JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 65, NO. 17, 2015 ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00 PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacc.2015.03.017

TRAINING STATEMENT ACC 2015 Core Cardiovascular Training Statement (COCATS 4) (Revision of COCATS 3)

A Report of the ACC Competency Management Committee

Task Force Introduction/Steering Committee Task Force 3: Training in Electrocardiography, Members Jonathan L. Halperin, MD, FACC Ambulatory Electrocardiography, and Exercise Testing (and Society Eric S. Williams, MD, MACC Gary J. Balady, MD, FACC, Chair

Representation) Valentin Fuster, MD, PHD, MACC Vincent J. Bufalino, MD, FACC Martha Gulati, MD, MS, FACC Task Force 1: Training in Ambulatory, Jeffrey T. Kuvin, MD, FACC Consultative, and Longitudinal Cardiovascular Care Lisa A. Mendes, MD, FACC

Valentin Fuster, MD, PHD, MACC, Co-Chair Joseph L. Schuller, MD Jonathan L. Halperin, MD, FACC, Co-Chair Eric S. Williams, MD, MACC, Co-Chair Task Force 4: Training in Multimodality Imaging

Nancy R. Cho, MD, FACC Jagat Narula, MD, PHD, MACC, Chair William F. Iobst, MD* Y.S. Chandrashekhar, MD, FACC Debabrata Mukherjee, MD, FACC Vasken Dilsizian, MD, FACC Prashant Vaishnava, MD Mario J. Garcia, MD, FACC Christopher M. Kramer, MD, FACC Task Force 2: Training in Preventive Shaista Malik, MD, PHD, FACC Cardiovascular Medicine Thomas Ryan, MD, FACC Sidney C. Smith, JR, MD, FACC, Chair Soma Sen, MBBS, FACC Vera Bittner, MD, FACC Joseph C. Wu, MD, PHD, FACC J. Michael Gaziano, MD, FACC John C. Giacomini, MD, FACC Quinn R. Pack, MD Donna M. Polk, MD, MPH, FACC Neil J. Stone, MD, FACC Stanley Wang, MD, JD, MPH

This document was approved by the American College of Cardiology Board of Trustees in March 2015. For transparency, disclosure information for the ACC Board of Trustees, the board of the convening organization of this document, is available at: http://www.acc.org/about-acc/leadership/officers-and- trustees. The American College of Cardiology requests that this document be cited as follows: Halperin JL, Williams ES, Fuster V, Cho NR, Iobst WF, Mukherjee D, Vaishnava P, Smith SC Jr, Bittner V, Gaziano JM, Giacomini JC, Pack QR, Polk DM, Stone NJ, Wang S, Balady GJ, Bufalino VJ, Gulati M, Kuvin JT, Mendes LA, Schuller JL, Narula J, Chandrashekhar YS, Dilsizian V, Garcia MJ, Kramer CM, Malik S, Ryan T, Sen S, Wu JC, Ryan T, Berlacher K, Lindner JR, Mankad SV, Rose GA, Wang A, Dilsizian V, Arrighi JA, Cohen RS, Miller TD, Solomon AJ, Udelson JE, Garcia MJ, Blankstein R, Budoff MJ, Dent JM, Drachman DE, Lesser JR, Grover-McKay M, Schussler JM, Voros S, Wann LS, Hundley WG, Kwong RY, Martinez MW, Raman SV, Ward RP, Creager MA, Gornik HL, Gray BH, Hamburg NM, Mohler ER, White CJ, King SB III, Babb JD, Bates ER, Crawford MH, Dangas GD, Voeltz MD, Calkins H, Awtry EH, Bunch TJ, Kaul S, Miller JM, Tedrow UB, Jessup M, Ardehali R, Konstam MA, Mathier MA, Manno BV, McPherson JA, Sweitzer NK, O’Gara PT, Adams JE III, Drazner MH, Indik JH, Kirtane AJ, Klarich KW, Newby LK, Scirica BM, Sundt TM III, Warnes CA, Bhatt AB, Daniels CJ, Gillam LD, Stout KK, Harrington RA, Barac A, Brush JE Jr, Hill JA, Krumholz HM, Lauer MS, Sivaram CA, Taubman MB, Williams JL. ACC 2015 core cardiovascular training statement 4 (COCATS 4) (revision of COCATS 3). J Am Coll Cardiol 2015;65:1721–3. Copies: This document is available on the World Wide Web site of the American College of Cardiology (http://www.acc.org). For copies of this document, please contact Elsevier Inc. Reprint Department, fax 212-462-1935, e-mail [email protected]. Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology. Requests may be completed online via the Elsevier site (http://www.elsevier.com/about/policies/ author-agreement/obtaining-permission). 1722 Halperin et al. JACC VOL. 65, NO. 17, 2015 Core Cardiovascular Training Statement 4 MAY 5, 2015:1721– 3

Task Force 5: Training in Echocardiography Task Force 11: Training in Arrhythmia Diagnosis Thomas Ryan, MD, FACC, FASE, Chair and Management, Cardiac Pacing, and Kathryn Berlacher, MD, FACC Electrophysiology Jonathan R. Lindner, MD, FACC, FASE Hugh Calkins, MD, FACC, FHRS, Chair Sunil V. Mankad, MD, FACC, FASEy Eric H. Awtry, MD, FACC Geoffrey A. Rose, MD, FACC, FASE Thomas Jared Bunch, MD, FACC Andrew Wang, MD, FACC Sanjay Kaul, MBBS, FACC John M. Miller, MD, FACC, FHRS Task Force 6: Training in Nuclear Cardiology Usha B. Tedrow, MD, MSC, FHRSzz Vasken Dilsizian, MD, FACC, Chair James A. Arrighi, MD, FACC, FASNCz Task Force 12: Training in Heart Failure Rose S. Cohen, MD, FACC Mariell Jessup, MD, FACC, Chair Todd D. Miller, MD, FACC Reza Ardehali, MD, PHD, FACC Allen J. Solomon, MD, FACC Marvin A. Konstam, MD, FACCxx James E. Udelson, MD, FACC, FASNC Bruno V. Manno, MD, FACC Task Force 7: Training in Cardiovascular Michael A. Mathier, MD, FACC Computed Tomographic Imaging John A. McPherson, MD, FACC Mario J. Garcia, MD, FACC, Chair Nancy K. Sweitzer, MD, PHD, FACC Ron Blankstein, MD, FACC Matthew J. Budoff, MD, FSCAIx Task Force 13: Training in Critical Care Cardiology John M. Dent, MD, FACC Patrick T. O’Gara, MD, FACC, Chair Douglas E. Drachman, MD, FACC Jesse E. Adams III, MD, FACC John R. Lesser, MD, FACC Mark H. Drazner, MD, MSC, FACC Maleah Grover-McKay, MD, FACC, FASNC Julia H. Indik, MD, FACC Jeffrey M. Schussler, MD, FACC, FSCAIk Ajay J. Kirtane, MD, SM, FACC Szilard Voros, MD, FACC{ Kyle W. Klarich, MD, FACC L. Samuel Wann, MD, MACC, FASNCz L. Kristen Newby, MD, MHS, FACC Benjamin M. Scirica, MD, MPH, FACC Task Force 8: Training in Cardiovascular Thoralf M. Sundt III, MD, FACC Magnetic Resonance Imaging Chair Christopher M. Kramer, MD, FACC, Task Force 14: Training in Care of Adult Patients W. Gregory Hundley, MD, FACC with Congenital Heart Disease Raymond Y. Kwong, MD, MPH Carole A. Warnes, MD, FACC, Chair Matthew W. Martinez, MD, FACC Ami B. Bhatt, MD, FACC Subha V. Raman, MD, FACC# Curt J. Daniels, MD, FACC R. Parker Ward, MD, FACC Linda D. Gillam, MD, MPH, FACC Karen K. Stout, MD, FACC Task Force 9: Training in Vascular Medicine Mark A. Creager, MD, FACC, MSVM, Chair Task Force 15: Training in Cardiovascular Research Heather L. Gornik, MD, FACC, FSVM** and Scholarly Activity Bruce H. Gray, DO, MSVMyy Robert A. Harrington, MD, FACC, Chair Naomi M. Hamburg, MD, FACC, FSVM Ana Barac, MD, PHD, FACC William F. Iobst, MD* John E. Brush, JR, MD, FACC Emile R. Mohler III, MD, FACC, FSVM Joseph A. Hill, MD, PHD, FACC Christopher J. White, MD, FACC Harlan M. Krumholz, MD, SM, FACC Task Force 10: Training in Cardiac Michael S. Lauer, MD, FACCkk Catheterization Chittur A. Sivaram, MBBS, FACC Spencer B. King III, MD, MACC, FSCAI, Chair Mark B. Taubman, MD, FACC Joseph D. Babb, MD, FACC, FSCAIk Jeffrey L. Williams, MD, FACC Eric R. Bates, MD, FACC, FSCAI Michael H. Crawford, MD, FACC George D. Dangas, MD, FACC, FSCAI Michele D. Voeltz, MD, FACC Christopher J. White, MD, FACC, FSCAI JACC VOL. 65, NO. 17, 2015 Halperin et al. 1723 MAY 5, 2015:1721– 3 Core Cardiovascular Training Statement 4

{Society of Atherosclerosis Imaging and Prevention Representative. #Society for Cardiovascular Magnetic Resonance Representative. *American Board of Internal Medicine Representative. **Society for Vascular Medicine Representative. yAmerican Society of Echocardiography yyAmerican Board for Vascular Medicine Representative. Representative. zzHeart Rhythm Society Representative. zAmerican Society of Nuclear Cardiology xxHeart Failure Society of America Representative. Representative. kkDr. Lauer participated in this work as part of his official Federal xSociety for Cardiovascular Computed Tomography duties. However, the opinions expressed in this paper do not Representative. necessarily reflect the official positions of the NHLBI, the NIH, or the kSociety for Cardiovascular Angiography and U.S. Department of Health and Human Services. Interventions Foundation Representative.

ACC Eric S. Williams, MD, MACC, Chair Susan Fernandes, LPD, PA-C Competency Jonathan L. Halperin, MD, FACC, Co-Chair Rosario Freeman, MD, FACC Management Nkechinyere Ijioma, MD Committee James A. Arrighi, MD, FACC Jeffrey T. Kuvin, MD, FACC Eric H. Awtry, MD, FACC Joseph E. Marine, MD, FACC Eric R. Bates, MD, FACC John A. McPherson, MD, FACC Salvatore Costa, MD, FACC Lisa A. Mendes, MD, FACC Lori Daniels, MD, FACC Chittur A. Sivaram, MBBS, FACC Akshay Desai, MD, FACC Andrew Wang, MD, FACC Douglas E. Drachman, MD, FACC Howard H. Weitz, MD, FACC JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL.65,NO.17,2015 ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00 PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacc.2015.03.020

COCATS 4 Introduction

Jonathan L. Halperin, MD, FACC Valentin Fuster, MD, PHD, MACC Eric S. Williams, MD, MACC

1. EVOLUTION OF TRAINING Council for Graduate Medical Education (ACGME) RECOMMENDATIONS FOR SPECIALISTS and its Internal Medicine Residency Review Com- IN ADULT CARDIOVASCULAR MEDICINE mittee. The ACGME establishes both common and subspecialty-specific program requirements regarding Recommendations for training in adult cardiovascular training duration, institutional infrastructure, faculty medicine were first published in the Journal in 1995 as leadership and clinician educators, and training a consensus statement emanating from the Core Car- environment and safety, as well as the minimum re- diology Training Symposium (COCATS) held at Heart quirements for program content. Whereas the ACGME House in Bethesda, Maryland, the previous year (1). accredits training programs, the American Board of The term “COCATS” has since been used when refer- Internal Medicine (ABIM) certifies individuals as ring to the American College of Cardiology (ACC) specialists in cardiovascular disease. Successful curriculum recommendations for fellowship programs completion of training in a program with ACGME and has come to designate the Core Cardiology accreditation is a requirement to sit for the ABIM Training Statement (rather than the symposium). The Cardiovascular Disease certifying examination. 1995 recommendations were contained in 10 Task Although the ACGME, ABIM, and ACC represent in- Force reports covering overall training in clinical dependent organizations, their alignment on training cardiology and specialized areas of cardiovascular standardsisimportant,andCOCATShasbeenan medicine. As advances in cardiovascular science and important contributor to the development of the technology evolved, training recommendations were training requirements for cardiovascular disease. revised extensively in 2002 and published as COCATS provides additional curricular content detail “COCATS 2” (2).Inthatiteration,the10original beyond the ACGME minimum requirements for gen- Task Force reports were updated and additional eral cardiovascular disease to define progressive reports were developed that addressed training rec- levels of skill and competency in designated areas. ommendations in the areas of vascular medicine, Over the past several years, there has been a pro- catheter-based peripheral vascular interventions, and gressive move toward competency-based training, cardiovascular magnetic resonance imaging. Subse- the key characteristic of which is evaluation focused quent evolution necessitated further revisions, and on specific learner outcomes. The central require- training recommendations for cardiac electrophysi- ments of such training are to delineate the specific ology and cardiac computed tomography were first components of competency within the subspecialty, published in 2006 as an update to COCATS 2 (3) and define the tools necessary to assess training, and then as a full revision (COCATS 3) in 2008 (4).As establish milestones that should be met as fellows in previous COCATS documents, the terms “fellow” progress toward independence. This evolution is and “trainee” are used interchangeably, as are manifested in COCATS 4, including the overarching “cardiovascular medicine” and “cardiology.” 6-domain structure (Table 1)promulgatedbythe ACGME/American Board of Medical Specialties 2.OVERSIGHTOFPOSTGRADUATE (ABMS)andendorsedbytheABIM(5). EDUCATION FOR SPECIALISTS IN These competencies should be interpreted, devel- CARDIOVASCULAR MEDICINE oped, and evaluated in the context of subspecialty training, recognizing that more basic competencies in Regulatory oversight of training in internal medicine these domains will or should have been acquired and its subspecialties is provided by the Accreditation during residency training in internal medicine, a prerequisite for cardiovascular fellowship. Further- more, maintenance of core competencies over the The American College of Cardiology requests that this document be cited course of one’sprofessionalcareerisasimportantas as follows: Halperin JL, Williams ES, Fuster V. COCATS 4 introduction. J Am Coll Cardiol 2015;65:1724–33. initial competency acquisition.

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TABLE 1 ACGME Core Competencies Entrustable Professional Activities for TABLE 2 Subspecialists in Cardiovascular Disease n Patient Care that is compassionate, appropriate, and effective for treating health problems and promoting health. n Cardiovascular Consultation—evaluate, diagnose, and develop treatment n Medical Knowledge about established and evolving biomedical, clinical, plans for patients with known, with suspected, or at risk of developing and cognate (e.g., epidemiological and social-behavioral) sciences and cardiovascular disease. the application of this knowledge to patient care. n Acute Cardiac Care—manage patients with acute cardiac conditions. n Practice-Based Learning and Improvement that involve investigation n Chronic Cardiovascular Disease Management—manage patients with and evaluation of a fellow’s patient care, self-appraisal, and assimilation chronic cardiovascular diseases. of scientific evidence, and improvements in patient care. n Cardiovascular Testing—appropriately utilize cardiovascular testing. n Interpersonal and Communication Skills that result in effective infor- n Disease Prevention and Risk Factor Control—implement disease pre- mation exchange and teaming with patients, their families, and other vention and risk factor control measures, addressing comorbidities. health professionals. n Team-Based Care—work effectively to promote patient-centered n Professionalism as manifested by a commitment to carrying out pro- interdisciplinary team-based care. fessional responsibilities, adherence to ethical principles, and sensitivity n Lifelong Learning—engage in lifelong learning. to a diverse patient population. n Systems-Based Practice as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to Some human resource professionals draw a distinction provide care that is of optimal value. between the terms “competence” and “competency,” These minimum general competencies were endorsed by the ACGME in February 1999 “ ” (www.acgme.org), and all Residency Review Committees and Institutional Review using competence to describe the actions necessary to Committees were to include this minimum language in their respective Program and perform a function optimally (concerned with effect and fi Institutional Requirements by June 2001. The de nitions are available at http://www. “ ” ncbi.nlm.nih.gov/pmc/articles/PMC3043418/. output rather than effort and input), and competency to ACGME ¼ Accreditation Council for Graduate Medical Education. describe the behaviors that lie behind optimum perfor- mance, such as critical thinking and analytical skills (describing what individuals bring to the profession). Each COCATS Task Force report that follows covers a Because performance requires a combination of behavior, specific field of competency in cardiovascular disease, attitude,andaction,the2termsareusedinterchangeably includes curricular content (milestones) within each in the Task Force reports. domain, and lists potential evaluation tools. It is impor- tant to emphasize several points regarding the compe- tency tables that accompany each Task Force report. First, 3. REVISION OF TRAINING COMPONENTS each curricular milestone need not be independently SINCE EARLIER ITERATIONS OF COCATS evaluated or documented by a formal outcome measure; rather, representative components may be assessed, or in This iteration of COCATS contains a number of structural some cases, assessed in aggregate. Second, the curricular changes in the cardiovascular curriculum since the rec- milestones underpin the more global ACGME/ABIM ommendations issued in 2008. There is a substantially reporting milestones (6); the ACC will also provide tools stronger focus on ambulatory, consultative, and longitu- to facilitate mapping of the relevant curricular compe- dinal care, reflecting a commitment to patient-centric tencies that support achievement of the more global education in clinical cardiology. The intent is for ACGME/ABIM reporting milestones. This is intended to training of the cardiologist as a consultant with a longi- help training program directors respond to this reporting tudinal commitment to the care of the patient to be requirement. Third, the 12-, 24-, and 36-month designa- pervasive throughout the 3-year general cardiology tions that appear in each competency table are intended fellowship. The curriculum also includes a requirement as a roadmap for a typical fellow, helping evaluators that continuity clinics be integrated with service rotations determine whether an individual fellow is progressing in specialized fields such as heart failure, congenital heart on-track toward independent competency. Training pro- disease, geriatric cardiology, and arrhythmias to encom- grams vary widely in their sequencing of educational pass training in this context. experiences, and fellows vary in the pace at which they Two Task Force reports address areas of training not achievecompetency.Thetimeestimatesaresimplyex- covered in previous editions of COCATS: critical care amples and may, therefore, not apply to all programs or cardiology and multimodality noninvasive cardiovascular trainees. Variability is expected and acceptable, as long as imaging, although the latter was addressed as a separate programs provide mechanisms to assess the development publication in 2009 (7). A third report expands consider- of key competencies over time. A supplement to this ably on the pursuit of research and scholarly activity document gathers all of the tables in a compendium. during fellowship training. This revision emphasizes the The aggregated competencies described in COCATS 4 importance of active participation in research and schol- form the basis for the overarching Entrustable Profes- arly activities and outlines a variety of approaches and sional Activities (EPAs) of our profession, namely, those formats to meet this important academic requirement for activities that patients and the public expect all compe- cardiology trainees in the context of a commitment to tent clinical cardiologists to be able to perform (Table 2). lifelong learning.

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This revision of COCATS incorporates the training for Organ Sharing for heart transplant physicians. recommendations for the 4 basic noninvasive imaging Level III heart failure training will require at least 1 modalities—echocardiography (Task Force 5), nuclear additional year of training in advanced heart failure and cardiology (Task Force 6), cardiac computed tomography transplantation. (Task Force 7), and cardiovascular magnetic resonance (Task Force 8)—which are introduced in a new section on 4. MIGRATION TO A multimodality imaging (Task Force 4). Each was written COMPETENCY-BASED CURRICULUM by an individual writing group and represents a revision of a previously published document, except for multi- COCATS 4 utilizes the 6 general competency domains modality imaging, which includes the chairs of the promulgated by the ACGME/ABMS (Table 1)todefine the Task Forces for each component imaging modality and core competencies in clinical cardiology, and structures experts in multimodality imaging. In the previous the curriculum for training to achieve them. The ACC has training paradigm, fellows often rotated through these also adopted this format for its competency and training laboratories as individual silos of imaging technologies, statements, career milestones, lifelong learning, and with individual conferences and separate didactic teach- educational programs and has developed tools to assist ing offerings attached to each modality. The 2008 physicians in assessing, enhancing, and documenting Training Statement on Multimodality Noninvasive Car- competencies. diovascular Imaging indicated that novel methods of Each Task Force report includes a table delineating the training (e.g., allowing concurrent training and consoli- competencydomainsandassociatedcurricularmile- dating curricula among modalities) could allow fellows to stones for training. The milestones are categorized into develop higher-level expertise in more than 1 modality in Level I, II, and III training (defined in the following text) a3-yearfellowship(7). It is increasingly important to and indicate the stage of fellowship training (12, 24, or 36 utilize multimodality imaging principles in conferences months, and additional time points) by which the typical and didactic sessions and to critically discuss the benefits trainee should achieve the designated level of compe- and limitations of various imaging techniques for a given tence. The tables also describe potential evaluation tools clinical indication. for assessing competence in each domain. Level I com- As described in the echocardiography (Task Force 5) petencies may be achieved at earlier or later time points. report, competence in both transesophageal echocardi- Although these tables delineate key competency compo- ography and contrast echocardiography is necessary to nents, they are not comprehensive, and the full spectrum achieve Level II training (defined in Section 5); basic of competency components required of Level I–trained competence in stress echocardiography can be achieved cardiologists is embodied in the Task Force reports that in Level II training. Additional training beyond Level II is together delineate the training requirements and scope of recommended for full competence and independence in curriculum. advanced echocardiography. It is vital to the excellence of a training program that The need for core training in procedural techniques, faculty help trainees develop clinical skills and supervise, such as electrocardiography, ambulatory monitoring, guide, and critique performance and interpretation of and conventional exercise stress testing, is clearly procedures. Although the Task Force reports provide, defined, with the expectation that trainees will develop in some cases, minimum numbers of procedures that increasing sophistication in the application of these should be completed with acceptable outcomes to achieve techniques over the course of the 36-month fellowship. levels of training, performance and interpretation of Training in interventional cardiology as described in a given number of procedures is neither synonymous the Task Force 10 report is limited to formal training with satisfactory completion nor sufficient to define programs in the United States that satisfy the basic adequate training. The numbers of procedures performed standards developed by the ACGME and are accredited and/or interpreted have been developed to be consistent by the ACGME. This Level III training must be achieved with volume recommendations found in the ACC/ during a fourth year of dedicated fellowship American Heart Association practice guidelines, ACC/ experience. American Heart Association /American College of Physi- The Task Force 11 report indicates more specificpro- cians clinical competence statements, expert consensus cedural time and case volume to gain expertise in cardiac statements, and other relevant consensus documents, implantable electronic device management. Training when available; however, the specified volumes of tests in heart failure and transplantation as outlined in the or procedures performed and/or interpreted successfully Task Force 12 report has been revised relative to the to achieve competence are intended as general guidance 1995 and 2002 reports. Level III training in heart failure based on the educational needs and progress of typical acknowledges the requirements of the United Network trainees. When duration of exposure or volume of

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procedures or cases has been suggested, specified n Level III—This level of training requires additional numbers should be considered approximate. The objec- experience beyond the general cardiology fellowship to tives are to ensure exposure to a sufficient breadth of acquire specialized knowledge and competencies in clinical material and pathology and to provide faculty performing, interpreting, and training others to sufficient opportunity to evaluate competency in a given perform specific procedures or for the trainee to render area. Similarly, approximate time frames are guides to advanced, specialized care at a high level of skill. Level facilitate scheduling, reflecting the periods required III training cannot generally be obtained during the by the typical trainee to gain requisite knowledge, skills, standard 3-year general cardiology fellowship and re- and experience in each subdiscipline. Given the com- quires additional exposure in a program that meets plexity and time constraints of training programs, many requirements delineated in Advanced Training State- of the requirements in time and case numbers in various ments (formerly in Clinical Competence Statements) procedures may be satisfied concurrently. Examples and developed for each specialized field of endeavor. include training in stress testing during rotations Advanced (Level III) trained faculty should be available in echocardiography or nuclear cardiology, and experi- to participate in training Level I fellows in cardiac ence in cardiovascular magnetic resonance or cardiac catheterization, interventional cardiology, and cardiac computed tomography interpretation during other imag- electrophysiology, but are not required for Level I ing rotations. training in other fields.

