the fundamentals of cardiac pacing, recog-izing normal and abnormal pacemaker function, indica-ions for temporary and permanent pacing and the implan-ation of ICDs (4), pacing modes, and understanding basicechniques for interrogation, programming, and surveillancef pacemakers and ICDs. Trainees should learn the indica-ions and limitations of biventricular pacing in patients withongestive heart failure.

The cardiology trainee should be formally instructed innd gain experience with the insertion, management, andollow-up of temporary pacemakers (4); measurement ofacing and sensing thresholds and recording of intracardiaclectrograms for management of patients with temporaryacemakers; and indications and techniques for elective andmergency cardioversions (15). Temporary pacemaker andardioversion exposure can be performed in other venuesuch as the cardiac catheterization laboratory or the criticalare setting. Insertion of a minimum of 10 temporaryacemakers and performance of at least 10 elective cardio-ersions are required. The cardiology trainee should beormally instructed in and gain experience with the appli-ation of and use of transcutaneous pacing systems. Thesexperiences can be obtained throughout the cardiovascularlinical training period.

evel 2

ome trainees in cardiology may wish to acquire advancedraining in the management of arrhythmias but not under-ake training in all aspects of cardiac electrophysiology.evel 2 trainees should meet all Level 1 training require-ents and should obtain advanced training in normal and

bnormal cardiac electrophysiology and mechanisms ofrrhythmias. Level 2 training consists of a minimum of 6onths of training in noninvasive arrhythmia management

echniques designed to develop advanced competence androficiency in the diagnosis, treatment, and longitudinalare of patients with complex arrhythmias. Exposure androficiency in the performance and interpretation of otheroninvasive tests related to the evaluation of patients whoave arrhythmias should be part of the training. Level 2rainees should have a thorough knowledge of the basic andlinical pharmacology of antiarrhythmic agents and demon-trate proficiency in their use.

Of special importance for the Level 2 trainee is thecquisition of skills and experience for managing inpatientsnd outpatients with complex cardiac arrhythmias, includ-ng programming and follow-up management of all types ofradycardia pacing, biventricular pacing, and ICD systems.he trainee is expected to function as the primary program-ing operator who interrogates, interprets, prescribes, and

eprograms devices in at least 100 patients. The trainee athis level must also acquire advanced competency in tem-
orary pacing, cardioversion, interpretation of invasive elec- h
rophysiologic study data, and complex arrhythmia electro-ardiograph interpretation.

Although the Level 2 trainee must have significantxposure to invasive electrophysiology, ICDs, and the sur-ical aspects of arrhythmia control device implantation,evel 2 training by itself does not qualify the trainee toerform these invasive procedures. The Level 2 trainee hashe option of obtaining additional training in the surgicalspects of pacemaker implantation or may choose thedditional training required for invasive cardiac electrophys-ology, or both, as described under Level 3.

evel 3

his level of training is designed for the individual whoishes to specialize in invasive diagnostic and therapeutic

ardiac electrophysiology (16). Requirements of Levels 1nd 2 must be fully met. Prior procedure volume duringevel 1 and Level 2 training is cumulative and counts

owards the overall numbers to reach Level 3 training.Clinical cardiac electrophysiology training includes ainimum of 4 years of training in clinical cardiology and

lectrophysiology. Current ACGME requirements specify a-year training program in general cardiology, which con-ists of a core 24-month clinical program and an additional2 months, which may involve research and/or elective timen electrophysiology. A dedicated fourth year of training inCEP after 3 years is required. The appropriate use, safeerformance, and judicious interpretation of these complexrocedures require highly specialized training and compe-ence. Although CIED and invasive cardiac electrophysiol-gy training including ablation is usually done concomi-antly, sequential training is also acceptable as long as all ofhe requirements of training in this document are met.urthermore, an advanced knowledge base in basic CCEPnd pharmacology must provide a sound foundation for thecquisition of technical abilities and cognitive skills in theanagement of patients with complex arrhythmias.To complete Level 3, in addition to Level 1 and 2

equirements, trainees should perform at least 150 electro-hysiologic procedures and “be a primary operator andnalyze 100 to 150 initial diagnostic studies. At least 50 to5 of these procedures should involve patients with su-raventricular arrhythmias. Because therapy with antiar-hythmic devices forms a major part of current electrophys-ology practice, the trainee should also have been a primaryperator during more than 25 electrophysiological evalua-ions of implantable antiarrhythmic devices” (17).

Electrophysiologic procedures should cover the totalpectrum of arrhythmias, both supraventricular and ventric-lar tachyarrhythmias as well as bradyarrhythmias. Givenhe complexity of the field and the growing amount ofnformation and new procedures, it is common for traineeso extend training for an additional year or more to gaindvanced expertise in specific procedures, such as ischemicentricular tachycardia, ablation of patients with congential
eart disease, and atrial fibrillation ablation procedures and

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ead extractions. This type of advanced training can also bechieved during a post-training mentored practice.

Expertise in catheter placement, programmed electricaltimulation, endocardial mapping, catheter ablation, andnterpretation of data must be ensured by the electrophys-ology program director. The endocardial mapping experi-nce should include some exposure to left heart mapping byhe retrograde aortic approach. Training in trans-septalatheterization should be provided by an individual at theraining institution with expertise in the technique. Expe-ience with at least 10 trans-septal catheterization proce-ures is suggested as minimal required training. Participa-ion in a minimum of 75 catheter ablations, includingblation and modification of the atrioventricular (AV) node,V accessory pathways, atrial flutter, and atrial and ventric-lar tachycardia, is required (17). To gain expertise in atrialbrillation ablation requires additional expertise in catheteranipulation and integration of knowledge related to

-dimensional mapping systems. Given the rapid evolutionf new mapping technologies, it is unlikely that the traineeill be exposed to all mapping technologies as part of their

raining. Trainees should be exposed to tools for definitionf intracardiac anatomy, such as intravascular ultrasound,ardiovascular magnetic resonance, and computed tomog-aphy scans. No numeric guidelines have been establishedor training in atrial fibrillation ablation, but it is anticipatedhat the Level 3 trainee should participate in 30 to 50entored atrial fibrillation ablations, and data suggest that

xperience in 100 atrial fibrillation ablation procedures willinimize adverse effects (18).Level 3 training in electrophysiology requires ICD expe-

ience that includes assisting with the primary device im-lantation, with electrophysiologic testing at the time ofmplantation, and with follow-up assessment. The trainee inlectrophysiology also requires experience in left ventricularead implantation procedures. The ICD implant exposurencludes assisting with the device implantation, threshold,nd defibrillation threshold (DFT) testing at the time ofmplant and follow-up. Full Level 3 recommendations forhe implantation of CIEDs are explained in detail in theollowing text.

ptional Training in Device ImplantationApplicable to Level 2 or Level 3)

evel 2 and 3 trainees may choose to obtain additionalraining in the surgical aspects of device implantation. TheIED implantation training may be obtained concurrentlyr sequentially with Level 2 or Level 3 training, respectively.or those cardiology trainees who elect to obtain proficiency

n the surgical aspects of transvenous CIED implantationrevious or concurrent Level 2 training is required. TheIED training must include development of expertise inermanent atrial right and left ventricular lead and ICD

ead placement, threshold testing and programming ofevices, principles of surgical asepsis, surgical techniques of

mplantation, and management of implant-related compli- t

ations. Individuals receiving qualifying training in CIEDmplantation must participate as the primary operator (un-er direct supervision) in at least 75 CIED initial primarymplantations. Primary implantations should include at least5 ICD, 25 dual-chamber, and 25 CRT (either pacing orefibrillation) devices. Thorough ICD implant evaluationncluding ventricular fibrillation induction and defibrillationesting for a minimum of 25 implants is a necessary part ofhis training. Thirty CIED revisions or replacements, in-luding at least 10 ICD revisions as the primary operator, islso a necessary requisite of this level of training. Therainee must also participate in the follow-up of at least 200IED patient visits and acquire proficiency in advancedacemaker electrocardiography, interrogation, and pro-ramming of complex pacemakers. Of the follow-up visits,t least 100 should be in ICD and 100 in pacemakeratients. Level 2 training (6 months) with the option ofraining in pacemaker implantation (6 months) requires aotal of 1 year of advanced training beyond the cardiologyore Level 1. This may be obtained within a 3-yearardiology program if 1 of the 3 years is dedicated tocquiring pacemaker implantation skills plus related man-gement and follow-up skills. This training does not meethe ABIM requirements for admission to the CCEP exam-nation. As part of the training regarding implantableacemakers, exposure to the indications, implantation tech-iques, and follow-up of implantable loop recorders isesirable.The trainee pursuing a career in CCEP as addressed

nder Level 3 also has the option of obtaining expertise inhe surgical aspects of pacemaker or transvenous ICDmplantation, or both. The same amount of surgical expe-ience with bradycardia pacemaker implantation is requirednd may be supplemented with surgical training for ICDmplantation (15). If the Level 3 trainee chooses this option,e or she must participate as the primary implanter (underirect supervision) in at least 25 ICD system implantations,s well as possess the management and follow-up skillsddressed under Level 3. The Level 3 trainee wishing toecome proficient in implantation of biventricular pacing orefibrillating systems requires the aforementioned trainingnd involvement in implantation and follow-up of 25iventricular systems (5). He or she should be proficient atnterpreting data gained from noninvasive tools, such aschocardiography, used in the evaluation of resynchroniza-ion therapies. Pacemaker lead extraction is a specializedrocedure that requires special training but is not an obligateart of training for CCEP examination eligibility. Physi-ians being trained in lead extraction should perform ainimum of 20 lead extractions as the primary operator under

he direct supervision of a qualified training physician (19).Level 3 trainees for ICD implantation must have an

xtensive knowledge of ICD indications, contradictions,nd management of complications; an ability to determineefibrillation thresholds and manage high defibrillation
hresholds; an understanding of drug– and pacemaker–ICD

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nteractions; and a thorough knowledge of ICD program-ing and management of ICD malfunction and post-

perative complications. Level 3 training with the option ofacemaker or ICD implantation or both requires a mini-um of 1 year of dedicated CCEP and device implantation

raining beyond the 3-year cardiology program. In addition,evel 3 trainees must have an extensive knowledge of leftentricular lead indications, contraindications, and manage-ent of biventricular malfunctions and interactions, as well as

ost-operative complications. It has been advocated that phy-icians training in congestive heart failure/transplantationould pursue an additional year of training to achieve Level

and Level 3 competency in implantable devices byeeting all of the above COCATS training requirements

20). It is recommended that Level 3 fellowship training forCD implantation follow the aforementioned COCATSequirements.

valuation, Competence, and Privileges

he program director should maintain adequate records ofach individual’s training experiences and performance ofarious procedures for appropriate documentation for Levels, 2, and 3. The trainees should also maintain records ofarticipation in the form of a logbook containing clinicalnformation, procedure performed, and outcome of proce-ures, including any complications encountered.The ACC, AHA, and HRS have formulated a clinical

ompetence statement on invasive electrophysiology studies,atheter ablation, and cardioversion (17). Self-assessmentrograms and competence examinations in electrocardiog-aphy are available through the ACC and other organiza-ions. Training directors and trainees are encouraged totilize these resources.The ACGME has published the essential components ofspecialized program for training in CCEP. The ABIM

rovides a special examination for additional certification inCEP. Information concerning the training requirements

or admission to the examination can be obtained from theBIM; such requirements include 1 additional year of

raining in an ACGME-accredited electrophysiology pro-ram. Subsequent privileges to perform invasive procedureshould be granted primarily on the basis of the technicalxpertise acquired in the training program, the documentedraining, and the recommendations of the directors oflectrophysiology/pacing programs.

The Heart Rhythm Society strongly recommends theOCATS Task Force 6 training requirements for CIEDs.s the Society’s 2004 Clinical Competency Statement onraining Pathways for Implantation of Cardioverter Defi-rillators and Cardiac Resynchronization Devices (21) andhe 2005 Addendum (22) sunsets in October 2008, theociety recommends that physicians who wish to incorpo-ate CIED implantation and follow-up into their clinical
ractice meet the training requirements described in this
ocument and passage of the International Board of Hearthythm Examiners’ (IBHRE) Examination of Specialompetency in Cardiac Pacing and Cardioversion Defibril-

ation for the Physician (23) and or the American Board ofnternal Medicine CCEP Examination (for those whoomplete a CCEP fellowship, which demonstrate knowl-dge essential to the practice of heart rhythm management.

his is a revision of the 2006 document that was written byerald V. Naccarelli, MD, FACC—Chair; Jamie B. Conti,D, FACC; John P. DiMarco, MD, PhD, FACC; and

ynthia M. Tracy, MD, FACC (Heart Rhythm Societyepresentative).

doi:10.1016/j.jacc.2007.11.014


1. Josephson ME, Maloney JD, Barold SS, et al. Guidelines for trainingin adult cardiovascular medicine: Core Cardiology Training Sympo-sium (COCATS): Task Force 6: training in specialized electrophysi-ology, cardiac pacing and arrhythmia management. J Am Coll Cardiol1995;25:23–6.

2. Flowers NC, Abildskov JA, Armstrong WF, et al. ACC policystatement: recommended guidelines for training in adult clinicalcardiac electrophysiology: Electrophysiology/ElectrocardiographySubcommittee, American College of Cardiology. J Am Coll Cardiol1991;18:637–40.

3. Zipes DP, DiMarco JP, Gillette PC, et al. Guidelines for clinicalintracardiac electrophysiological and catheter ablation procedures: areport of the American College of Cardiology/American Heart Asso-ciation Task Force on Practice Guidelines (Committee on ClinicalIntracardiac Electrophysiologic and Catheter Ablation Procedures),developed in collaboration with the North American Society of Pacingand Electrophysiology. J Am Coll Cardiol 1995;26:555–73.

4. Naccarelli GV, Conti JB, DiMarco JP, Tracy CM. Task force 6:training in specialized electrophysiology, cardiac pacing and arrhyth-mia management. J Am Coll Cardiol 2006;47:904–10.

5. Gregoratos G, Abrams J, Epstein AE, et al. ACC/AHA/NASPE2002 guideline update for implantation of cardiac pacemakers andantiarrhythmia devices: a report of the American College of Cardiol-ogy/ American Heart Association/Task Force on Practice Guidelines(ACC/AHA/NASPE Committee to Update the 1998 PacemakerGuidelines). Circulation 2002;106:2145–61.

6. Hayes DL, Naccarelli GV, Furman S, et al. NASPE policy statement:NASPE training requirements for cardiac implantable electronicdevices (CIED). Selection, implantation and follow-up. Pacing ClinElectrophysiol 2003;26:1556–62.

7. Curtis AB, Langberg JJ, Tracy CM. Clinical competency statement:Implantation and follow-up of cardioverter defibrillators. J CardiovascElectrophysiol 2001;12:280–4.

8. Winters SL, Packer DL, Marchlinski FE, et al. Consensus statementon indications, guidelines for use, and recommendations for follow-upof implantable cardioverter defibrillators. Pacing Clin Electrophysiol2001;24:262–9.

9. Scheinman MM. Catheter ablation for cardiac arrhythmias, personnel,and facilities: North American Society of Pacing and Electrophysiol-ogy Ad Hoc Committee on Catheter Ablation. Pacing Clin Electro-physiol 1992;15:715–21.

0. American College of Cardiology Cardiovascular Technology AssessmentCommittee. Catheter ablation for cardiac arrhythmias: clinical applica-tions, personnel and facilities. J Am Coll Cardiol 1994;24:828–33.

1. Scheinman M, Akhtar M, Brugada P, et al. Teaching objectives forfellowship programs in clinical electrophysiology. Pacing Clin Elec-trophysiol 1988;11:989–96.

2. Mitchell LB, Dorian P, Gillis A, Kerr C, Klein G, Talajic M.Standards for training in adult clinical cardiac electrophysiology:
Canadian Cardiovascular Society Committee. Can J Cardiol 1996;12:476–80.

1

1

1

1

1

1

1

2

2

2

2

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3. Accreditation Council for Graduate Medical Education. Programrequirements for residency programs in clinical cardiac electrophysiol-ogy. Available at: http://www.acgme.org. Accessed June 15, 2007.

4. Zipes DP, Downing SM, Kangilaski R, Norcini JJ Jr. The first cardiacelectrophysiology examination for added qualifications: AmericanBoard of Internal Medicine. Pacing Clin Electrophysiol 1994;17:1327–31.

5. Clinical competence in elective direct current (DC) cardioversion: astatement for physicians from the ACP/ACC/AHA Task Force onClinical Privileges in Cardiology. J Am Coll Cardiol 1993;22:336–9.

6. Clinical competence in invasive cardiac electrophysiological studies:ACP/ACC/AHA Task Force on Clinical Privileges in Cardiology.J Am Coll Cardiol 1994;23:1258–61.

7. Tracy CM, Akhtar M, DiMarco JP, Packer DL, Weitz HH. Amer-ican College of Cardiology/American Heart Association clinical com-petence statement on invasive electrophysiology studies, catheter ablation,and cardioversion: a report of the American College of Cardiology/American Heart Association/American College of Physicians–American Society of Internal Medicine Task Force on Clinical Compe-tence. J Am Coll Cardiol 2000;36:1725–36.

8. Calkins H, Brugada J, Packer DL, et al. HRS/EHRA/ECAS expertconsensus statement on catheter and surgical ablation of atrial fibril-
lation: Recommendations for personnel, policy, procedures and i
follow-up. A report of the Heart Rhythm Society (HRS) Task Forceon Catheter and Surgical Ablation of Atrial Fibrillation. HeartRhythm 2007;4:816–61.

9. Wilkoff BL, Byrd CL, Love C. NASPE guidelines for lead extraction.Pacing Clin Electrophysiol 2000;23:544–51.

0. Naccarelli GV. Does it make sense to train plumbers as electricians?J Am Coll Cardiol 2004:44:1358–60.

1. Curtis AB, Ellenbogen KA, Hammill SC, Reynolds DW, WilberDSJ, Vain ME. Clinical competency statement: training pathways forimplantation of cardioverter-defibrillators and cardiac resynchron-ization devices. Heart Rhythm 2004;3:371–5.

2. Day JD, Curtis AB, Epstein AE, et al. Addendum to the clinicalcompetency statement: training pathways for implantation of cardio-verter defibrillators and cardiac resynchronization devices. HeartRhythm 2005;2:1161–3.

3. International Board of Heart Rhythm Examiners (IBHRE) wasformerly named NASPExAM. This physician exam is given at leasttwice a year. Available at: www.naspexam.org.

ey Words: ACCF Training Statement y COCATS 3 y specializedlectrophysiology y cardiac pacing y arrhythmia management y

mplantable devices y defibrillation y cardiac implantable electrical devices.

PPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FOR TRAINING INDULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 6: TRAINING INPECIALIZED ELECTROPHYSIOLOGY, CARDIAC PACING, AND ARRHYTHMIA MANAGEMENT

Name Consultant Research GrantScientific Advisory

Board Speakers’ BureauSteering


Dr. Jamie B. Conti None ● Guidant● Medtronic● St. Jude Medical

● St. Jude Medical None None None None

Dr. John P.DiMarco

● Guidant● Medtronic● Novartis● St. Jude Medical

● Guidant● Medtronic● Sanofi-Aventis

None ● Guidant None None None

Dr. Gerald V.Naccarellli

● AstraZeneca● Boehringer-Ingelheim● Cardiofocus● GlaxoSmithKline● Guidant● Medtronic● Sanofi-Aventis U.S.● Pharmaceuticals● Proctor & Gamble● Reliant Pharmaceuticals● Wyeth Pharmaceuticals● Zention

● Boehringer-Ingelheim

● Cardiome● Guidant● Medtronic● Sanofi-Aventis● WyethPharmaceuticals


Dr. Cynthia M.Tracy



http://www.acgme.org

http://www.naspexam.org

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380 Loscalzo et al. JACC Vol. 51, No. 3, 2008ACCF COCATS 3 Training Statement: Task Force 7 January 22, 2008:380–3

PPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FORRAINING IN ADULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 6:RAINING IN SPECIALIZED ELECTROPHYSIOLOGY, CARDIAC PACING, AND ARRHYTHMIA MANAGEMENT


Grant

ScientificAdvisoryBoard

Speakers’Bureau

SteeringCommittee

StockHolder Other

Dr. Rick A. Nishimura ● Official–Board of Trustees None None None None None None None

Dr. Stuart A. Winston ● Official–Board ofGovernors


Dr. Anne B. Curtis ● Organizational–HeartRhythm Society

● Biosense● Medtronic● St. JudeMedical

● Webster

● Medtronic None ● Boston Scientific● Medtronic● St. Jude Medical

None None None

Dr. Dwight W. Reynolds ● Organizational–HeartRhythm Society


Dr. Peter R. Kowey ● Content–ElectrophysiologyCommittee


Dr. Richard L. Page ● Content–ElectrophysiologyCommittee


Dr. Claudio D. Schuger ● Content–ElectrophysiologyCommittee

● Stereotaxis ● Guidant● Medtronic

None None None ● St JudeMedical

None


Task Force 7: Training in Cardiovascular Research

Joseph Loscalzo, MD, PHD, FACC, ChairGordon F. Tomaselli, MD, FACC, Douglas E. Vaughan, MD, FACC, Richard A. Walsh, MD, FACC

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ll cardiology training should be performed in institutions inhich the opportunity to participate in research is available.he training site should be one that will provide an atmospheref intellectual inquiry and support of the investigative process.

It is important that every cardiovascular trainee participateirectly in research. Cardiology is a dynamic clinical field inhich the rapid transfer of knowledge from basic and clinical

esearch to clinical care will continue to occur. This pattern willnly accelerate in the future. Cardiovascular research is definedn the broadest terms possible because recent history makes itbundantly clear that advances in the care of patients withardiovascular disease have come from diverse areas of medicalcience. If the clinical cardiologist is to maintain clinical compe-ence and improve clinical knowledge in step with the progress ofhe field, it is crucial to maintain a thorough understanding of theoncepts, methods, and pitfalls of the research process.

Every trainee should have direct involvement in the practicalspects of research, with emphasis on learning of how to reviewublished data, research design, data analysis, and logicaleduction. The research experience plays a unique role in
eveloping the skills in continuing self-education needed by all a
ardiovascular specialists. Trainees contemplating a career innvestigative cardiology bear a special responsibility to prepareffectively to advance understanding in the broad area ofardiovascular science and especially the clinical application ofew knowledge.

eneral Standards

raining Institution

he training institution must have staff and facilities foresearch. Opportunities for research for the trainees shoulde available not only within the clinical cardiovascularivision but also within the basic biomedical science depart-ents of the institution. Availability of expertise in epide-iological methods, outcome evaluation, biostatistics, and

iomedical ethics is essential. Optimally, cardiovascularraining should be performed in a university teachingospital or similar institution. Where this is not feasible, an
ctive ongoing affiliation with a university is essential.

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381JACC Vol. 51, No. 3, 2008 Loscalzo et al.January 22, 2008:380–3 ACCF COCATS 3 Training Statement: Task Force 7

reparation

efore their appointment, individual trainees should haveppropriate preparation in the biological, epidemiological,nd physical sciences basic to medicine. If additional courseork is desirable and appropriate, it should be available, and

rainees should be encouraged to avail themselves of it.

aculty

aculty of the training program must include several membersith proven skill as investigators, demonstrated by publishedriginal research in peer-reviewed journals. The critical mass ofhe faculty requires several cardiovascular investigators, not allf whom need to be clinical cardiologists. At least 1 full-timeaculty member from each training program should haveemonstrated skill as a clinical investigator.

ontent of Training Program

esearch “Tracks”

esearch training will ordinarily take place in 1 of 3 “tracks”:Level 1—Trainees entering the clinical practice of car-

iovascular medicine.Level 2—Trainees planning a commitment to teaching

nd clinical investigation.Level 3—Trainees planning a substantive commitment

o basic or clinically advanced cardiovascular research.

omponents of Research

he trainee should develop skills in at least the following areas:

. literature study, to ascertain the exact state of knowledgebefore undertaking new investigation;

. formulation of hypothesis and specific goals, ensuring thatthe hypothesis is testable, that the goals are appropriate,and that statistical power is achievable;

. development of the research plan and the protocol, includingstudy design, importance of appropriate controls inclinical investigation, and recruitment of subjects, ethi-cal considerations, informed consent and protection ofprivacy, data collection modes, full description of pro-cedures, and institutional approval of human investiga-tion, where appropriate, and writing a research grant;

. data collection, including preparation of routine data forms;

ummary of Training Requirements for Cardiovascular Research

Table 1 Summary of Training Requirements for Cardiovascular


Minimal Numberof Procedures

Co

7 Research 1

2

3 2

. development of analytic methods or procedural skills, asrequired, and particularly the handling of artifacts,missing data, outliers, and statistical inference;

. presentation of results, preferably both oral and written,emphasizing that no investigation is complete until it isreported as a full paper in peer-reviewed journals;

. risk– benefit analysis, regarding both patient (subject) andsocietal risk–benefit; and

. research ethics, recognition of key concepts in the con-duction of responsible research including but not re-stricted to data acquisition/management and protection,conflicts of interest, publication practices, and author-ship and scientific conduct.

linical Investigation

linical investigation must be performed under the supervisionf an experienced investigator and according to approvedrinciples of biomedical ethics and institutional rules foratient protection. It must be recognized that clinical researchs difficult because of the complexity of achieving valid scientificonclusions while working with a diverse population andimultaneously protecting the interests of each patient.

In the case of multicenter clinical trials, participation inhe full range of activities outlined here is required. Thelinician lacking expertise in these areas may be unable tonterpret critical reports that have a direct bearing on his orer practice. New data may be accepted uncritically or

mportant advances recognized tardily. The training pro-ram should provide frequent opportunities for faculty andrainees to review and analyze small- and large-scale clinicalnd basic research reports in depth.

uration of Research Training

or trainees planning careers in the clinical practice ofardiovascular medicine (Level 1), 6 to 12 months (and inany instances up to 18 to 24 months) should be devoted tospecific project or projects. This research can be under-

aken concurrently with other nonlaboratory clinical train-ng and may not require a dedicated block of time. For thoselanning a substantive commitment to teaching and clinicalnvestigation (Level 2), a minimum of 18 to 24 monthshould be devoted to clinical research. For those planning aubstantive commitment to advanced clinical researchLevel 3), a minimum of 2 full years should be devoted toentored clinical research of which at least 1 year could

arch

ative Durationing (Months)

Minimal CumulativeNumber of Cases Comments

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382 Loscalzo et al. JACC Vol. 51, No. 3, 2008ACCF COCATS 3 Training Statement: Task Force 7 January 22, 2008:380–3

ccur during fellowship training. Training requirements forevels 1, 2, and 3 are summarized in Table 1.

asic Research

or those planning a career in basic research (Level 3), 2 tofull-time years working directly with an experienced

entor are now needed in most cases. Such trainingonstitutes only the beginning of the education of anndependent cardiovascular investigator.

dvanced Training for Trainees Consideringntering Investigative Cardiology

rainees preparing for careers in research (Level 3) need anxtensive foundation in scientific investigation. Some traineesill have obtained thorough research preparation in combinedD/PhD programs, but may lack the specific skills or tools

hat are appropriate to their personal research goals. These maye obtained in a post-doctoral research fellowship experiencer as part of the cardiology traineeship. For full time training,he trainee should join the group or laboratory of a productivend active scientist, or clinical investigator (with an MD orhD degree), in any qualified institution (not necessarily wheree or she is obtaining direct training).Trainees who aim for a career in investigative cardiology but

ho have not had the opportunity to obtain a PhD degree orquivalent training at the time they begin their cardiologyraineeships should have the opportunity, and be encouraged,o obtain the necessary basic scientific analytic course work andaboratory or clinical research experience necessary for a productiveesearch career. Current models of this type of training include themerican Heart Association Clinician ScientistAward and theational Heart, Lung, and Blood Institute program for K08

Mentored Clinical Scientist Development), K23 (Mentoredatient-Oriented Research Career Development), or K99/R00

National Institutes of Health Pathway to Independence)wards.

eaching and Manuscript Review

t is important that the trainee be introduced to the basicrinciples and skills of education because almost all aca-emic cardiologists devote a significant amount of time toeaching. It is highly desirable to provide opportunities forhe critical review and analysis of manuscripts that haveeen published or are being considered for publication.

ompensation

ompensation during the often prolonged period of re-earch training should be sufficient to allow a full-timeommitment to this training. Within this context, Congressecently passed the Clinical Research Enhancement Act,hich mandates debt repayment for MDs or MD/PhDs

ngaging in research training. c

valuation

valuation by the Training Director,esearch Sponsor, or Both

valuation of a trainee’s progress and skills should beubjective as well as objective, based on agreed-upon criteriand standards, and should be ongoing throughout theraining period. The process and documentation currentlyequired for admittance to the American Board of Internal

edicine Subspecialty Board Examination serves as a modelor such evaluation. Each trainee’s competence and under-tanding should be documented at the completion of training.

ublication

rainees should be encouraged to publish substantive results,hereby providing an evaluation by peer-reviewed journals.

lexibility

t must be appreciated that the education of future investigativeardiologists is a continuing process and that they usuallyemain in an educational institution where they are immersedn clinical cardiology. They often have unique demands that

ay require altering the sequence and exposure of clinicalraining, consistent with their previous clinical experience.herefore, the program director should be afforded flexibility

n the assignment of responsibilities for the years of traininghile guaranteeing full clinical competence.

ummary

t is vital to the future intellectual health of cardiovascularedicine and the welfare of patients with cardiovascular

isease that all future cardiologists be familiar with therinciples and tools of research. Training in research re-uires the intense involvement of productive and establishednvestigators. Those trainees preparing for a career innvestigative cardiology require a carefully developed butexible educational plan that will permit them to beuccessful in their research careers over an extended period.

his is a revision of the 2002 document that was written byobert Roberts, MD, FACC—Chair; R. Wayne Alexander,D, PhD, FACC; Joseph Loscalzo, MD, FACC; and R.

anders Williams, MD, FACC.

doi:10.1016/j.jacc.2007.11.015


ardiovascular research y investigative cardiology.

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383JACC Vol. 51, No. 3, 2008 Young et al.January 22, 2008:383–9 ACCF COCATS 3 Training Statement: Task Force 8

PPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FOR TRAINING INDULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 7: TRAINING INARDIOVASCULAR RESEARCH



BoardSpeakers’

BureauSteering


Dr. Joseph Loscalzo None None None None None None None

Dr. Gordon F. Tomaselli ● Guidant● Pfizer

None None ● Guidant● Medtronic

None None None

Dr. Douglas E. Vaughan None None None None None None None

Dr. Richard A. Walsh None None None None None None None


PPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FORRAINING IN ADULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 7:RAINING IN CARDIOVASCULAR RESEARCH



BoardSpeakers’

BureauSteering


Dr. Rick A. Nishimura ● Official–Boardof Trustees


Dr. Chittur A. Sivaram ● Official–Boardof Governors

● 3F Therapeutics None None None None None None


Task Force 8: Training in Heart FailureEndorsed by the Heart Failure Society of America

James B. Young, MD, FACC, ChairWilliam T. Abraham, MD, FACC, Robert C. Bourge, MD, FACC,Marvin A. Konstam, MD, FACC (Heart Failure Society of America Representative),Lynne Warner Stevenson, MD, FACC

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ecognition, evaluation, and treatment of heart failure aressential components of clinical cardiology practice. In order tochieve competency in this subject, 3 distinct training levels areefined, with curriculum outlined, in this section (1–4). Allardiology fellowship training programs will provide, at theeast, a Level 1 curriculum in heart failure. More specifically,evel 1 training will provide an understanding of the depth andreadth of the heart failure syndrome, as well as nuances ofherapy including the important topic of heart failure preven-ion. Level 2 training will be for those individuals who wish toroaden their experience with heart failure patients, particularlyhose with more advanced and challenging syndromes. Thisurriculum can, in particular, provide the opportunity to learn
o manage devices (other than circulatory support systems) p
mplanted for heart failure therapy and arrhythmia or hemo-ynamic monitoring. Level 2 will also emphasize more detailedemodynamic assessment of these patients. Level 3 trainingill be for those who anticipate focusing the majority of their

ubsequent clinical or research activities on the syndrome ofeart failure with a curriculum requiring an additional 12onths of fellowship training above and beyond that required

or cardiology specialization board examination. It is recog-ized that not all cardiology fellowship training programs wille capable of providing the most intense Level 3 trainingurriculum. Level 3 training will offer a range of programs thatight, for example, include heart transplantation, mechanical

irculatory support devices, and advanced heart failure electro-
hysiology, although not necessarily all of these.

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This training scheme recognizes the fact that today, theres an ever-increasing number of treatments and interven-ions that improve outcomes and significantly alter theourse of the heart failure syndrome. These treatments haveenerally increased the complexity of care, and it hasecome clear that there is a need for additional and specialxpertise to best effect and improve utilization of many heartailure evaluation and treatment strategies. It is also recog-ized that a significant portion of initial and follow-up careor heart failure patients will continue to be under theurview of general cardiologists and primary care clinicians;owever, the more advanced Level 2 and 3 programs willrovide increased sophistication and more skills necessary toanage advanced heart failure syndromes.It is important to point out that Level 3 training and

ubsequent competency does not necessarily require theame level of experience with cardiac transplantation re-uired for qualification as a heart transplant physician undernited Network of Organ Sharing (UNOS) criteria (5). It

s anticipated that a much broader group of individuals wille interested in establishing competency in advanced heartailure cardiology than will be directly managing patientsndergoing cardiac transplantation. Nonetheless, many pro-rams will offer an experience within the Level 3 curriculumhat can establish heart transplant physician competencyccording to UNOS criteria. Furthermore, in developingevel 3 heart failure training criteria there was an expecta-

ion that, at some point in time, a secondary subspecialty ofdvanced heart failure management would likely evolve.lthough timing for such a proposal moving forward isnclear, it is desirable to anticipate a curriculum that wouldualify individuals for this distinction. The cumulativeuration for training in heart failure will then be 1 monthor Level 1 taken as part of 9 months of required nonlabo-atory clinical practice rotation, and it is assumed thatrainees will obtain additional training in heart failurereventive cardiovascular medicine beyond the 1-monthore training as part of the experience during other clinicalonths such as consult services and the coronary care unit.evel 2 will require 6 months of dedicated rotations during

he 36-month clinical cardiology training period, and Level

ummary of Training Requirements for Heart Failure

Table 1 Summary of Training Requirements for Heart Failure

Task Force Area LevelMinimal Numberof Procedures

Cuof

8 Heart failure andtransplantation

123

will require 12 months beyond the basic 36-month coreraining program (Table 1).

raining in Heart Failure

evel 1: General Training

he fundamental concepts of heart failure’s pathophysiol-gy and its treatment should be understood by all trainees inardiovascular medicine as part of the core Level 1 trainingurriculum. Training in the clinical management of heartailure should include supervised experience in both inpa-ient and outpatient settings, and will expose the trainee to

broad spectrum of underlying causes of heart failure.rainees should be well acquainted with the nuances of

herapy for heart failure that are specific to different etiol-gies and should be well informed about the pharmacologyf standard cardiovascular drugs used to treat heart failure.rainees should be equally aware of the treatment strategies

or patients with both chronic disease and acute exacerba-ions. An important element of the curriculum will be torain clinicians to appropriately refer heart failure patientsor pacemaker, defibrillator, and percutaneous cardiovas-ular interventions; surgical procedures (including inser-ion of mechanical circulatory support devices); andardiac transplantation.

eart Failure Level 1 Training Curriculum:ore Curriculum

he heart failure training Level 1 curriculum must includehe following to ensure that trainees have formal instructionnd clinical experience in the evaluation and management ofatients from each of the following categories (it is antici-ated that training programs will provide that experience increative combination of emergency department, inpatient,

nd outpatient settings):

1. Neurohormonal activation and its importance in thedevelopment of cardiovascular pathology and the syn-drome of heart failure

2. The concept and significance of ventricular remodeling

ive Durationng (Months)


1*†62

*Can be taken as part of 9 monthsof required nonlaboratoryclinical practice rotation.

†It is assumed that trainees willobtain additional training inheart failure and preventivecardiovascular medicine beyondthe 1-month core training aspart of the experience duringother clinical months, such asconsult services and coronary

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3. Cardiomyocyte biology as it applies to heart failure,focusing on the underlying abnormalities in the myo-cytes of the failing heart

4. Patients with heart failure with dilated or nondilatedventricles

5. Patients with new onset heart failure6. Patients with acute decompensation of chronic heart

failure7. Geriatric patients with heart failure8. Patients with heart failure associated with cancer

chemotherapy9. Patients with heart failure who are pregnant or recently

post-partum0. Patients with heart failure and congenital heart disease1. Patients with heart failure representing diverse ethnic

groups, with attention to specific diagnostic and ther-apeutic issues within these groups

2. Men and women with heart failure3. Patients with heart failure before and after cardiac and

noncardiac surgery4. Patients with inherited forms of cardiomyopathy5. Patients with hypertrophic cardiomyopathy6. Patients with infiltrative and inflammatory cardiomy-

opathies7. Patients with heart failure and atrial and ventricular

arrhythmias8. Patients with heart failure due to pulmonary pathology

hese scenarios represent a broad and basic spectrum oflinical heart failure, and it is anticipated that most cardi-logy fellowship training programs will have the ability toeet this criteria. However, it is accepted that for some

pecific situations (i.e., heart failure patients with congenitaleart disease or pregnancy-related heart failure states) clin-

cal material may not be readily available. In those specificituations didactic training would be an acceptable substi-ute for formal inpatient or outpatient clinical exposure.

VALUATION OF HEART FAILURE

ith respect to evaluation of patients with heart failure,rainees must have formal instruction and clinical experiencen the following specific areas:

. Clinical trial evidence with respect to the diagnosis ofheart failure

. Clinical features (history and physical exam) in all formsand etiologies of heart failure

. Application and interpretation of approaches to evalu-ating symptom severity, functional capacity, and health-related quality of life in patients with heart failure

. Exercise physiology, including the role and interpreta-tion of maximal and submaximal exercise testing andcardiopulmonary exercise testing

. Indications for, and interpretation of, results of alldiagnostic tests and modalities relevant to evaluationand management of patients with, or suspected of
having, heart failure or cardiac dysfunction; in particu- s
lar, the impact of such testing on the management ofthese patients

. Evaluation of the patient presenting with new onsetheart failure and with acute exacerbation of chronicheart failure, including differential diagnosis, specificetiologies, and exacerbating factors

. Role and interpretation of hemodynamic monitoringand its use in managing patients with new onset heartfailure or exacerbation of chronic heart failure

. Indications for referral of patients for mechanical circu-latory support and cardiac transplantation

. Indications for and evaluation of patients for implantationof left ventricular assist devices as destination therapy

EART FAILURE MANAGEMENT

ith respect to managing patients with heart failure,ellows must have formal instruction and clinical experiencen the following specific areas:

. Clinical trial evidence relevant to the management ofheart failure

. Indication, prescription, pharmacology, adverse effects,and appropriate monitoring of all classes of drugsrelevant to the heart failure patient, including thoseknown to benefit patients with heart failure, thosesuspected of benefiting patients with heart failure, andthose known or suspected of adversely affecting patientswith heart failure, in both the acute and chronic setting

. Indication and prescription of nonpharmacologic/non-device treatment modalities in heart failure, includingdiet and exercise

. Indications for cardiac transplant

. Evidence for differences in appropriate managementand response to therapy based on differences in etiology,cardiac structure and function, age, gender, ethnicbackground, and comorbidity

. Impact of psychosocial factors on the manifestations,expression, and management of heart failure

REVENTION OF HEART FAILURE

ith respect to heart failure prevention, trainees must haveormal instruction regarding conditions and factors knowno predispose to, or exacerbate, heart failure syndromes.pecifically, a curriculum that emphasizes comprehensiveardiovascular risk factor modification more generally (e.g.,revention of atherosclerosis), and with respect to the heartailure syndrome, specifically, will be required.

evel 2: Intensified Experience in Heart Failure

rainees who wish to have more training in advanced heartailure should be enrolled in programs that include specificutpatient clinics and inpatient services designed for pa-ients requiring therapy for heart failure, as described forevel 1. However, such programs, in addition to ensuring aurriculum that satisfies the specifics of Level 1 training,lso must offer a greater intensity and exposure to a broader
pectrum of heart failure therapy modalities. Level 2 train-

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ng can be accomplished within the scope of the 3 years ofnitial cardiology training. Trainees in a Level 2 curriculumhould actively participate in didactic activities relating morepecifically to heart failure, including research conferences,eminars, and journal clubs with the heart failure syndromeheir primary focus.

eart Failure Level 2 Training Curriculum:dditional Elements

n addition to satisfying all Level 1 curriculum requirementsutlined in the previous text, trainees will be required toave additional experiences in the interpretation of ad-anced heart failure patient hemodynamic data during bothcute and chronic interventions and during the assessmentf prognosis. One example of an additional curriculum athe Level 2 stage would be trainee rotations throughutpatient electrophysiology clinics to focus on the interro-ation, evaluation, and programming of implantable elec-rophysiologic devices used to treat and manage heart failureatients.

evel 3: Advanced Training in Heart Failure

n addition to demonstrating proficiency in the specifiednd required Level 1 and elective Level 2 curriculum,dvanced Level 3 training requires further demonstration ofroficiency in additional arenas that include exposure toatients with more advanced or challenging heart failureonditions. Level 3 curriculum training will require andditional 12 months of training above and beyond thatequired for basic cardiology fellowship. A variety of curric-lums can be created to satisfy Level 3 training require-ents, but at the core of all will be the following required

omponents:

asic Mechanisms of Heart Failure

n addition to the curriculum specified in Level 1 training,ellows should have formal instruction and attain under-tanding of the following to be considered a more advancedevel 3 clinician:

. More advanced training in cardiomyocyte and extracel-lular matrix biology, including calcium dysregulation;mechanisms of arrhythmia generation; beta-receptorabnormalities; mechanisms of apoptosis; metabolic ab-normalities of the failing myocyte; and the roles ofmatrix remodeling in the progression of heart failure

. Genetics, including a) common mutations leading tohypertrophic and dilated cardiomyopathies and b) anunderstanding of genetic polymorphisms related to myo-cardial disease and to targeted heart failure treatment

eart Failure Disease Management

o qualify for heart failure Level 3 training, fellows mustave a more in-depth and formal instruction in heart failureisease management, have clinical experience, and demon-
trate proficiency as part of a multidisciplinary care team in
clinical setting dedicated to heart failure. Managingultidisciplinary heart failure clinics and home-based care

ervices is envisioned as a primary role of the advanced heartailure cardiologist, who should achieve proficiency in:

1. Specific behavioral strategies to enhance adherence to aheart failure therapeutic regimen

2. Supervision of home-based titration and monitoring ofdiuretics and neurohormonal antagonists with surveil-lance for renal dysfunction and electrolyte disturbances

3. The comprehensive education and counseling needs ofheart failure patients and family members

4. Education and counseling strategies5. The importance of nonpharmacologic, as well as phar-

macologic, management6. End-of-life care, including care options and participa-

tion in a multidisciplinary palliative care team7. Assessment for quality of life, psychological problems

(e.g., anxiety and depression), cognitive impairment,literacy problems, social isolation, financial problems,and other barriers to adherence and risk factors forrehospitalization

8. Management of heart failure with multiple comorbidities9. Collaboration with nurses, dietitians, social workers,

pharmacists, and other health professionals in themanagement of patients to stabilize or improve healthstatus and prevent hospitalization

0. Transitional care principles, that is, facilitating commu-nication between caregivers and physician extenders

linical Research

he heart failure Level 3 training assumes a more in-depthnderstanding of research in the heart failure field. Traineest this level, therefore, should have a thorough knowledgend understanding of the principles of clinical research,ufficient to fully evaluate the validity and relevance oflinical research findings. This understanding should comerom both didactic instruction and participation in clinicalesearch projects as a trainee. Level 3 curriculum shouldnsure that training includes insight into:

. Principles of informed consent and the ethical conductof clinical research

. Basic statistical methodologies, including sample sizeestimation and evaluation of significance

. An understanding of the advantages and disadvantagesof various clinical trial designs

. Understanding of the various end points employed inclinical investigation in heart failure, including thoseemployed for the measurement of clinical outcomes,functional status, and symptoms, as well as use ofsurrogate and composite end points

. An understanding of the impact and interpretation of
testing multiple end points simultaneously

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xpanded Heart Failure Populations

dvanced training further requires demonstration of profi-iency in the management of additional more challengingohorts of heart failure patients (with the specified levels ofxposure listed in parentheses if meeting UNOS criteria as aheart transplant physician” is desired). It is recognized that notll programs offering Level 3 training will have heart transplantr mechanical circulatory support programs that will satisfyNOS criteria for heart transplant physician designation.

. Patients requiring end-of-life hospice-based care

. Patients with hemodynamic compromise severe enoughto warrant chronic inotropic drug infusion support

. Patients with heart failure and noncardiac organ trans-plants

. Patients who are being evaluated for cardiac transplantor mechanical assist devices (at least 30)

. Patients who have undergone cardiac transplant (at least30, of whom at least 5 are seen during initial transplanthospitalization)

. Patients with heart failure on mechanical circulatoryassist devices (at least 5, of whom at least 2 are beingmanaged during perioperative hospitalization)

. Patients with heart failure being evaluated for implant-able cardioverter-defibrillators (ICDs) (at least 50) andpatients with heart failure being evaluated for cardiacresynchronization therapy (CRT) (at least 50)

. Device interrogation and interpretation in patients withimplanted ICD or ICD-CRT devices (at least 100)

dditional Training Within a Level 3 Curriculum

or select individuals trained in advanced heart failureardiology, it may be desirable to achieve additional trainingnd credentialing. Examples of this include areas such asardiac transplantation and mechanical circulatory supportevices (as previously discussed), electrophysiologic device

mplants, and more sophisticated cardiovascular imaging. Its recognized that training programs may choose to incor-orate opportunities for achieving competencies in thesereas, either concurrently or consecutively with the 12-onth Level 3 requirements, which are consistent with

hose training requirements specified elsewhere in thisocument. Further, as these fields evolve, combinationrograms may be established that are specifically designed to
rovide for joint competencies in these and other areas. y
ummary

raining in heart failure can be segregated into 3 distinctnd ascending or tiered levels of intensity. Level 1 representshe basic training and competency that every cardiologyellowship trainee must experience and demonstrate. Level 2raining represents a significant intensification of training,o that a trainee can subsequently focus some of his or herubsequent clinical activities on heart failure patients oresearch. Level 3 training offers competencies required forndividuals specializing in advanced heart failure cardiology.uch competency includes advanced training in such areass cardiac transplantation, ventricular assist devices, andeart failure disease management. Many programs will offerxposure sufficient to qualify the trainee for the UNOSesignation of heart transplant physician in the Level 3urriculum. Within this rapidly evolving field, in which newiagnostic and treatment modalities are emerging, overime, additional competencies may be warranted to supple-ent present training and competency standards.

doi:10.1016/j.jacc.2007.11.016


. Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005guideline update for the diagnosis and management of chronic heartfailure in the adult: summary article: a report of the AmericanCollege of Cardiology/American Heart Association Task Force onPractice Guidelines (Writing Committee to Update the 2001 Guide-lines for the Evaluation and Management of Heart Failure). J AmColl Cardiol 2005;46:1116 – 43.

. Swedberg K, Cleland J, Dargie H, et al. Task Force for theDiagnosis and Treatment of Chronic Heart Failure of the EuropeanSociety of Cardiology. Guidelines for the diagnosis and treatment ofchronic heart failure: executive summary (update 2005). Eur Heart J2005;26:1115– 40.

. Liu P, Arnold JM, Belenkie I, et al., Canadian Cardiovascular Society.The 2002/3 Canadian Cardiovascular Society consensus guidelineupdate for the diagnosis and management of heart failure. Can J Cardiol2003;19:347–56.

. HFSA 2006 comprehensive heart failure practice guideline. J Card Fail2006;12:e1–122.

. UNOS Designated Transplant Program Criteria Bylaw, Appendix B,Attachment I, Section VII. (Transplant Surgeon and Physician) March23, 2007.

ey Words: ACCF Training Statement y COCATS 3 y heart failure
heart transplantation.

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PPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FOR TRAINING INDULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 8: TRAINING INEART FAILURE


BoardSpeakers’

BureauSteering


Dr. William T.Abraham

● Amgen● AstraZeneca● Boehringer-Ingelheim● CHF Solutions● GlaxoSmithKline● Guidant● Medtronic● Merck● Pfizer● ResMed Respironics● Scios● St. Jude Medical

● Amgen● Biotronik● CHF Solutions● GlaxoSmithKline● Heart FailureSociety ofAmerica

● NationalInstitutes ofHealth

● MarylandResearchInstitute

● Medtronic● Myogen● Orqis Medical● Otsuka● Paracor● Scios

● CardioKine● CardioKinetix● CHF Solutions● Department of Veterans AffairsCoop Studies Program

● National Institutes of Health● Savacor● Editorial Board Involvement:Congestive Heart FailureCurrent Cardiology ReviewsCurrent Heart Failure ReportsExpert Review of

Cardiovascular TherapyJournal Watch CardiologyPACE-Pacing and Clinical

ElectrophysiologyThe American Heart Hospital

JournalThe Journal of Heart Failure

None None None HonorariumRecipient—

● AstraZeneca● Boehringer-Ingelheim

● GlaxoSmithKline● Guidant● Medtronic● Merck● Pfizer● ResMedRespironics

● Scios● St. JudeMedical

Dr. Robert C.Bourge

● Medtronic● Orquis● Remon Technologies● United Therapeutics● Vasogen

● Medtronic● Orquis● Scios● UnitedTherapeutics

● Vasogen

● Medtronic● Orquis● United Therapeutics● Remon Technologies● Vasogen

None ● Medtronic● Orquis● Scios● Vasogen

None ● Stock options:RemonTechnologies

Dr. Marvin A.Konstam

● GlaxoSmithKline● Merck● Otsuka● Pfizer

● GlaxoSmithKline● Merck● Otsuka● Pfizer

None ● Medtronic● Pfizer

None ● OrqisMedical

None

Dr. LynneWarnerStevenson

● Medtronic● Scion


Dr. James B.Young

● Amgen● AstraZeneca● Boehringer-Ingelheim● GlaxoSmithKline● Guidant● Medtronic● Protemix● Vasogen

● Amgen● AstraZeneca● Boehringer-Ingelheim

● GlaxoSmithKline● Guidant● Medtronic● Vasogen

None None ● Amgen● AstraZeneca● Boehringer-Ingelheim

● GlaxoSmithKline● Medtronic● Protemix● Vasogen

None None


ATT

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389JACC Vol. 51, No. 3, 2008 Child et al.January 22, 2008:389–93 ACCF COCATS 3 Training Statement: Task Force 9

PPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FORRAINING IN ADULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 8:RAINING IN HEART FAILURE



BoardSpeakers’

BureauSteering


Dr. Rick A. Nishimura ● Official–Board ofTrustees


Dr. Barry Greenberg ● Organizational–HeartFailure Society ofAmerica

● AstraZeneca● Boston Scientific● GlaxoSmithKline● Merck● NitroMed● Novartis● Scios


Dr. James A. Hill ● Content–ElectrophysiologyCommittee


Dr. Maryl Johnson ● Content–Heart FailureCommittee

● Astellas● CareMark

None None None None None ● Defensewitness-2005

Dr. Mitchell T.Saltzberg

● Content–Heart FailureCommittee

● CHF Solutions● Medtronic

None None ● Guidant● Medtronic● Scios

None None ● Institutional-CHFSolutions

● Guidant● Medtronic● Scios

Dr. Richard J. Shemin ● Content–Heart FailureCommittee

● EdwardsLifesciences

● St. Jude Medical



Task Force 9: Training in the Care of Adult PatientsWith Congenital Heart Disease

John S. Child, MD, FACC, ChairMichael D. Freed, MD, FACC, Constantine Mavroudis, MD, FACC,Douglas S. Moodie, MD, FACC, Amy L. Tucker, MD, FACC

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emarkable advances in surgical and catheter managementf congenital heart disease (CHD) over the last half centuryave allowed greater than 85% of children with CHD tourvive to adulthood (1). It is estimated that there are nowver 1 million adult survivors with CHD in North Americalone; thus, there are now more adults than children withHD in the United States, and the number appears to be

rowing by about 5% per year (2). Adults with CHD havepecial health care needs and often present complex com-inations of problems that are generally unrecognized byhose in a traditional internal medicine–based cardiology
raining program (3). Medical cardiologists are experts in n
he care of adult-acquired diseases that affect the heart andirculation, but currently most have little or no training inHD, particularly in complex disorders. Adult CHD and

linical experiences for cardiology fellows vary widely (4).any adults with CHD continue to be cared for by

ediatric cardiologists because the numbers of medicalardiologists specializing in this complicated field are fewnd insufficient (5,6). This report suggests an approach toore systematic training of medical cardiologists in the

ecognition and care of adults with CHD based uponrevious Bethesda Conference descriptions of workforce
eeds and educational requirements (6).

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390 Child et al. JACC Vol. 51, No. 3, 2008ACCF COCATS 3 Training Statement: Task Force 9 January 22, 2008:389–93

evels of Training

e differentiate 3 levels of training and expected expertisen the care of adult patients with CHD:

Level 1 training represents the level of knowledgeppropriate for all trainees in medical cardiology and indi-ates the knowledge content that each graduate of such arogram should acquire (6). This level of training shouldllow for sufficient knowledge to manage simple adult CHDnd to recognize the moderate or complex diseases andbtain the appropriate consultations or referrals for properare. This level of knowledge should be tested in theubspecialty Certification Examination in Cardiovasculariseases and will provide the graduate with sufficient

xpertise to recognize and evaluate common congenitaleart disorders in adults. This expertise should includenowledge of the outcomes, residua, sequelae, and compli-ations of medical management, of invasive catheter-basedherapy, and of surgical palliation, correction, or repair.pecific disease categories of commonly treated disordershould be emphasized (see Post-operative residua/sequelae,able 1). However, for trainees with Level 1 expertise,

onsultation with a pediatric cardiologist or Level 2- orevel 3-trained adult CHD cardiologist is advisable whenajor management decisions are made concerning patientsith moderately to severely complex cardiac disease.Level 2 training represents additional training for fellows

ho plan to care for adult patients with CHD so that theyay acquire expertise in the clinical evaluation and man-

gement of such patients. Some exposure to pediatricardiology is recommended. Level 2 training generallyequires 1 year of training in adult CHD: either a 1-yearormal program at a regional or tertiary care adult CHDenter or cumulative experience of 12 months throughepetitive rotations or electives as a cardiology fellow withxperienced adult CHD cardiologists (6). Some consider-

evel 1 Training in Congenital Heart Diseasen Adults

Table 1 Level 1 Training in Congenital Heart Diseasein Adults

Core Curriculum Knowledge Areas

Basic science Basic embryology, anatomy, pathology,physiology, genetics

Natural history/management

Clinical recognition and management ofpatients with common defects presenting inadulthood to include genetic counseling,care of pregnancy, and management duringnoncardiac surgery

Post-operative residua/sequelae

Includes but is not limited to specific diagnosessuch as tetralogy of Fallot, atrial septaldefects, ventricular septal defects,transposition of the great arteries (e.g., atrialbaffle and arterial switch operations), singleventricle (e.g., Fontan operation), andventricular outflow tract lesions (all levels ofaortic and pulmonic stenosis andcoarctation of the aorta)

Other Indications for and access to local or regional

iexpert consultation

tion can be given to those months spent learning CHD ineneral, be it in pediatric, adolescent, or adult CHDrograms. This training should prepare the individual to beell-equipped for the routine care of even moderate to

omplex adult CHD and to recognize when more advancedonsultation or referral is advisable.