The emphasis of COCATS is on Level I training—delin- 5. STRUCTURE AND LEVELS OF TRAINING eating competencies that all cardiology fellows must acquire during the standard fellowship that follows resi- The ABIM subspecialty board on cardiovascular disease dency training in internal medicine. Level II training is requires 3 years of cardiology fellowship training. Addi- defined for fields in which specific competencies can be tional training beyond the standard 3-year general cardi- undertaken during about 6 months of the 3-year training ology fellowship is required to sit for certification period (depending upon the career focus of trainees) and examinations in clinical cardiac electrophysiology, inter- measured by a standardized qualifying instrument such ventional cardiology, advanced heart failure and trans- as a subspecialty examination. Level II training is not plant cardiology, and adult congenital heart disease. As available or described for fields lacking this criterion. outlined in this document, additional years of training are Level III training is described only in broad terms to also recommended for trainees who desire advanced provide context for trainees and clarify that these expertise in specialized areas, those who want dedicated advanced competencies are not covered during the gen- time for basic and/or clinical research training, or eral cardiology fellowship and require an additional both.InthisrevisionofCOCATS,recommendationsfor period of training and designation by an independent such advanced training experiences are proposed rela- certification board, often coupled with a certifying ex- tive to the discipline of cardiovascular medicine being amination. The advanced training requirements required addressed. to achieve Level III competency will be addressed in Throughout the Task Force reports, training is defined subsequent, separately published clinical competence in terms of the following levels: and advanced training statements. The Steering Com- n Level I—The basic training required of all trainees to be mittee and Task Forces recognize that implementation of competent consultant cardiologists. This can be these changes in training requirements will occur incre- accomplished during a standard 3-year training pro- mentally over time. gram in general cardiology. A summary of the various clinical rotations is depicted n Level II—This refers to the additional training in 1 or conceptually in Figure 1. It is important to emphasize that more areas that enables some cardiologists to perform the intent of this diagram is to illustrate relationships or interpret specific diagnostic tests and procedures or among and potential overlaps across the various clinical render more specialized care for specific patients and and educational experiences during fellowship training conditions. This level of training is recognized only for rather than the specific sequence or duration of rotations. those areas in which a nationally accepted instrument Trainees vary with respect to the length of time spent in or benchmark, such as a qualifying examination, is each area of study based upon prior experience, aptitude, available to measure specificknowledge,skills,or career goals, and interests. Training in cardiovascular competence. Level II training may be achieved by some medicine involves the acquisition of specialized skills and trainees in selected areas during the standard 3-year capabilities in specific technologies as well as experiences general cardiology fellowship, depending on the in longitudinal care and scholarly activity that are trainee’s career goals and use of elective periods. pervasive across virtually the entire fellowship period.

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FIGURE 1 The COCATS Curriculum for Level I Training in Cardiovascular Medicine

This schematic summarizes the components of training during the standard 3-year cardiovascular fellowship. The various clinical rotations are depicted in a conceptual format to illustrate relationships and potential overlap across the various educational experiences rather than the sequence or duration of rotations. Basic experiences in the acute hospital setting typically occur mainly during the first 24 months, although in some cases, some experiences may be deferred to the third year. Exposure to noninvasive diagnostic testing modalities typically occurs at various points throughout the fellowship as trainees develop the ability to integrate the information generated by these modalities into patient care with increasing sophistication. The outer ring of the diagram denotes longitudinal experiences that pervade the entire fellowship training period. These include consultative, ambulatory, and longitudinal patient care and integration of disease prevention strategies into patient management. Proportionate time frames indicated for each experience represent those required by the typical fellow to acquire the required competencies but should be considered approximate. Depending on available resources and particular char- acteristics of some training programs and the background, skills, and career goals of individual trainees, it may be possible to combine certain components of training or to develop certain competencies concurrently with others. Elective time may be devoted to additional training in 1 or more areas selected on the basis of the individual trainee’s needs and career goals. This additional exposure will enable some trainees to gain Level II competence to perform or interpret certain procedures or render more specialized care for specific patients and conditions. Time allocated to research and scholarly activity may be scheduled continuously or at specific points in the 36-month fellowship depending on the trainee’s prior experience, rate of progress, and professional objectives. ACHD ¼ adult congenital heart disease; CCT ¼ cardiovascular computed tomography; CMR ¼ cardiovascular magnetic resonance; CV ¼ cardiovascular; ECG ¼ electrocardiography.

For the typical fellow, approximately half of a year during components are addressed in each Task Force report. the standard 3-year fellowship could be allocated to pur- Case-based conferences are vital to train fellows and suits aligned with the individual’s choice for subsequent develop their skills in evidence-based decision making. advanced training. The individual Task Force reports that Self-learning is emphasized, and Internet-based, online include sections on Level III training provide information educational programs, many of which 1 are interactive, about ancillary fields upon which fellows may choose to play an increasingly important role in learning during focus during general cardiology training to better prepare fellowship and beyond. Such didactic activities are out- them for advanced training in their area of interest. lined throughout the Task Force reports. In most clinical The rapid evolution of cardiovascular science and car- rotations, emphasis should be placed on evidence-based diovascular medicine requires that all training programs practice guideline recommendations, standards for have an experienced faculty, adequate facilities, and a recording clinical data, and appropriate use criteria for rich assortment of didactic offerings for fellows. Specific diagnostic and therapeutic procedures.

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The COCATS Steering Committee, Task Force chairs specific feedback to trainees as they progress through and members, and ACC recognize the need to assist training. trainees, faculty, and program directors with the transi- As much as possible, methods for evaluation and tion from the historical curriculum that was based on documentation of competence have been standardized exposuretimeandcasevolumetothecurrent across the various Task Force reports. An optimum competency-based model. Also recognized is the related training environment includes bidirectional evaluations, need for faculty development tools to facilitate the in which faculty evaluate and provide positive or negative assessment of competency among fellows in training. feedback to trainees and trainees evaluate faculty. The The developers of COCATS are additionally aware of program director should review these evaluations with other challenges facing fellowship programs during the trainee and faculty individually and collectively at this transitional period related to ACGME/ABIM milestone group meetings with both fellows and faculty to address reporting requirements, and the writing groups allow for the curriculum and training environment. Fellows and flexibility in implementation as long as the emphasis on faculty should be formally evaluated after each rotation; competency-based learning is preserved. timely evaluations better enable trainees to process and incorporate feedback into their learning objectives. By 6. EVALUATION OF COMPETENCY AND using a competency- and curricular milestone-based REPORTING OF EDUCATIONAL MILESTONES framework, the ACC has identified specific observable behaviors that, ideally, are easier to evaluate. In addition A key characteristic of competency- and curricular to easing evaluation, this format should also aid in milestone-based training is integration with outcomes- providing more specific feedback to trainees as they based evaluations. Evaluation of competence is an inte- progress through multiple levels of training. gral, continuous, and critical part of the educational Evaluation may be accomplished using a variety of process for the cardiology fellow across the spectrum of modalities on a daily basis. It should include the afore- training. Evaluation tools include a variety of modalities, mentioned tools, but may also include other innovative such as direct observation by instructors, in-training ex- evaluation methods as available. Overall clinical progress aminations, procedure logbooks, conference and case and deficiencies should also be assessed for each trainee presentations, multisource evaluations, trainee portfo- at least twice annually by the training program’s Clinical lios, simulation, and self-reflection. Case management, Competency Committee and reported with recommen- judgment, and interpretive and technical skills must be dations to the cardiology fellowship program director. evaluated regularly in every trainee and discussed with Evaluations are ultimately the responsibility of the the trainee at least twice annually. Quality of care and fellowship program director and should be performed at follow-up; reliability; judgment, decisions, or actions that least twice annually for each fellow using a variety of result in complications; interaction with other physicians, evaluation tools. patients, and laboratory support staff; initiative; and the ability to make appropriate independent decisions should 7. COMPOSITION OF THE be considered. TASK FORCES AND INTEGRATION OF The ACGME distinguishes levels of advancement in TRAINING RECOMMENDATIONS each of the general competencies using milestones that describe a developmental progression from early As knowledge in cardiovascular medicine continues to learner status through advancing or improving compe- expand, training must keep pace. This report represents tency, readiness for unsupervised practice, and at a consensus and was created using the overall format the pinnacle, aspirational achievement by learners. The of the previous COCATS documents. Individual task program must develop an evaluation system that forces were empaneled to address each component of accurately determines each fellow’sprogressionalong training in cardiology and structured similarly to include this developmental continuum. Mechanisms should the following members: representatives of the ACC be incorporated so that fellows who perform sub- and key cardiovascular subspecialty organizations for a optimally or who exhibit critical deficiencies can be given fieldofstudy,acardiovascular training program counseled and provided with opportunities for correc- director who is not a subspecialist in the subject of tive action. Likewise, fellows who are progressing the particular report, a training program director in the appropriately should be challenged to excel. With the particular field, an early-career cardiologist practicing in curricular competency milestones, the ACC provides a the field who has completed fellowship training within schema for evaluating the trainee’s progressive com- 5 to 8 years, experienced specialists practicing in both petency development over the course of the training academic and community-based practice settings, and program. This curricular milestone framework facilitates physicians experienced in developing and applying

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training standards according to the core competencies Following peer review, the revised document was structure promulgated by the ACGME/ABMS. posted for public comment from December 20, 2014, to The writing groups reviewed the 2008 COCATS 3 Task January 6, 2015, resulting in 34 additional comments from Force reports and made revisions, additions, and de- an array of reviewers from both the community-based and letions based on published data and expert opinion. Major academic practice settings, cardiovascular training pro- changes in curricular content most often related to evo- gram directors, sub-subspecialty training program di- lution of subspecialty areas in cardiology and widespread rectors, early-career professionals (in practice <8years), acceptance of emerging technologies in clinical practice. fellows in training, and government employees. The Collectively, the Task Force reports reflect a broad effort authors addressed these comments to finalize the to establish consistent training criteria across all aspects document. of cardiology. All individual COCATS reports were approved by the respective Task Forces, the COCATS Steering Committee, 8. DOCUMENT REVIEW AND ENDORSEMENT and the ACC Competency Management Committee and were subsequently ratified by the ACC Board of Trustees. fl COCATS 4 was reviewed by 55 external peer reviewers, Endorsement by participating societies is re ected in each culminating in over 900 comments that were addressed Task Force report. This document is considered current by authors. The entire document was peer reviewed until the ACC Competency Management Committee re- by the ACC Competency Management Committee, the vises or withdraws it. Cardiology Training and Workforce Committee, and a member of the ACC Board of Trustees and the ACC Board 9. AUTHOR AFFILIATIONS of Governors. A member of the ACC Competency Man- agement Committee served as lead reviewer to ensure The Steering Committee is grateful for the time and effort a fair and balanced peer review resolution process. devoted to this COCATS revision by the Task Force Individual Task Force reports were reviewed by the members and reviewers who provided valuable input. following ACC councils: Task Force 2 report: Prevention Staff of the American College of Cardiology provided su- of Cardiovascular Disease Section Leadership Council; perb support to the COCATS 4 effort, and their contribu- Task Force 3 and 11 reports: Electrophysiology Section tions are recognized with appreciation. Leadership Council; Task Force 4 to 8 reports: Imaging The ACC determined that relationships with industry Section Leadership Council; Task Force 9 report: or other entities were not relevant to the creation of this Peripheral Vascular Disease Section Leadership Council; general cardiology training statement; however, employ- Task Force 10 report: Interventional Section Leadership ment and affiliation information for authors and peer re- Council; Task Force 12 report: Heart Failure and Trans- viewers are provided in Appendixes 1 and 2, respectively, plant Section Leadership Council; and Task Force 15 along with disclosure reporting categories. Comprehen- report: Academic Cardiology Section Leadership Council. sive disclosure information for all authors, including re- Representatives from several organizations also re- lationships with industry and other entities, is available viewed the document: Introduction and Task Force 1 as an online supplement to this document. and 9 reports: the ABIM; Task Force 5 report: the American Society of Echocardiography; Task Force 6 and ACC PRESIDENT AND STAFF 7 reports: the American Society of Nuclear Cardiology; Task Force 7 report: the Society of Cardiovascular Patrick T. O’Gara,MD,MACC,President Computed Tomography and the Society of Atheroscle- Shalom Jacobovitz, Chief Executive Officer rosis Imaging and Prevention; Task Force 7, 9, and 10 William J. Oetgen, MD, MBA, FACC; Executive Vice reports: the Society for Cardiovascular Angiography and President, Science, Education, and Quality Interventions; Task Force 8 report: the Society for Car- Janice Sibley, MS, MA, Vice President, Education diovascular Magnetic Resonance; Task Force 9 report: Robyn Snyder, BS, Team Lead, Education Design the Society for Vascular Medicine; Task Force 11 report: Dawn R. Phoubandith, MSW, Director, Competency the Heart Rhythm Society; and Task Force 12 report: the Management Heart Failure Society of America. The American Heart Tanja Kharlamova, Associate, Physician Clinical Pathways Association reviewed the entire document. All reviewers Kimberly Kooi, MHA, Associate, Education Design and their affiliations in the review process and employ- Projects ment information can be found in the appendix con- Grace Ronan, Team Lead, Policy Publication taining peer reviewer disclosure information in each Amelia Scholtz, PhD, Publications Manager, Clinical report. Policy and Pathways

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REFERENCES

1. American College of Cardiology. COCATS guidelines Training. Introduction. J Am Coll Cardiol 2006;47: Academic Internal Medicine. Available at: http://www. for training in adult cardiovascular medicine: Core 894–7. acgme.org/acgmeweb/Portals/0/PDFs/Milestones/ Cardiology Training Symposium. June 27-28, 1994. InternalMedicineSubspecialtyMilestones.pdf. Accessed 4. Beller GA, Bonow RO, Fuster V. ACCF 2008 rec- J Am Coll Cardiol 1995;25:1–34. February 25, 2015. ommendations for training in adult cardiovascular 2. Beller GA, Bonow RO, Fuster V. ACC revised rec- medicine core cardiology training (COCATS 3)—revision 7. Thomas JD, Zoghbi WA, Beller GA, et al. ACCF 2008 ommendations for training in adult cardiovascular of the 2002 COCATS training statement. J Am Coll training statement on multimodality noninvasive car- medicine: core cardiology training II (COCATS 2)— Cardiol 2008;51:335–8. diovascular imaging: a report of the American College of Cardiology Foundation/American Heart Association/ revision of the 1995 COCATS training statement. J Am 5. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next – American College of Physicians Task Force on Clinical Coll Cardiol 2002;39:1242 6. GME accreditation system: rationale and benefits. Competence and Training. J Am Coll Cardiol 2009;53: N Engl J Med 2012;366:1051–6. 3. Beller GA, Bonow RO, Fuster V. ACCF 2006 update 125–46. for training in adult cardiovascular medicine (focused 6. Gitlin S, Flaherty J, Arrighi J, et al. The Internal update of the 2002 COCATS 2 Training Statement): a Medicine Subspecialty Milestones Project: a joint report of the American College of Cardiology Foun- initiative of the Accreditation Council for Graduate dation/American Heart Association/American College Medical Education and the American Board of Internal KEY WORDS ACC Training Statement, COCATS, of Physicians Task Force on Clinical Competence and Medicine in collaboration with the Alliance for fellowship training, clinical competence

APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 INTRODUCTION

Institutional/ Ownership/ Organizational Speakers Partnership/ Personal or Other Expert Committee Member Employment Consultant Bureau Principal Research Financial Benefit Witness

Jonathan L. Halperin Icahn School of Medicine None None None None None None at Mount Sinai—Professor of Medicine

Eric S. Williams Indiana University School of None None None None None None Medicine—Professor (Cardiology) and Associate Dean; Indiana University Health—Cardiology Service Line Leader

Valentin Fuster Icahn School of Medicine at None None None None None None Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute— Director

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects the authors’ employment and reporting categories. To ensure complete transparency, authors’ comprehensive healthcare-related disclosure information—including relationships with industry not pertinent to this document—is available in an online data supplement. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/ relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional information about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology.

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APPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 INTRODUCTION

Institutional/ Organizational Ownership/ or Other Speakers Partnership/ Personal Financial Expert Name Employment Representation Consultant Bureau Principal Research Benefit Witness

Richard Kovacs Indiana University, Krannert Official Reviewer, None None None None None None Institute of Cardiology—Q.E. ACC Board of Trustees and Sally Russell Professor of Cardiology

Dhanunjaya Kansas University Cardiovascular Official Reviewer, None None None None None None Lakkireddy Research Institute ACC Board of Governors

Howard Weitz Thomas Jefferson University Official Reviewer, None None None None None None Hospital—Director, Division Competency Management of Cardiology; Sidney Kimmel Committee Lead Reviewer Medical College at Thomas Jefferson University—Professor of Medicine

Furman McDonald American Board of Internal Organizational Reviewer, None None None None None None Medicine—Vice President ABIM Graduate Medical Education, Department of Academic Affairs; Professor, Medicine

Allan Klein Cleveland Clinic—Professor, Organizational Reviewer, None None None None None None Medicine; Director, ASE Pericardial Center

Dennis Calnon OhioHealth Heart and Vascular Organizational Reviewer, None None None None None None Physicians—Director, Cardiac ASNC Imaging, Riverside Methodist Hospital

Kousik Krishnan Rush University Medical Center— Organizational Reviewer, None None None None None None Associate Professor, Medicine Heart Rhythm Society and Pediatrics; Director, Arrhythmia Device Clinic

Richard Patten Lahey Hospital And Medical Organizational Reviewer, None None None None None None Center, Division of HFSA Cardiovascular Medicine

John Hodgson Metrohealth Medical Center Organizational Reviewer, None None None None None None SCAI

Michael Ragosta University of Virginia Health Organizational Reviewer, None None None None None None System, Cardiovascular Division SCAI

Aditya M. Sharma University of Virginia Health Organizational Reviewer, None None None None None None System, Cardiovascular Division— SCAI Assistant Professor, Medicine

Kanwar Singh University of Virginia Health Organizational Reviewer, None None None None None None System, Cardiovascular Division SCAI

Warren Manning Beth Israel Deaconess Medical Organizational Reviewer, None None None None None None Center, Division of Cardiology— SCMR Professor, Medicine and Radiology

Geoffrey Barnes University of Michigan Frankel Organizational Reviewer, None None None None None None Cardiovascular Center, SVM Cardiovascular Medicine and Vascular Medicine

Esther S.H. Kim Cleveland Clinic—Staff Physician, Organizational Reviewer, None None None None None None Department of Cardiovascular SVM Medicine Alex Auseon Ohio State University Medical Content Reviewer, Academic None None None None None None Center—Assistant Professor, Cardiology Section Leadership Clinical Medicine, Division Council of Cardiology

(continued on the next page)

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APPENDIX 2. CONTINUED

Institutional/ Organizational Ownership/ or Other Speakers Partnership/ Personal Financial Expert Name Employment Representation Consultant Bureau Principal Research Benefit Witness

Kenneth VCU Medical Center—Director, Content Reviewer, Cardiology None None None None None None Ellenbogen Clinical Electrophysiology Training and Workforce Laboratory Committee

Michael Emery Greenville Health System Content Reviewer, Sports and None None None None None None Exercise Cardiology Section Leadership Council

Bulent Gorenek Eskisehir Osmangazi University Content Reviewer, None None None None None None Medical School Electrophysiology Section Leadership Council

Brian D. Hoit University Hospitals Case Content Reviewer, Cardiology None None None None None None Medical Center Training and Workforce Committee

Howard M. Julien Thomas Jefferson University Content Reviewer, None None None None None None Hospital, Jefferson Health System— Heart Failure Cardiology Fellow in Training and Transplant Section Leadership Council

Andrew Kates Washington University Content Reviewer, Academic None None None None None None School of Medicine Cardiology Section Leadership Council

Kristen Patton University of Washington Content Reviewer, None None None None None None Electrophysiology Section Leadership Council

Robert Piana Vanderbilt University Content Reviewer, None None None None None None Medical Center—Professor, Interventional Council Medicine and Cardiology

Gregory Piazza Brigham and Women’s Content Reviewer, None None None None None None Hospital/Harvard Medical PVD Council School, Cardiovascular Division

Tanveer Rab Emory University School of Content Reviewer, None None None None None None Medicine—Associate Professor, Interventional Council Medicine and Cardiology/ Interventional Cardiology

Arash Sabati Children’s Hospital of Content Reviewer, None None None None None None Los Angeles ACPC Council

David Vorchheimer Montefiore-Einstein Center Content Reviewer, None None None None None None for Heart and Vascular Care— Individual Director, Clinical Cardiology; Professor, Clinical Medicine

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects peer reviewers’ employment, representation in the review process, as well as reporting categories. Names are listed in alphabetical order within each category of review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional infor- mation about the ACC Disclosure Policy for Writing Committees. ABIM ¼ American Board of Internal Medicine; ACC ¼ American College of Cardiology; ACPC ¼ Adult Congenital/Pediatric Cardiology; ASE ¼ American Society of Echocardiography; ASNC ¼ American Society of Nuclear Cardiology; HFSA ¼ Heart Failure Society of America; PVD ¼ peripheral vascular disease; SCAI ¼ Society for Cardiovascular Angiography and Interventions; SCMR ¼ Society for Cardiovascular Magnetic Resonance; SVM ¼ Society for Vascular Medicine; VCU ¼ Virginia Commonwealth University.