Level 3 training represents the level of knowledgeeeded by those graduates who wish to make a clinical andcademic/research commitment to this field and not onlyecome competent in the care of the entire spectrum ofdult patients with CHD but also participate in teachingnd research of adult CHD (6). Some exposure to pediatricardiology is recommended. Level 3 trainees generallyequire 2 years of training. These 24 months may either beontiguous or cumulative experience, and some recognitionan be given to overall experience in CHD, be it pediatric,dolescent, or adult (e.g., prior pediatric cardiology trainingr rotations). It is probably preferable that at least 12onths of this training be contiguous in order to obtain

oth the maximum clinical continuity of care as well asufficient time to dedicate to clinical research in the field.uch Level 3 training would be sufficient to clinicallyanage the most complex adult CHD in a regional or

ertiary center, to pursue an academic career, to train othersn the field, or to direct an adult CHD center program.

evel 1: Basic Training for All Medicalardiology Fellows

ll medical cardiology trainees should be exposed to a coref information regarding adults with CHD. The goal ofevel 1 training is for all graduates to be able to recognizend evaluate common, simple congenital heart lesions andhe sequelae of the more commonly repaired congenitaleart defects. These graduates should always consider con-ultation and collaborative patient management with a Level- or 3-trained specialist or pediatric cardiologist whenajor management decisions are made for adults withHD and for periodic discussions of ongoing care.We suggest that at least 6 h of formal lectures within the

ore curriculum of the training program be devoted to CHDn adults. Table 1 indicates the content suggested for these

h, covering key basic and clinical aspects of these disor-ers. A proposed curriculum is as follows: Hour 1 � basicmbryology, anatomy, pathology, and physiology andnown genetics of common lesions; Hour 2 � clinicaliagnosis (history, exam, electrocardiogram, x-ray) andanagement of at least 6 common lesions expected to be

ncountered in adults, operated or not; Hour 3 � specificssues relevant to cyanotic CHD and Eisenmenger syn-rome; Hour 4 � explanation of methods and outcomes oft least 6 usual surgical and catheter palliative and reparativeechniques for CHD; Hour 5 � common echocardio-raphic features in operated and unoperated adult CHD;nd Hour 6 � various topics which could include manage-ent during pregnancy, endocarditis prophylaxis, counsel-

ng on genetics and contraception, employment, and exer-

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391JACC Vol. 51, No. 3, 2008 Child et al.January 22, 2008:389–93 ACCF COCATS 3 Training Statement: Task Force 9

ise. Within those 6 h of core curriculum, the traineeshould be taught about the major outpatient managementssues in adult CHD and when to consult or refer for morepecialized advice. Current available modes of supplement-ng this education include readily available American Col-ege of Cardiology educational products (adult CHD sec-ion of the Adult Clinical Cardiology Self-Assessmentrogram and the Echocardiography Self-Assessment Pro-ram) or Web-based sites specific to CHD.

In addition to the didactic material in the core curricu-um, trainees ideally should be exposed to adult patientsith CHD on a regular basis. This could be done in the

ontext of ongoing weekly case conferences usually alreadyresent in the medical cardiology training program. Forxample, at least 1 of the patients discussed in case confer-nces each month could be an adult with CHD. In addition,rainees are encouraged to become involved in an ongoingHD outpatient clinic, to see older children or adolescentsith a pediatric cardiology colleague, or both. If the trainingrogram does not have expertise in CHD or have access toHD locally, partnering with an expert regional adultHD facility for an elective rotation of 1 to 4 weeks totalay be a valuable supplement.Trainees should be exposed to the evaluation of CHD

ith various diagnostic modalities during usual clinicalotations (electrocardiography, electrophysiology, transtho-acic and transesophageal echocardiography, nuclear cardi-logy, and the cardiac catheterization laboratory [includingnvasive transcatheter techniques]). Exposure to other ad-anced imaging techniques now commonly utilized inHD (e.g., magnetic resonance imaging [MRI] and com-uted tomography [CT]) is highly desirable. Didactic ma-erial for these rotations should include materials on diag-osis and management of the adult with CHD.

evel 2: Special Expertise in Adults Withongenital Heart Disease

t least 1 year of concentrated exposure is generally neces-ary for those trainees who have little or only basic priornowledge of CHD and who wish to care independently fordult CHD patients. Table 2 indicates the knowledge areashat should be covered during this year’s period.

In addition to didactic materials, the training shouldnclude the following activities and aims:

. Participation in a regular (preferably one that meetsmore than once a week) outpatient clinic organized forthe care of adults with CHD. The Level 2 traineeshould be involved with the care of a minimum of 10patients per week.

. Participation in formal rotations in pediatric cardiologyfor either a total block of or cumulative equivalent of 1to 2 months, including exposure to neonates and chil-dren with CHD via conferences, outpatient clinics,diagnostic laboratories (e.g., echocardiography, cathe-
terization laboratory, and so on), and inpatient services s
including consultations and exposure to children withpost-operative CHD in the intensive care unit. Giventhat such fellows will not likely be experienced in thecritical care of pediatric patients, all inpatient participa-tion should be observed and supervised by experiencedpediatric cardiologists.

. Acquisition of familiarity with the range of diagnosticand therapeutic methods, including direct experience inechocardiography, cardiac catheterization, and advancedimaging techniques (MRI and CT), and understandingof the applications of catheter-based techniques both forelectrophysiologic mapping and arrhythmia ablationand for anatomic-hemodynamic intervention.

. Participation in the perioperative care of patients withCHD (preferably in adults), including direct observa-tion of surgical repair.

. Engagement in the perioperative care of in-hospitalpatients with CHD with both cardiac and noncardiacmedical and surgical issues.

rogram Requirements

wo basic requirements are indicated for a program to trainffectively at Level 2: 1) the presence of associated formalrograms in pediatric cardiology and cardiovascular surgerynd 2) at least 1 faculty member with a career commitmento the care of adult patients with CHD (this faculty member

evel 2 Training in Congenital Heart Diseasen Adults

Table 2 Level 2 Training in Congenital Heart Diseasein Adults

Anatomy, physiology, clinical presentation, and natural history of specific lesions

Diagnostic methods

Physical examination

Electrocardiography

Significance of arrhythmias/electrophysiologic testing

Chest roentgenogram

Echocardiography, both transthoracic and transesophageal

Catheterization/angiography

Radionuclide angiography

Other advanced imaging methods; specifically CMR/CT

Therapeutic methods

Pharmacologic management

Surgical procedures

Catheter interventional procedures

Residua and sequelae of interventions (surgical and catheter)

Introduction to appropriate outpatient management

Reproduction issues

Counseling for pregnancy and management during pregnancy and delivery

Contraception

Evaluation for noncardiac surgery

Palliative care (e.g., management of pulmonary vascular obstructive disease)

Athletic and other activity counseling

Employment counseling and socioeconomic issues

Insurability

Psychosocial issues

T � computed tomography; CMR � cardiovascular magnetic resonance.

hould have achieved by either combined lifelong experience

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392 Child et al. JACC Vol. 51, No. 3, 2008ACCF COCATS 3 Training Statement: Task Force 9 January 22, 2008:389–93

f, or have been specifically trained in, the skills equivalento Level 3 training).

evel 3: Advanced Expertise in Adults Withongenital Heart Disease

o obtain a comprehensive understanding of all aspects ofHD, a 2-year program is recommended with continuedarticipation in clinical practice relating to CHD. In addi-ion to the aforementioned guidelines for Level 2 training,his training should include active participation in clinicalnd/or laboratory research in conjunction with clinicalctivities and direct participation in at least 40 diagnosticardiac catheterization procedures in CHD, with traineesemonstrating a comprehensive understanding of the entireemodynamic spectrum of anatomic abnormalities inHD. Finally, trainees should interpret at least 300 trans-

horacic echocardiograms and 50 transesophageal echocar-iographic examinations and have the ability to indepen-ently interpret such studies in a wide range of CHD (Table). The advanced trainee should also be trained in thenterpretation of advanced imaging techniques (i.e., MRInd/or CT and angiography in CHD.

Because relatively few centers in the United States havemassed a sufficient number of adult CHD patients whoave been followed up in an organized manner, regional-

zation of training in the care of the complex CHD patients necessary (6).

rainee Evaluation and Documentation ofore Competence

or Level 1 training in CHD, the global Cardiologyellowship Program Director shall: 1) either directly, or vian adult CHD faculty designee, attest to the clinicalompetence of each cardiology fellow; 2) administer a coreompetence written and/or oral exam at the finish or

ummary of Training Requirements for Care of Adult Patients With

Table 3 Summary of Training Requirements for Care of Adult P


Minimal Numberof Procedures

9 Congenital heartdisease

1

2

3

EE � transesophageal echocardiography; TTE � transthoracic echocardiography.

ompletion of the core 6 adult CHD lectures; 3) require c

atient care log documentation of at least 50 supervisednpatient or outpatient encounters with patients with arimary diagnosis of some form of CHD during the core-year fellowship; and 4) log interpretation of at least 50upervised adult CHD advanced cardiac diagnostic studiescardiac catheterization, echocardiography, and/or cardiac

RI/CT procedures) during the core 3-year fellowship.

his is a revision of the 2002 document that was originallyritten by Carole A. Warnes, MD, MRCP, FACC—Chair;ichael D. Freed, MD, FACC; Richard R. Liberthson, MD;

nd Constantine Mavroudis, MD, FACC.

doi:10.1016/j.jacc.2007.11.017


. Perloff JK, Child JS. Congenital Heart Disease in Adults. 2nd edition.Philadelphia, PA: WB Saunders, 1998.

. Warnes CA, Liberthson R, Danielson GK, et al. Task force 1: thechanging profile of congenital heart disease in adult life. Care of theadult with congenital heart disease. Presented at the 32nd BethesdaConference, Bethesda, Maryland, October 2–3, 2000. J Am CollCardiol 2001;37:1170–5.

. Foster E, Graham TP Jr., Driscoll DJ, et al. Task force 2: special healthcare needs of adults with congenital heart disease. Care of the adult withcongenital heart disease. Presented at the 32nd Bethesda Conference,Bethesda, Maryland, October 2–3, 2000. J Am Coll Cardiol 2001;37:1176–83.

. Gurvitz MZ, Chang RK, Ramos FJ, Allada V, Child JS, Klitzner TS.Variations in adult congenital heart disease training in adult andpediatric cardiology fellowship programs. J Am Coll Cardiol 2005;46:893–8.

. Murphy DJ Jr., Foster E. ACCF/AHA/AAP recommendations fortraining in pediatric cardiology. Task force 6: training in transition ofadolescent care and care of the adult with congenital heart disease. J AmColl Cardiol 2005;46:1399–401.

. Child JS, Collins-Nakai RL, Alpert JS, et al. Task force 3: workforcedescription and educational requirements for the care of adults withcongenital heart disease. Care of the adult with congenital heart disease.Presented at the 32nd Bethesda Conference, Bethesda, Maryland,October 2–3, 2000. J Am Coll Cardiol 2001;37:1183–7.

ey Words: ACCF Training Statement y COCATS 3 y adult

enital Heart Disease

ts With Congenital Heart Disease

ulative Durationaining (Months)


ore lectures� �Can be taken as part of9 months of requirednonlaboratory clinicalpractice rotation.

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393JACC Vol. 51, No. 3, 2008 Blumenthal et al.January 22, 2008:393–8 ACCF COCATS 3 Training Statement: Task Force 10

PPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FOR TRAINING INDULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 9: TRAINING INHE CARE OF ADULT PATIENTS WITH CONGENITAL HEART DISEASE



BoardSpeakers’

BureauSteering


Dr. John S. Child None None None None None None None

Dr. Michael D. Freed None None None None None None None

Dr. Constantine Mavroudis None None None None None None None

Dr. Douglas S. Moodie None None None None None None None

Dr. Amy L. Tucker None None None None None None ● AdenosineTherapeutics


PPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FORRAINING IN ADULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 9:RAINING IN THE CARE OF ADULT PATIENTS WITH CONGENITAL HEART DISEASE



BoardSpeakers’

BureauSteering



● Official–Boardof Trustees




● 3F Therapeutics None None None None None None


Task Force 10: Training in PreventiveCardiovascular Medicine

Roger S. Blumenthal, MD, FACC, ChairC. Noel Bairey Merz, MD, FACC, Vera Bittner, MD, MSPH, FACC,Tyler J. Gluckman, MD, Fellow-in-Training Member

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he missions of the American College of Cardiology andhe American Heart Association have been to ensureptimal care to those with or at risk for developing cardio-ascular disease (CVD). The cardiovascular specialist isxpected to contribute significantly to the treatment andrevention of CVD in the setting of a rapidly growing fieldf knowledge ranging from molecular and cellular mecha-isms to clinical outcomes. Over the past 2 decades, thereave been dramatic increases in knowledge concerningpecific risk factors in atherosclerosis, hypertension, throm-osis, and other forms of vascular dysfunction. Clinical trialsave proven that strategies aimed at the appropriate detec-ion and modification of risk factors can slow progression of
therosclerosis and hypertension and reduce the occurrence b
f clinical events in both primary and secondary preventionettings. More recently, it has been shown that atheroscle-osis can be stabilized or even modestly reversed. Finally, therowing knowledge base of molecular genetics applied tohe study of the cardiovascular system has a potentially greatelevance to the future clinical practice of preventive cardio-ascular medicine.

Despite the fact that clinical outcomes can be improvedy promotion of favorable life habits and behaviors and byhe proper use of drug treatment, the application of preven-ive interventions in the clinical practice of cardiovascularedicine is not optimal. Prevention of CVD, in both the

rimary and secondary prevention setting, must no longer
e peripheral to the practice of the cardiovascular specialist.

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394 Blumenthal et al. JACC Vol. 51, No. 3, 2008ACCF COCATS 3 Training Statement: Task Force 10 January 22, 2008:393–8

he cardiovascular specialist must become proficient in therimary and secondary prevention of CVDs, including thebility to recommend specific primary and secondary pre-entive measures and to identify patients with subclinicalVD who may benefit from more aggressive risk factorodification.It is imperative that cardiovascular training programs

rovide the necessary education and training to promoteest practices among their trainees, who bear the responsi-ility to provide optimal preventive services to their patients.his report outlines specific areas of knowledge and skillsecessary to achieve this goal and also defines required andecommended standards to achieve this goal.

eneral Standards and Environment

here should be adequate faculty, both in number and expe-ience, to conduct a training program in preventive cardiovas-ular medicine. In addition to this, it is highly desirable for ateast some of the faculty to have expertise in vascular biology,therosclerosis, hypertension, disorders of lipid metabolism,besity and weight management, diet and nutrition, smokingessation, diabetes mellitus, thrombosis, clinical epidemiology,ardiac rehabilitation, clinical pharmacology, genetics, and thesychosocial aspects of CVD. Ideally, specific faculty in theardiovascular medicine training program should be able toerve as topic-area experts in one or more of these specifiedreas. This is important because the faculty should be able tounction as preventive cardiovascular medicine role models.

entoring is important for cardiovascular trainees in theirormative years, and prevention-oriented role models shouldunction in this capacity.


ptimal knowledge and skills required for the practice ofVD prevention are extensive and can be divided into 3 levels.

evel 1

evel 1 training should be required of all cardiovascularpecialists and includes exposure to the following topics.

eneral Content Areas

. Cardiovascular biology• Cellular mechanisms of atherosclerotic vascular disease• Genetics

. Clinical epidemiology• Incidence and prevalence of CVD• Relationship between risk factors/markers and CVD

outcomes• Gender and racial differences (1)• Population demographics (aging and socioeconomic

status) (2) p

. Biostatistics• Analytical methods• Software for basic analyses

. Clinical trials• Statistical analyses (tracking experimental data)• Study design (including calculation of sample size)

and understanding of methodology• Data collection• Data safety and monitoring• Meta-analyses

. Outcomes research• Medical economics• Cost/benefit analyses• Policy and legislation

. Cardiovascular pharmacology• Mechanism of action• Safety profile• Efficacy and indication

. Behavioral and psychosocial aspects of CVD (3)• Affective disorders (depression, anxiety)• Compliance• Behavior modification (coping)

. Risk assessment• Traditional risk factors• Nontraditional risk factors (e.g., high-sensitivity C-reactive

protein [4], apolipoprotein B, lipoprotein [a])• Advanced risk assessment (renal, hepatic, inflamma-

tory, and autoimmune related)

. Assessment of subclinical atherosclerosis• Coronary artery calcification (5–10)• Carotid intima-media thickness (11–13)• Ankle-brachial index (14,15)

0. Risk factor management• Hypertension• Lipids• Nutrition• Thrombosis• Smoking• Exercise• Pre-diabetes, insulin resistance, metabolic syn-

drome, and diabetes mellitus• Atherosclerosis reversal

1. Disease management• Multidisciplinary approach• Adherence• Education of primary care physicians

pecific Content Areas

xposure to specific content areas in CVD prevention isssential. These specific areas, outlined in an ABC format16,17), must encompass diagnosis and treatment in both
rimary and secondary prevention settings.

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A

Antiplatelet/Anticoagulant Therapy

• Aspirin• Clopidogrel (P2Y12 receptor antagonists)• Warfarin sodium: use in patients with atrial fibrilla-

tion and/or left ventricular thrombus

Angiotensin Converting Enzyme Inhibitor (ACE-I)/Angiotensin Receptor Blocker (ARB) Therapy

• ACE-I• ARB• ACE-I and ARB combination therapy

Antianginal/Anti-Ischemic Therapies

• Nitrates• Beta blockers• Calcium channel blockers• Novel antianginals (i.e., ranolazine)

Atherothrombosis

• Hypercoagulable states/thrombosis• Peripheral arterial disease

B

Blood Pressure Control

• Familiarity with the Joint National Committee onPrevention, Detection, Evaluation, and Treatment ofHigh Blood Pressure guidelines (18)

Beta-Blocker Therapy

• Antiarrhythmic, antianginal and sympatholytic effects• Secondary prevention of CVD in patients with a

myocardial infarction, heart failure/left ventricularsystolic dysfunction or hypertension

C

Cholesterol Management

• Familiarity with National Cholesterol Education Pro-gram guidelines for low-density lipoprotein-cholesterol,high-density lipoprotein-cholesterol, and triglycerides (19)

Cigarette Smoking Cessation

• Role of tobacco in the development and progression ofCVD and as a predictor of future cardiovascular eventsin persons with established coronary artery disease (20)

• Familiarity with combination, long-term behavioralsupport and pharmacologic therapy with or withoutnicotine replacement for smoking cessation

D

Diet and Weight Management

• Diet: Familiarity with appropriate cardiovascular dietary
choices and interventions for change in dietary habits p
• Weight Management: Familiarity with definitions ofnormal, overweight, and obese states and measures todefine abnormal weights (body mass index, waist:hipratio); association of weight and increased rates ofcardiovascular events, death, and development ofcomorbid conditions (diabetes mellitus, hypertension,hypercholesterolemia); caloric reductions and in-creased activity to reach ideal body weight

Diabetes Mellitus and the Metabolic Syndrome

• Familiarity with these terms (as they relate to patientswith and without CVD); guidelines for diagnosis andrecommended interventions (lifestyle changes, clini-cal pharmacotherapy)

• Role of diabetes mellitus as a potential risk factor forCVD and accelerated rates of atherosclerosis (21)

E

Exercise/Cardiac Rehabilitation (22–24)

• Association of inadequate levels of exercise with riskof cardiovascular events

• Role of cardiac rehabilitation for patients withchronic stable angina pectoris, recent myocardialinfarction, recent coronary artery bypass graft surgery,noncoronary heart surgery, cardiac transplant, and/orleft ventricular systolic function

Ejection Fraction

• Assessment for patients with known CVD• Role of adjunctive therapies (aldosterone blockade,

digitalis, etc.) in patients with left ventricular systolicfunction

lthough detailed, it is important to realize that this list ofey measures should not be considered all-inclusive. Theeld of cardiovascular prevention is ever changing, aspidemiologic and clinical trial data accumulates. Because ofhis, training programs should be oriented toward providinghe most up-to-date guidelines for all risk factors in therimary and secondary prevention of CVD.Level 1 training in these areas should ideally be under-

aken in a 1-month (or longer) rotation dedicated toreventive cardiovascular medicine (Table 1). An acceptablelternative would be a 3-month (or longer) clinical cardiol-gy rotation that allows concomitant exposure to a compre-ensive cardiovascular rehabilitation program at least 1 dayach week. This would allow incorporation of a broad rangef preventive approaches in addition to the predominantehabilitation focus of physical exercise (11). Ideally, the-month rotation should include weekly attendance at aardiac rehabilitation program, a diabetes mellitus or endo-rinology clinic, and a lipid disorders clinic.

As an alternative, training in these areas could be ob-ained in consultative, inpatient, and outpatient rotations,ith additional didactic sessions focusing on cardiovascular
revention topics. If the latter approach is taken, the time

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396 Blumenthal et al. JACC Vol. 51, No. 3, 2008ACCF COCATS 3 Training Statement: Task Force 10 January 22, 2008:393–8

llotted should be equivalent to at least 1 month of full-timeraining. Training program directors may also considerupplementing clinical experiences with short courses de-oted exclusively to preventive cardiovascular medicine orisk factor evaluation and management.

evel 2

evel 2 training should achieve a level of expertise such thathe trainee could serve as an independent consultant tother cardiovascular practitioners in the management ofardiovascular risk factors. This should involve 6 to 12onths of training within the 36 months of a cardiovascular

raining program and should include time for direct evalu-tion of patients with advanced atherosclerosis, hyperten-ion, hyperlipidemia, recurrent thrombosis, cardiac rehabil-tation, or related subspecialty conditions.

Level 2 training should involve blocks of time spent inypertension, lipid, and diabetes clinics or services, periph-ral vascular laboratories, and clinical and cardiac rehabili-ation services with additional exposure to behavioral med-cine, exercise physiology, clinical epidemiology, outcomesesearch, and vascular biology. To achieve training at Level, aggregate training in preventive laboratories and serviceshould account for a minimum of 6 months of a typical-year training program in cardiovascular medicine.

evel 3

evel 3 requires advanced training to qualify as director of alinical service, research program, or both. Examples includehe director of a preventive cardiovascular medicine, hyper-ension or lipid service; director of a cardiac rehabilitationrogram, director of a vascular medicine laboratory; or arainee who obtains an MPH degree in clinical epidemiol-gy, outcomes research, or both.Training at this level would require 1 year of a 36-month

raining program. This level of experience may requiredditional formal education and training beyond a basic-year program. Alternatively, 2 to 3 years in a vasculariology laboratory or health services outcomes research/linical epidemiology program would be required to attainxpertise in these fields which would possibly lead tochievement of an advanced degree.

The most effective preventive cardiovascular medicine

ummary of Training Requirements for Preventive Cardiovascular M

Table 1 Summary of Training Requirements for Preventive Card

LevelDuration of Training

(Months)Cumulative Duration of

Training (Months)

1 1 1

2 6 to 12 6 to 12

3 12 12

VD � cardiovascular disease.

ervices incorporate the skills and knowledge of multiple

roviders, including cardiovascular physicians, nurses, nurseractitioners, physician assistants, dietitians, behavioraledicine specialists, and exercise physiologists. They oper-

te on principles of interdisciplinary and multidisciplinaryeamwork, and they use systemic approaches to patient care.lthough such programs are more effective than routine

ardiovascular practice, few training programs offer oppor-unities to learn these new skills. Programs interested inffering Level 3 training should incorporate these newoncepts into the training program and trainees interestedn Level 3 training should seek programs that offer thesedvanced approaches to patient care.

valuation

hereas knowledge of preventive interventions and mech-nisms has blossomed in the past 10 years, clinical practicen this area lags behind in virtually all practice settings. Evencademic centers, where most trainees are taught, fail torovide ideal preventive services to cardiovascular patients.valuation of the training in preventive cardiovascularedicine could logically include efforts by clinical programs

o evaluate their own clinical inputs and outcomes andemonstrate commitment to ongoing quality improvementn clinical prevention. Programs could also use the Adultlinical Cardiology Self-Assessment Program (ACCSAP)

ducation programs and examinations to ensure traineesand faculty) have acquired appropriate knowledge of pre-entive cardiovascular medicine.

his is a revision of the 2002 document that was written byhillip Greenland, MD, FACC—Chair; Edward D. Frohlich,D, FACC; C. Noel Bairey Merz, MD, FACC; and Richard

. Pasternak, MD, FACC. We are especially indebted to thealuable comments and suggestions by M. Dominique Ashen,hD, CRNP, and Matthew J. Budoff, MD.

doi:10.1016/j.jacc.2007.11.018


1. Mosca L, Appel LJ, Benjamin EJ, et al., AHA. Evidence-basedguidelines for cardiovascular disease prevention in women. American

ine

cular Medicine

Types of Training Experiences

Genetics of CVD, risk prediction, clinical epidemiology, biostatistics,clinical trials, outcomes research, clinical pharmacology, behaviormodification, and disease management.

Blocks of time devoted to study of patients with advanced atherosclerosis,hypertension, hyperlipidemia, recurrent thrombosis, cardiacrehabilitation, or related subspecialty work.

In-depth study of one of the above areas.

edic

iovas

Heart Association scientific statement. Arterioscler Thromb Vasc Biol2004;24:e29–50.

1

1

1

1

1

1

1

1

1

1

2

2

2

2

2

K

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T

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2. Foot DK, Lewis RP, Pearson TA, Beller GA. Demographics andcardiology, 1950–2050. J Am Coll Cardiol 2000;35:66B–80B.

3. Miller NH, Hill M, Kottke T, Ockene IS. The multilevel compliancechallenge: recommendations for a call to action: a statement forhealthcare professionals. Circulation 1997;95:1085–90.

4. Pearson TA, Mensah GA, Alexander WR, et al. Markers of inflam-mation and cardiovascular disease. Application to clinical and publichealth practice. A statement for healthcare professionals from theCenters for Disease Control and Prevention and the American HeartAssociation. Circulation 2003;107:499–511.

5. Agatston AS, Janowitz WR, Hildner FJ, Zusmer NR, Viamonte MJr., Detrano R. Quantification of coronary artery calcium usingultrafast computed tomography. J Am Coll Cardiol 1990;15:827–32.

6. Gopal A, Budoff MJ. Coronary calcium scanning. Am Heart Hosp J2006;4:43–50.

7. Smith SC, Greenland P, Grundy SM. Prevention Conference V:beyond secondary prevention: identifying the high-risk patient forprimary prevention. Executive summary. Circulation 2000;101:111– 6.

8. Mieres JH, Shaw LJ, Arai A, et al. The role of non-invasive testing inthe clinical evaluation of women with suspected coronary arterydisease: American Heart Association consensus statement. Circulation2005;111:682–96.

9. Greenland P, Smith SC Jr., Grundy SM. Improving coronary heartdisease risk assessment in asymptomatic people: role of traditional riskfactors and noninvasive cardiovascular tests. Circulation 2001;104:1863–7.

0. O’Rourke RA, Brundage BH, Froelicher VF, et al. American Collegeof Cardiology/American Heart Association expert consensus docu-ment on electron beam computed tomography for the diagnosis andprognosis of coronary artery disease. J Am Coll Cardiol 2000;36:326–40.

1. Veller MG, Fisher CM, Nicolaides AN. Measurement of the ultra-sonic intima-media complex thickness in normal subjects. J Vasc Surg1993;17:719–25.

2. Salonen JT, Salonen R. Ultrasound B-mode imaging in observationalstudies of atherosclerotic progression. Circulation 1993;87 SupplII:II56–65.

3. Spence JD. Ultrasound measurement of carotid plaque as a surrogateoutcome for coronary artery disease. Am J Cardiol 2002;89:10B–5B.

4. Grundy SM, Cleeman JI, Merz CN, et al. Implications of recentclinical trials for the National Cholesterol Education Program Adult
Treatment Panel III guidelines. Circulation 2004;110:227–39. c
5. Greenland P, Abrams J, Aurigemma GP, et al. Prevention ConferenceV: beyond secondary prevention: identifying the high-risk patient forprimary prevention—noninvasive tests of atherosclerotic burden. Cir-culation 2000;101:e16–22.

6. Gluckman TJ, Baranowski B, Ashen MD, et al. A practical andevidence-based approach to cardiovascular disease risk reduction. ArchIntern Med 2004;164:1490–500.

7. Gluckman TJ, Sachdev M, Schulman SP, Blumenthal RS. A simpli-fied approach to the management of non-ST-segment elevation acutecoronary syndromes. JAMA 2005;293:349–57.

8. Chobanian AV, Bakris GL, Black HR, et al. The seventh report onprevention, detection, evaluation and treatment of high blood pressure:the JNC 7 report. JAMA 2003;289:2560–72.

9. Executive summary of the third report of the National EducationalCholesterol Education Program (NCEP) Expert Panel on Detection,Evaluation and Treatment of High Blood Cholesterol in Adults(Adult Treatment Panel III). JAMA 2001;285:2486–97.

0. Ockene IS, Miller NH. Cigarette smoking, cardiovascular disease andstroke: a statement for healthcare professionals from the AmericanHeart Association: American Heart Association Task Force on RiskReduction. Circulation 1997;96:3243–7.

1. Grundy SM, Benjamin IJ, Burke GL, et al. Diabetes and cardiovas-cular disease: a statement for healthcare professionals from the Amer-ican Heart Association. Circulation 1999;100:1134–46.

2. Fletcher GF. How to implement physical activity in primary andsecondary prevention: a statement for healthcare professionals from theTask Force on Risk Reduction, American Heart Association. Circu-lation 1997;96:355–7.

3. Balady GJ, Ades PA, Comoss P, et al. Core components of cardiacrehabilitation/secondary prevention programs: a statement for healthcareprofessionals from the American Heart Association and the AmericanAssociation of Cardiovascular and Pulmonary Rehabilitation WritingGroup. Circulation 2000;102:1069–73.

4. Smith SC Jr., Allen J, Blair SN, et al. AHA/ACC guidelines forsecondary prevention for patients with coronary and other atheroscle-rotic vascular disease: 2006 update. J Am Coll Cardiol 2006;47:2130–9.

ey Words: ACCF Training Statement y COCATS 3 y preventive
ardiovascular medicine y cardiovascular disease.
PPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FOR TRAINING INDULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 10: TRAINING INREVENTIVE CARDIOVASCULAR MEDICINE

Name Consultant Research GrantScientific

Advisory BoardSpeakers’

BureauSteering


Dr. Vera A. Bittner None None None None None None None

Dr. Roger S.Blumenthal

None ● AstraZeneca● Kos Pharmaceuticals● Merck● Pfizer● Sanofi-Aventis● Schering-Plough

None ● AstraZeneca● Kos Pharmaceuticals● Merck● Pfizer● Sanofi-Aventis● Schering-Plough

None None None

Dr. Tyler J.Gluckman


Dr. C. Noel BaireyMerz

● Bayer None None None None None Stock owned–● BostonScientific

● Eli Lilly● Medtronic● Johnson &Johnson


f publication.

ATT

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398 Creager et al. JACC Vol. 51, No. 3, 2008ACCF COCATS 3 Training Statement: Task Force 11 January 22, 2008:398–404

PPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FORRAINING IN ADULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 10:RAINING IN PREVENTIVE CARDIOVASCULAR MEDICINE

Name* Affiliation Consultant Research GrantScientific

Advisory BoardSpeakers’

BureauSteering





Dr. Gregg C.Fonarow


● AstraZeneca● Bristol Myers-Squibb

● GlaxoSmithKline● Guidant● Merck● Medtronic● Nitromed● St. Jude MedicalCenter

● Pfizer● Sanofi-Aventis● Scios

● GlaxoSmithKline● Medtronic


Dr. Alan D.Forker


None ● GlaxoSmithKline● Merck● Novartis● Pfizer● Reliant● Sankyo● Sanofi-Aventis● Takeda

None ● Medcom: Coach● Medcom:Vascular BiologyWorking Group

● Merck● Novartis● Pfizer● Takeda

None None None

Dr. Rita F.Redberg


None None ● CV Therapeutics None None None None


Task Force 11: Training in Vascular Medicine andPeripheral Vascular Catheter-Based InterventionsEndorsed by the Society for Cardiovascular Angiography and Interventionsand the Society for Vascular Medicine

Mark A. Creager, MD, FACC, ChairJohn P. Cooke, MD, PHD, FACC, Jeffrey W. Olin, DO, FACC (Society for Vascular MedicineRepresentative), Christopher J. White, MD, FACC

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ardiovascular physicians frequently encounter vascular dis-ases. Atherosclerosis and thrombosis, in particular, areystemic disorders with clinical manifestations in mosteripheral circulations. These and other vascular diseasesccount for substantial cardiovascular morbidity and mor-ality. Moreover, technological advances in imaging tech-iques and catheter-based interventions have brought man-gement of vascular diseases firmly into the sphere of theardiovascular specialist. Training in vascular medicine
hould be incorporated in a cardiovascular fellowship in t
rder to accommodate the clinical demands of this contem-orary paradigm. Accordingly, 3 levels of training in vascu-

ar medicine are described.Level 1—Basic training in vascular medicine that all

ellows should receive to acquire a sufficient knowledge baseo care for many patients with vascular disease.

Level 2—Additional training for fellows who wish toevelop special expertise in evaluating and managing pa-ients with vascular disease. This level does not include
raining in catheter-based interventions.

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399JACC Vol. 51, No. 3, 2008 Creager et al.January 22, 2008:398–404 ACCF COCATS 3 Training Statement: Task Force 11

Level 3—Training for noncoronary peripheral vascularatheter-based vascular interventions. This level of trainings to ensure that the fellow develops both the cognitive andechnical skills requisite to making appropriate decisionsegarding invasive and interventional treatment of patientsith vascular disease.

evel 1: Basic Training for Allardiovascular Fellows

he essentials of vascular medicine should be taught to allellows. Vascular medicine training should be integrated intohe fellowship program and include the evaluation and man-gement of vascular diseases, exposure to noninvasive diagnos-ic modalities, angiography, and peripheral catheter-basednterventions. The equivalent of at least 2 months of theellowship, either as dedicated rotations or in the aggregate asn integral component of other rotations, should be devoted toascular medicine. Acquisition of this fundamental knowledgeill permit the fellow to recognize a broad array of vasculariseases and common medical disorders associated with vascu-

ar disease, to initiate appropriate medical management, and toppropriately refer patients to a vascular specialist when nec-ssary for further evaluation and intervention. This level ofraining, however, is not sufficient to qualify the trainee as aascular specialist capable of managing complex vascular pa-ients.

omponents of Training

he fellow should receive training in the evaluation andanagement of arterial, venous, and lymphatic diseases,

uch as peripheral arterial disease, acute arterial occlusion,arotid artery disease, renal artery stenosis, aortic aneurysm,asculitis, vasospasm, venous thrombosis and insufficiency,ummary of Training Requirements for Vascular Medicine and Perip

Table 1 Summary of Training Requirements for Vascular Medic


(Months) Com

1 2 Evaluation and manlymphatic diseashypercoagulable

Noninvasive vascula(i.e., ultrasound,

2 (vascular medicinespecialist)†

12 Outpatient vascularInpatient vascular mNoninvasive vasculaMRA/CTAPeripheral vascularVascular surgery

3 (peripheral vascularintervention)‡

12 Outpatient vascularInpatient medical coVascular imaging, in

CTA (1 to 2 montPeripheral vascular

These are estimates based on the most recently published guidelines and will be kept current asraining, or both, emphasizing either the medical evaluation and management of the vascular patiLevel 3). Level 2 training is not a prerequisite for Level 3 training but is intended for individuals wh

raining in peripheral vascular intervention can be fulfilled during a fourth year of interventional trainingCTA � computed tomography angiography; MRA � magnetic resonance angiography.

nd lymphedema (Table 1). Training should also includenstruction in the recognition and management of medicalisorders associated with vascular diseases, including hyper-ension, hypercholesterolemia, diabetes mellitus, and hyper-oagulable states. Fellows should also be trained to perform

comprehensive pre-operative evaluation of the patientndergoing vascular surgery, to be cognizant of the indica-ions and risks of pre-operative testing, and to manageardiovascular problems in the perioperative period.

Trainees should receive instruction in the noninvasiveascular laboratory and know the indications for vascularests, such as segmental pressure measurements, pulse-olume recordings, and duplex ultrasonography, as well ashe information that can be derived from such testing.urthermore, the fellow should understand the imaging

echniques that can be used to further assess the aorta, venaavae, and peripheral arteries and veins, such as computedomography angiography (CTA) and magnetic resonancengiography (MRA), and recognize the indications foratheter-based interventions and surgical revascularization.

All cardiovascular medicine fellowship candidates shouldarticipate in noncardiac peripheral angiography (i.e., aorto-raphy; angiography of first-order branch vessels of the aorta,uch as the iliac, renal, or subclavian arteries; and second-orderranch vessels, such as the internal mammary arteries; andulmonary angiography) in patients with whom they arenvolved from pre-catheterization clinical evaluation to finalisposition. This training will not qualify the trainee to

ndependently perform peripheral angiography.

tructure of the Level 1 Training Program

aculty

n a few institutions, leadership for the vascular medicineomponent of the training program will come from vascularl Catheter-Based Interventions

nd Peripheral Catheter-Based Interventions

s of Training Cumulative Number of Procedures*

nt of arterial, venous, androsclerotic risk factors, and

ratory and vascular imagingTA)

ine clinice consultation serviceratory, examinations

erization

Noninvasive vascular lab100 venous ultrasounds100 carotid artery ultrasounds100 limb artery ultrasounds75 renal/mesenteric vascular ultrasounds100 physiologic arterial examinations

ine cliniction serviceg ultrasound, MRA,

erization and intervention

Peripheral vascular interventions100 diagnostic peripheral angiograms50 peripheral angioplasties/tents10 peripheral thrombolytic

infusions/thrombectomy

ines are updated. After completing Level 1, trainees can elect to pursue Level 2 training, Level 3the noninvasive vascular laboratory (Level 2) or peripheral vascular catheter-based interventions

to become a vascular medicine specialist. †The prerequisite for Level 2 training is Level 1 training

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focused on peripheral vascular intervention or concurrently with cardiac interventional training.