APPENDIX 3. ABBREVIATION LIST

ABIM ¼ American Board of Internal Medicine ABMS ¼ American Board of Medical Specialties ACC ¼ American College of Cardiology ACGME ¼ Accreditation Council for Graduate Medical Education COCATS ¼ Core Cardiovascular Training Statement

Downloaded From: http://content.onlinejacc.org/ by Dawn Phoubandith on 06/10/2015 JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL.65,NO.17,2015 ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00 PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacc.2015.03.023

TRAINING STATEMENT COCATS 4 Task Force 1: Training in Ambulatory, Consultative, and Longitudinal Cardiovascular Care

Valentin Fuster, MD, PHD, MACC, Co-Chair William F. Iobst, MD* Jonathan L. Halperin, MD, FACC, Co-Chair Debabrata Mukherjee, MD, FACC Eric S. Williams, MD, MACC, Co-Chair Prashant Vaishnava, MD Nancy R. Cho, MD, FACC

1. INTRODUCTION 1.1.2. Document Development and Approval The writing committee developed the document, 1.1. Document Development Process approved it for review by individuals selected by the 1.1.1. Writing Committee Organization ACC and representing the ABIM, and addressed the The writing committee was selected to represent the comments. The document was revised and posted for American College of Cardiology (ACC) and included a public comment from December 20, 2014, to January 6, cardiovascular training program director; a member 2015. Authors addressed additional comments to of the ACC Competency Management Committee; a complete the document. A member of the ACC Com- cardiologist early in his career; specialists represent- petency Management Committee served as lead fi ing both the academic and community-based practice reviewer. The nal document was approved by the settings; as well as physicians, including a staff Task Force, COCATS Steering Committee, and ACC fi physician from the American Board on Internal Competency Management Committee and was rati ed Medicine (ABIM), experienced in defining and by the ACC Board of Trustees in March 2015. This applying training standards according to the 6 document is considered current until the ACC Compe- general competency domains promulgated by the tency Management Committee revises or withdraws it. Accreditation Council for Graduate Medical Educa- 1.2. Background and Scope tion (ACGME) and American Board of Medical The Task Force was charged with updating previously Specialties (ABMS), and endorsed by the ABIM. The published standards for training fellows in general ACC determined that relationships with industry or clinical cardiology enrolled in ACGME–accredited fel- other entities were not relevant to the creation of this lowships (1) onthebasisofthefollowingfactors: general cardiology training statement. Employment 1) changes that have occurred in the field since 2008 and affiliation information for authors and peer and as part of a broader effort to establish consistent reviewers is provided in Appendixes 1 and 2, training criteria across all aspects of cardiology; and respectively, along with disclosure reporting cate- 2) the evolving framework of competency-based med- gories. Comprehensive disclosure information for all ical education described by the ACGME Outcomes authors, including relationships with industry and Project and the 6 general competencies endorsed by other entities, is available as an online supplement to the ACGME and ABMS. This document does not provide this document. specific guidelines for training in advanced cardiovas- cular subspecialty areas but, where appropriate, iden- tifies opportunities to obtain advanced training. The background and overarching principles

*American Board of Internal Medicine Representative. governing fellowship training are provided in the The American College of Cardiology requests that this document be cited COCATS 4 Introduction, and readers should become as follows: Fuster V, Halperin JL, Williams ES, Cho NR, Iobst WF, familiar with this foundation before considering Mukherjee D, Vaishnava P. COCATS 4 task force 1: training in ambulatory, consultative, and longitudinal cardiovascular care. J Am Coll Cardiol the details of training in ambulatory, consultative, 2015;65:1734–53. and longitudinal cardiovascular care. The Steering JACC VOL. 65, NO. 17, 2015 Fuster et al. 1735 MAY 5, 2015:1734– 53 COCATS 4 Task Force 1

Committee and Task Force recognize that implementation program, and satisfactory completion of training must of these changes in training requirements will occur be documented by the program director on the recom- incrementally over time. mendation of a competency committee. The variety and For most areas of adult cardiovascular medicine, types of encounters and the scope of training required by 3 levels of training are delineated: the typical fellow are summarized in Section 4. Training to become a general or specialized physician n Level I training, the basic training required of should prepare the trainee to provide high-quality care, trainees to become competent consultant cardiologists, which the Institute of Medicine definesaseffective, is required of all fellows in cardiology and can be efficient, equitable, safe, timely, and patient-centered (2). accomplished during a standard 3-year training pro- The specific training necessary to become a competent gram in general cardiology. cardiovascular specialist should address prevention of n Level II training refers to the additional training in 1 or adverse events such as myocardial infarction, stroke, or more areas that enables some cardiologists to perform premature death from disease of the heart or blood or interpret specific diagnostic tests and procedures or vessels. Training should facilitate cardiovascular health render more specialized care for specific patients and and foster well-being across the lifespan, healthy conditions. This level of training is recognized for those aging, and event- and intervention-free survival. Hence, a areas in which an accepted instrument or benchmark, key attribute of this aspect of training is the establishment such as a qualifying examination, is available to mea- of relationships with patients that span several years. sure specific knowledge, skills, or competence. Level II Experience in ambulatory, consultative, and longitu- training in selected areas may be achieved by some dinal care should incorporate 3 general approaches: trainees during the standard 3-year general cardiology 1) acquisition of key skills through practical exposure fellowship, depending on the trainees’ career goals and and clinical practice; 2) participation in consultative use of elective rotations. cardiology; and 3) a formal curriculum that emphasizes n Level III training requires additional experience the pathophysiological mechanisms and core know- beyond the general cardiology fellowship to acquire ledge of cardiovascular diseases. Cardiologists should specialized knowledge and competencies in perform- embrace novel and evolving areas such as clinical ap- ing, interpreting, and training others to perform spe- plications of genetics, mechanical cardiac assist devices, cific procedures and rendering advanced, specialized remote monitoring, and transplantation and immuno- care at a high level of skill. Level III training typically therapy; become facile in managing or comanaging requires training beyond the standard 3-year general patients with congenital heart disease, pulmonary hy- cardiology fellowship. pertension, age-related disorders, and dementia; and Most cardiac care occurs in the ambulatory setting. apply preventive strategies that promote health and Although hospital-based care is increasingly directed longevity. at patients who are acutely ill or are undergoing invasive As a highly trained medical subspecialist, the modern procedures, the importance of training and competence in cardiologist must serve as an effective member of the thelongitudinalcareofambulatory patients, including professional healthcare team. In many cases, the cardi- in disease prevention and management, has been ologist will assume the role of team leader. At other increasingly emphasized. Anticipating reallocation of times, the delivery of high-quality, patient-centered health resources toward ambulatory care, an expanded care will require that the cardiologist defer to the commitment to training in outpatient care for all cardi- expertise of other members of the team. Negotiating ology trainees is required, regardless of a trainee’s field of these multiple roles requires skill as a communicator, interest or subspecialization. Training in ambulatory, competence with emerging technology, and effective consultative, and longitudinal care is a bedrock of car- collaboration with all healthcare professionals. On an diovascular fellowship upon which all subspecialized, interpersonal level, the cardiologist must acknowledge advanced, and procedure-oriented training is based. mistakes when they occur, learn from them and redirect Accordingly, a single level of training is delineated for this a course of action to optimize outcomes, engender trust aspect of cardiology fellowship, with the expectation that by exhibiting benevolence, avoid or divulge material the principles delineated in this report should pervade all conflicts, and motivate and inspire patients and col- other aspects of cardiovascular training. The approximate leagues. A lifelong commitment to mastery and main- numbers of cases, procedures, and experiences recom- tenance of these skills and to learning is essential to mended are based on published guidelines, competency both providing high-quality, patient-centric, ambula- statements, and the opinions of the members of tory, consultative, and longitudinal care and assuming the writing group. Training should be directed by a leadership role in directing cardiovascular patient appropriately prepared mentors in an ACGME-accredited management. 1736 Fuster et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 1 MAY 5, 2015:1734– 53

2. GENERAL STANDARDS the Internet and medical records. In addition, there should be accessible facilities for outpatient laboratory In published guidelines for ambulatory, consultative, and evaluations, including blood specimen collection for longitudinal cardiovascular care that are organized transmittal to a certified clinical laboratory and the stan- around individual disease states or cardiovascular pro- dard and specialized equipment for performing the cedures, the ACC and AmericanHeartAssociationhave routine diagnostic procedures delineated in Section 2.3. promulgated congruent recommendations that address The facility should be capable of accommodating common faculty, facility requirements, emerging technologies, and cardiovascular emergencies either onsite or at a nearby practice. We also recommend strongly that candidates for institutional facility to which a patient in distress can be certification in cardiovascular diseases review the specific readily transported under direct and continuous physi- requirements of the ABIM. cian or nursing supervision.

2.1. Faculty 2.3. Equipment Faculty should include specialists who are able to pro- Clinic or ambulatory care facilities require equipment for vide integrated assessment of cardiovascular risk and are measuring blood pressure and transcutaneous oxygen knowledgeable and skilled in the principles of bedside saturation and for electrocardiography, with access clinical examination; differential diagnosis; electrocar- to chest x-ray, echocardiography, ambulatory cardiac diography; chest x-ray; echocardiography; stress testing; rhythm monitoring, and exercise stress testing. An elec- ambulatory rhythm and electrophysiological monitoring; tronic or paper-based medical record system must be cardiovascular development and aging; hypertension available that meets federal data security requirements evaluation and management; dyslipidemia; abnormalities yet that can be accessed by authorized caregivers at all of glucose metabolism; congenital and valvular heart dis- times for the purposes of both data entry and retrieval — — ease; evaluation, staging, and management of cardiac at but not limited to the point of care. failure; cardiac arrhythmia diagnosis and management; 2.4. Ancillary Support and clinical applications of genetics and cardiovascular pharmacology. Faculty must also have a thorough under- Ancillary support should be available to facilitate standing of the attitudes and proficiencies required of appointment scheduling and follow-up; manage clinical trainees to ensure acquisition of the additional ACGME/ and financial records; retrieve laboratory and other ABMS general competencies of systems-based practice, clinical reports; enable telephone communications be- practice-based learning and improvement, interpersonal tween patients and providers (e-mailing optional); and communication skills, and professionalism as they provide clean, prepared examining and consultation pertain to the delivery of cardiovascular care. A minimum rooms; and properly contain, control, and remove medical of 2 key clinical faculty members, including the program waste. director, must be board-certified in cardiovascular disease or possess equivalent qualifications based on training in a 3. TRAINING COMPONENTS similar environment for a similar length of time, and they

must have expertise in the requisite skills and at least 5 3.1. Didactic Program years of clinical experience beyond fellowship training. Didactic instruction may take place in a variety of for- Programs must also maintain at least a 1:1.5 ratio of quali- mats, including but not limited to lectures, conferences, fied faculty to enrolled trainees. journal clubs, grand rounds, clinical case presentations, and patient safety or quality improvement conferences. A 2.2. Facilities formal curriculum should include, in addition to the Facilities should be sufficient to ensure an environment evaluation and management of patients across the full suitable for safe and effective ambulatory patient care spectrum of cardiovascular diseases, relevant non- and include a patient reception area; clean, orderly, pri- cardiovascular disease topics commonly complicated by vate examination rooms with sinks; examination gowns; cardiovascular disease to which the trainee might other- gloves; sphygmomanometers; ophthalmoscopes and wise have been less exposed. Among the topics to related equipment; consultation rooms with seating for consider are acute and chronic pulmonary disease; sleep- the physician, patient, and at least 1 additional person disordered breathing; malignancies and the cardio- such as a member of the patient’s family, which can vascular effects of cancer chemotherapy; hematologic beusedfororinadditiontoaplaceforcasereview disorders including thrombophilia; diabetes mellitus; and discussion between the trainee and faculty preceptor; kidney disease; acute and chronic dialysis; intracranial and workstations with computer terminals for access to and extracranial cerebrovascular disease; and stroke. JACC VOL. 65, NO. 17, 2015 Fuster et al. 1737 MAY 5, 2015:1734– 53 COCATS 4 Task Force 1

3.2. Clinical Experience competency domains are: medical knowledge, patient Rotation on cardiology consultation services is an care and procedural skills, practice-based learning and essential component of training in clinical cardiology. improvement, systems-based practice, interpersonal and The training required to achieve this Level I competency communication skills, and professionalism. The ACC has fi requires firsthand experiences as a consultant in both the used this structure to de ne and depict the components inpatientandoutpatientsettings.Itisimportantthatthe of the core clinical competencies for cardiology. The cardiology consultation service expose the trainee to a curricular milestones for each competency and domain broad array of patients with disease of varied acuity and also provide a developmental roadmap for fellows as a range of comorbidities. During the required rotations they progress through various levels of training and on the consultation service, trainees should conduct serve as an underpinning for the ACGME/ABIM reporting several initial patient evaluations daily in addition to milestones. The ACC has adopted this format for its providing follow-up care after the initial consultation. competency and training statements, career milestones, Often, transition of care between inpatient and outpa- lifelong learning, and educational programs. Addition- tient settings is an important component of care. In ally, the ACC has developed tools to assist physi- addition to the inpatient consultation experience, cians in assessing, enhancing, and documenting these trainees should obtain robust clinical experiences in an competencies. outpatient setting that promotes continuity of patient Table 1 delineates each of the 6 competency domains care over the course of the fellowship. Current recom- as well as the associated curricular milestones for mendations include that fellows should be responsible, training in ambulatory, consultative, and longitudinal on average, for 4 to 8 patients per half-day session. In cardiovascular care. The milestones indicate the stage of each clinical setting, trainees should gain hands-on fellowship training (12, 24, or 36 months, and additional experience under the supervision of a faculty mentor or time points) by which the typical cardiovascular trainee preceptor in a fashion that emphasizes patient-centered should achieve the designated level. Given that pro- education in all aspects of cardiovascular management. grams may vary with respect to the sequence of clinical It is important that, in these experiences, the trainee experiences provided to trainees, the milestones at assume the role of a consultant responsible for commu- which various competencies are reached may vary as nication with the patient, family members, referring well. Level I competencies may be achieved at earlier or physicians, pharmacists, nurses, and other healthcare later time points. The table also describes examples of personnel. evaluation tools suitable for assessment of competence in each domain. It is also important to emphasize that 3.3. Teaching Others although the table delineates key competency com- ponents for ambulatory, consultative, and longitudinal An important aspect of subspecialty training is the care,itisnotcomprehensive.Additionalcompetency ability to educate trainees, such as medical students, components required of a consultant cardiologist residents, or fellows in other fields,onsuchtopicsasthe (Level I) are described in the other COCATS 4 Task Force cardiovascular physical examination, pharmacology, reports. electrocardiography, and cardiac imaging, at a level commensurate with their training and experience. This applies to peer-to-peer education through topic reviews, 4.2. Duration and Structure of Training journal clubs, clinical case presentations, quality assur- The specific competencies for training are delineated in ance programs, and preparation of case reports for Table 1. Continuity of longitudinal patient care is publication. The objectives include enhancement of fundamental to training in ambulatory and consultative communication skills, consolidation of knowledge in core cardiovascular care. Hence, although it is expected that topic areas, development of enduring educational mate- all trainees will engage in this activity for no less than rials (e.g., syllabi, lecture slides, or web-based tools), and 1 half-day weekly for at least 40 weeks of each year nurturing a commitment to lifelong learning and main- of training during the general 3-year cardiovascular tenance of competency. fellowship, attendance in weekly clinic sessions alone is not sufficient to satisfy this training requirement. 4. SUMMARY OF TRAINING REQUIREMENTS Longitudinal care implies not only continuity in the ambulatory setting, but also a commitment to: 4.1. Development and Evaluation of Core Competencies 1) following patients in the event of hospitalization; Training and requirements in cardiovascular disease 2) telephone contacts or other communication with and address the 6 general competencies promulgated by the about the patient; 3) interactions with family members, ACGME/ABMS and endorsed by the ABIM. These collaborating physicians, and other members of the 1738 Fuster et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 1 MAY 5, 2015:1734– 53

Core Competency Components and Curricular Milestones for Training in Ambulatory, Consultative, and Longitudinal TABLE 1 Cardiovascular Care

Competency Component Milestones (Months) MEDICAL KNOWLEDGE 12 24 36 Add

1 Know the major cardiovascular risk stratification tools and the principles of primary and secondary I cardiovascular disease prevention.

2 Know the roles of genetics, family history, and the environmental and lifestyle factors in the development and I clinical course of cardiovascular disease.

3 Know the effects of age on cardiovascular function, on response to medications, and in the risks of diagnostic I and therapeutic procedures.

4 Know the differential diagnosis of chest pain and the distinguishing features of the various etiologies. I

5 Know the cardinal findings and differential diagnosis of palpitations, lightheadedness, and syncope, and the I distinguishing features of the various etiologies.

6 Know the cardinal findings and differential diagnosis of dyspnea. I

7 Know the differential diagnosis of peripheral edema and the distinguishing clinical features of the various I etiologies.

8 Know the roles of kidney, hepatic, pulmonary, hematologic, rheumatologic, and endocrine disorders in the I development, manifestations, and responses to treatment in patients with cardiovascular disease.

9 Know the clinical pharmacology of cardiovascular medications, and drug–drug interactions of cardiac and I noncardiac medications, including in special populations and in patients with relevant comorbidities.

10 Know the roles of lifestyle, activity level, body mass, nutrition, alcohol, and/or drug use in cardiovascular risk I and disease.

11 Know the potential cardiovascular toxicity and side effects of major classes of drugs used for the management I of patients with common medical conditions, including antimicrobial agents, immune system modulators, chemotherapeutic agents, and antiparkinson drugs.

12 Know the roles of stress, anxiety, and depression in patients with suspected cardiovascular disease. I

13 Know the guideline recommendations for blood pressure, blood glucose, and lipid management in diverse I patient populations with and without cardiovascular disease.

14 Know the appropriate use indications for cardiovascular screening studies, including carotid and abdominal I ultrasound (or other imaging) modalities.

15 Know the differential diagnosis and distinguishing characteristics of heart murmurs and bruits. I

16 Know the characteristic clinical manifestations, differential diagnosis, and appropriate testing for peripheral I vascular disease.

17 Know the mechanisms and cardinal symptoms and findings of stroke, transient cerebral ischemia, and I dementia.

18 Know the principles, modalities, and appropriate indications for palliative care. I

EVALUATION TOOLS: chart-stimulated recall, conference presentation, direct observation, and in-training examination.

PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

1 Skill to effectively and efficiently perform an initial outpatient cardiovascular consultation and establish a I differential diagnosis.

2 Skill to appropriately utilize diagnostic testing—both for initial diagnosis and for follow-up care. I

3 Skill to integrate clinical and testing results to establish diagnosis, assess cardiovascular risk, and formulate I treatment and follow-up plans.

4 Skill to appropriately obtain and integrate consultations from other healthcare professionals in a timely I manner.

5 Skill to recognize acute cardiovascular disorders or high-risk states that require immediate treatment and/ I or hospitalization and prioritize management steps in patients with complex or multicomponent illness.

6 Skill to establish an effective medical regimen and monitor for side-effects, intolerance or noncompliance, I and patient safety. JACC VOL. 65, NO. 17, 2015 Fuster et al. 1739 MAY 5, 2015:1734– 53 COCATS 4 Task Force 1

TABLE 1 Core Competency Components, continued

Competency Component Milestones (Months) PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

7 Skill to assess the cardiovascular risks associated with recreational and/or competitive sports for individual I patients and to counsel patients about levels of physical activity appropriate to their cardiovascular health in the context of disease prevention; rehabilitation; and promotion of longevity, functional capacity, and quality of life.

8 Skill to effectively carry out chronic disease management in patients with chronic ischemic heart disease, I hypertension, heart failure, and peripheral vascular disease.

9 Skill to coordinate ambulatory and longitudinal follow-up care. I

10 Skill to effectively facilitate transition of care from hospital to ambulatory or intermediate-care settings. I

11 Skill to perform preoperative assessments for noncardiac procedures in patients with cardiovascular disease. I

EVALUATION TOOLS: chart-stimulated recall, conference presentation, and direct observation.

SYSTEMS-BASED PRACTICE 12 24 36 Add

1 Effectively lead or participate in team-based care in patients with or at risk of developing cardiovascular I disease.

2 Effectively facilitate transitions of care. I

3 Effectively utilize electronic medical record systems, including clinical protocols and treatment/evaluation I prompts.

4 Effectively and appropriately use remote communication tools in the care of patients. I

5 Appropriately utilize and work with cardiac rehabilitation and intermediate care facilities. I

6 Recognize and address social, cultural, and financial barriers to patient compliance. I

EVALUATION TOOLS: direct observation and multisource evaluation.

PRACTICE-BASED LEARNING AND IMPROVEMENT 12 24 36 Add

1 Utilize point-of-care electronic resources to provide up-to-date clinical information and guideline-driven I evaluation and treatment.

2 Identify gaps and carry out personalized education activities to address them. I

3 Integrate validated performance and patient satisfaction measures into clinical practice to foster continuous I quality improvement.

EVALUATION TOOLS: chart-stimulated recall, direct observation, and reflection and self-assessment.

PROFESSIONALISM 12 24 36 Add

1 Practice patient-centered care with shared decision-making and appreciation of patients’ values and I preferences.

2 Incorporate appropriate use criteria and risk–benefit considerations in treatment decisions. I

3 Practice in a manner that fosters patient benefit above self-interest and avoids conflict of interest. I

4 Interact respectfully with patients, families, and all members of the healthcare team, including ancillary and I support staff.

EVALUATION TOOLS: chart-stimulated recall, direct observation, and multisource evaluation.

INTERPERSONAL AND COMMUNICATION SKILLS 12 24 36 Add

1 Communicate effectively with patients and families across a broad spectrum of ethnic, social, cultural, I socioeconomic, and religious backgrounds.

2 Exhibit sensitivity and empathy in dealing with life-threatening and end-of-life issues. I

3 Communicate effectively and in a timely manner with primary care and other referring or collaborating I members of the healthcare team.

EVALUATION TOOLS: direct observation and multisource evaluation.