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edicine specialists. In many programs, however, the exposureo vascular medicine will come from faculty in other disciplines,uch as cardiology, hematology, neurology, vascular surgery,nd vascular radiology. All faculty responsible for trainingellows in vascular medicine should be board certified or boardligible and recognized as experts in their subspecialties.

acilities

he principal training institution should have facilities toare for patients with vascular disease that include a nonin-asive vascular laboratory accredited by the Intersocietalommission for the Accreditation of Vascular Laboratories

ICAVL), a peripheral vascular catheterization laboratory, aomprehensive vascular surgery program, and offices forutpatient evaluation and treatment.

ontent of Conferences

onferences should incorporate case presentations and for-al lectures that review current diagnostic and therapeutic

pproaches to arterial, venous, and lymphatic disease. Caseresentations should illustrate the use of clinical tools,oninvasive laboratory testing, and angiography. Confer-nces should provide the trainee with information regardinghe natural history of peripheral vascular disorders, theong-term risks and benefits of peripheral intervention, andoninterventional approaches to vascular disease. Formal

ectures on the pathobiology of vascular diseases, includingtherosclerosis, restenosis, and thrombosis, should be incor-orated.

rainee Evaluation

he fund of knowledge regarding vascular disease must bevaluated in every trainee. Quality of clinical skills; reliabil-ty; judgments or actions that result in patient complica-ions; and interaction with other physicians, patients, andaboratory support staff are key components of the evalua-ion. Initiative and ability to make independent and appro-riate decisions are to be considered. The program directoras the responsibility to confirm or deny the experience andompetence of trainees.

evel 2: Requirements for Training Fellowsishing to Pursue a Career inascular Medicine

ellows planning a career in vascular medicine require aistinct and comprehensive training program. In addition tohe 24 months required for board eligibility in cardiovascu-ar medicine, another 12 months of training, typicallyuring a third or fourth year, should provide a curriculum tonable the fellow to become an expert in vascular medicine1,2). The prerequisite for Level 2 training is Level 1raining in vascular medicine. The fellow who wishes to berained in peripheral vascular intervention will require ad-
itional training as outlined in later text (see Level 3). e

rainees who plan a vascular medicine track as part of theirardiovascular fellowship should spend at least 2 to 3onths on an inpatient vascular medicine consultation

ervice; 3 months in the noninvasive vascular laboratory; 1 tomonths learning MRA and CTA; and 1 to 2 months in

he peripheral vascular catheterization laboratory (Table 1).n addition, at least one-half to 1 day per week throughouthe year should be spent in the outpatient vascular medicinelinic. In addition, there should be sufficient exposure to theiagnosis and treatment of peripheral arterial disease, aorticiseases, cerebrovascular disease, renal artery stenosis, ve-ous thromboembolic diseases, chronic venous disorders,

ymphatic diseases, vasculitides, atheromatous embolization,asospastic disease, and chronic venous insufficiency, as wells other uncommon vascular diseases.

The time spent on the inpatient hospital service andutpatient clinic should include experience with risk factorodification, including smoking cessation interventions and

reatment of dyslipidemia, hypertension, and thrombophilicisorders, because these are important components of manyascular diseases. Additional rotations could be allocated toascular surgery, hematology, neurology, and rheumatologyo acquire fundamental experience in these important areass they relate to vascular medicine.

Expertise in the noninvasive vascular laboratory is one ofhe most important aspects of training for the vascularedicine specialist. Although the principles of ultrasound

re the same whether one is performing an echocardiogramr a vascular ultrasound, there are many important differ-nces in technique and interpretation that require specialraining. The trainee should understand the principles ofltrasound physics, Doppler characteristics, and transducerechnology. The fellow should perform and interpret theollowing vascular studies under supervision: 1) duplexltrasonography of the veins and arteries of the upper andower extremities; 2) the aorta; 3) the renal and mesentericrteries and veins; 4) the carotid arteries; 5) infrainguinalypass grafts; and 6) physiologic tests of peripheral arteriesnd veins, among others. The number of noninvasiveascular laboratory procedures required for each of thetudies performed in the vascular laboratory should followhe guidelines recommended by the ICAVL (3). Thesenclude, but are not limited to, 100 venous, 100 periph-ral artery (including bypass grafts), 100 carotid artery,nd 75 visceral artery and venous (renal and mesenteric)uplex ultrasound studies, as well as 100 physiologicrterial examinations.

In addition, dedicated time should be spent learning theasic principles of MRA and CTA. The trainees shouldcquire the cognitive and clinical skills necessary to reviewhe MRA and CTA of peripheral vessels, including theorta, and brachiocephalic, limb, renal, and mesentericrteries when evaluating patients with vascular disease. This
xperience is not intended to qualify the trainee in the

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erformance and formal interpretation of MRA or CTA.xpertise in MRA and CTA will require additional time to

cquire the comprehensive skills needed to perform andndependently interpret these imaging modalities (see theask Force 12 and 13 reports).During the period of training in the catheterization labora-

ory, the fellow should learn the fundamentals of angiographynd peripheral catheter-based interventions. The traineehould participate in peripheral diagnostic angiograms anderipheral interventions, including angioplasty, stent implan-ation, and thrombolysis. Training should emphasize interpre-ation of angiograms and permit the fellow to acquire annderstanding of the indications and potential outcomes ofnvasive diagnostic procedures and catheter-based treatments.his experience is not intended to qualify the trainee as an

nterventionalist (see Level 3).


aculty

he trainee should be exposed to individuals who havepecial training in vascular medicine and cardiovasculariseases. Ideally, these faculty will be board certified inascular medicine and/or endovascular medicine by themerican Board of Vascular Medicine. It is recognized,owever, that this may not be possible at all institutions.herefore, the cardiovascular fellow may need to spend time

n other departments or divisions to gain the necessaryxpertise to be a vascular medicine specialist. As per Level 1raining, all faculty responsible for training fellows inascular medicine should be board certified or board eligiblend recognized as experts in their subspecialties. Areashere this may be most important include the noninvasiveascular laboratory, angiography suite, vascular surgery,ematology, neurology, and rheumatology. The facultyhould be required to provide didactic and practical educa-ion to the fellow, as well as appropriate feedback about therainee’s performance.

acilities

dequate space should be available in the outpatient clinicso see patients. The noninvasive vascular laboratory shoulde accredited by the ICAVL and have equipment of suitableuality to perform all of the studies previously listed. Therehould be dedicated, fully equipped areas for magneticesonance and computed tomographic imaging. A periph-ral vascular catheterization laboratory equipped as stated inhe following text should also be a requirement for theardiovascular fellow’s training in vascular medicine. Therehould be an active and comprehensive vascular surgeryrogram at the institution, and facilities for treatment of leglcers should be available.


he cardiovascular fellowship program should have a com-
rehensive conference series for topics of importance for the d
ascular medicine specialist. A conference dedicated to aore curriculum of topics should be scheduled throughouthe year. Additional conferences could include angiographynd imaging, vascular medicine grand rounds, a journallub, and morbidity and mortality.

valuation of Trainee and Faculty

s with every successful post-graduate training program,his program requires bi-directional evaluations. The facultyvaluates and provides positive and negative feedback to therainee, and the trainee evaluates the faculty. Formal eval-ations of the fellows and faculty should occur after eachotation. The program director should review these evalua-ions with the trainee and with the faculty individually.

echanisms should be incorporated into the training pro-ram so that the fellow who performs suboptimally can beounseled and further action can be taken if necessary. Themerican Board of Vascular Medicine administers a certi-

ying examination in vascular medicine. The fellow will bexpected to take and pass this examination.

evel 3: Training for Peripheral Vascularatheterization and Intervention

atheter-based peripheral angiography (arterial and venous)nd interventional procedures are important components ofmodern clinical cardiovascular practice. The trainee who

lans to perform peripheral catheter-based angiography andnterventions will be required to complete an additionaleriod of training in these special procedures to obtain theasic fund of knowledge, technical skills, and the clinical

udgment requisite for performing these invasive studies (1).


rainees who plan to perform independent peripheral vas-ular catheterization (arteriography and venography) andnterventions must become knowledgeable about normalascular anatomy and common anatomic variants and be-ome familiar with the common patterns of collateralormation. They must learn the theoretical and practicalspects of radiation physics and safety. A working knowl-dge of the cardiovascular angiographic laboratory equip-ent, including physiologic recorders, pressure transducers,

lood gas analyzers, image intensifiers, cine processing,igital imaging, and image archiving, is required. Annderstanding of the fundamental principles of pressureaveform recording and analysis is mandatory.Trainees should receive specific training in the techniques

f vascular access from multiple sites (femoral, popliteal, andpper extremity arteries and veins). They should be trainedo manipulate guidewires and catheters, place and deployngioplasty equipment and devices, perform catheter-irected thrombolysis/thrombectomy, and obtain hemosta-is via the application of compression and vascular closure
evices. They should acquire the ability to perform vascular

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nterventions in each of the following: aorta and lowerxtremity arteries, cervical arteries, brachiocephalic andpper extremity arteries, mesenteric and renal arteries,entral and peripheral veins, and pulmonary arteries. Train-es must learn the indications, limitations, and complica-ions of vascular interventional procedures, and understandhe alternative treatments.

Level 3 training in peripheral angiography and catheter-ased peripheral vascular intervention must also provide theellow with the cognitive tools requisite to evaluating andanaging patients with vascular disease. In some respects,

his overlaps with Level 2 training. Trainees should spendhe equivalent of 1 month on an inpatient vascular consul-ation service, 1 to 2 months dedicated to vascular imagingincluding duplex ultrasonography, and MRA and CTA),nd 1 half-day per week in an outpatient vascular clinic tocquire the knowledge necessary to manage patients witheripheral arterial disease, aortic diseases, renal artery ste-osis, cerebrovascular disease, venous thrombosis, and otherelevant vascular diseases (Table 1). The trainees shouldcquire the cognitive and clinical skills necessary to reviewuplex ultrasound studies of peripheral arteries and veins asell as the MRA and the CTA of peripheral vessels,

ncluding the aorta, and brachiocephalic, limb, renal, andesenteric arteries when evaluating patients with vascular

isease as described for Level 2 training. This experience isot intended to qualify the trainee in the performance andormal interpretation of vascular ultrasound studies, MRA,r CTA. Level 2 training is not a prerequisite for Level 3raining but is suggested for those wishing to acquireomprehensive training in vascular medicine in order toomplement skills developed during Level 3 training.


aculty

he training program must have a director of the catheter-zation laboratory who has primary responsibility for admin-stration and teaching. The program director must be boardertified in interventional cardiology or have equivalentredentials. More than 1 faculty member is required toarticipate in the peripheral interventional training of theellows. All faculty responsible for training fellows inatheter-based peripheral angiography and interventionhould be board certified or board eligible by the Americanoard of Internal Medicine (ABIM) Subspecialty Board onardiovascular Disease and recognized by his or her peers as

n expert in peripheral catheter-related intervention. Ide-lly, faculty should have received additional certification inardiovascular intervention by the ABIM Subspecialtyoard on Cardiovascular Disease or passed the Americanoard of Vascular Medicine Endovascular Examination.

acilities

fully equipped and staffed angiographic and hemody-
amic laboratory dedicated to cardiovascular procedures is s
equired. All training facilities must be equipped and staffednd function in accordance with the most recent Americanollege of Cardiology (ACC) recommendations for periph-

ral transluminal angioplasty, training, and facilities. Pe-ipheral vascular surgery must be performed in the trainingnstitution to support catheter-based interventions.

atients

ll trainees should be exposed to adult patients withascular diseases as outlined in the previous text. Thesenclude patients with peripheral arterial disease, aortic dis-ases, cerebrovascular disease, renal artery stenosis, venoushromboembolic diseases, vasculitides, atheromatous embo-ization, and uncommon vascular diseases.

The trainee planning a career in angiography andatheter-based vascular interventions must be trained toerform procedures in acutely and chronically ill patients,ncluding emergency patients with acute limb ischemia.

uration of Training

or the cardiovascular trainee who plans to independentlyerform peripheral angiography and catheter-based periph-ral vascular interventions, Level 1 training in vascularedicine, and Level 1 and Level 2 training in the cardiac

atheterization laboratory are required as a prerequisite (alsoee the Task Force 3 report). Requirements for Level 3raining in peripheral vascular intervention can be fulfilleduring a fourth year of interventional training focused oneripheral vascular intervention or concurrently with cardiacnterventional training.

For trainees planning to perform peripheral vascularnterventional procedures, dedicated peripheral vascular in-erventional fellowship training is required, during whichime the minimum requirements specified by the Clinicalompetence Statement on Vascular Medicine and Catheter-ased Peripheral Vascular Interventions must be met (1).hese requirements can be met during a fourth year of

nterventional training focused on peripheral vascular inter-ention or concurrently with cardiac interventional training.urrent guidelines for competence indicate that trainees

hould perform at least 100 diagnostic angiograms, 50eripheral angioplasties, and 10 peripheral thrombolytic/hrombectomy interventions.


ll trainees must attend a regular cardiovascular catheterizationnd angiography conference. It is important that the cardiol-gist understand the complexities and limitations of the car-iovascular angiographic laboratory. Formal conferenceshould stress the relation of medical history, physical exami-ation findings, hemodynamic findings, and angiographicndings for the selection of patients for therapy (i.e., medicine,urgery, or intervention). Interaction with the other vascularpecialists at these conferences is important.

The trainee should be familiar with the rationale for patient
election for these diagnostic studies and should be required to

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ttend conferences at least weekly for the duration of theatheterization/angiography rotation. Attendance at regularorbidity and mortality conferences is a requirement.

rainee Evaluation

ase selection and procedural judgment, as well as interpretivend technical skills, must be evaluated in every trainee. This isarticularly important for the trainee who eventually will workull time in a diagnostic cardiovascular angiography laboratoryr perform catheter-based vascular interventional procedures.uality of the clinical follow-up; reliability; judgments or

ctions that result in patient complications; interaction withther physicians, patients, and laboratory support staff; appro-riate initiative; and the ability to make independent andppropriate decisions should be considered.

The competence of all cardiology trainees in cardiovas-ular angiography and intervention should be documentedy both the program director and the director of theatheterization laboratory. The program director has theesponsibility to confirm or deny the technical competencend catheterization laboratory exposure of trainees. Theranting of hospital privileges remains within the purview ofhe individual institution.

Evaluation of the trainee who undertakes special trainingn catheter-based peripheral angiography and vascular in-ervention shall include the documentation (in the form of

logbook containing clinical information, procedure per-ormed, and outcome of the procedure, including any
omplications experienced by the patient) of the perfor-
mt

ance of at least the minimum number of procedures setorth in the Clinical Competence Statement on Vascular

edicine and Catheter-Based Peripheral Vascular Inter-entions (1). Evaluation of the trainee for catheter-basederipheral vascular intervention shall include the documen-ation (in the form of a logbook) of the performance of ateast the minimum number of procedures set forth in thelinical Competence Statement (1).

his is an update of the 2002 document that was written byark A. Creager, MD, FACC—Chair; John P. Cooke, MD,

hD, FACC; Jeffrey W. Olin, DO, FACC (Society of Vascularedicine and Biology Representative); and Christopher J.hite, MD, FACC.

doi:10.1016/j.jacc.2007.11.019


. Creager MA, Goldstone J, Hirshfeld JW Jr., et al. ACC/ACP/SCAI/Society for Vascular Medicine/SVS clinical competence statement onvascular medicine and catheter-based peripheral vascular interventions.J Am Coll Cardiol 2004;44:941–57.

. Creager MA, Hirsch AT, Cooke JP, et al. Postgraduate training invascular medicine: proposed requirements and standards. Vasc Med2003;8:47–52.

. Intersocietal Commission for the Accreditation of Vascular Laborato-ries. The Standards, revised 2005. Available at: http://www.icavl.org/icavl/pply/standards.htm. Accessed May 21, 2007.

ey Words: ACCF Training Statement y COCATS 3 y vascular
edicine y peripheral vascular catheter-based intervention y computed
omography angiography y peripheral vascular intervention.

PPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FOR TRAINING INDULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 11: TRAINING INASCULAR MEDICINE AND PERIPHERAL VASCULAR CATHETER-BASED INTERVENTIONS


GrantScientific

Advisory Board Speakers’ BureauSteering


Dr. John P. Cooke ● Athenagen ● Genzyme None ● Bristol-MyersSquibb

None ● Athenagen● Lumen

None

Dr. Mark A.Creager

None ● Bristol-MyersSquibb

● Sanofi-AventisU.S. Partnership

● Biomarin ● Bristol-MyersSquibb

● Sanofi-Aventis U.S.Partnership

● Bristol-MyersSquibb

● Genzyme● Sanofi-AventisU.S.Partnership

● Sigma Tau,Vasogen

None None

Dr. Jeffrey W. Olin ● Bristol-MyersSquibb

● Genzyme● Sanofi


● Genzyme● Sanofi● Vasogen


● Sanofi

None ● Genzyme● Vasogen

None None

Dr. Christopher J.White



f publication.

http://www.icavl.org/icavl/pply/standards.htm














































































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404 Pohost et al. JACC Vol. 51, No. 3, 2008ACCF COCATS 3 Training Statement: Task Force 12 January 22, 2008:404–8

PPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FORRAINING IN ADULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 11:RAINING IN VASCULAR MEDICINE AND PERIPHERAL VASCULAR CATHETER-BASED INTERVENTIONS


Grant


Speakers’Bureau

SteeringCommittee

StockHolder Other




Dr. Jeffrey J.Cavendish



Dr. Matthew R. Wolff ● Official–Board ofGovernors


Dr. John E. Brush, Jr. ● Content–IndividualReviewer


Dr. Marie D. Gerhard-Herman

● Content–PeripheralVascular DiseaseCommittee


Ms. Cathy Pensyl ● Content–PeripheralVascular DiseaseCommittee


Dr. KennethRosenfield

● Content–PeripheralVascular DiseaseCommittee

● Abbott Vascular● Cordis● Endotex● Ev3● Medical Simulation● The Medicines Co.● Xtent

● Abbott Vascular● Bard● Boston Scientific● Cordis

None ● BostonScientific

None ● MedicalSimulation

● Xtent

None


Task Force 12: Training in Advanced CardiovascularImaging (Cardiovascular Magnetic Resonance [CMR])Endorsed by the Society for Cardiovascular Magnetic Resonance

Gerald M. Pohost, MD, FACC, ChairRaymond J. Kim, MD, FACC, Christopher M. Kramer, MD, FACC,Warren J. Manning, MD, FACC (Society for Cardiovascular Magnetic Resonance Representative)

T

cm

sti

ardiovascular magnetic resonance (CMR) (Table 1), onef the newest cardiovascular imaging modalities, providesseful, often unique information with which all cardiologistshould be conversant. Accordingly, cardiovascular traineeshould receive training that would provide at least a basicnderstanding of the methods and utility of CMR in theractice of cardiology. To accomplish such an understand-ng for fellows with different levels of interest in CMR,raining in CMR should be provided at 3 levels—general,pecialized, and advanced.

raining Levels

Level 1—General training (1 month) should provide theardiovascular trainee with a working knowledge of CMRethods and their diagnostic utility.Level 2—Specialized training (at least 3 months) de-

igned to provide the trainee in cardiovascular diseases withhe skills necessary to independently interpret CMR imag-ng studies.