Add ¼ additional months beyond the 3-year cardiovascular fellowship. 1740 Fuster et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 1 MAY 5, 2015:1734– 53

healthcare team; and 4) general availability to address and the influence of diet, exercise, alcohol, or recrea- whatever cardiovascular or related issues or conditions tional or illicit drugs. It is also essential to understand might arise in the course of long-term clinical the roles of stress, anxiety, and depression in exacer- management. bating hypertension, chest pain, cardiac arrhythmias, heart failure, and other conditions. 4.2.1. Acquisition of Key Skills 3. In formulating and executing an effective clinical The ultimate goal of fellowship training is the integration management plan, the trainee should understand the of a sound foundation of knowledge and understanding cumulative burden of multiorgan dysfunction. Rarely of cardiac systems and the roles of testing and technol- does a physician encounter a purely cardiac patient. As ogy, on the one hand, with the ability to manage difficult the population ages, a panoply of conditions converge, and challenging situations, on the other hand. These and an appreciation of the interplay between indi- goals require the effective integration of the ACGME vidual patient characteristics and the natural history 6 general competencies into the delivery of safe and of disease enables the clinician to anticipate out- effective patient care. The cardiologist must accept re- comes and complications, which is key to successful sponsibility; identify, acknowledge, and overcome gaps management. The cardiologist must balance emerging in knowledge; maintain flexibility and adjust direction; concepts and traditional strategies. Reliance on think creatively; keep an open mind; incorporate secondhand data should be avoided in favor of direct humanism; and employ discipline and organization to interaction with and examination of the patient, as well follow through with plans, motivate patients, and inspire as direct review of prior testing data from both within others on the healthcare team. Although the ambulatory and outside of one’s own facility to enable compre- care or outpatient setting represents an ideal environ- hensive and insightful evaluation of a given problem in ment for initial acquisition of these skills through the context of the individual. teaching, mentoring, and example, mastery cannot be achieved without years of experience and a commitment 4.2.1.1.2. Clinical Decision-Making to lifelong learning. Although clinical judgment is acquired through experi- ence over time, strategies facilitating the development of 4.2.1.1. Medical Knowledge, Clinical Decision-Making, and clinical judgment can be taught and honed. Specific Skills in Transitional Care clinical examples (patient-specific teachable moments) The ambulatory patient often presents less obvious help convey the art of medicine. Here, the timing of evidence of disease than the hospitalized patient. tests, procedures, or interventions is vital, matching Therefore, outpatient training is directed at acquiring the intensity of action to the level of risk and severity of knowledge, enhancing judgment, and sharpening skills the condition. An example is to prefer initiation or in effectively transitioning patient care. adjustment of 1 drug at a time in nonurgent situations and proceed in logical sequence, rather than changing 4.2.1.1.1. Medical Knowledge and Clinical Evaluation multiple aspects of a regimen concurrently. Clinical The trainee should routinely question why the patient has decision-making regarding testing and/or therapeutic developed a given condition or problem and address decisions should also consider the balance of risk and the underlying etiology to guide diagnostic testing and benefit for the individual patient. In applying manage- treatment. ment recommendations from resources such as clinical practice guidelines, cardiovascular trainees must take 1. The cardiologist must be alert to life-threatening con- into account the needs of special populations and ditions that cannot be overlooked, while also recog- appreciate the impact of comorbidities, particularly in nizing the most likely causes of symptoms or older patients with cardiovascular disease who typically asymptomatic conditions and maintaining awareness have multiple concurrent medical conditions that influ- of rare possible causes. He/she should learn to dis- ence outcomes. tinguish urgent situations from those that can be addressed more methodically. 2. It is valuable to understand the controversies and/or 4.2.1.1.3. Effective Translation of Clinical Information complexities that surround the evaluation or manage- It is not sufficient to perform only an initial consultation ment of particular cardiovascular diseases or con- and outline recommendations; specific instructions ditions, including comorbidities; the influences of should be individualized and written down. Follow-up at genetics and aging; variations in drug metabolism timely intervals to assess and measure responses and and interactions; the impact of renal or hepatic outcomes on the basis of symptoms, functional status, dysfunction; fluid balance; and the patient’s lifestyle weight, blood pressure, and heart rate form the JACC VOL. 65, NO. 17, 2015 Fuster et al. 1741 MAY 5, 2015:1734– 53 COCATS 4 Task Force 1

foundation for gauging clinical progress. The clinical attending physicians can often have a more substantial problem, plan, rationale, potential risks or adverse ef- educational impact in the outpatient environment than in fects, and specific directions given to the patient require the acute care hospital setting. The requisite skills include careful documentation. Systematic quality assurance re- the ability to interpret cues from body language, quires recording and quantifying both successful and including recognition of fear, anxiety, depression, and unsuccessful outcomes. denial of illness, and to inspire, motivate, encourage, coach, and openly discuss goals of care and end-of-life issues. It is important to identify and overcome defen- 4.2.1.2. Interpersonal and Communication Skills sive or passive-aggressive attitudes and behavior. The 4.2.1.2.1. Communication Skills cardiologist must enlist the support of spouses, children, An important objective of office- or clinic-based clinical and others with personal relationships to the patient as training is to develop a rapport and communicate well as aides, companions, and nurses in the patient’s effectively with the patient; convey understanding interest. Interactions with ancillary staff may provide of the clinical condition and prognosis; and deliver this helpful insight into patient care issues, including identi- information in a respectful, empathetic, and caring fying and overcoming barriers to effective care (e.g., manner. Outpatient encounters provide opportuni- home situation, insurance coverage). Interpersonal skills ties to heighten a physician’s sensitivity to patient are essential for meaningful professional communication needs, values, and preferences, thus establishing the with physician colleagues; fellowship training in the foundation for a relationship based on compassion and ambulatory setting provides a prime opportunity to trust. develop and master these skills. To develop the ability to communicate with patients across a range of cultural, ethnic, and socioeconomic 4.2.1.3. Patient Care and Procedural Skills in Transitional Care backgrounds, the trainee must be sensitive to financial, The trainee should recognize the challenges at the in- cultural, and social barriers to diagnostic and treatment terfaces between hospital admission, inpatient manage- recommendations. Effective communication may require ment, and discharge. Such challenges include the need for aqualified language translator. It also requires empa- early outpatient follow-up in select circumstances (e.g., thetic understanding of the emotional impact of and following hospitalization for heart failure), the need for response to disease. Ultimately, the cardiologist must strategies to minimize adverse outcomes and avoid or employ psychological insight to address the patient’s delay readmission, deployment of ancillary resources to hopes, fears, and desires and then leverage these to pro- maintain surveillance of the patient’s condition at home, mote healthy behavior. Appreciation of differences be- and understanding indications for and components of tween men and women, young and old, working, retired, cardiac rehabilitation and health maintenance. Similarly, indigent, middle-class, wealthy, educated, informed, ur- in the longitudinal care of hospital inpatients, the cardi- ban versus rural dwelling, and other demographic vari- ologist must ensure continuity during transitions of care ables is necessary to modulate and individualize medical to and from the intensive care unit and less acute settings decision-making and discussion. and before and after invasive cardiovascular procedures or surgery. 4.2.1.2.1.1. Communication With Other Providers Beyond standard communication skills, the cardiolo- As a consultant to other physicians, the trainee should gist must be technologically proficient in the use of elec- develop communication and practice management skills tronic health records and information systems and necessary to comanage patients with other providers, as incorporate automatic reminders, callbacks, test and noted in the following text. procedure result tracking, laboratory flow sheets, and surveillance to ensure timely scheduling of interventions 4.2.1.2.1.2. Communication With Referring Physicians and surveillance. Trainees must also know and adhere to Timely communication with referring physicians, referral the requirements and precautions regarding the confi- of patients with unusual or complex conditions when dentiality of medical information. appropriate, and close interaction with surgical and interventional colleagues are essential to shared, in- 4.2.1.3.1. Remote Communication Tools formed decision-making and successful outcomes. The appropriate use of electronic communication and cost-effective use of technology, such as remote moni- 4.2.1.2.2. Interpersonal Skills toring with ambulatory telemetry, point-of-care interna- Successful clinicians share a common asset: interpersonal tional normalized ratio systems for patient self-testing, skills. This is among the most difficult skills to teach and downloading readouts from implanted cardiac because it is highly dependent on personality, but arrhythmia devices, is essential. 1742 Fuster et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 1 MAY 5, 2015:1734– 53

4.2.1.3.2. Remote Interaction Systems verbal feedback to the trainee and reporting to the Real-time interaction with emergency care facilities, Clinical Competency Committee and program director. clinics, other physicians, rehabilitation centers, and ancillary caregivers by telephone, fax, or electronic record 4.2.1.5. Professionalism messaging avoids redundancy of care, reduces the risk of 4.2.1.5.1. Advocacy and Mindset error, and helps control cost. Examples are avoiding The trainee should develop the mindset of being the adverse drug interactions through access to lists of con- patient’s advocate to engender confidence and mutual current medications and unnecessarily repeating tests or trust and optimize clinical outcomes. That being said, procedures through access to prior results. while maintaining empathy, the trainee should retain sufficient detachment to ensure objectivity, avoid bias, 4.2.1.3.3. Access to Internet Data and sustain equanimity. Among the most important Within the context of the patient’s condition, information features of such a mindset approach are the following: that is widely accessible on the Internet may provide 1. Training in patient-centered care, emphasizing shared valuable insight, but caution is needed to avoid incorpo- decision-making and patient autonomy and eschewing rating misinformation and inferences. Information must conflicts of interest. Thus, when ordering a test or be validated through searches of primary sources, trust- recommending a course of action, the cardiologist worthy textbooks, or recommendations from evidence- should clearly convey what is in the best interest of the based practice guidelines. The trainee should become patient. Furthermore, accepting part of the burden of familiar with the array of electronic medical record sys- worry and responsibility for the patient in difficult tems and information technology resources that facilitate times—and a readiness to credit the patient, family, or systems-based practice. caregivers when the outcome is successful—catalyzes trust. 4.2.1.4. Practice-Based Learning 2. Having the equanimity to avoid distress, frustration, or 4.2.1.4.1. Adherence to Accepted Algorithms resentment when confronted with noncompliance Disease-specific algorithms for clinical decision-making while managing limited time and multiple obligations. and patient management provide foundations for indi- 3. Developing the ability to challenge assumptions, open vidualizing delivery of care for patients with cardiac one’s thinking, and seek additional opinions. Accep- conditions. Integration of personnel and electronic sys- tance of one’s limitations is important in the evolution tems for organized follow-through based on target end- of a fully-developed physician and can both enhance points should emphasize the collaborative management overall patient care and help prevent physician of patients undergoing cardiac surgery or invasive pro- burnout and cynicism. cedures and an integrated approach to team-based patient care. 4.2.1.5.2. Ability to Delegate The ability to delegate appropriately to trusted ancillary 4.2.1.4.2. Appropriate Use Criteria staff, other physicians, nurses, dieticians, physical ther- The trainee should incorporate relevant appropriate use apists, and other healthcare professionals is critical to criteria into decision making in the ambulatory setting. ensure that sufficient time is available to meet re- Outpatient training should offer a venue in which to sponsibilities to many patients. Micromanaging too many practice evidence- and guideline-based care. details can lead to exhaustion and increase rather than reduce the risk of error. 4.2.1.4.3. Performance Measures and Practice Improvement The clinical trainee should gain exposure to his/her rele- 4.2.1.5.3. Management Plan vant, individual performance metrics through periodic The trainee should be able to formulate a specificplanand reviews, including systematic updating and re-evaluation present options to the patient, family, and referring of patient charts as a means of performance assessment. physician. He/she should discuss risks and potential Trainees should also identify opportunities for focused adverse outcomes of medications or other interventions improvement; establish a pattern of enhancing compe- or, conversely, the risks of foregoing actions, tests, or tency; and ensure continuous quality improvement. treatments in relation to outcome. Furthermore, the These activities should be conducted at least twice cardiology fellow must acquire skills in communicating annually throughout the fellowship as integral to the unfortunate information when there are no remaining ambulatory care experience and be subject to both self- options, while conveying hope and open availability for assessment and review by faculty mentors, including discussion. JACC VOL. 65, NO. 17, 2015 Fuster et al. 1743 MAY 5, 2015:1734– 53 COCATS 4 Task Force 1

4.2.2. Cardiovascular Subspecialty Clinics are several other key areas of cardiology that are not fi Opportunities should be provided to expose trainees to a individually addressed in COCATS 4 via speci cTask range of ambulatory patients across a spectrum of cardio- Force reports. These include stable ischemic heart dis- vascular diseases and conditions. This may involve a ease, acute coronary syndromes, valvular heart disease, variety of mechanisms depending on the specialty, such as and pericardial disease. The curricular competency joining senior clinician tutors or attending clinics as a components and milestones for these topics are sum- primary cardiovascular physician under the direction of marized in Tables 2 to 5. Training in many of these areas faculty. Exposure to as many of the following specialty is carried out in consultative, ambulatory, or longitudi- experiencesaspossibleisrecommended: 1) hospital-based nal care experiences. For other topics, such as cardiac fl general cardiology clinic; 2) general cardiology in the office tumors, trauma, in ammatory and infectious diseases of of a senior clinician; 3) an obstetrical clinic visited by the heart, and the evaluation and management of pa- pregnant patients with heart disease, optimally in the tients with known or suspected cardiovascular disease context of an interdisciplinary approach to high-risk undergoing cardiac or noncardiac surgery, selected as- pregnancy; 4) a geriatric clinic visited by elderly patients pects are included in the competency tables of the with heart disease, optimally in an interdisciplinary geri- relevant COCATS 4 Task Force reports. atric practice; and 5) prevention and rehabilitation pro- 5. EVALUATION OF COMPETENCY grams or clinics visited by patients with dyslipidemia, diabetes, hypertension, obesity, or other risk factors in both primary and secondary prevention situations. In Evaluation tools in clinical cardiology include direct addition, exposure to patients with pulmonary hyperten- observation by instructors, in-training examinations, case sion, sleep-disordered breathing, advanced heart failure, logbooks, conference and case presentations, multisource fl peripheral vascular diseases, complex arrhythmias, and evaluations, trainee portfolios, simulation, and re ection implanted pacemakers and defibrillators, and to adult and self-assessment. Case management, judgment, patients with congenital heart disease or genetic disorders interpretive, and bedside skills must be evaluated in should occur both in general clinical cardiology practice every trainee. Quality of care and follow-up; reliability; and, when possible, through participation in organized judgment, decisions, or actions that result in complica- subspecialty practices or clinics under the direction of tions; interaction with other physicians, patients, and Level III–trained specialists in these fields. The overarching laboratory support staff; initiative; and the ability to make objective of these specialized ambulatory care experiences appropriate decisions independently should be consid- is to expose the trainee to the range of services available in ered. Trainees should maintain records of participation these tertiary care settings and enhance his/her ability to and advancement in the form of a Health Insurance – generate timely referrals when indicated, interact appro- Portability and Accountability Act (HIPAA) compliant priately with experts in the care of their own patients, and electronic database or logbook that meets ACGME enhance the overall quality of cardiovascular care available reporting standards and summarizes pertinent clinical to the population. information (e.g., number of cases, diversity of referral sources, diagnoses, disease severity, outcomes, and 4.3. Competency in the Care of Patients With disposition). The faculty, under the aegis of the program fi Speci c Cardiovascular Conditions director, should record and verify each trainee’sexperi- Together, the COCATS 4 Task Force reports form the ences, assess performance, and document satisfactory core curriculum in cardiovascular medicine and describe achievement. The program director is responsible for a wide range of clinical experiences during which confirming experience and competence and reviewing the general cardiology trainees are expected to achieve overall progress of individual trainees with the Clinical competencies in evaluating and managing patients with, Competency Committee to ensure achievement of or at risk of developing, acute and chronic cardiovascular selected training milestones and identify areas in which disorders, in both hospital and outpatient settings. There additional focused training may be required. 1744 Fuster et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 1 MAY 5, 2015:1734– 53

TABLE 2 Core Competency Components and Curricular Milestones for Training in Stable Ischemic Heart Disease

Competency Component Milestones (Months) MEDICAL KNOWLEDGE 12 24 36 Add

1 Know the epidemiology, pathophysiology, and natural history of atherosclerotic vascular disease and the I characteristic features of stable and unstable coronary artery plaque.

2 Know the determinants of coronary blood flow and myocardial oxygen consumption. I

3 Know the differential diagnosis of chest pain syndromes and the characteristic clinical features of typical I angina, atypical angina, and noncardiac chest pain.

4 Know the clinical features and natural history of angina pectoris in special populations: women, the elderly, I and patients with diabetes.

5 Know the causes of angina pectoris not related to atherosclerotic coronary disease (including valvular I heart disease, hypertrophic cardiomyopathy, cocaine, congenital coronary anomalies, vasculitis, and coronary artery spasm).

6 Know the medical conditions that can provoke or exacerbate angina pectoris. I

7 Know the differential diagnosis and prognosis of myocardial ischemia in patients with nonobstructive I coronary disease.

8 Know the characteristic electrocardiographic features of ischemia. I

9 Know the indications, contraindications, and limitations of noninvasive testing in the context of the pretest I likelihood and predictive value for diagnosis of coronary artery disease.

10 Know the role of noninvasive testing in risk-assessment, including the clinical, functional capacity, ECG, I and hemodynamic stress test findings indicative of advanced coronary disease or high-risk state.

11 Know the lifestyle, activity, and exercise guidelines and risk factor treatment targets in patients with stable I ischemic heart disease.

12 Know the indications, contraindications, and clinical pharmacology of medications used to improve I symptoms and/or prognosis in patients with stable ischemic heart disease.

13 Know the role of left ventricular systolic function in clinical decision-making and in estimation of prognosis I in patients with ischemia.

14 Know the indications, limitations, and risk of coronary angiography in patients with known or suspected I ischemia.

15 Know the anatomic and physiologic catheterization findings indicating significant coronary artery I obstruction and the coronary angiographic features indicative of a high-risk state.

16 Know the indications, risks, and benefits of percutaneous or surgical revascularization versus medical I therapy in patients with stable ischemic heart disease.

17 Know the treatment options for refractory symptomatic stable ischemic heart disease. I

18 Know the indications for noninvasive or invasive evaluation following revascularization procedures. I

EVALUATION TOOLS: direct observation and in-training examination.

PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

1 Skill to obtain and utilize history, physical examination, and electrocardiogram findings in patients with I chest pain syndromes to establish a clinical probability of the presence of symptomatic coronary artery disease.

2 Skill to distinguish stable versus unstable coronary syndromes. I

3 Skill to select evidence-based and cost-effective noninvasive testing for diagnosis and/or risk assessment I in patients with chest pain syndromes.

4 Skill to interpret and apply results of noninvasive testing in the management of patients with stable I ischemic heart disease.

5 Skill to perform and interpret exercise electrocardiographic testing. I

6 Skill to establish an effective anti-ischemic medical regimen for patients with ischemia. I

7 Skill to identify appropriate candidates for coronary angiography and percutaneous or surgical I revascularization.

8 Skill to interpret and integrate diagnostic cardiac catheterization findings into patient management. I JACC VOL. 65, NO. 17, 2015 Fuster et al. 1745 MAY 5, 2015:1734– 53 COCATS 4 Task Force 1

TABLE 2 Core Competency Components, continued

Competency Component Milestones (Months) PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

9 Skill to implement lifestyle, physical activity guidelines, and pharmacologic interventions to safely control I and achieve target levels of risk factors.

10 Skill to perform preoperative risk assessment in cardiovascular patients undergoing noncardiac surgery. I

11 Skill to perform diagnostic cardiac catheterization. II

EVALUATION TOOLS: chart-stimulated recall, conference presentation, direct observation, and logbook.

SYSTEMS-BASED PRACTICE 12 24 36 Add

1 Incorporate risk–benefit analysis and cost considerations in treatment decisions. I

2 Utilize a multidisciplinary coordinated approach for patient management, including transfer of care I and employment-related issues.

EVALUATION TOOLS: chart-stimulated recall, conference presentation, direct observation, and multisource evaluation.

PRACTICE-BASED LEARNING AND IMPROVEMENT 12 24 36 Add

1 Utilize decision and support tools for accessing guidelines and pharmacologic information at the I point of care.

2 Identify competency gaps and engage in opportunities to achieve focused education and performance I improvement.

EVALUATION TOOLS: conference presentation, direct observation, and in-training examination.

PROFESSIONALISM 12 24 36 Add

1 Exhibit sensitivity to patient preference and end-of-life issues. I

2 Identify and manage conflicts of interest. I

3 Practice within the scope of personal expertise or technical skills. I

EVALUATION TOOLS: chart-stimulated recall, direct observation, multisource evaluation, and reflection and self-assessment.

INTERPERSONAL AND COMMUNICATION SKILLS 12 24 36 Add

1 Communicate with and educate patients and families across a broad range of cultural, ethnic, and I socioeconomic backgrounds.

2 Engage in shared decision-making with patients about their condition and the options for diagnosis I and treatment.

EVALUATION TOOLS: direct observation and multisource evaluation.

Add ¼ additional months beyond the 3-year cardiovascular fellowship. 1746 Fuster et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 1 MAY 5, 2015:1734– 53

TABLE 3 Core Competency Components and Curricular Milestones for Training in Acute Coronary Syndromes

Competency Component Milestones (Months) MEDICAL KNOWLEDGE 12 24 36 Add

1 Know the epidemiology, causes, pathophysiology, and natural history of ACS, including the roles of plaque I rupture or erosion, platelet activation, and thrombosis.

2 Know the disorders that can simulate or mask acute coronary syndromes. I

3 Know the risk-assessment tools in acute coronary syndromes. I

4 Know the indications and clinical pharmacology of antiplatelet, anticoagulant, and other pharmacologic I therapies.

5 Know the post-acute coronary syndromes risk assessment, rehabilitation, and secondary prevention measures. I

ST-Elevation Myocardial Infarction

6 Know the characteristic symptoms, physical findings, electrocardiographic patterns, and biomarker findings. I

7 Know the effects and time course of ischemic injury on ventricular function and remodeling. I

8 Know the characteristic hemodynamic complications (including hypotension, low cardiac output, heart failure, I and shock).

9 Know the characteristic arrhythmia and conduction complications. I

10 Know the characteristic mechanical complications (including papillary muscle rupture and myocardial rupture). I

11 Know the characteristic findings and complications of right ventricular infarction. I

12 Know indications, contraindications, and risks of reperfusion therapies and the clinical, electrocardiographic, I and angiographic signs of reperfusion.

13 Know the relative benefits and risks of fibrinolysis and primary percutaneous coronary intervention as an initial I reperfusion strategy.

14 Know the indications for transfer, angiography, and revascularization in patients who did not receive primary I percutaneous coronary intervention (including those who received fibrinolysis or did not receive initial reperfusion therapy).

Non–ST-Elevation Acute Coronary Syndromes

15 Know the differential diagnosis and the characteristic clinical, electrocardiographic, and biomarker features for I diagnosis and risk stratification.

16 Know the relative risks and benefits of an initial invasive versus an ischemia-guided strategy for angiography I and revascularization.

EVALUATION TOOLS: chart-stimulated recall, conference presentation, direct observation, and in-training examination.

PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

1 Skill to evaluate and diagnose patients with ST-elevation myocardial infarction and initiate appropriate I reperfusion therapy within guideline time limits.

2 Skill to employ appropriate antiplatelet, anticoagulant, and other pharmacologic therapies. I

3 Skill to recognize and treat hemodynamic disturbances (including hypotension, low cardiac output, I heart failure, acute pulmonary edema, and shock) and diagnose the cause.

4 Skill to recognize and treat arrhythmias and conduction disturbances. I

5 Skill to recognize and treat mechanical complications (including papillary muscle rupture and myocardial I rupture).

6 Skill to recognize and treat patients with right ventricular infarction. I

7 Skill to assess ventricular function and utilize in treatment strategy decisions. I

8 Skill to interpret invasive hemodynamic data and angiographic findings and apply to treatment strategies. I

9 Skill to perform and interpret coronary angiography. II

10 Skill to insert intra-arterial and pulmonary artery catheters and interpret the findings. I

11 Skill to assess overall risk, identify candidates for invasive evaluation and treatment, and establish optimal I medical regimen in non–ST-elevation acute coronary syndromes. JACC VOL. 65, NO. 17, 2015 Fuster et al. 1747 MAY 5, 2015:1734– 53 COCATS 4 Task Force 1

TABLE 3 Core Competency Components, continued

Competency Component Milestones (Months) PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

12 Skill to identify patients who would benefit from mechanical circulatory support. I

13 Skill to achieve risk-factor target levels for secondary prevention. I

EVALUATION TOOLS: chart-stimulated recall, conference presentation, direct observation, and simulation.

SYSTEMS-BASED PRACTICE 12 24 36 Add

1 Work with emergency medical systems, emergency departments, and hospital teams to establish effective first I medical contact strategies for cardiovascular emergencies.

2 Identify and address financial, cultural, and social barriers to diagnostic and treatment recommendations. I

3 Utilize a multidisciplinary coordinated approach for patient management, including transfer of care and I employment-related issues.

4 Practice in a manner that fosters the balance of appropriate utilization of finite resources with the net clinical I benefit for the individual patient.

EVALUATION TOOLS: chart-stimulated recall, conference presentation, direct observation, multisource evaluation, and record review.

PRACTICE-BASED LEARNING AND IMPROVEMENT 12 24 36 Add

1 Identify gaps in performance and knowledge and perform appropriate personal learning activities. I

2 Utilize decision support tools for accessing guidelines and pharmacologic information at the point of care. I

EVALUATION TOOLS: chart-stimulated recall, direct observation, and reflection and self-assessment.

PROFESSIONALISM 12 24 36 Add

1 Exhibit sensitivity to patient preference and end-of-life issues. I

2 Demonstrate sensitivity and responsiveness to diverse patient populations. I

3 Demonstrate a commitment to carry out professional responsibilities, appropriately refer patients, and respond I to patient needs in a way that supersedes self-interest.

4 Interact respectfully with patients, families, and all members of the healthcare team, including ancillary and I support staff.

EVALUATION TOOLS: direct observation and multisource evaluation.