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405JACC Vol. 51, No. 3, 2008 Pohost et al.January 22, 2008:404–8 ACCF COCATS 3 Training Statement: Task Force 12

Level 3—Advanced training is provided for those wholtimately wish to be responsible for the operation of aMR laboratory. Level 3 criteria must include adequate

evels of patient care, teaching, and research.

verview of CMR Training

ll cardiovascular medicine trainees should be taught theasic types of CMR studies and their indications. Men-ored interpretation of CMR studies should be coupledith comparison and integration of results with other

elevant clinical and laboratory testing. A mentor is anndividual with the equivalent of Level 3 CMR training.his training generally should be acquired through theccreditation Council for Graduate Medical Education

ACGME)—an approved cardiology or radiology pro-ram with expertise in CMR and under the aegis of aevel 3-qualified mentor in a laboratory accredited by anrganization such as the Intersocietal Commission on theccreditation of MR Laboratories (ICAMRL). Occa-

ionally, a Level 3-qualified mentor will not be availablen the institution housing the general fellowship pro-ram, but is available at a nearby nonacademic medicalenter accredited for CMR by an organization such as theCAMRL. Under these circumstances it is acceptable torovide the training in CMR at such a medical center for

lassification of CMR Procedures

Table 1 Classification of CMR Procedures

1. Standard CMR procedures, including:

a. Tomographic still-frame CMR for morphology using “bright” and/or “dark blood

b. Cine and other approaches to CMR for assessment of ventricular function

c. Magnetic resonance angiography and cine CMR of the great vessels, anomalou

d. Delayed contrast-enhanced CMR for myocardial infarction, scar, intraventricularviability assessment and visualization of other causes of abnormal myocardial

e. First-pass CMR (with vasodilator infusion) or cine CMR with stress (with inotroppatients with coronary microvascular disease

f. Phase-contrast velocity mapping for blood flow quantification for shunt sizing an

g. Peripheral magnetic resonance angiography

2. Less common procedures, including:

a. Myocardial tagging (approach unique to CMR that allows more detailed evaluatfor evaluation of pericardial disease)

b. Coronary magnetic resonance imaging of the native coronary arteries

c. Magnetic resonance spectroscopy using 31P (to assess “high energy phosphate

MR � cardiovascular magnetic resonance.

omponents of CMR Training

Table 2 Components of CMR Training

1. Didactic activities

a. Lectures (It will be necessary in learning the physical principles and in case intecases.)

b. Self-study (it is possible to use cases from teaching files, journals, textbooks, ortrainee’s records and should not comprise any more than 50% of the cases stu

2. Independent interpretation of CMR cases (performed in the mentoring CMR labor

3. Participation in CMR case study interpretation

4. “Hands-on” CMR experience

MR � cardiovascular magnetic resonance.

ll levels of training. The CMR training center and therainee should maintain a logbook or other specificecords to document the cases reviewed and the didacticours in which the trainee has participated.The depth of knowledge should increase with increasing

evels of training. In the case of the Level 3 trainee,pecialized training and, for academic trainees, researchraining related to CMR should be offered as a part of anstablished training program (Table 2).

evel 1: General Training (1 Month Minimum)

he trainee should have exposure to the methods and theultiple applications of CMR for a period of not less thanmonth or its equivalent when integrated with other

raining activities. This experience should provide basicackground knowledge in CMR sufficient for the practice ofdult cardiology and referral for CMR evaluation, but notor the practice or independent clinical interpretation ofMR. As a practical matter, many fellowship programs in

ardiovascular medicine may not be able to fulfill CMRraining. In these instances, fellows should be encouraged tobtain experience in an alternate program with appropriateraining and accreditation in the performance of CMRtudies.

ods with and/or without a paramagnetic contrast agent

ary arteries, and coronary artery bypass grafts

bus, and microvascular obstruction (associated with myocardial infarction) anditium

t) for myocardial perfusion evaluation, ischemia detection, and assessment of

rmination of valvular regurgitation and stenosis

intramural and transmural myocardial function than ventriculography alone and

olism”) or other nuclei

tion to derive such information from relevant lectures; no more than 5% of the

onic/on-line courses. Such self-study cases need to be well documented in the

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nterpretation of CMR studies. During his or her 1onth of training, the trainee should actively participate in

aily CMR study interpretation under the direction of aevel 2- or Level 3-trained CMR physician-mentor. For all

tudies in which angiographic, echocardiographic, radionu-lide, computed tomographic, or hemodynamic data arevailable, this other imaging information should be corre-ated with CMR studies. Studies should include the rangef procedures listed in Table 1. Experience in interpretationa minimum of 25 cases) may include studies from anstablished CMR teaching file.ectures and self-study in CMR. This component shouldonsist of lectures on the basic aspects of CMR and paralleleading material consisting of selected articles, digital train-ng programs, or CMR text. The lectures and readinghould provide the fellow with an understanding of CMRpplications. Specificity, sensitivity, diagnostic accuracy,tility in assessing prognosis, costs, artifacts, indications,ontraindications, and pitfalls must be included for eachardiovascular diagnostic subset. Such information could beffectively transmitted within a weekly noninvasive or clin-cal teaching conference during which CMR data areresented.A basic understanding of magnetic resonance physics should

e provided, including the following: 1) the physics of mag-etic resonance as it relates to image intensity and contrast,

ncluding flow, T1, T2, density of nuclear species (e.g.,roton), and contrast agents; 2) sources of artifacts, includingotion, arrhythmias, and metal objects; 3) safety of implanted

evices (e.g., pacemakers, automatic implantable cardioverter-efibrillators), external ferromagnetic devices, and gadolinium-ased contrast agents (for a summary of safety issues in CMR,ee www.mrisafety.com); and 4) basic post-processing ap-roaches and analyses.

ands-On Experience

ands-on experience is not necessary for Level 1.

evel 2: Specialized Trainingat Least 3 Months)

raining for Level 2 should include the CMR experienceescribed for Level 1. Level 2 is for those trainees whoish to practice the clinical subspecialty of CMR, includ-

ng independent interpretation of CMR studies. Level 2rainees must have at least 3 months of dedicated CMRraining (where 1 month is defined as 4 weeks and 1 weeks defined as 35 h), including the basic elements listed inhe following text. The trainee would be expected toecome familiar with the CMR techniques listed in
able 1.
ackground

n understanding of CMR physics should be substantiallyore advanced than in Level 1 training (see the following

ext).

idactic Activities

nterpretation of CMR studies. During their 3 or moreonths of experience, trainees should actively participate in

aily CMR study interpretation under the direction of aevel 2 or Level 3 (preferred) CMR-qualified physician-entor. For all studies in which other cardiac imaging data

re available, such information should be correlated withMR data. The trainee should interpret at least 150 CMR

xaminations during this training period, including 50 forhich the trainee is present during the scanning procedure,

deally as the primary operator, and is the primary inter-reter. Up to 50 of the 100 examinations for which therainee is not the primary interpreter can be derived fromstablished teaching files, journals and/or textbooks, orlectronic/on-line courses. Careful documentation of allase material and the details of the way in which the caseas derived are essential.ectures and self-study in CMR. Course work would

nclude the components for Level 1 training but should alsonclude more advanced lectures and reading materials. Thisork, with parallel reading, should continue for the dura-

ion of the traineeship. Course work should include theollowing:

. Physics: Trainees should receive didactic lectures from aCMR-trained physician (who has achieved Level 2 or 3in CMR) and/or physicist on the basic physics ofmagnetic resonance in general and as it relates to CMRin particular. The content should include the samematerials as in Level 1 (basic) plus lectures with support-ive reading on the following topics:a. Image formation, including k-space, gradient echo,

spin echo, fast spin echo, echo planar, spiral, steadystate free precession (SSFP), and parallel imaging

b. Specialized imaging sequences, including flow andmotion, phase imaging, time of flight, contrastagents, and radiofrequency tagging

c. Hardware components, including the elements of gra-dient coil design, receiver coils, and digital sampling

. Applications, interpretation, indications, and contraindi-cations: Level 2 didactic activities should include anunderstanding of the sensitivity, specificity, accuracy,utility, costs, acquisition approaches, and disadvantagesof all of the contemporary techniques in CMR. Thefollowing techniques should be covered in the didacticprogram:a. Imaging of structure and tissue characterization (T1,

T2, spin echo, gradient echo, SSFP, image contrastmechanisms, and fat suppression)

b. Imaging of function (cine and tagged cine magnetic
resonance including SSFP imaging approaches)
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407JACC Vol. 51, No. 3, 2008 Pohost et al.January 22, 2008:404–8 ACCF COCATS 3 Training Statement: Task Force 12

c. Volumetric imaging of mass, biventricular volumes,and ejection fraction (using cine magnetic resonanceimaging)

d. Flow imaging (e.g., velocity-encoded techniques)e. Imaging of myocardial infarction, scarring, and via-

bility assessment (delayed contrast-enhancement im-aging)

f. Pharmacologic stress testing with evaluation of ven-tricular function and/or first-pass perfusion imagingusing a contrast agent

g. Magnetic resonance angiography (vascular)h. Mechanisms, types, and pharmacologic aspects of

CMR contrast agentsi. Electrocardiogram and peripheral pulse gating and

triggering including timing of image acquisitionwithin the R-R interval, motion artifacts and theireffects on CMR images; respiratory motion suppres-sion methods (e.g., breath-holding and navigators)

j. Magnetic resonance spectroscopy methods (e.g.,depth resolved surface coil spectroscopy, or DRESS,and 3-dimensional Fourier transform approaches)

k. CMR image analysis and post-processing toolsl. Contraindications for CMR study

m. Incidental findings suggesting pathology outside ofthe cardiovascular system

valuation

he person responsible for the CMR training program muste responsible for assessing the competence of the CMRrainee at the completion of the program. This is accom-lished by examining the ability of the trainee in thenderstanding of the acquisition methods, the interactiveole of the operator during the performance of CMRtudies, and the interpretation of the data acquired duringaily reading sessions. This may be supplemented by formalidactic training.

evel 3: Advanced Training (at Least 12onths for Those Interested in Pursuing alinical or Academic Career in CMR orirecting a CMR Laboratory)

evel 3 CMR training represents the highest level ofraining and would enable the cardiovascular trainee toummary of Requirements for Each Level of CMR Training

Table 3 Summary of Requirements for Each Level of CMR Train


(Months)

1 1 25� mentored interpretations (by

2 3 to 6* 150� mentored interpretations (b50 as primary interpreter (and

3 At least 12 oftraining*

300� mentored interpretations byif possible)†

This time represents the number of months spent reviewing cases, and interpreting, performing, an
ut at least 50% of the time should represent mentored laboratory experience. †The case recommendatextbook, or electronic/on-line courses/continuing medical education. No less than 50% of the cases sho
ursue a clinical or academic career in CMR and to direct aMR laboratory. Level 3 training in CMR could bebtained as part of a 3- or 4-year cardiology fellowship. Inddition to the recommendation for Level 2, the Level 3cademic program should include active participation in anngoing basic and/or clinical CMR research, with indepen-ent responsibility for a specific portion of that research.ocused research work with publication of 1 or moreanuscripts is an essential component of Level 3 training.evel 3 training must be performed under the guidance of at

east one Level 3-trained CMR physician.In parallel with research activities, the Level 3 traineeust participate in clinical imaging, which should include

upervised interpretation of at least 300 CMR cases. Therainee must be physically present and involved in thecquisition and the primary interpretation of at least 100MR cases. In the remaining 200 cases, the trainee should

eview at least 100 of these cases with the Level 3 mentor.he remaining cases can be derived from established teach-

ng files, journals and/or textbooks, or electronic/on-lineourses. Careful documentation of all case material andetails of the way in which the case was derived are essential.Knowledge of magnetic resonance physics must be more

dvanced than that included in Level 2 training and includehe following:

. An understanding of why certain specialized imagingsequences are applicable for specific clinical protocols,including imaging of heart function, coronary arteries,perfusion, delayed enhancement, and peripheral arteries.

. Basic understanding of the clinically applicable spectro-scopic methods.

. The essentials of data collection, including capturing ofdigital data, the maintenance of accurate databases andrecords, signal processing, and the approaches for quan-titating data.

valuation

valuation should be similar to that of Level 2.

ummary of recommendations

he overall requirements for training in CMR are summa-ized in Table 3.

Number of Cases

l 2– or Level 3–trained physician)

rtified Level 2– or Level 3– [preferred] qualified CMR physician, including at leastor, if possible)†

el 3–qualified CMR physician including 100� as primary interpreter (and operator,

ing about cardiovascular magnetic resonance (CMR), and need not be a consecutive block of time,

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his is an update of the 2006 document that was written byatthew J. Budoff, MD, FACC—Chair; Stephan Achenbach,D (Society of Cardiovascular Computed Tomography Repre-

entative); Zahi A. Fayad, PhD, FACC (Society of Atheroscle-osis Imaging and Prevention Representative); Daniel S.erman, MD, FACC; Michael Poon, MD, FACC; Allen J.aylor, MD, FACC; Barry F. Uretsky, MD, FACC (Society

or Cardiovascular Angiography and Interventions Represen- s

ative); and Kim Allan Williams, MD, FACC (Americanociety of Nuclear Cardiology Representative).

doi:10.1016/j.jacc.2007.11.020


ardiovascular imaging y cardiovascular magnetic resonance y steady
tate free precession.
PPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FOR TRAINING INDULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 12: TRAINING INDVANCED CARDIOVASCULAR IMAGING (CARDIOVASCULAR MAGNETIC RESONANCE [CMR])


Grant


Speakers’Bureau

SteeringCommittee

StockHolder Other

Dr. Raymond J.Kim

● Mallinckrodt ● Siemens None None None None ● Heart IT—Founder

Dr. ChristopherM. Kramer

● GE Healthcare ● Astellas● Novartis

None ● GE Healthcare None None ● Siemens—Researchsupport

Dr. Warren J.Manning


Dr. Gerald M.Pohost

None ● GE Healthcare None ● TakedaPharmaceuticals

None None None


PPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FORRAINING IN ADULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 12:RAINING IN ADVANCED CARDIOVASCULAR IMAGING (CARDIOVASCULAR MAGNETIC RESONANCE [CMR])


Grant


Speakers’Bureau

SteeringCommittee

StockHolder Other


● Official–Board of Trustees None None None None None None None

Dr. RaymondY. K. Kwong

● Organizational–Society forCardiovascular MagneticResonance


Dr. NathanielReichek

● Organizational–Society forCardiovascular MagneticResonance


he individuals listed above did not declare any relationships with industry. This table represents the relationships of peer reviewers with industry that were reported by the authors as relevant to this topic.t does not necessarily reflect relationships with industry at the time of publication. *Names are listed in alphabetical order with each category of review.

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409JACC Vol. 51, No. 3, 2008 Budoff et al.January 22, 2008:409–14 ACCF COCATS 3 Training Statement: Task Force 13

Task Force 13: Training in Advanced CardiovascularImaging (Computed Tomography)Endorsed by the American Society of Nuclear Cardiology, Society ofAtherosclerosis Imaging and Prevention, Society for CardiovascularAngiography and Interventions, and Society of Cardiovascular ComputedTomography

Matthew J. Budoff, MD, FACC, ChairStephan Achenbach, MD (Society of Cardiovascular Computed Tomography Representative),Daniel S. Berman, MD, FACC, Zahi A. Fayad, PHD, FACC (Society of Atherosclerosis Imagingand Prevention Representative), Michael Poon, MD, FACC, Allen J. Taylor, MD, FACC,Barry F. Uretsky, MD, FACC (Society for Cardiovascular Angiography and Interventions Representative),Kim Allan Williams, MD, FACC (American Society of Nuclear Cardiology Representative)

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omputed tomography (CT) is one of the most rapidlyvolving techniques for assessing cardiovascular anatomy.he complex nature of the imaging devices and anatomy

nd the rapidly advancing uses of these modalities requirehe trainee to be introduced to this modality. Clinicalpplication of CT encompasses noncontrast (coronary cal-ium evaluation), contrast (CT angiography and function),nd hybrid studies (combining nuclear cardiac scanningith CT). Computed tomography, like invasive catheter-

zation, provides information concerning cardiovascularnatomy and function (i.e., ejection fraction). Hybrid de-ices are rapidly evolving to incorporate state-of-the-art,igh-speed multi-detector computed tomography (MDCT)echnology, along with the latest positron emission tomog-aphy (PET) and single-photon emission computed tomog-aphy (SPECT) detector systems. Current hybrid systemsMDCT plus nuclear) provide attenuation correction forPECT and PET thereby further improving the diagnosticccuracy of more traditional radionuclide techniques.

It should be noted that the guidelines for fellows-in-trainingutlined here and those for physicians in practice previouslyublished have slightly different targets for time and experience1). The fellows-in-training are expected to get exposure to CThroughout their training, incorporating the results with echo-ardiography, nuclear cardiology, cardiovascular magnetic res-nance (CMR), and cardiac catheterization when appropriate.hysicians in practice who are first being exposed to cardio-ascular computed tomography (CCT) will most likely notave this comprehensive approach. Guidelines for practicinghysicians are published by the American College of Cardiol-gy/American Heart Association Task Force on Clinical
ompetence in Computed Tomography and Magnetic Reso- a
ance (2). Fellowship training in CT should include instruc-ion in the basic aspects, but only those fellows who go beyondhe basic level are trained sufficiently for independent interpre-ation of CT studies. Every trainee should be educated in these of CT and in cardiovascular anatomy, physiology, andathophysiology, as well as physics of CT and radiationeneration and exposure. As many CCT studies are doneefore and after intravenous administration of iodinated con-rast, a thorough understanding of contrast injection methods,dverse events and their treatments, and contrast kinetics inatients will be required. In particular, knowledge is needed inhe methods of contrast-enhanced imaging of the pericardium,ight ventricle, right atrium, and superior and inferior venaavae as well as imaging of the left heart, surrounding greatessels, and the central circulation.

By the end of the fellowship, trainees should have beenxposed to CCT studies, both in interpretation and perfor-ance. It is currently recognized that many programs might

ot have availability of CCT, and options should be madevailable to obtain training at a different facility if the primaryrogram cannot accommodate. The trainee should master theelation between the results of the CT examination and findingsf other cardiovascular tests, such as catheterization, nuclearardiology, magnetic resonance, and echocardiography. Everyardiology fellow should be exposed to and be familiar with theechnical performance, interpretation, strengths, and limitations ofT and its multiple clinical applications. It is recognized that CT

s an evolving technology in a rapid phase of development andmprovement, with an expanding list of clinical indications.

For appropriate use of this technology, it is possible to definelevels of expertise (Table 1). All cardiology fellows must

ttain at least the first level of expertise. This entails under-

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410 Budoff et al. JACC Vol. 51, No. 3, 2008ACCF COCATS 3 Training Statement: Task Force 13 January 22, 2008:409–14

tanding the basic principles, indications, applications, andechnical limitations of CT and the interrelation of thisechnique with other diagnostic methods. This level will notualify a trainee to perform CT or to interpret CT independently.

Level 2 is defined as the minimum recommended training fortrainee to independently perform and interpret CCT. Level 3

xpertise would enable the trainee to direct a CT laboratory.

eneral Standards

he CT laboratory in which training is undertaken shoulde under the direct supervision of a full-time qualifiedirector (or directors) who has achieved Level 3 training.raining guidelines in the present document are primarilyirected to trainees performing CCT examinations in adultatients with acquired and congenital heart disease. Partic-pation of additional full- or part-time faculty is highlyesirable because of the multiple applications of CT (i.e.,ttenuation correction of nuclear imaging, noncontrast andontrast studies, function, structure, congenital, and vascularmaging). The CCT examination is an operator-dependentrocedure in which it is possible to introduce confoundingrtifacts or omit data of diagnostic importance. Hands-onraining is important, not to develop technical expertise incquiring images, but rather as a valuable aid to learnomographic cardiac anatomy, integrate planar views into a-dimensional framework (nonplanar and oblique/ultiplanar imaging), and understand the distinction be-

ween reliable and unreliable data. Understanding theource of the artifacts (breath-holding, gating, or arrhyth-ias) present on the images is vital.


lthough numbers of studies and time intervals of trainingre given as guidelines, these numbers are less importanthan depth of understanding and quality of the clinicalxperience. It is recommended that fellows keep a log

equirements for CCT Study Performance andnterpretation to Achieve Level 1, 2, and 3linical Competence

Table 1Requirements for CCT Study Performance andInterpretation to Achieve Level 1, 2, and 3Clinical Competence

CumulativeDuration of

Training

Minimum Numberof MentoredExaminations

Present DuringPerformance

Minimum Numberof MentoredExaminationsInterpreted

Level 1 1 month* — 50†

Level 2 2 months* 35 150 CCT cases†

Level 3 6 months* 100 300 CCT cases†

This represents cumulative time spent interpreting, performing, and learning about cardiovascu-ar computed tomography (CCT), and need not be a consecutive block of time, but at least 50% ofhe time should represent supervised laboratory experience. In-lab training time is defined as ainimum of 35 h/week. †The caseload recommendations may include studies from an estab-

ished teaching file, previous CCT cases, journals and/or textbook, or electronic/on-line courses/ontinuing medical education.

ocumenting their involvement in CT studies, as well as c

heir exposure to appropriate continuing medical educationours.The recommendations for all levels of training in the

ollowing text represent a cumulative experience, and it isxpected that for many fellows, the training will not beontinuous. A summary of the training requirements isiven in Table 1. For all Level 2 and Level 3 requirements,he minimum time in a CCT laboratory is 50% of the timeisted. The remaining time required can be garnered byupervised time, CT exposure in courses, case studies,D/DVD training, time at major medical meetings devoted

o performance of CCT, or other relevant educationalraining activities, to name just a few examples. Theaseload recommendations may include studies from anstablished teaching file, previous CCT cases, andlectronic/on-line experience or courses.

escription of Cases

ctivities that qualify for the 35 cases where the candidates “physically present and involved in the acquisition andnterpretation of the case”:

The following 3 elements must be met:

. Candidate must be present in the scanning suite (orcontrol room) or in the presence of a video feed duringCT raw data acquisition and image reconstruction fromthat raw data.

. Interactive manipulation of the reconstructed data setsfor evaluation of the scan must be performed by thecandidate. Individual cases should include all compo-nents of cardiac structure and function as well asnoncardiac structures as indicated.

. During this data evaluation process, there must be anopportunity for interaction between the candidate andtrainer.

Activities that qualify for the additional 100 cases include:

. A maximum of 50 cases from an educational CD orpresentation granting continuing medical educationcredit that contains CT data review, clinical informa-tion, and appropriate clinical correlative information(e.g., invasive coronary angiographic images).

. Up to 100 but not less than 50 of the cases must involveinteractive manipulation of reconstructed data sets usinga workstation or equivalent.

evel 1 Training (1 Month, at Least 50xaminations Interpreted)

evel 1 is defined as the minimal introductory training foramiliarity with CCT, but it is not sufficient for independentnterpretation of CCT images. The individual should haventensive exposure to the methods and the multiple appli-ations of CCT for a period of at least 1 month. The time
ommitment for training is defined as 35 h per week. This

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hould provide a basic background in CCT for the practicef adult cardiology. During this cumulative 4-week experi-nce, individuals should have been actively involved in CCTnterpretation under the direction of a qualified (preferablyevel 3–trained) physician-mentor (1). There should be aentored interpretative experience of at least 50 cases for all

tudies in which other cardiovascular imaging methods arelso available, correlation with CCT findings, and interpre-ation. Mentored interpretive experience may include stud-es from an established teaching file or previous CCT casesnd also includes the potential for CD/DVD and on-lineraining.

For all levels of competence, it is expected that theandidate will attend lectures on the basic concepts of CCTnd include parallel self-study reading material. A basicnderstanding of CCT should be achieved including: thehysics of CCT imaging, the basics of CCT scan perfor-ance, safety issues in CCT performance, side effects (and

heir treatment) of medications used currently includingeta blockers and nitrates, post-processing methods, andasics of CCT interpretation as compared with otherardiovascular imaging modalities including echocardiogra-hy, nuclear cardiology, CMR, and invasive cardiac andascular x-ray angiography. Furthermore, auxiliary cardiaciagnostics should include recognition of ventricular hyper-rophy, dilation, valve pathologies such as mitral stenosis/nnular and leaflet calcification, cardiac masses, aortic valveathology (number of cusps) and calcification/aortic steno-is, pericardial and infiltrative myocardial disease, internalammary arteries, left atrial and pulmonary and coronary

enous abnormalities, thoracic aortic pathology, and saphe-ous vein grafts.

evel 2 Training (2 Months of Training andnterpretation of 50 Noncontrast and 150ontrast Studies Total, 35 of Which theellow is Present During Performance)

evel 2 is defined as the minimum recommended trainingor a physician to independently perform and interpretCT. To accomplish this, the fellow should devote an

dditional 1 month, or the equivalent, interpreting a mini-um of 150 contrast studies total. The noncontrast and

ontrast studies may be evaluated in the same patients. Ofhese, at least 35 cases should be performed with the fellowresent under appropriate supervision. Competence at this

evel implies that the fellow is sufficiently experienced tonterpret the CT examination accurately and independently.ontinued exposure to special CT procedures, such asybrid studies with nuclear imaging and integration of

mages into electrophysiologic procedures, is appropriateuring Level 2 training.Didactic studies should include advanced lectures, read-

ng materials, and formal case presentations. These didactic i

tudies should include information on the sensitivity, spec-ficity, accuracy, utility, costs, advantages, and disadvantagesf CCT as compared with other cardiovascular imagingodalities. Each fellow should receive documented training

rom a CCT mentor and/or physicist on the basic physics ofT in general and on CCT in particular. Lectures will

nclude discussions of anatomy, contrast administration andinetics, and the principles of 3-dimensional imaging andost-processing. The fellow should also receive training inrinciples of radiation protection, the hazards of radiationxposure to both patients and CT personnel, and appropri-te post-procedure patient monitoring.

A fellow with Level 2 and Level 3 training shouldemonstrate clear understanding of the various types of CTcanners available for cardiovascular imaging (electron beamomography and MDCT) and understand, at a minimum,he common issues related to imaging, post-processing, andcan interpretation including:

Indications and risk factors that might increase thelikelihood of adverse reactions to contrast mediaRadiation exposure factorsCT scan collimation (slice thickness)CT scan temporal resolution (scan time per slice)Table speed (pitch)Field of viewWindow and level view settingsAlgorithms used for reconstructionContrast mediaPresence and cause of artifactsPost-processing techniques and image manipulation onwork stationsTotal radiation dose to the patient

ncidental Noncardiac Findings

uring a CCT examination, the standard use of a smalleld of view (e.g., limited lung fields) precludes completevaluation of the entire thorax. However, to address theossibility that significant noncardiac imaging findings,e.g., aortic disease, hilar adenopathy, large pulmonaryodules, and pulmonary emboli) might be present on aCT scan, specific interpretation of the extra-cardiac fields

hould be performed. The patient and the referring physi-ian should understand that the focus of the CCT exami-ation is the detection of cardiac disease, and the scan doesot encompass the entire lung field. Regarding the cardio-ascular medicine specialist performing CCT, the Taskorce recognizes and endorses education and training ofuch individuals in the recognition of incidental scan find-ngs in support of quality imaging care of patients withardiovascular disease. These cases require referral to apecialist or a radiologist with expertise in chest imaging. Tohis end, it is felt that Level 2 and Level 3 training should
nclude the review of all CCT cases for noncardiac findings.

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he review of 150 CCT cases for incidental findings shouldnclude the review of a dedicated teaching file of 25 CCTases featuring the presence of significant noncardiac pa-hology. Furthermore, part of the core curricula for Level 2nd Level 3 should include specific lectures on non-CCTathology.

evel 3 Training (Total 6 Months of Training,nclusive of Level 1 and 2, 150 Additionalxaminations)

evel 3 training represents the highest level of exposure/xpertise that would enable an individual to serve as airector of an academic CCT section or director of an

ndependent CCT facility or clinic. This individual woulde directly responsible for quality control and training ofechnologists and be a mentor to other physicians seekinguch training. For a trainee desiring to direct a CT labora-ory (Level 3), a total of 6 months of training devoted to CTs required, with an additional 6 months experience whichan be obtained concurrently with training in other imagingodalities. To attain Level 3, candidates should be involvedith interpretation of at least 100 noncontrast and 300

ontrast CCT examinations. For at least 100 of these cases,he candidate must be physically present and be involved inhe acquisition and interpretation of the case. At the discretionf the director, increasing independence in interpretationnd over-reading of CT studies can be implemented.

In addition to the recommendations for Level 1 andevel 2 training, Level 3 training should include active andngoing participation in a basic research laboratory, clinicalesearch, or graduate medical teaching. Level 3 traininghould also include exposure to administrative aspects ofunning a CT laboratory and documented experience in CTesearch, as well as understanding of new and evolving CTnd nuclear/CT technologies. To complete Level 3, therainee should fulfill all of the previously described require-ents and develop competence in performing and interpreting

pecial procedures, such as hybrid studies and electrophysi-logic studies (integration of CT images with fluoroscopicmages to provide enhanced visualization for ablation).

raining for Physicians in Practice

t should be recognized how difficult it is to recreate thereadth and intensity of a training fellowship once anndividual has assumed the full-time responsibilities of aractice setting. For the practicing physician interested inbtaining equivalent training, please refer to the recenteport of the ACC/AHA/American College of Physiciansask Force on Clinical Competence on Computed Tomog-

aphy and Magnetic Resonance (2). M

ascular CT Imaging

ascular CT, at this point, represents an optional portion ofraining. As a cardiovascular specialist, it is expected that theardiology fellow acquire skills beyond the cardiac structuresnd coronary tree. It is well established that CT has a highensitivity and specificity for vascular disease outside theeart. Carotid, renal, and peripheral imaging has been wellalidated, even prior to MDCT availability. The additionalenefits of large volumes of coverage per rotation with theewer MDCT scanners allows for very rapid imaging of thearotid, renal, or peripheral vascular bed, with minimalontrast requirements and great spatial resolution. The lackf motion of these vascular beds makes imaging less difficultor interpretation than coronary evaluation. Furthermore,he acquisition of the images are much easier for peripheraleds, and physics, acquisition parameters, and reconstruc-ion techniques learned during cardiac evaluations are sim-lar for vascular imaging. However, vascular imaging re-uires additional knowledge of the anatomy, as well asathophysiology of each vascular bed. For the candidate tochieve Level 2 competence in cardiac and vascular CT, it isecommended that an additional 35 mentored contrast cases bencluded (over the 150 case requirement for cardiac), specifi-ally targeting peripheral vascular beds. To achieve Level 3 forardiac and vascular CT, 100 additional mentored vascularases should be reviewed by the trainee. There is currently noathway for vascular CT imaging without meeting the Level 2r Level 3 criteria for CCT outlined in Table 1.

rainee Evaluation

ven in academic centers, where most trainees are taught,here is currently a failure to provide ideal CCT services toardiovascular patients. The individual must have knowledgef the specific equipment to be used in each procedure,ncluding x-ray contrast, CCT physics, and radiation exposure.ssessment of technical performance is best done by directversight during interpretation of procedures. The competencef all cardiology trainees in CCT should be documented byoth the cardiovascular program director and the programirector of the CCT laboratory. Records must be maintainedf all evaluations and of the number and type of all laboratoryrocedures performed by each trainee. Numbers of cases thathe trainee is involved in, both in the live acquisition of cases,s well as the number of cases the trainee is involved in thenterpretation is critical for competence in CCT. The use ofxaminations (e.g., the Cardiac Computed Tomography Self-ssessment Program [CCTSAP]) at the end of CCT training

s strongly encouraged. All procedures performed by the traineeust be documented electronically or in a logbook.

his is an update of the 2006 document that was written by
atthew J. Budoff, MD, FACC—Chair; Stephan Achen-

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ach, MD (Society of Cardiovascular Computed Tomographyepresentative); Zahi A. Fayad, PhD (Society of Athero-

clerosis Imaging and Prevention Representative); Daniel S.erman, MD, FACC; Michael Poon, MD, FACC; Allen J.aylor, MD, FACC; Barry F. Uretsky, MD, FACC (Society

or Cardiovascular Angiography and Interventions Repre-entative); and Kim Allan Williams, MD, FACC (Americanociety of Nuclear Cardiology Representative).

doi:10.1016/j.jacc.2007.11.021


. Budoff MJ, Achenbach S, Fayad Z, et al. Task Force 12: training in
advanced cardiovascular imaging (computed tomography): endorsed by c
the American Society of Nuclear Cardiology, Society for CardiovascularAngiography and Interventions, Society of Atherosclerosis Imaging andPrevention, and Society of Cardiovascular Computed Tomography.J Am Coll Cardiol 2006:47;915–20.

. Budoff MJ, Cohen MC, Garcia M, et al. ACC/AHA clinical compe-tence statement on cardiac imaging with computed tomography andmagnetic resonance: a report of the American College of Cardiology/American Heart Association/American College of Physicians TaskForce on Clinical Competence (ACC/AHA Committee on CardiacTomography). J Am Coll Cardiol 2005;46:383–402.


ardiovascular imaging y computed tomography y positron emissionomography y single-photon emission computed tomography y

ardiovascular magnetic resonance.

PPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FOR TRAINING INDULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 13: TRAINING INDVANCED CARDIOVASCULAR IMAGING (COMPUTED TOMOGRAPHY)


BoardSpeakers’

BureauSteering


Dr. StephanAchenbach

● Bristol-MyersSquibb Imaging

● Siemens None ● Bracco● Siemens

None None None

Dr. Daniel S.Berman

● Tyco-Mallinckrodt

● Astellas● Bristol-MyersSquibb Imaging

● GE Healthcare

● SpectrumDynamics

None None ● SpectrumDynamics

● Cedars-Sinai MedicalCenter—Softwareroyalties

Dr. Matthew J.Budoff

None None None ● GE Healthcare None None None

Dr. Zahi A. Fayad None None None None None None None

Dr. Michael Poon None None ● Chase Medical● Siemens● TeraRecon

None None None None

Dr. Allen J. Taylor None ● KosPharmaceuticals

● Pfizer ● KosPharmaceuticals

None None None

Dr. Barry F. Uretsky None None None None None None None

Dr. Kim AllanWilliams


● Bristol-MyersSquibb Imaging

● CV Therapeutics● GE Healthcare

● GE Healthcare ● Astellas● GE Healthcare

None None None


ATT

Tp


PPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY—ACCF 2008 RECOMMENDATIONS FORRAINING IN ADULT CARDIOVASCULAR MEDICINE CORE CARDIOLOGY TRAINING (COCATS 3)—TASK FORCE 13:RAINING IN ADVANCED CARDIOVASCULAR IMAGING (COMPUTED TOMOGRAPHY)

Name* Affiliation Consultant Research Grant


Speakers’Bureau

SteeringCommittee

StockHolder Other

Dr. David J.Clardy






Dr. John J.Mahmarian



Dr. Mylan C.Cohen



Dr. Harvey S.Hecht

● Organizational–Societyof AtherosclerosisImaging andPrevention


Dr. Paolo Raggi ● Organizational–Societyof AtherosclerosisImaging andPrevention


Dr. AmjadAlmahameed

● Organizational–Societyfor Vascular Medicine

● GlaxoSmithKline None None ● Aventis● GlaxoSmithKline● Sanofi

None ● GlaxoSmithKline None

Dr. Joshua A.Beckman



Dr. Susan M.Begelman



Dr. Leonardo C.Clavijo



Dr. James B.Froehlich



Dr. Scott Kinlay ● Organizational–Societyfor Vascular Medicine


Dr. Emile R.Mohler, III



Dr. John E.Brush, Jr.

● Content–IndividualReviewer


Dr. MarcelloDiCarli

● Content–IndividualReviewer

● Bracco● Bristol-MyersSquibb Imaging

● GE Healthcare

● Astellas● Bracco● Bristol-MyersSquibb Imaging

● GE Healthcare

● Bracco● Bristol-MyersSquibbImaging

● GEHealthcare

● Astellas● Bracco● GE Healthcare

None None None