INTERPERSONAL AND COMMUNICATION SKILLS 12 24 36 Add

1 Effectively communicate with acutely ill patients across a broad range of cultural, ethnic, and socioeconomic I backgrounds.

2 Communicate with all healthcare providers involved in patient care. I

EVALUATION TOOLS: chart-stimulated recall, direct observation, and multisource evaluation.

Add ¼ additional months beyond the 3-year cardiovascular fellowship. 1748 Fuster et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 1 MAY 5, 2015:1734– 53

TABLE 4 Core Competency Components and Curricular Milestones for Training in Valvular Heart Disease

Competency Component Milestones (Months) MEDICAL KNOWLEDGE 12 24 36 Add

1 Know the characteristic features and natural history of congenital bicuspid aortic valve disease. I

2 Know the etiology, natural history, pathophysiology, and differential diagnosis of acquired aortic, mitral, I pulmonic, and tricuspid valve diseases.

3 Know the characteristic features and natural history of rheumatic valvular heart disease. I

4 Know the cardinal symptoms and physical findings of aortic and of mitral stenosis and their role in I management decisions.

5 Know the cardinal symptoms and physical findings of chronic aortic and chronic mitral regurgitation and I their roles in management decisions.

6 Know the causes and distinguishing characteristics of acute versus chronic mitral and aortic regurgitation. I

7 Know the natural history, clinical features, and complications of mitral valve prolapse. I

8 Know the appropriate indications for, and characteristic findings of, echocardiographic testing for diagnosis I and assessment of severity during initial evaluation and upon follow-up.

9 Know the role of stress testing in assessment of valvular heart disease. I

10 Know the indications for magnetic resonance imaging and computed tomography in the assessment I of valvular heart disease.

11 Know the indications for, and characteristic findings with, cardiac catheterization in patients with valvular I heart disease.

12 Know the indications for, and clinical pharmacology of, drugs used for the treatment of native and I prosthetic valvular heart disease, including anticoagulation and antibiotic prophylaxis.

13 Know the effects of arrhythmias on the clinical manifestations, risks of complications, and management of I valvular heart disease.

14 Know the indications and expected outcomes for surgical therapy in valvular heart disease, including valve I selection and repair versus replacement.

15 Know the indications and expected outcomes for transcatheter therapy in valvular heart disease. I

16 Know the etiology, natural history, physical findings, differential diagnosis, complications, and treatment I of native valve and prosthetic valve endocarditis.

17 Know the effects of pregnancy on the clinical manifestations and management of patients with valvular I heart disease (native and prosthetic).

EVALUATION TOOLS: chart-stimulated recall, direct observation, and in-training examination.

PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

1 Skill to identify cardinal physical findings and ECG abnormalities in patients with valvular heart disease. I

2 Skill to distinguish innocent from pathologic heart murmurs. I

3 Skill to manage patients with valvular heart disease and coronary artery disease. I

4 Skill to select appropriate testing and integrate results with clinical findings in the evaluation I and management of patients with valvular heart disease.

5 Skill to distinguish aortic stenosis from hypertrophic obstructive cardiomyopathy and other causes of I left ventricular outflow tract obstruction.

6 Skill to recognize bicuspid aortic valve disease and its associated abnormalities. I

7 Skill to recognize impact of ventricular dysfunction on clinical decision-making in valvular heart disease. I

8 Skill to recognize the cause and impact of pulmonary hypertension in management of valvular heart I disease.

9 Skill to determine candidacy and optimal timing of cardiac surgical or transcatheter treatments in patients I with valvular heart disease.

10 Skill to perform and interpret transesophageal echocardiography in patients with valvular heart disease. II

11 Skill to perform and interpret diagnostic catheterization in patients with valvular heart disease. II

EVALUATION TOOLS: chart-stimulated recall, direct observation, logbook, and simulation. JACC VOL. 65, NO. 17, 2015 Fuster et al. 1749 MAY 5, 2015:1734– 53 COCATS 4 Task Force 1

TABLE 4 Core Competency Components, continued

Competency Component Milestones (Months) SYSTEMS-BASED PRACTICE 12 24 36 Add

1 Participate in interdisciplinary decision-making with regard to surgery and transcatheter therapy. I

2 Practice in a manner that fosters the balance of appropriate utilization of finite resources with the net I clinical benefit for the individual patient.

EVALUATION TOOLS: chart-stimulated recall, conference presentation, direct observation, and multisource evaluation.

PRACTICE-BASED LEARNING AND IMPROVEMENT 12 24 36 Add

1 Identify competency gaps and engage in opportunities to achieve focused education and performance I improvement.

2 Utilize decision support tools for accessing guidelines and pharmacologic information at the point of care. I

EVALUATION TOOLS: in-training examination and reflection and self-assessment.

PROFESSIONALISM 12 24 36 Add

1 Exhibit sensitivity to patient preference and end-of-life issues. I

2 Practice within the scope of personal expertise or technical skills. I

EVALUATION TOOLS: in-training examination and reflection and self-assessment.

INTERPERSONAL AND COMMUNICATION SKILLS 12 24 36 Add

1 Engage in shared decision-making with patients about their condition and the options for diagnosis I and treatment.

EVALUATION TOOLS: direct observation and multisource evaluation.

Abbreviations as in Table 2. 1750 Fuster et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 1 MAY 5, 2015:1734– 53

TABLE 5 Core Competency Components and Curricular Milestones for Training in Pericardial Disease

Competency Component Milestones (Months) MEDICAL KNOWLEDGE 12 24 36 Add

1 Know the pathophysiology, differential diagnosis, and natural history of acute and relapsing pericarditis. I

2 Know the pathophysiology, differential diagnosis, and natural history of pericardial effusion and pericardial I tamponade.

3 Know the pathophysiology, differential diagnosis, and natural history of constrictive pericarditis. I

4 Know the cardinal physical findings of acute pericarditis, pericardial tamponade, and constrictive pericarditis. I

5 Know the indications for pericardiocentesis. I

6 Know the indications for, and clinical pharmacology of, drugs used for the treatment of acute and relapsing I pericarditis.

7 Know the effects of pericardial disease on other organ systems. I

8 Know pericardial anatomy and structural abnormalities (pericardial cyst and congenital absence of the I pericardium).

9 Know the indications for, and characteristic findings in, imaging studies of pericardial diseases. I

10 Know the indications for surgical referral in pericardial diseases and the expected outcomes. I

EVALUATION TOOLS: chart-stimulated recall, global evaluation, and in-training examination.

PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

1 Skill to clinically evaluate, diagnose, and manage patients with acute pericarditis and with chronic relapsing I pericarditis.

2 Skill to identify cardinal physical findings and evaluate and manage patients with pericardial effusion, including I tamponade.

3 Skill to identify cardinal physical findings and evaluate and manage patients with constrictive pericarditis. I

4 Skill to appropriately select and incorporate data from laboratory testing and noninvasive imaging in the I evaluation and management of patients with pericardial disease.

5 Skill to perform pericardiocentesis. II

6 Skill to distinguish constrictive pericarditis from restrictive cardiac disease. I

7 Skill to identify patients who should be referred for cardiac catheterization in the evaluation of pericardial disease. I

8 Skill to identify patients with constrictive pericarditis who are candidates for referral for consideration of cardiac I surgery.

EVALUATION TOOLS: direct observation, global evaluation, logbook, and simulation.

SYSTEMS-BASED PRACTICE 12 24 36 Add

1 Utilize a multidisciplinary coordinated approach for patient management, including transfer of care and I employment-related issues.

2 Incorporate risk-benefit analysis and cost considerations in diagnostic and treatment decisions. I

EVALUATION TOOLS: chart-stimulated recall, conference presentation, direct observation, and multisource evaluation.

PRACTICE-BASED LEARNING AND IMPROVEMENT 12 24 36 Add

1 Identify competency gaps and engage in opportunities to achieve focused education and performance I improvement.

EVALUATION TOOLS: chart-stimulated recall, in-training examination, and reflection and self-assessment.

PROFESSIONALISM 12 24 36 Add

1 Exhibit sensitivity to patient preference and end-of-life issues. I

2 Practice within the scope of personal expertise or technical skills. I

EVALUATION TOOLS: direct observation, global evaluation, and multisource evaluation. JACC VOL. 65, NO. 17, 2015 Fuster et al. 1751 MAY 5, 2015:1734– 53 COCATS 4 Task Force 1

TABLE 5 Core Competency Components, continued

Competency Component Milestones (Months) INTERPERSONAL AND COMMUNICATION SKILLS 12 24 36 Add

1 Communicate with and educate patients and families across a broad range of cultural, ethnic, and socioeconomic I backgrounds.

2 Engage in shared decision-making with patients about their condition and the options for diagnosis and treatment. I

EVALUATION TOOLS: direct observation, global evaluation, and multisource evaluation.

Add ¼ additional months beyond the 3-year cardiovascular fellowship.

REFERENCE

1. Baughman KL, Duffy FD, Eagle KA, Faxon DP, 2. Institute of Medicine (U.S.) Committee on Quality Hillis LD, Lange RA. Task force 1: training in clinical of Health Care in America. Crossing the Quality Chasm: KEY WORDS ACC Training Statement, cardiology. J Am Coll Cardiol 2008;51:339–48. A New Health System for the 21st Century. Washing- ambulatory care, clinical competence, COCATS, ton, DC: National Academies Press (U.S.); 2001. consultative care, fellowship training, Available at: http://www.ncbi.nlm.nih.gov/books/ longitudinal care NBK222274/. Accessed March 26, 2015.

APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 1: TRAINING IN AMBULATORY, CONSULTATIVE, AND LONGITUDINAL CARDIOVASCULAR CARE

Ownership/ Institutional/ Speakers Partnership/ Personal Organizational or Other Expert Committee Member Employment Consultant Bureau Principal Research Financial Benefit Witness

Valentin Fuster Icahn School of Medicine at Mount None None None None None None (Co-Chair) Sinai, Zena and Michael A. Wiener Cardiovascular Institute—Director

Jonathan L. Halperin Icahn School of Medicine at Mount None None None None None None (Co-Chair) Sinai—Professor of Medicine

Eric S. Williams Indiana University School of None None None None None None (Co-Chair) Medicine—Professor (Cardiology) and Associate Dean; Indiana University Health—Cardiology Service Line Leader

Nancy R. Cho Cardiology and Medicine None None None None None None Associates—Cardiologist

William F. Iobst The Commonwealth Medical None None None None None None College—Vice President, Academic and Clinical Affairs, Vice Dean; Former employment during writing effort: American Board of Internal Medicine— Vice President, Academic Affairs

Debabrata Mukherjee Texas Tech University Health None None None None None None Sciences Center—Chief, Cardiovascular Medicine

Prashant Vaishnava The Icahn School of Medicine at None None None None None None Mount Sinai, Mount Sinai Heart—Director, Quality Assurance; Assistant Professor of Medicine

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects authors’ employment and reporting categories. To ensure complete transparency, authors’ comprehensive healthcare-related disclosure information—including relationships with industry not pertinent to this document—is available in an online data supplement. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/ relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional information about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology. 1752 Fuster et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 1 MAY 5, 2015:1734– 53

APPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 1: TRAINING IN AMBULATORY, CONSULTATIVE, AND LONGITUDINAL CARDIOVASCULAR CARE

Institutional/ Organizational Ownership/ or Other Speakers Partnership/ Personal Financial Expert Name Employment Representation Consultant Bureau Principal Research Benefit Witness

Richard Kovacs Indiana University, Krannert Official Reviewer, None None None None None None Institute of Cardiology—Q.E. and ACC Board of Trustees Sally Russell Professor of Cardiology

Dhanunjaya Kansas University Cardiovascular Official Reviewer, None None None None None None Lakkireddy Research Institute ACC Board of Governors

Howard Weitz Thomas Jefferson University Official Reviewer, None None None None None None Hospital—Director, Division of Competency Management Cardiology; Sidney Kimmel Committee Lead Reviewer Medical College at Thomas Jefferson University—Professor of Medicine

Furman McDonald American Board of Internal Organizational Reviewer, None None None None None None Medicine—Vice President ABIM Graduate Medical Education, Department of Academic Affairs and Professor, Medicine

Kiran Musunuru Brigham and Women’s Organizational Reviewer, None None None None None None Hospital, Harvard University AHA

Kenneth Ellenbogen VCU Medical Center—Director, Content Reviewer, Cardiology None None None None None None Clinical Electrophysiology Training and Workforce Laboratory Committee

Michael Emery Greenville Health System Content Reviewer, Sports and None None None None None None Exercise Cardiology Section Leadership Council

Rosario Freeman University of Washington— Content Reviewer, None None None None None None Director, Cardiology Fellowship Competency Management Programs; Medical Director, Committee Noninvasive Diagnostic Services; Associate Professor of Medicine

Brian D. Hoit University Hospitals Case Content Reviewer, Cardiology None None None None None None Medical Center Training and Workforce Committee

Larry Jacobs Lehigh Valley Health Network, Content Reviewer, Cardiology None None None None None None Division of Cardiology; Training and Workforce University of South Florida— Committee Professor, Cardiology

Andrew Kates Washington University School Content Reviewer, Academic None None None None None None of Medicine Research Council

Chittur A. Sivaram University of Oklahoma—Vice Content Reviewer, None None None None None None Chief, Cardiovascular Section Competency Management Committee

David Montefiore-Einstein Center Content Reviewer, None None None None None None Vorchheimer for Heart & Vascular Care— Individual Director, Clinical Cardiology; Professor, Clinical Medicine

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects peer reviewers’ employment, representation in the review process, as well as reporting categories. Names are listed in alphabetical order within each category of review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional infor- mation about the ACC Disclosure Policy for Writing Committees. ABIM ¼ American Board of Internal Medicine; ACC ¼ American College of Cardiology; AHA ¼ American Heart Association; VCU ¼ Virginia Commonwealth University. JACC VOL. 65, NO. 17, 2015 Fuster et al. 1753 MAY 5, 2015:1734– 53 COCATS 4 Task Force 1

APPENDIX 3. ABBREVIATION LIST

ABIM ¼ American Board of Internal Medicine ABMS ¼ American Board of Medical Specialties ACC ¼ American College of Cardiology ACGME ¼ Accreditation Council for Graduate Medical Education COCATS ¼ Core Cardiovascular Training Statement HIPAA ¼ Health Insurance Portability and Accountability Act JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL.65,NO.17,2015 ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00 PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacc.2015.03.018

TRAINING STATEMENT COCATS 4 Task Force 2: Training in Preventive Cardiovascular Medicine

Sidney C. Smith, JR, MD, FACC, Chair Quinn R. Pack, MD Vera Bittner, MD, FACC Donna M. Polk, MD, MPH, FACC J. Michael Gaziano, MD, FACC Neil J. Stone, MD, FACC John C. Giacomini, MD, FACC Stanley Wang, MD, JD, MPH

1. INTRODUCTION public comment from December 20, 2014, to January 6, 2015. Authors addressed the additional comments 1.1. Document Development Process from the public to complete the document. The final 1.1.1. Writing Committee Organization document was approved by the Task Force, COCATS Steering Committee, and ACC Competency Manage- The writing committee was selected to represent mentCommitteeaswellasratified by the ACC Board the American College of Cardiology (ACC) and included of Trustees in March 2015. This document is consid- a cardiovascular training program director, a car- ered current until the ACC Competency Management diology clinic director, early-career cardiovascular Committee revises or withdraws it. disease (CVD) prevention experts, highly experienced specialists representing both the academic and community-based practice settings, a physician expe- 1.2. Background and Scope rienced in defining and applying training standards Atherosclerotic vascular disease, with its clinical according to the core competencies structure that is manifestations of myocardial infarction, stroke, and promulgated by the Accreditation Council for Graduate peripheral vascular disease, is the world’sleading Medical Education (ACGME) and American Board of cause of death, morbidity, and mortality and is, Medical Specialties (ABMS)andendorsedbythe therefore, the major focus of training in prevention and American Board of Internal Medicine (ABIM), and a in the strategies recommended in this document. Other fellow in training. The ACC determined that relation- disease prevention issues are dealt with in specific ships with industry or other entities were not relevant sections. The missions of the ACC and the American to the creation of this general cardiovascular training Heart Association have been to ensure optimal care to statement. Employment and affiliation details for the those with or at risk for developing atherosclerotic authors and peer reviewers are provided in Appendixes cardiovascular disease (ASCVD). The cardiovascular 1 and 2, respectively, along with disclosure reporting specialist is expected to contribute significantly to categories. Comprehensive disclosure information for treating and preventing CVD in the setting of a rapidly all authors, including relationships with industry and growing field of knowledge ranging from molecular other entities, is available as an online supplement to and cellular mechanisms to clinical outcomes. Over the this document. past 2 decades, there have been dramatic increases in knowledge concerning specificriskfactors,and 1.1.2. Document Development and Approval guidelines have been developed to address these fac- The writing committee developed the document, tors relating to atherosclerosis, hypertension, throm- approved it for peer review by individuals selected by bosis, and other forms of vascular dysfunction. the ACC, and then addressed peer reviewers’ com- Despite the fact that clinical outcomes can be ments. The document was revised and posted for improved by promoting favorable life habits and be- haviors and by the proper use of drug treatment, the application of preventive interventions in the clinical The American College of Cardiology requests that this document be cited practice of cardiovascular medicine is not optimal. as follows: Smith SC Jr, Bittner V, Gaziano JM, Giacomini JC, Pack QR, Part of this problem may be the insufficient attention Polk DM, Stone NJ, Wang S. COCATS 4 task force 2: training in preventive cardiovascular medicine. J Am Coll Cardiol 2015;65:1754–62. that prevention education currently receives during JACC VOL. 65, NO. 17, 2015 Smith, Jr. et al. 1755 MAY 5, 2015:1754– 62 COCATS 4 Task Force 2

cardiovascular fellowship. A recent survey of cardiovas- accepted instrument or benchmark, such as a qualifying cular fellowship programs revealed that most programs examination, is available to measure specificknowledge, do not meet current ACC/COCATS training recommenda- skills, or competence. In the case of prevention, the Task tions for CVD prevention (1).Inboththeprimaryand Force identified no specific competencies for Level II secondary prevention settings, ASCVD prevention must training. Given the central importance of prevention to no longer be peripheral to thepracticeofthecardiovas- managing patients with CVD, all competencies have cular specialist. The cardiovascular specialist must been identified as Level I (required for all fellows) or become proficient in primary and secondary prevention of relegated to advanced training postfellowship. ASCVD, having the ability to recommend specificprimary n Level III training—Although there are programs for and secondary preventive measures and to identify pa- advanced training in prevention, such as may be tients with subclinical ASCVD who may benefitfrommore required to qualify as director of a clinical service, aggressive risk factor modification.Itisimportantforthe research program, or both, there is, as yet, no formal cardiovascular fellow to understand which therapies Level III certification process for added qualification in promoted widely in practice and/or on the internet have a prevention. Cardiologists who wish to focus their careers strong evidence base and which do not. on CVD prevention may wish to consider advanced It is imperative that cardiovascular training programs training outside of the ACGME-accredited training pro- provide the necessary education and training to promote gram (see Section 4.2.2.AdvancedTraining). best practices among their trainees, who bear the re- sponsibility to provide optimal preventive services to 2. GENERAL STANDARDS their patients. This report outlines specificareasof knowledge and skills necessary to achieve this goal and ASCVD, or its antecedent risk factors, acquired at a young also defines the required and recommended standards to age is often strongly related to poor lifestyle habits such as achieve this goal. The report updates previously pub- unhealthy diet, sedentary behavior, and tobacco use. If lished standards for training cardiology fellows enrolled widely implemented, evidence-based population strate- in cardiac fellowship programs on the basis of changes in gies have the promise to reduce the burden of CVD risk the field since 2008 (2) and as part of a broader effort to factors in the community and make preventive strategies establish consistent training criteria across all aspects of more effective for high-risk patients (3). As noted earlier, cardiology. It also addresses the evolving framework of training in CVD prevention should be an essential part of all competency-based medical education described by the cardiovascular fellowship programs. Several important ACGME Outcomes Project and the 6 general competencies statements and guidelines provide the basis for training in endorsed by the ACGME and ABMS. For the purpose of the assessment and treatment of patients at risk of car- this document, all references to ASCVD prevention refer diovascular events. These statements have been devel- to both primary and secondary prevention. oped by organizations such as the ACC; American Heart The background and overarching principles governing Association; and National Heart, Lung, and Blood Institute fellowship training are provided in the COCATS 4 Intro- andshouldbeincludedascorereferencesintrainingas duction, and readers should become familiar with this they become available and are updated (4–11).Thisevi- foundation before considering the details of training in a dence base will be especially useful when cardiologists subdiscipline such as CVD prevention. The Steering begin practice after training and/or assume leadership Committee and Task Force recognize that implementation positions. of these changes in training requirements will occur incrementally over time. 2.1. Faculty For most areas of adult cardiovascular medicine, 3 Thereshouldbeadequatefaculty,bothinnumberand levels of training are delineated: experience, to conduct training in preventive cardiovas- cular medicine. It is also highly desirable for at least some n Level I training, the basic training required of faculty to have expertise in vascular biology, atheroscle- trainees to become competent consultant cardiologists, rosis, hypertension, disorders of lipid metabolism, is required of all fellows in cardiology, and can be obesity and weight management, sleep medicine, diet accomplished as part of a standard 3-year training and nutrition, smoking cessation, diabetes mellitus, program in cardiology. thrombosis, clinical epidemiology, cardiac rehabilitation, n Level II training refers to additional training in 1 or more exercise physiology, clinical pharmacology, genetics and areas that enables some cardiologists to perform or pharmacogenomics, and the psychosocial aspects of CVD. interpret specific procedures or render more specialized Ideally, specific faculty in the cardiovascular medicine care for specific patients and conditions. This level of training program should be able to serve as topic area training is recognized only for those areas in which an experts in 1 or more of these areas. This is important 1756 Smith, Jr. et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 2 MAY 5, 2015:1754– 62

because the faculty should be able to function as role sex, and ethnicity. It should include patients who have models in preventive cardiovascular medicine. Mentoring undergone revascularization, cardiac transplantation, is important for cardiovascular trainees in their formative and other complex cardiovascular procedures. Given the years, and prevention-oriented role models should func- importance of CVD as a global threat, training obtained tion in this capacity. outside of the primary institution, including interna- tional experiences, can provide valuable insight to 2.2. Facilities trainees on the challenges involved in reducing cardio- Facilities should be adequate to ensure experience in vascular risk in less technologically developed health managing patients undergoing cardiac rehabilitation, as systems. well as to provide instruction on lifestyle measures such as diet, weight loss, physical activity, psychosocial eval- 3.3. Hands-On Experience uation, and smoking cessation. Programs without access Hands-on experience is important for training in CVD to cardiac rehabilitation at the sponsoring institution may prevention. Trainees in cardiology should spend 6 to 12 be able to access community resources or arrange for months devoted to managing patients with advanced appropriate electives at other sites. atherosclerosis, heart failure, valvular heart disease, 2.3. Equipment arrhythmia, dyslipidemia, obesity, sedentary lifestyle, and hypertension. Additionally, trainees should partici- Access to Web-based programs for assessing cardiovas- pate in delivering cardiac rehabilitation in the appropriate cular risk is important. The availability of equipment inpatient and outpatient environments to acquire the specified for noninvasive imaging (see COCATS 4 Task core competencies. Opportunities to practice in disease Force 5: Echocardiography; Task Force 6: Nuclear Cardi- prevention or wellness centers and in pediatric and ology; Task Force 7: Cardiovascular Computed Tomogra- adolescent prevention clinics may add valuable perspec- phy; and Task Force 8: Cardiovascular Magnetic tive and education on issues facing patients with less- Resonance) is essential. advanced disease states. 2.4. Ancillary Support 4. SUMMARY OF TRAINING REQUIREMENTS Ancillary support to provide counseling on diet, exercise, weight loss, smoking cessation, and managing psychoso- cial risk factors should be available. 4.1. Development and Evaluation of Core Competencies Training and requirements in CVD prevention address the 3. TRAINING COMPONENTS 6 general competencies promulgated by the ACGME/ ABMS and endorsed by the ABIM. These competency do- 3.1. Didactic Program mains include: medical knowledge, patient care and Didactic instruction may take place in a variety of for- procedural skills, practice-based learning and improve- mats, including, but not limited to, lectures, conferences, ment, systems-based practice, interpersonal and journal clubs, grand rounds, clinical case presentations, communication skills, and professionalism. The ACC has and patient safety or quality improvement conferences. used this structure to define and depict the components The importance of clinical history should be taught on a of the core clinical competencies for cardiology. The regular basis and emphasized in patient-related confer- curricular milestones for each competency and domain ences. Clinical history includes family history; assessment also provide a developmental roadmap for fellows as they of diet, physical activity, fitness, and other lifestyle progress through various levels of training and serve as an habits; physical examination; and electrocardiographic underpinning for the ACGME/ABIM reporting milestones. manifestations and findings from other noninvasive im- The ACC has adopted this format for its competency and aging tests used to identify subclinical atherosclerosis. training statements, career milestones, lifelong learning, and educational programs. Additionally, it has developed 3.2. Clinical Experience tools to assist physicians in assessing, enhancing, and Rotation on general cardiovascular services is an essential documenting these competencies. component of training in CVD prevention. Level I trainees Table 1 delineates each of the 6 competency domains should gain firsthand experience in treatment strategies as well as their associated curricular milestones for for primary and secondary prevention, as well as in training in CVD prevention. The milestones indicate the management of complex dyslipidemia and advanced stage of fellowship training (12, 24, or 36 months, and hypertension. additional time points) by which the typical cardiovas- Training in CVD prevention should involve prevention cular trainee should achieve the designated level. across the risk continuum for patients of varying age, Because programs may vary with respect to the sequence JACC VOL. 65, NO. 17, 2015 Smith, Jr. et al. 1757 MAY 5, 2015:1754– 62 COCATS 4 Task Force 2

TABLE 1 Core Competency Components and Curricular Milestones for Training in Cardiovascular Disease Prevention

Competency Component Milestones (Months) MEDICAL KNOWLEDGE 12 24 36 Add

1 Know the structure of the normal artery and the basic vascular biology of atherosclerotic vascular disease. I

2 Know the principles of genetics as applied to cardiovascular disease and pharmacogenomics as applied to I cardiovascular therapy.

3 Know the impact of family history on disease risk and utility of family screening in cardiovascular disease prevention. I

4 Know the clinical epidemiology of cardiovascular disease, including incidence/prevalence, sex and ethnic differences, I and the influence of traditional risk factors and demographics on outcomes.

5 Know the principles for implementation both of individual and population-based cardiovascular disease prevention. I

6 Know the major tools to assess both lifetime and 10-year risks of a first cardiovascular event and influence I primary prevention measures.

7 Know the evidence for incremental benefit over a traditional risk-based approach, as well as the advantages, I disadvantages, and limitations of screening methods to assess subclinical atherosclerosis (including biomarkers, coronary calcification, carotid intima-media thickness, and ankle-brachial index).

8 Know the effects of diabetes mellitus, obesity, hypertension, lipid disorders, physical inactivity, and tobacco use I on the development and progression of atherosclerosis, and their treatment strategies.

9 Know the physiology and assessment of diabetes mellitus and principles of its management and comanagement I in patients with cardiovascular disease.

10 Know the physiology, assessment, and management of lipid disorders, including in special populations. I

11 Know the physiology, presentation, evaluation and management of hypertensive disorders, including refractory I hypertension.

12 Know the principles of nutrition and obesity assessment and management, including the roles of pharmacotherapy I and bariatric surgery.

13 Know the roles and management principles for behavioral and psychosocial contributions to cardiovascular disease. I

14 Know the principles and roles of exercise physiology, physical activity counseling, and cardiac rehabilitation. I

15 Know the tools and principles for managing and counseling regarding tobacco cessation. I

16 Know the effects of systemic diseases and their treatments (including renal, hepatic, inflammatory, and I autoimmune-related disorders) on cardiovascular risk factors and their management.

17 Know adverse effects of obstructive and central sleep apnea on the incidence and control of hypertension, I atrial fibrillation and other arrhythmias, congestive heart failure, and atherosclerosis.

18 Know the indications for noninvasive screening for carotid artery disease, abdominal aortic aneurysm, and I peripheral vascular disease.

19 Know the impact of reproductive stages, pregnancy, and hormonal treatment for reproductive disorders on I cardiovascular risk.

20 Know the principles of antithrombotic therapy in cardiovascular disease. I

21 Know the pharmacology, indications, contraindications, and interactions of medications commonly used in I cardiovascular disease prevention and therapy (e.g., antithrombotic agents, antihypertensive agents, lipid-lowering agents, agents used in diabetes mellitus management, and agents used in cessation of tobacco).

EVALUATION TOOLS: chart-stimulated review, direct observation, and in-training examination.

PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

1 Skill to perform global risk assessment and appropriately utilize diagnostic testing—both in patients at risk for I and those with prior cardiovascular events or diagnoses.

2 Skill to evaluate a patient’s family history and appropriately recommend family screening. I

3 Skill to identify patients who may have common systemic disorders that affect cardiovascular disease diagnosis I and treatment such as sleep apnea and thyroid disorders.

4 Skill to implement and prescribe lifestyle approaches for the prevention and treatment of hypertension, I dyslipidemia, tobacco use, obesity, and diabetes mellitus.

5 Skill to assess physical activity patterns and exercise capacity and provide physical activity counseling and I exercise prescription, as well as counseling on whether to return to sports. 1758 Smith, Jr. et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 2 MAY 5, 2015:1754– 62

TABLE 1 Core Competency Components, continued

Competency Component Milestones (Months) PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

6 Skill to identify patients who will benefit from low-density lipoprotein apheresis. I

7 Skill to identify patients for whom antiplatelet therapy is indicated. I

8 Skill to identify and address factors that contribute to nonadherence to treatment regimen. I

9 Skill to utilize individualized risk–benefit assessment in the management of patients and adapt prevention I strategies to patients with specific comorbidities (e.g., diabetes mellitus, chronic kidney disease, arthritis).

10 Skill to appropriately integrate new medical information into patient care. I

EVALUATION TOOLS: chart-stimulated recall, direct observation, and registry and/or hospital program quality data.

SYSTEMS-BASED PRACTICE 12 24 36 Add

1 Practice in a manner that best balances appropriate utilization of finite resources with the net clinical benefit I for the individual patient.

2 Utilize an interdisciplinary team approach for disease management. I

3 Coordinate patient care among healthcare providers, including transfer of care. I

4 Identify and address financial, cultural, and social barriers to treatment implementation and adherence. I

5 Appropriately utilize specialty care for patients with advanced or complex diabetes mellitus, complex lipid I disorders, refractory hypertension, obesity, depression, or sleep apnea.

6 Appropriately utilize disease management tools and protocols as an aid in the management of patients with I high risk-factor burden and established chronic diseases.

EVALUATION TOOLS: direct observation and multisource evaluation.

PRACTICE-BASED LEARNING AND IMPROVEMENT 12 24 36 Add

1 Identify knowledge and performance gaps and engage in opportunities to achieve focused education and I performance improvement.

2 Utilize point-of-service resources to enhance adherence to guidelines and protocols and obtain new information I from clinical trials and professional societies.

EVALUATION TOOLS: chart-stimulated recall, direct observation, registry and/or hospital program quality data, and reflection and self-assessment.

PROFESSIONALISM 12 24 36 Add

1 Know and promote adherence to guidelines and appropriate use criteria. I

2 Demonstrate respect for individuals with lifestyle disorders such as obesity and tobacco use. I

3 Practice prevention in your personal lifestyle and promote a culture of healthy lifestyle choices and physical I activity in your work environment and community.

EVALUATION TOOLS: conference presentation, direct observation, and multisource evaluation.

INTERPERSONAL AND COMMUNICATION SKILLS 12 24 36 Add

1 Communicate with and educate patients and families across a broad range of cultural, ethnic, and socioeconomic I backgrounds regarding appropriate risk factor modification.

2 Communicate in ways that patients and families can understand the evidence on which recommendations I are based.

3 Evaluate a patient’s health literacy and appropriately adapt counseling strategies and tools. I

4 Communicate effectively with patients, families, and referring physicians. I

EVALUATION TOOLS: direct observation and multisource evaluation.

Add ¼ additional months beyond the 3-year cardiovascular fellowship. JACC VOL. 65, NO. 17, 2015 Smith, Jr. et al. 1759 MAY 5, 2015:1754– 62 COCATS 4 Task Force 2

of clinical experiences provided to trainees, the mile- attendance at a cardiac rehabilitation program, diabetes stones at which various competencies are reached may mellitus or endocrinology clinic, hypertension clinic, and vary as well. Level I competencies may be achieved at lipid disorders clinic. Another alternative includes earlier or later time points. The table also describes obtaining training in these areas through consultative, examples of evaluation toolssuitableforassessing inpatient, and outpatient rotations, with additional competence in each domain. didactic sessions, such as monthly lectures focusing on cardiovascular prevention topics. If the latter approach is 4.2. Training Requirements taken, the time allotted should be equivalent to at least Training for CVD prevention should be incorporated 1 month of full-time training. Training program directors into all aspects of a cardiovascular training program. may also consider supplementing clinical experiences Given the importance of prevention in managing pa- with short courses devoted exclusively to preventive tients with CVD, all competencies to be obtained during cardiovascular medicine or risk factor evaluation and the 3-year fellowship program are denoted as Level I, management. required for every trainee. Advanced postfellowship training can be obtained to acquire a body of knowledge 4.2.2. Advanced Training Requirements and career pathway to specialize in CVD prevention, The most effective preventive cardiovascular medicine leading to a leadership focus in this field. The specific services incorporate the skills and knowledge of multiple training elements required are discussed in the providers, including cardiovascular physicians, nurses, following sections. nurse practitioners, physician assistants, dietitians, sleep and behavioral medicine specialists, and exercise physi- 4.2.1. Level I Training Requirements ologists. They operate on principles of interdisciplinary Clinical trials have proven that strategies aimed at teamwork and use systemic approaches to patient care. appropriately detecting and modifying risk factors can Although such programs are more effective than routine slow progression of atherosclerosis and hypertension cardiovascular practice, few training programs offer op- and reduce the occurrence of clinical events in both portunities to learn these new skills. Programs interested primary and secondary prevention settings. More in offering advanced training should incorporate these recently, it has been shown that atherosclerosis can be new concepts into the training program, and trainees stabilized or even modestly reversed with an associated interested in advanced training should seek programs reduction in undesirable clinical outcomes. Finally, the that offer these approaches to patient care (12).Thetype growing knowledge base of cardiovascular molecular of skills developed in such advanced training programs genetics has potentially important implications for the might include competency in managing patients using future clinical practice of preventive cardiovascular low-density lipoprotein apheresis; leadership training to medicine. Level I training is required of all cardiovas- serve as director of a preventive cardiovascular medicine, cular specialists and includes the milestones outlined in hypertension, or lipid service, a cardiac rehabilitation Table 1.Itisimportanttorealizethatthislistofkey program, or vascular or sleep medicine laboratory; or, in measures should not be considered all-inclusive. The the case of a trainee, obtaining a master’sdegreeinpublic field of cardiovascular prevention is ever-changing, as health, clinical epidemiology, or outcomes research. These epidemiologic and clinical trial data accumulate. competencies are beyond the Level I training in preventive Training programs should be oriented toward imple- cardiovascular medicine included in a cardiovascular menting the most up-to-date guidelines for all risk fac- fellowship program. Fellows interested in advanced tors in CVD prevention. training may wish to consider training and certification To achieve this level of competency, the Task Force through participation in various subspecialty societies believes the typical fellow will require 1 month of dedi- (e.g., the American Association of Cardiovascular and cated training in ASCVD prevention. A potential mecha- Pulmonary Rehabilitation, American Academy of Sleep nism to obtain this level of training could be participation Medicine, American Society of Hypertension, National in a 1-month (or longer) rotation dedicated to preventive Lipid Association, Association for the Treatment of cardiovascular medicine (Table 1). Acceptable alternatives Tobacco Use and Dependence, and The Obesity Society/ include a 3-month (or longer) clinical cardiovascular American Board of Obesity Medicine) or to participate in rotation that allows concomitant exposure to a compre- additional training in CVD prevention during 3rd year hensive cardiovascular rehabilitation program at least electives or during a 4th year of training in non–ACGME 1 day each week. This would allow incorporation of a training programs in CVD prevention (12).Specific compe- broad range of preventive approaches in addition to the tencies for prevention specialists and medical directors of predominant rehabilitation focus of physical exercise. cardiac rehabilitation programs have been published pre- Ideally, the 1-month rotation should include weekly viously (5,13). 1760 Smith, Jr. et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 2 MAY 5, 2015:1754– 62

5. EVALUATION OF COMPETENCY The ACC, American Heart Association, and American College of Physicians published a curriculum on CVD Evaluation tools in CVD prevention include direct obser- prevention (5). The ACC offers an Adult Clinical Cardiol- vation by instructors, in-training examinations, case log- ogy Self-Assessment Program (ACCSAP) that includes in- books, conference and case presentations, multisource formation on preventive cardiovascular medicine, and evaluations, trainee portfolios, simulation, and reflection other societies offer similar self-assessment programs and self-assessment. Case management, judgment, (e.g., the National Lipid Association Self-Assessment interpretation, and bedside skills must be evaluated in Program). Training directors and trainees are encour- every trainee. Quality of care and follow-up; reliability; aged to incorporate resources such as these in the course judgment, decisions, or actions that result in complica- of training, to utilize in-service examinations, and to tions; interaction with other physicians, patients, and ensure trainees (and faculty) have acquired appropriate laboratory support staff; initiative; and the ability to knowledge of preventive cardiovascular medicine. make appropriate decisions independently should be Under the aegis of the program director, the faculty considered. Trainees should maintain records of partici- should record and verify each trainee’s experiences, pation and advancement in the form of a Health assess performance, and document satisfactory achieve- Insurance Portability and Accountability Act (HIPAA)– ment. The program director is responsible for confirming compliant electronic database or logbook that meets experience and competence and reviewing the overall ACGME reporting standards and summarizes pertinent progress of individual trainees with the Clinical Compe- clinical information (e.g., number of cases, dates, and tency Committee to ensure achievement of selected patient identifiers such as medical record number and training milestones and identify areas in which additional faculty supervisor). focused training may be required.

REFERENCES

1. Pack QR, Keteyian SJ, McBride PE, et al. Current 6. Greenland P, Alpert JS, Beller GA, et al. 2010 ACCF/ 10. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC status of preventive cardiology training among United AHA guideline for assessment of cardiovascular risk in guideline on lifestyle management to reduce cardiovas- States cardiology fellowships and comparison to asymptomatic adults: a report of the American College cular risk: a report of the American College of Cardiology/ training guidelines. Am J Cardiol 2012;110:124–8. of Cardiology Foundation/American Heart Association American Heart Association Task Force on Practice Task Force on Practice Guidelines. J Am Coll Cardiol Guidelines. J Am Coll Cardiol 2014;63:2960–84. 2. Blumenthal RS, Merz CN, Bittner V, et al. Task force 2010;56:e50–103. 10: training in preventive cardiovascular medicine. 11. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ J Am Coll Cardiol 2008;51:393–8. 7. Smith SC Jr., Benjamin EJ, Bonow RO, et al. AHA/ ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College 3. Mozaffarian D, Afshin A, Benowitz NL, et al. Popu- ACCF secondary prevention and risk reduction therapy of Cardiology/American Heart Association Task Force lation approaches to improve diet, physical activity, for patients with coronary and other atherosclerotic on Practice Guidelines and The Obesity Society. J Am and smoking habits: a scientific statement from the vascular disease: 2011 update: a guideline from the Coll Cardiol 2014;63:2985–3023. American Heart Association. Circulation 2012;126: American Heart Association and American College of 1514–63. Cardiology Foundation endorsed by the World Heart 12. Pack QR, Keteyian SJ, McBride PE. Subspecialty Federation and the Preventive Cardiovascular Nurses training in preventive cardiology: the current status 4. Go AS, Bauman MA, Coleman King SM, et al. An – Association. J Am Coll Cardiol 2011;58:2432 46. and discoverable fellowship programs. Clin Cardiol effective approach to high blood pressure control: a 2012;35:286–90. science advisory from the American Heart Association, 8. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 the American College of Cardiology, and the Centers ACC/AHA guideline on the treatment of blood 13. King M, Bittner V, Josephson R, et al. Medical di- for Disease Control and Prevention. J Am Coll Cardiol cholesterol to reduce atherosclerotic cardiovascular rector responsibilities for outpatient cardiac rehabili- 2014;63:1230–8. risk in adults: a report of the American College of tation/secondary prevention programs: 2012 update: a Cardiology/American Heart Association Task Force statement for health care professionals from the 5. Bairey Merz CN, Alberts MJ, Balady GJ, et al. on Practice Guidelines. J Am Coll Cardiol 2014;63: American Association for Cardiovascular and Pulmo- ACCF/AHA/ACP 2009 competence and training state- 2889–934. nary Rehabilitation and the American Heart Associa- ment: a curriculum on prevention of cardiovascular tion. J Cardiopulm Rehabil Prev 2012;32:410–9. disease: a report of the American College of Cardio- 9. Goff DC Jr., Lloyd-Jones DM, Bennett G, et al. logy Foundation/American Heart Association/American 2013 ACC/AHA guideline on the assessment of car- College of Physicians Task Force on Competence and diovascular risk: a report of the American College of Training (Writing Committee to Develop a Competence Cardiology/American Heart Association Task Force KEY WORDS ACC Training Statement, and Training Statement on Prevention of Cardiovas- on Practice Guidelines. J Am Coll Cardiol 2014;63: cardiovascular disease prevention, clinical cular Disease). J Am Coll Cardiol 2009;54:1336–63. 2935–59. competence, COCATS, fellowship training JACC VOL. 65, NO. 17, 2015 Smith, Jr. et al. 1761 MAY 5, 2015:1754– 62 COCATS 4 Task Force 2

APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 2: TRAINING IN PREVENTIVE CARDIOVASCULAR MEDICINE

Institutional/ Ownership/ Organizational Speakers Partnership/ Personal or Other Expert Committee Member Employment Consultant Bureau Principal Research Financial Benefit Witness

Sidney C. Smith, Jr. University of North Carolina, None None None None None None (Chair) Heart and Vascular Center— Professor of Medicine

Vera Bittner University of Alabama at None None None None None None Birmingham—Medical Director, Coronary Care Unit; Professor of Medicine; Section Head, Preventive Cardiology; and Medical Director, Cardiac Rehabilitation

J. Michael Gaziano Brigham and Women’s Hospital, None None None None None None Cardiology Division—Chief, Division of Aging

John C. Giacomini Stanford University Medical None None None None None None Center—Professor and Associate Chief, Division of Cardiovascular Medicine; Fellowship Director; VA Palo Alto Health Care System—Chief, Cardiology Section

Quinn R. Pack Henry Ford Hospital—Cardiologist None None None None None None

Donna M. Polk Brigham and Women’s None None None None None None Hospital—Director, Cardiovascular Fellowship Program

Neil J. Stone Northwestern Medicine— None None None None None None Professor of Medicine; Preventive Cardiology

Stanley Wang Austin Heart—Cardiologist and None None None None None None Sleep Specialist; Heart Hospital of Austin Sleep Disorders Center—Medical Director

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects authors’ employment and reporting categories. To ensure complete transparency, authors’ comprehensive healthcare-related disclosure information—including RWI not pertinent to this document—is available in an online data supplement. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional information about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology. 1762 Smith, Jr. et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 2 MAY 5, 2015:1754– 62

APPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 2: TRAINING IN PREVENTIVE CARDIOVASCULAR MEDICINE

Institutional/ Organizational Ownership/ or Other Speakers Partnership/ Personal Financial Expert Name Employment Representation Consultant Bureau Principal Research Benefit Witness

Richard Kovacs Indiana University, Krannert Official Reviewer, None None None None None None Institute of Cardiology—Q.E. ACC Board of Trustees and Sally Russell Professor of Cardiology

Dhanunjaya Kansas University Cardiovascular Official Reviewer, None None None None None None Lakkireddy Research Institute ACC Board of Governors

Howard Weitz Thomas Jefferson University Official Reviewer, Competency None None None None None None Hospital—Director, Division Management Committee of Cardiology; Sidney Kimmel Lead Reviewer Medical College at Thomas Jefferson University— Professor of Medicine

Kiran Musunuru Brigham and Women’s Hospital, Organizational Reviewer, AHA None None None None None None Harvard University

Mouaz Al-Mallah King Abdul-Aziz Cardiac Content Reviewer, None None None None None None Center—Associate Professor Prevention Council of Medicine

Michael Emery Greenville Health System Content Reviewer, Sports None None None None None None and Exercise Cardiology Section Leadership Council

Brian D. Hoit University Hospitals Case Content Reviewer, Cardiology None None None None None None Medical Center Training and Workforce Committee

Larry Jacobs Lehigh Valley Health Network, Content Reviewer, Cardiology None None None None None None Division of Cardiology; Training and Workforce University of South Florida— Committee Professor, Cardiology

Richard Josephson University Hospitals Harrington Content Reviewer, None None None None None None Heart & Vascular Institute, Prevention Council Case Medical Center; Case Western Reserve School of Medicine—Division of Cardiology

Andrew Kates Washington University Content Reviewer, Academic None None None None None None School of Medicine Cardiology Section Leadership Council

Deirdre Mattina Henry Ford Hospital— Content Reviewer, None None None None None None Senior Staff Physician, Prevention Council Cardiology

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects peer reviewers’ employment, representation in the review process, as well as reporting categories. Names are listed in alphabetical order within each category of review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional infor- mation about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology; AHA ¼ American Heart Association.

APPENDIX 3. ABBREVIATION LIST

ABIM ¼ American Board of Internal Medicine ASCVD ¼ atherosclerotic cardiovascular disease ABMS ¼ American Board of Medical Specialties COCATS ¼ Core Cardiovascular Training Statement ACC ¼ American College of Cardiology CVD ¼ cardiovascular disease ACCSAP ¼ Adult Clinical Cardiology Self-Assessment Program HIPAA ¼ Health Insurance Portability and Accountability Act ACGME ¼ Accreditation Council for Graduate Medical Education JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 65, NO. 17, 2015 ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00 PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacc.2015.03.021

TRAINING STATEMENT COCATS 4 Task Force 3: Training in Electrocardiography, Ambulatory Electrocardiography, and Exercise Testing

Gary J. Balady, MD, FACC, Chair Jeffrey T. Kuvin, MD, FACC Vincent J. Bufalino, MD, FACC Lisa A. Mendes, MD, FACC Martha Gulati, MD, MS, FACC Joseph L. Schuller, MD

1. INTRODUCTION ACC, and then addressed the peer reviewers’ com- ments. The document was revised and posted for 1.1. Document Development Process public comment from December 20, 2014, to January 1.1.1. Writing Committee Organization 6, 2015. Authors addressed the additional comments from the public to complete the document. The final The writing committee was selected to represent the document was approved by the Task Force, COCATS American College of Cardiology (ACC) and included a Steering Committee, and ACC Competency Manage- cardiovascular training program director, an early- ment Committee as well as ratified by the ACC Board career cardiologist, highly experienced members re- of Trustees in March 2015. This document is consid- presenting both academic and community-based ered current until the ACC Competency Management practice settings, and physicians experienced in Committee revises or withdraws it. defining and applying training standards according to the core competencies structure promulgated by the 1.2. Background and Scope Accreditation Council for Graduate Medical Education The Task Force was charged with updating previously (ACGME) and American Board of Medical Specialties published standards for training fellows in clinical (ABMS)andendorsedbytheAmericanBoardofIn- cardiology enrolled in ACGME–accredited fellowships ternal Medicine (ABIM). The ACC determined that (1) on the basis of: 1) changes in the field since 2008; relationships with industry or other entities were not and 2) the evolving framework of competency-based relevant to the creation of this general cardiovascular medical education described by the ACGME Out- training statement. Employment and affiliation de- comes Project and the 6 general competencies end- tails for the authors and peer reviewers are provided orsedbyACGMEandABMS.Theupdatingeffortwas in Appendixes 1 and 2, respectively, along with also convened as part of a broader effort to establish disclosure reporting categories. Comprehensive consistent training criteria across all aspects of car- disclosure information for all authors, including re- diology. The background and overarching principles lationships with industry and other entities, is avail- governing fellowship training are provided in the able as an online supplement to this document. COCATS 4 Introduction, and readers should become 1.1.2. Document Development and Approval familiar with this foundation before considering the details of training in a subdiscipline such as electro- The writing committee developed the document, cardiography (ECG), ambulatory ECG, and exercise approved it for review by individuals selected by the ECG testing. The Steering Committee and Task Force recognize that implementation of these changes in training requirements will occur incrementally. The American College of Cardiology requests that this document be cited as follows: Balady GJ, Bufalino VJ, Gulati M, Kuvin JT, Mendes LA, 1.3. Training Levels Schuller JL. COCATS 4 task force 3: training in electrocardiography, ambulatory electrocardiography, and exercise testing. J Am Coll Cardiol For most areas of cardiovascular medicine, 3 levels of 2015;65:1763–77. training are delineated: 1764 Balady et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 3 MAY 5, 2015:1763– 77

n Level I training, which is the basic training required to training in cardiovascular diseases (8). The recommenda- become a competent cardiovascular consultant, is tions from the different organizations are congruent and required of all cardiovascular fellows and can address faculty, facility requirements, emerging technol- be accomplished as part of a standard 3-year training ogies, and practice applications. We recommend strongly program in cardiovascular medicine. All cardiologists that candidates for the ABIM examination for certification should attain Level I training in ECG, ambulatory ECG, in cardiovascular diseases review the ABIM’srequirements and exercise ECG testing, as these skills are funda- with specific attention to the ECG components, which mental to the practice of clinical cardiology. Although include special question formats for ECG interpretation many of the skills and competencies for each of (9). The following recommendations are aimed at trainees these procedures can be acquired within the first in cardiovascular training programs. 12 months of training, it is expected that such skills will Cardiovascular fellowship programs should satisfy the be further developed and refined over the 3-year requirements regarding facilities and faculty for training training period. in ECG. Eligibility for the ABIM cardiovascular diseases n Level II training refers to the additional training in 1 or examination requires that training take place in a program more areas that enables some cardiovascular specialists accredited by the ACGME. to perform or interpret specificdiagnostictestsand procedures or to render more specialized care for pa- 2.1.1. Faculty tients and conditions. This level of training is recog- Faculty should include specialists skilled in ECG in- nized for those areas in which an accepted instrument terpretation. This should include specialists in both clin- or benchmark, such as a qualifying examination, is ical cardiac electrophysiology and cardiology. Faculty available to measure specific knowledge, skills, or should be board-certified in cardiovascular diseases or competence. Level II training in selected areas may be possess equivalent qualifications. A physician is consid- achieved by some trainees during the standard 3-year ered to have equivalent qualifications if he or she trained cardiovascular fellowship, depending on the trainees’ in a similar environment for a similar duration of time and career goals and use of elective rotations. There is no performed the required number of procedures. Level II training for ECG, ambulatory ECG, and exercise ECG testing. 2.1.2. Facilities n Level III training requires additional training and Facilities should provide adequate training in multiple experience beyond the cardiovascular fellowship to clinical settings, including inpatient, outpatient, emer- acquire specialized knowledge and competencies in gent, and invasive (catheterization and/or electrophysi- performing, interpreting, and training others to ology laboratory). Facilities should also be available for fi perform speci c procedures or render advanced, didactic teaching. specialized care at a high level of skill. There is no Level III training in ECG, ambulatory ECG, and exercise ECG 2.1.3. Equipment testing. Equipment should be sufficient to provide reliable and reproducible ECGs and should include computerized de- 2. ELECTROCARDIOGRAPHY vices that record and store a graphic display and auto- matically generate a preliminary interpretation. ECG is the most commonly used diagnostic test in cardi- ology. When properly interpreted, it contributes sub- 2.1.4. Ancillary Support stantially to the diagnosis and management of patients Ancillary support staff should be well trained and with cardiac disorders, and it is essential to diagnosing available to administer high-quality ECG testing and cardiac arrhythmias and acutemyocardialischemicsyn- collect the appropriate data, preferably in an electronic dromes, which account for the majority of cardiac catas- format. trophes. ECG is appropriately used as a screening test in many circumstances. 2.2. Training Components 2.1. General Standards 2.2.1. Didactic Program Three organizations—the ACC, American Heart Association Didactic instruction may take place in a variety of for- (AHA), and Heart Rhythm Society—have together provided mats, including, but not limited to, lectures, conferences, recommendations for standardizing and interpreting the journal clubs, grand rounds, clinical case presentations, electrocardiogram (2–7) and have provided training re- and patient safety or quality improvement conferences. quirements and guideline standards for ECG training as Fellows must be trained to interpret a large number of well as educational objectives for the ECG component of ECGs and review all interpretations with experienced JACC VOL. 65, NO. 17, 2015 Balady et al. 1765 MAY 5, 2015:1763– 77 COCATS 4 Task Force 3

faculty. Programs should encourage the trainee to inter- sequence of clinical experiences provided to trainees, the pret a majority of ECGs side by side with faculty for milestones at which various competencies are reached immediate review and feedback. Formal, correlative may also vary. Level I competencies may be achieved at conferences in ECG are highly recommended as part of the earlier or later time points. The table also describes ex- fellowship curriculum and should be held regularly dur- amples of evaluation tools suitable for assessing compe- ing training. In addition, the role of ECG in clinical prac- tence in each domain. tice should be thoroughly reviewed. 2.3.2. Training Requirements 2.2.2. Clinical Experience All trainees should achieve Level I training in ECG inter- Training in ECG interpretation should include clinical pretation. Attainment of skills and competencies during correlationinpatientsfromawiderangeofclinicalset- the training program is paramount and must be empha- tings, such as intensive care units, emergency rooms, and sized. There is no established threshold number of studies pacemaker/defibrillator clinics, as well as exposure to all that can serve as a training landmark; however, inter- forms of clinically-encountered arrhythmias, normal preting approximately 3,000 to 3,500 ECGs within 36 variants, and electrocardiographic patterns associated months should provide ample experience to acquire such with acquired and congenital heart disease. Trainees competencies. This represents the procedural volume should be trained to review, edit, and amend ECGs typically required to obtain competency, but the trainee generated by computerized systems that provide a pre- must also demonstrate that competence is achieved, as liminary interpretation. assessed by the outcomes evaluation measures. Acquisi- tion of competence may be accomplished by 1 or more 2.2.3. Hands-On Experience training periods assigned specifically for ECG interpreta- Hands-on experience is essential for training in ECG tion or as a continuous experience through clinical interpretation. Additionally, trainees are expected to ac- rotations. The cardiovascular subspecialist should be quire the technical skills necessary to competently familiar with nearly all clinically encountered arrhyth- perform and record high-quality, standard 12-lead ECG mias (normal variants) and electrocardiographic patterns tracings. associated with acquired and congenital heart disease and those that may accompany high-level exercise 2.3. Summary of Training Requirements and athletic conditioning (10).Thisknowledgeshould 2.3.1. Development and Evaluation of Core Competencies include an understanding of the physiological mecha- Training and requirements for ECG and ambulatory ECG nisms for arrhythmias and ECG waveforms, rather than address the 6 general competencies promulgated by the simple recognition of patterns. The trainee should un- ACGME/ABMS and endorsed by the ABIM. These compe- derstand the clinical implications, sensitivity, and spec- tency domains are: medical knowledge, patient care and ificity of the ECG. Training in ECG interpretation requires procedural skills, practice-based learning and improve- additional experience with interpreting complex ar- ment, systems-based practice, interpersonal and rhythmias and those normal and abnormal rhythms communication skills, and professionalism. The ACC has associated with pacemaker and implantable defibrillator used this structure to define and depict the components devices. As such rhythms can be quite complex, trainees of the core clinical competencies for cardiology. The should be able to recognize when to seek consultation curricular milestones for each competency and domain and assistance from an experienced electrophysiologist. also provide a developmental roadmap for fellows as they TheECGknowledgebaseisincludedinAppendixes 1 progress through various levels of training and serve as an and 2, and contains minimum requirements for each underpinning for the ACGME/ABIM reporting milestones. trainee. The ACC has adopted this format for its competency and The trainee should also be familiar with the instru- training statements, career milestones, lifelong learning, mentation necessary to acquire, process, and store ECGs and educational programs. Additionally, it has developed in both analog and digital formats; understand the effect tools to assist physicians in assessing, enhancing, and of acquisition rates and filter settings; and recognize documenting these competencies. electronic artifacts. In addition, they should be able to Table 1 delineates each of the 6 competency domains, accurately measure basic ECG intervals in both analog and as well as their associated curricular milestones for digital systems. training in ECG and ambulatory ECG. The milestones There is no Level II or III training in ECG. The inter- indicate the stage of fellowship training (12, 24, or 36 pretive skills for highly complex arrhythmia diagnosis, months, and additional time points) by which the typical signal-averaged ECG interpretation, and those normal cardiovascular trainee should achieve the designated and abnormal rhythms associated with pacemaker and level. Given that programs may vary with respect to the implantable defibrillator devices would be acquired 1766 Balady et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 3 MAY 5, 2015:1763– 77

TABLE 1 Core Competency Components and Curricular Milestones for Training in ECG/Ambulatory ECG

Competency Component Milestones (Months) MEDICAL KNOWLEDGE 12 24 36 Add

1 Know the basic principles of ECG and the operation/use of the instruments to acquire, display, and store ECGs I (see Appendix 3).

2 Know the underlying cellular and ionic mechanisms in the genesis of surface ECGs and the effects of the autonomic I nervous system (see Appendix 3).

3 Know the normal values for electrical axis and ECG intervals, durations, and voltage. I

4 Know the anatomy of the specialized conducting tissue and the spread of excitation in conduction system and I myocardium.

5 Know re-entry, automaticity, and triggered activity mechanisms for cardiac arrhythmias. I

6 Know the types and mechanisms of aberrancy. I

7 Know capture and fusion complexes and the ECG pattern criteria for distinguishing supraventricular arrhythmias I with aberrancy, accessory pathway conduction, pacing, and artifact from ventricular arrhythmias.

8 Know the concepts of concealed conduction and exit block and their manifestation on the ECG. I

9 Know the characteristic ECG patterns of key clinical diagnoses (see Appendix 4). I

10 Know the ECG changes that are commonly seen in highly trained athletes and the challenges in distinguishing I normal from abnormal findings.

11 Know the indications for, and limitations of, continuous (Holter) and intermittent (event) ambulatory ECG I recording.

EVALUATION TOOLS: direct observation, ECG and rhythm interpretation during simulation training (e.g., mock codes), global evaluation, and in-training examination.

PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

1 Technical skills to perform and record high-quality, standard 12-lead ECG tracings. I

2 Skill to identify normal ECG patterns, normal variants, and artifacts (including incorrect lead placement). I

3 Skill to identify ECG signs of atrial abnormalities and right and left ventricular hypertrophy or enlargement. I

4 Skill to identify types and significance of intraventricular conduction delay or block (including functional or I aberrant conduction abnormalities).

5 Skill to identify types of atrioventricular dissociation. I

6 Skill to identify first-degree, second-degree (types I, II, 2:1, and high-degree), and third-degree atrioventricular I blocks.

7 Skill to identify the ECG patterns and localization of cardiac ischemia and infarction. I

8 Skill to identify the ECG changes of electrolyte and metabolic abnormalities and drug effects. I

9 Skill to identify nonspecific QRS and ST-T wave changes. I

10 Skill to identify atrial, atrioventricular, nodal, and ventricular arrhythmias. I

11 Skill to identify each of the specific patterns and rhythms in Appendix 4. I

12 Skill to integrate ECG findings into clinical and risk assessments and the management of patients. I

13 Skill to select and interpret ambulatory ECG recording studies. I

14 Skill to identify normal and abnormal pacemaker rhythms/functions, and when to seek consultation from an I electrophysiologist for advanced interpretation.

EVALUATION TOOLS: direct observation, ECG examination, and in-training examination.

SYSTEMS-BASED PRACTICE 12 24 36 Add

1 Skill to retrieve and utilize ECG tracings in electronic data systems. I

EVALUATION TOOLS: conference presentation and direct observation. JACC VOL. 65, NO. 17, 2015 Balady et al. 1767 MAY 5, 2015:1763– 77 COCATS 4 Task Force 3

TABLE 1 Core Competency Components, continued

Competency Component Milestones (Months) PRACTICE-BASED LEARNING AND IMPROVEMENT 12 24 36 Add

1 Identify knowledge and performance gaps and engage in opportunities to achieve focused education and performance I improvement.

EVALUATION TOOLS: conference presentation and ECG examination.

PROFESSIONALISM 12 24 36 Add

1 Practice within the scope of expertise and technical skills. I

2 Know and adhere to evidence-based and appropriate use criteria for ECG testing. I

EVALUATION TOOLS: conference presentation, direct observation, multisource evaluation, and reflection and self-assessment.

INTERPERSONAL AND COMMUNICATION SKILLS 12 24 36 Add

1 Communicate testing results to physicians and patients in an effective and timely manner. I

EVALUATION TOOL: multisource evaluation.

Add ¼ additional months beyond the 3-year cardiovascular fellowship; ECG ¼ electrocardiography/electrocardiogram. during specialized training in electrophysiology (see sleeping and waking hours and what should be consid- COCATS 4 Task Force 11 report). ered “abnormal,” realizing that the clinical significance of some findings on ambulatory monitoring remains 3. AMBULATORY ECG MONITORING unresolved.

3.1. General Standards Observation and documentation of cardiac rhythm during daily activities and of the relation between the rhythm The ACC and the AHA have addressed competency, disturbances and patient symptoms are important factors training requirements, and guidelines for ambulatory ECG for clinical decision making and should be a focus for (8). The following recommendations are aimed at trainees training in cardiovascular medicine. Major indications for in cardiovascular training programs. ambulatory ECG monitoring include the following: 3.1.1. Faculty detection of—or ruling out—rhythm disturbances as a cause of symptoms, detection and assessment of ar- The trainee should participate in interpretation sessions rhythmias believed to be associated with an increased risk with a staff cardiologist knowledgeable in the indications for cardiovascular events, identification and accurate for the test, the techniques of recording, and the clinical interpretation of ambulatory ST-T wave changes, assess- significance and correlations of findings. Faculty should ment of the efficacy of antiarrhythmic and anti-ischemic be board-certified in cardiovascular diseases or possess therapy, and investigation of the effects of therapeutic equivalent qualifications. A physician is considered to devices (e.g., pacemakers, implantable cardioverter- have equivalent qualifications if he or she trained in a defibrillators). similarenvironmentforasimilardurationoftimeand Multiple methods of ambulatory ECG recording and performed the required number of procedures. If dedi- analysis are available for clinical use, including contin- cated electrophysiology faculty are available, the trainee uous short-term recorders (e.g., Holter monitors) and should take advantage of this knowledge for evaluating intermittent longer-term recorders (e.g., patient- and managing complex arrhythmias. Faculty should be activated event and loop recorders, auto-triggered re- available to discuss individual cases and provide formal corders, patch-type extended Holter monitoring, and educational experiences. ambulatory telemetry monitoring) (11).Thetrainee should understand the similarities and differences be- 3.1.2. Facilities tween these devices; the indications, advantages, and Cardiovascular departments (heart stations) should have disadvantages of each device; and the potential pitfalls staff and space available for collecting and organizing inherent in the technology. In addition, the trainee ambulatory ECG data, preferably using digital technology. should have current knowledge about what may repre- These data should be readily accessible for faculty and sent a “normal” finding for various age groups during fellows in a timely fashion. In addition, access to patients’ 1768 Balady et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 3 MAY 5, 2015:1763– 77

medical information, preferably via an electronic health understanding available technologies, advising the pa- record, is important to correlate findings with clinical tient, ordering the test, placing the monitor on or in the status. The reviewer of the ambulatory ECG should be patient, and downloading the information. Analysis and able to locate and communicate with the treating physi- interpretation of the data are critical to developing com- cian to convey critical information. petency in this area. Trainees should also understand how to relay critical findings to the patients and other 3.1.3. Equipment healthcare team members. Each of these steps should be The trainee should be familiar with the various devices overseen by an attending cardiologist comfortable with that are available for both continuous and intermittent this testing modality. recording of cardiac rhythms (11). Trainees should un-

derstand how to place the equipment to collect cardiac 3.3. Summary of Training Requirements monitoring data accurately. Refer to Table 1 for a list of ambulatory ECG core 3.1.4. Ancillary Support competencies. Ancillary support should be available to administer ambulatory ECG testing and collect the appropriate data, 3.3.1. Training Requirements preferably in an electronic format. Attainment of skills and competencies during the training program is paramount and must be emphasized. There is 3.2. Training Components no established threshold number of studies that can serve 3.2.1. Didactic Program as a training landmark. However, interpreting approxi- A comprehensive educational program should be pro- mately 100 to 200 ambulatory ECGs within 36 months vided to trainees to complement hands-on interpretation should provide ample experience to acquire such com- of ambulatory ECG recordings. The training program shall petencies. This volume of procedures is typically required include didactic lectures, interactive case presentations, to obtain competency, but there must also be demon- and self-directed learning. The educational offerings for stration of achievement of competence, as assessed by the ambulatoryECGshouldbecombinedwithteachingabout outcomes evaluation measures. Acquisition of compe- ECG and other topics in electrophysiology. Over the tence may be accomplished by 1 or more training periods course of cardiovascular fellowship training, trainees assigned specifically for interpretation of ambulatory should understand how to interpret and report ambula- ECGs or as a continuous experience through clinical tory ECG information and should be taught about ad- rotations. Trainees should be exposed to both full- vances in ECG technology and the importance of this type disclosure (complete printout) and computer-assisted of testing in evaluating patients with cardiovascular ambulatory ECG systems. In addition, trainees should be disease. exposed to transtelephonic and event-recorder devices for prolonged ambulatory ECG. Furthermore, trainees 3.2.2. Clinical Experience should be exposed to recordings such as artifact, pace- Trainees should be exposed to a wide array of ambu- maker, and implantable cardioverter-defibrillator pat- latory ECG monitors from a mix of patient populations, terns; heart rate variability studies; and repolarization including those with complex rhythm disturbances and abnormalities. Trainees should demonstrate knowledge congenitalandacquiredstructuralheartdisease. of the operation and limitations of a variety of types of Trainees should be responsible for analyzing and ambulatory ECG instrumentation. In addition, all trainees interpreting all aspects of the ambulatory ECG study. should be skilled in interpreting in-hospital telemetry When appropriate, the trainee should have knowledge ECGs. Trainees should understand the indications and of the patient’s medical background and rationale for limitations of testing from structured training by experi- testing. An experienced attending cardiologist in enced cardiologists with specific expertise in ambulatory ambulatory ECG should oversee the trainee and be ECG. Such training will provide knowledge to satisfy responsible for evaluating and documenting the clinical competence in ambulatory ECG as indicated by trainee’s progress and skill level. In addition, expert the ACC/AHA/American College of Physicians–American consultation should be sought for complex arrhythmias Society of Internal Medicine Task Force on Clinical from faculty with advanced training in electrophysi- Competence (8). ology, if available. There is no Level II or III training in ambulatory ECG. The interpretive skills for highly complex arrhythmia 3.2.3. Hands-On Experience diagnosis, insertion and management of implantable loop Trainees should be provided with the opportunity to learn recorders, and those normal and abnormal rhythms all aspects of ambulatory ECG monitoring, including associated with pacemaker and implantable defibrillator JACC VOL. 65, NO. 17, 2015 Balady et al. 1769 MAY 5, 2015:1763– 77 COCATS 4 Task Force 3

devices would be acquired during specialized training in a similar duration of time and performed the required electrophysiology (see COCATS 4 Task Force 11 report). number of procedures.

4.1.2. Facilities 4. EXERCISE ECG TESTING The laboratory should regularly perform exercise tests that involve a broad spectrum of both inpatients and out- Exercise ECG testing is among the most fundamental and patients with a variety of known and suspected cardio- widely-used tests in the evaluation of patients with car- vascular disorders. Specific standards regarding the diovascular disease. It is easy to administer, perform, and exercise testing environment are outlined by the AHA (14). interpret and is readily available in hospital or practice settings. Initially developed to detect the presence of 4.1.3. Equipment myocardial ischemia due to coronary artery disease, the The laboratory should contain exercise testing equipment exercise ECG is now widely recognized for its utility in for testing and monitoring, as well as emergency medi- predicting prognosis. Exercise test variables beyond the cations and equipment as outlined by the AHA (14). ST segment, especially when used in combination with clinical information, yield important information to pre- 4.1.4. Ancillary Support dict outcomes and guide therapy in a broad range of The exercise testing laboratory staff generally consists of individuals. Exercise ECG testing can be applied in the a variety of personnel that may include exercise physi- evaluation and management of patients with a wide ologists, nurses, nurse practitioners, physicians’ assis- variety of cardiovascular conditions, including coronary tants, and medical technicians. These individuals often artery disease, valvular heartdisease,congenitalheart perform several duties, including assessing and preparing disease, genetic cardiovascular conditions, arrhythmias, patients for the test; conducting the technical aspects of and peripheral arterial disease. When appropriately used the test, including protocol selection and patient moni- withadjunctivemodalitiestomeasuregasexchangeand toring; and assisting the physician staff with patient ventilation, or imaging techniques such as echocardiog- management and medical emergencies should the need raphy or nuclear perfusion imaging, the power of the arise. Appropriate training requirements and information exercise ECG test is further enhanced. This section pro- about the cognitive and performance skills necessary to vides training and competency requirements specificto competently supervise exercise tests are available in exercise ECG testing. Other COCATS 4 Task Force reports published guidelines (8,14). will address training and competency requirements for exercise and pharmacological stress testing when com- 4.2. Training Components binedwithimagingtechniques. 4.2.1. Didactic Program Didactic instruction may take place in a variety of for- 4.1. General Standards mats, including, but not limited to, individual instruction The ACC and AHA have addressed competency, training during exercise test performance and interpretation requirements, and guidelines for exercise testing and sessions, lectures, conferences, journal clubs, grand – testing laboratories (12 15). The recommendations are rounds, and clinical case and correlative conferences. In congruent and address faculty, facility requirements, addition, self-learning—through required reading mate- emerging technologies, and practice. The trainee should rial that includes relevant guidelines, textbooks, seminal become familiar with each of these standards and papers, and emerging literature regarding exercise recommendations. testing—is essential. Such learning material should be provided, updated, and monitored by the exercise labo- 4.1.1. Faculty ratory director or other faculty. Faculty should be effective teachers who are experts in the clinical use and interpretation of exercise ECG testing 4.2.2. Clinical Experience and who perform these tests on a regular basis. Such The trainee must become proficient in the interpretation facultyshouldbesupervisedbythephysicianmedical of commonly used measurements available from the ex- director of the exercise testing laboratory, such that the ercise test that are performed in a wide variety of patients specifics of exercise test performance, protocols, and with various cardiovascular conditions and other comor- interpretation are consistent with the laboratory’spol- bidities. The trainee must acquire a working knowledge of icies and standards. The faculty should be board-certified cardiovascular exercise physiology and a keen under- in cardiovascular disease or possess equivalent qualifica- standing of appropriate and inappropriate physiological tions. A physician is considered to have equivalent qual- responses to exercise. Understanding all of the technical ifications if he or she trained in a similar environment for aspects of testing is essential to ensure proper test 1770 Balady et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 3 MAY 5, 2015:1763– 77

performance and interpretation of results. The trainee may vary as well. Level I competencies may be achieved must be thoroughly familiar with methods used in at earlier or later time points. The table also describes determining exercise capacity and its importance in examples of evaluation tools suitable for assessment of prognostic evaluation and activity prescription. The competence in each domain. trainee should become proficient in integrating data such as hemodynamic measurements, exercise ECG analyses, 4.3.2. Training Requirements and non–ST-segment variables in both the diagnostic and The committee recommends that all trainees achieve prognostic assessment of the patient. This training will Level I training in exercise ECG interpretation. The provide knowledge to satisfy clinical competence in ex- training of a cardiovascular fellow should include active ercise testing, as indicated by the ACC/AHA/American participation in a fully equipped exercise testing labora- College of Physicians–American Society of Internal Med- tory. Attainment of skills and competencies during the icine Task Force on Clinical Competence (15). training program is paramount and must be emphasized. Level I trainees will gain competency in supervision and 4.2.3. Hands-On Experience interpretation of the standard exercise ECG test. There is The training program should be structured so that the no established threshold number of studies that can serve trainee is guided in the laboratory by a specially trained as a training landmark; however, personally supervising exercise professional until the trainee has become profi- and interpreting approximately 200 to 300 exercise tests cient at conducting and personally monitoring exercise within 36 months should provide ample experience to tests under a variety of clinical circumstances. The trainee acquire such competencies. This volume of procedures is must be given the responsibility of initially interpreting typically required to develop competency, but the trainee all phases of the exercise study, as well as providing that must also demonstrate competence, as assessed by the detailed interpretation to, and reviewing it with, the outcomes evaluation measures. Acquisition of compe- attending cardiologist who is responsible and experi- tence may be accomplished by 1 or more training periods enced in exercise testing. assigned specifically for interpretation of exercise ECG testing; competence may be acquired concurrently 4.3. Summary of Training Requirements with training in an exercise imaging laboratory as part 4.3.1. Development and Evaluation of Core Competencies of the training requirements in nuclear cardiology or The training and requirements for exercise testing echocardiography. address the 6 general competencies promulgated by the The trainee should become knowledgeable in perform- ACGME/ABMS and endorsed by the ABIM. These compe- ing both heart rate–limited and maximal or near-maximal tency domains are: medical knowledge, patient care and treadmill testing and, when available, stationary cycle procedural skills, practice-based learning and improve- exercise tests. The training program should provide the ment, systems-based practice, interpersonal and opportunity for the trainee to know and understand car- communication skills, and professionalism. The ACC has diovascular exercise physiology and pathophysiology. used this structure to define and depict the components The trainee should also be taught the technical aspects of the core clinical competencies for cardiology. The of exercise testing, such as skin preparation, electrode curricular milestones for each competency and domain selection and application, choice of exercise testing pro- also provide a developmental roadmap for fellows as they tocols, blood pressure monitoring during exercise, and progress through various levels of training and serve as an monitoring of the patient for adverse signs or symptoms. underpinning for the ACGME/ABIM reporting milestones. The trainee should be exposed to the technical aspects and The ACC has adopted this format for its competency and interpretation of cardiopulmonary exercise testing, when training statements, career milestones, lifelong learning, available. The trainee should be thoroughly familiar with and educational programs. Additionally, it has developed evidence-based indications and contraindications to tools to assist physicians in assessing, enhancing, and exercise testing. documenting these competencies. Level I trainees will become proficient in the supervi- Table 2 delineates each of the 6 competency domains, sion and interpretation of exercise tests in a wide variety as well as their associated curricular milestones for of complex patients for a variety of indications, including training in exercise–ECG testing. The milestones indicate the evaluation of coronary artery disease, valvular heart the stage of fellowship training (12, 24, or 36 months, and disease, congenital heart disease, genetic cardiovascular additional time points) by which the typical cardio- conditions, arrhythmias, and peripheral arterial disease. vascular trainee should achieve the designated level. All trainees are expected to know the indications for Recognizing that programs may vary with respect to the ordering and the utility of the information provided by sequence of clinical experiences provided to trainees, the cardiopulmonary exercise testing, exercise testing for milestones at which various competencies are reached measurement of ankle-brachial indices in patients with JACC VOL. 65, NO. 17, 2015 Balady et al. 1771 MAY 5, 2015:1763– 77 COCATS 4 Task Force 3

TABLE 2 Core Competency Components and Curricular Milestones for Training in Exercise ECG Testing

Competency Component Milestones (Months) MEDICAL KNOWLEDGE 12 24 36 Add

1 Know the indications, risks, limitations, and contraindications for exercise stress testing both for diagnosis and risk I stratification in patients with suspected or known coronary heart disease.

2 Know the principles and details of exercise testing, including the standard requirements of a safe testing laboratory, I and technical requirements of proper lead placement and skin preparation.

3 Know the application of Bayes’ theorem to interpret exercise test results. I

4 Know the common exercise test protocols and targets. I

5 Know the concept of metabolic equivalent (MET) and estimation of exercise intensity in different modes of exercise. I

6 Know the ECG criteria for a positive test. I

7 Know the normal and abnormal heart rhythm and blood pressure responses to graded exercise and in recovery. I

8 Know the ECG, exercise capacity, and/or hemodynamic findings indicating a strongly-positive test or adverse I prognosis.

9 Know the changes in the ECG that may result from exercise, hyperventilation, ischemia, hypertrophy, conduction I disorders, electrolytes, and drugs.

10 Know the criteria and indications for stopping a test before reaching the target heart rate. I

11 Know the significance of exercise-associated arrhythmias. I

12 Know the use of exercise testing in special groups (women, asymptomatic subjects, post–myocardial infarction, or I patients with recent acute coronary syndrome).

13 Know the use, precautions, and contraindications of exercise testing in patients with valvular and myocardial diseases. I

14 Know the effects of baseline ECG abnormalities and medications on exercise testing. I

15 Know clinical and baseline ECG findings that warrant the addition of imaging to the exercise ECG. I

16 Know the indications for the selection of pharmacologic rather than exercise testing. I

17 Know the indications for, and the sensitivity and specificity of, adding echocardiographic or nuclear perfusion I imaging to stress ECG testing.

18 Known the indications for myocardial perfusion imaging and the appropriate selection of exercise versus I pharmacologic stress testing.

19 Know the role of stress testing in assessment of valvular heart disease. I

20 Know the role of exercise ECG testing in the evaluation of arrhythmias. I

21 Know the role of exercise ECG testing in the evaluation of genetic cardiovascular conditions (e.g., long QT syndrome), I including hypertrophic cardiomyopathy.

22 Know the role of cardiopulmonary exercise testing in the evaluation of dyspnea. I

23 Know the role of exercise testing in physical activity and exercise prescription in patients with cardiovascular disease. I

24 Know the role of exercise testing with measurement of ankle-brachial indices in the evaluation of patients with I known or suspected peripheral arterial disease.

EVALUATION TOOLS: chart-stimulated recall, direct observation, and in-training examination.

PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

1 Skill to select clinically appropriate exercise test type and protocol for diverse patient types and clinical settings. I

2 Skill to safely perform appropriate heart rate—limited and maximal or near-maximal treadmill exercise tests. I

3 Skill to identify and effectively treat complications during and following stress testing. I

4 Skill to utilize exercise symptoms and capacity, ECG findings, and hemodynamic response in the risk assessment I and management of patients.

5 Skill to interpret limb segmental blood pressure measurements, pulse volume recordings, and treadmill vascular I exercise tests.

6 Skill to utilize data from the exercise test in deriving an exercise prescription for patients with cardiovascular disease. I

EVALUATION TOOLS: chart-stimulated recall, conference presentation, direct observation, and logbook. 1772 Balady et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 3 MAY 5, 2015:1763– 77

TABLE 2 Core Competency Components, continued

Competency Component Milestones (Months) SYSTEMS-BASED PRACTICE 12 24 36 Add

1 Effectively lead and coordinate the exercise test interprofessional team (including nurses and technicians) to I ensure safe and efficient care.

2 Incorporate risk/benefit analysis and cost considerations in test selection. I

EVALUATION TOOLS: conference presentation, direct observation, and multisource evaluation.

PRACTICE-BASED LEARNING AND IMPROVEMENT 12 24 36 Add

1 Identify knowledge and performance gaps and engage in opportunities to achieve focused education and I performance improvement.

2 Review practice alignment with guidelines. I

EVALUATION TOOLS: conference presentation, direct observation, and reflection and self-assessment.

PROFESSIONALISM 12 24 36 Add

1 Demonstrate sensitivity and responsiveness to diverse patient populations. I

2 Know and adhere to evidence-based and appropriate use criteria for utilizing stress testing. I

EVALUATION TOOLS: conference presentation, direct observation, multisource evaluation, and reflection and self-assessment.

INTERPERSONAL AND COMMUNICATION SKILLS 12 24 36 Add

1 Communicate with and educate patients and families across a broad range of cultural, ethnic, and socioeconomic I backgrounds.

2 Communicate testing results to physicians and patients in an effective and timely manner. I

EVALUATION TOOL: multisource evaluation.

Abbreviations as in Table 1.

peripheral arterial disease, and exercise testing per- and bedside skills must be evaluated in every trainee. formed to evaluate complex arrhythmia and genetic car- Quality of care and follow-up; reliability; judgment, diovascular conditions; however, additional time would decisions, or actions that result in complications; be needed to acquire the skills to perform and interpret interaction with other physicians, patients, and labora- these tests. Level I trainees should be proficient in proper tory support staff; initiative; and the ability to make test selection (exercise ECG, exercise imaging, pharma- appropriate decisions independently should be consid- cological imaging) for a given indication tailored to the ered. Trainees should maintain records of participation physical and medical conditions of a given patient (see and advancement in the form of a Health Insurance COCATS 4 Task Force 5 and 6 reports). This includes the Portability and Accountability Act (HIPAA)–compliant use of exercise testing in special populations such as electronic database or logbook that meets ACGME athletes and patients with valvular heart disease or hy- reporting standards and summarizes pertinent clinical pertrophic cardiomyopathy. information (e.g., number of cases, diversity of referral There is no Level II or III training in exercise ECG sources, diagnoses, disease severity, outcomes, and testing. disposition). The ACC, AHA, and Heart Rhythm Society have 5. EVALUATION OF COMPETENCY formulated a clinical competence statement on ECG (8), and the ACC/AHA have jointly formulated a competence Evaluation tools in ECG, ambulatory ECG, and exercise statement on stress testing (15). Self-assessment programs ECG testing include direct observation by instructors, and competence examinations in ECG are available in-training examinations, case logbooks, conference and through the ACC and other organizations. Training di- case presentations, multisource evaluations, trainee rectors and trainees are encouraged to incorporate these portfolios, simulation, and reflection and self- resources into their curriculum in order to document the assessment. Case management, judgment, interpretive, trainee’s competency. In addition, on a regular basis, JACC VOL. 65, NO. 17, 2015 Balady et al. 1773 MAY 5, 2015:1763– 77 COCATS 4 Task Force 3

faculty should assess and document the trainee’sprog- the overall progress of individual trainees with the Clin- ress, including technical performance and ability to ical Competency Committee to ensure achievement of interpret results. The program director is responsible for selected training milestones and identify areas in which confirming experience and competence and for reviewing additional focused training may be required.

REFERENCES

1. Myerburg RJ, Chaitman BR, Ewy GA, et al. Task force tion Electrocardiography and Arrhythmias Committee, 10. Maron BJ, Friedman RA, Kligfield P, et al. Assess- 2: training in electrocardiography, ambulatory elec- Council on Clinical Cardiology; the American College of ment of the 12-lead electrocardiogram as a screening trocardiography, and exercise testing. J Am Coll Car- Cardiology Foundation; and the Heart Rhythm Society. test for detection of cardiovascular disease in healthy diol 2008;51:348–54. J Am Coll Cardiol 2009;53:982–91. general populations of young people (12-25 years of age): a scientific statement from the American Heart 2. Kligfield P, Gettes LS, Bailey JJ, et al. Recommenda- 6. Hancock EW, Deal BJ, Mirvis DM, et al. AHA/ACCF/ Association and the American College of Cardiology. tions for the standardization and interpretation of the HRS recommendations for the standardization and J Am Coll Cardiol 2014;64:1479–514. electrocardiogram. Part I: the electrocardiogram and its interpretation of the electrocardiogram. Part V: elec- technology: a scientific statement from the American trocardiogram changes associated with cardiac cham- 11. Mittal S, Movsowitz C, Steinberg JS. Ambulatory Heart Association Electrocardiography and Arrhythmias ber hypertrophy: a scientific statement from the external electrocardiographic monitoring: focus on Committee, Council on Clinical Cardiology; the American American Heart Association Electrocardiography and atrial fibrillation. J Am Coll Cardiol 2011;58:1741–9. College of Cardiology Foundation; and the Heart Arrhythmias Committee, Council on Clinical Cardiol- 12. Fletcher GF, Ades PA, Kligfield P, et al. Exercise Rhythm Society. J Am Coll Cardiol 2007;49:1109–27. ogy; the American College of Cardiology Foundation; standards for testing and training: a scientific state- and the Heart Rhythm Society. J Am Coll Cardiol 2009; 3. Mason JW, Hancock EW, Gettes LS. Recommenda- ment from the American Heart Association. Circulation 53:992–1002. tions for the standardization and interpretation of the 2013;128:873–934. electrocardiogram. Part II: electrocardiography diag- 7. Wagner GS, Macfarlane P, Wellens H, et al. AHA/ 13. Gibbons RJ, Balady GJ, Beasley JW, et al. ACC/AHA nostic statement list: a scientific statement from the ACCF/HRS recommendations for the standardization guidelines for exercise testing: executive summary: a American Heart Association Electrocardiography and and interpretation of the electrocardiogram. Part VI: report of the ACC/AHA Task Force on Practice Guide- Arrhythmias Committee, Council on Clinical Cardiol- acute ischemia/infarction: a scientific statement from lines (Committee on Exercise Testing). Circulation ogy; the American College of Cardiology Foundation; the American Heart Association Electrocardiography 1997;96:345–54. and the Heart Rhythm Society. J Am Coll Cardiol 2007; and Arrhythmias Committee, Council on Clinical Car- 49:1128–35. diology; the American College of Cardiology Founda- 14. Myers J, Arena R, Franklin B, et al. Recommenda- fi tion; and the Heart Rhythm Society. J Am Coll Cardiol tions for clinical exercise laboratories: a scienti c 4. Surawicz B, Childers R, Deal BJ, et al. AHA/ 2009;53:1003–11. statement from the American Heart Association. ACCF/HRS recommendations for the standardization Circulation 2009;119:3144–61. and interpretation of the electrocardiogram. Part III: 8. Kadish AH, Buxton AE, Kennedy HL, et al. ACC/AHA intraventricular conduction disturbances: a scientific clinical competence statement on electrocardiography 15. Rodgers GP, Ayanian JZ, Balady G, et al. ACC/AHA statement from the American Heart Association Elec- and ambulatory electrocardiography: a report of the clinical competence statement on stress testing: a trocardiography and Arrhythmias Committee, Council ACC/AHA/ACP-ASIM Task Force on Clinical Compe- report of the ACC/AHA/ACP-ASIM Task Force on Clin- – on Clinical Cardiology; the American College of Cardi- tence (ACC/AHA Committee to Develop a Clinical ical Competence. J Am Coll Cardiol 2000;36:1441 53. ology Foundation; and the Heart Rhythm Society. J Am Competence Statement on Electrocardiography and Coll Cardiol 2009;53:976–81. Ambulatory Electrocardiography). J Am Coll Cardiol 2001;38:2091–100. 5. Rautaharju PM, Surawicz B, Gettes LS, et al. AHA/ KEY WORDS ACC Training Statement, ACCF/HRS recommendations for the standardization 9. American Board of Internal Medicine. The American ambulatory electrocardiography, COCATS, and interpretation of the electrocardiogram. Part IV: Board of Internal Medicine: ABIM Certification electrocardiography, exercise the ST segment, T and U waves, and the QT interval: a Guide. Available at: http://www.abim.org/certification. electrocardiography, exercise treadmill test, scientific statement from the American Heart Associa- Accessed June 14, 2013. stress test 1774 Balady et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 3 MAY 5, 2015:1763– 77

APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 3: TRAINING IN ELECTROCARDIOGRAPHY, AMBULATORY ELECTROCARDIOGRAPHY, AND EXERCISE TESTING

Institutional/ Organizational Ownership/ or Other Speakers Partnership/ Personal Financial Expert Committee Member Employment Consultant Bureau Principal Research Benefit Witness

Gary J. Balady (Chair) Boston Medical Center/Boston None None None None None None University—Director, Noninvasive Cardiovascular Labs; Professor of Medicine

Vincent J. Bufalino Midwest Heart Specialists None None None None None None Edward Heart Hospital— Senior Vice President of the Advocate CV Institute; Senior Director of Cardiology

Martha Gulati The Ohio State University None None None None None None Medical Center Division of CV Medicine—Director for Preventive Cardiology and Women’s Cardiovascular Health

Jeffrey T. Kuvin Tufts Medical Center None None None None None None CardioVascular Center— Associate Chief, Division of Cardiology; Director, Cardiovascular Education and Fellowship Training

Lisa A. Mendes Vanderbilt University Medical None None None None None None Center—Associate Professor of Medicine; Director, Cardiovascular Medicine Fellowship, Division of Cardiovascular Medicine

Joseph L. Schuller University of Colorado None None None None None None Hospital—Assistant Professor

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects authors’ employment and reporting categories. To ensure complete transparency, authors’ comprehensive healthcare-related disclosure information—including relationships with industry not pertinent to this document—is available in an online data supplement. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/ relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional information about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology. JACC VOL. 65, NO. 17, 2015 Balady et al. 1775 MAY 5, 2015:1763– 77 COCATS 4 Task Force 3

APPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 3: TRAINING IN ELECTROCARDIOGRAPHY, AMBULATORY ELECTROCARDIOGRAPHY, AND EXERCISE TESTING

Institutional/ Organizational Ownership/ or Other Speakers Partnership/ Personal Financial Expert Name Employment Representation Consultant Bureau Principal Research Benefit Witness

Richard Kovacs Indiana University, Krannert Official Reviewer, None None None None None None Institute of Cardiology—Q.E. ACC Board of Trustees and Sally Russell Professor of Cardiology

Dhanunjaya Kansas University Cardiovascular Official Reviewer, None None None None None None Lakkireddy Research Institute ACC Board of Governors

Howard Weitz Thomas Jefferson University Official Reviewer, None None None None None None Hospital—Director, Division of Competency Management Cardiology; Sidney Kimmel Committee Lead Reviewer Medical College at Thomas Jefferson University—Professor of Medicine

Kiran Musunuru Brigham and Women’s Organizational Reviewer, None None None None None None Hospital, Harvard University AHA

Kenneth VCU Medical Center—Director, Content Reviewer, None None None None None None Ellenbogen Clinical Electrophysiology Cardiology Training and Laboratory Workforce Committee

Michael Emery Greenville Health System Content Reviewer, None None None None None None Sports and Exercise Cardiology Section Leadership Council

Bulent Gorenek Eskisehir Osmangazi University Content Reviewer, None None None None None None Medical School Electrophysiology Section Leadership Council

Brian D. Hoit University Hospitals Case Content Reviewer, None None None None None None Medical Center Cardiology Training and Workforce Committee

Larry Jacobs Lehigh Valley Health Network, Content Reviewer, None None None None None None Division of Cardiology; Cardiology Training and University of South Florida— Workforce Committee Professor, Cardiology

Andrew Kates Washington University Content Reviewer, None None None None None None School of Medicine Academic Cardiology Section Leadership Council

Kristen Patton University of Washington Content Reviewer, None None None None None None Electrophysiology Section Leadership Council

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects peer reviewers’ employment, representation in the review process, as well as reporting categories. Names are listed in alphabetical order within each category of review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional infor- mation about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology; AHA ¼ American Heart Association; VCU ¼ Virginia Commonwealth University. 1776 Balady et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 3 MAY 5, 2015:1763– 77

APPENDIX 3. ELECTROCARDIOGRAPHIC CORE COMPETENCIES: TECHNICAL ASPECTS AND ELECTROPHYSIOLOGY

Anatomy and Electrophysiology n Anatomy of the specialized conducting system (sinoatrial node, atrioventricular node, His bundle, bundle branches), concept of the trifascicular conduction system n Spread of excitation in the ventricles n Difference between unipolar and bipolar leads n Einthoven triangle; frontal and horizontal lead reference system n Vectorial concepts n Significance of a positive and negative deflection in relation to lead axis n Relation between electrical and mechanical activity

Technique and the Normal ECG n Effect of improper electrode placement (limb and precordial) n Effect of muscle tremor n Effect of poor frequency response of the equipment n Effect of uneven paper transport n Measurement of PR, QRS, QT, normal values/rate correction of QT interval n Normal ranges of axis in the frontal plane n 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 hypertrophy, and strain) n Normal QRS/T angle n Differential diagnosis of normal ST-T, T-wave variants (e.g., “juvenile” pattern and early repolarization syndrome)

Arrhythmias: General Concepts n Re-entry, automaticity, triggered activity n Aberration (various mechanisms) n Capture and fusion complexes n Escape (passive, accelerated) complexes or rhythms: atrial, junctional, and ventricular n Interpolated premature beat n Parasystole (atrial, junctional, ventricular), modulated parasystole n Vulnerability n Exit block n Reciprocation n Concealed conduction n Supernormality

ECG ¼ electrocardiogram. JACC VOL. 65, NO. 17, 2015 Balady et al. 1777 MAY 5, 2015:1763– 77 COCATS 4 Task Force 3

APPENDIX 4. ECG CORE COMPETENCIES: PATTERN AND ARRHYTHMIA RECOGNITION

General Features n Atrioventricular re-entrant n Right ventricular hypertrophy Pacemaker n Normal ECG tachycardia (AVRT) with an n Biventricular hypertrophy n Fixed-rate pacemaker n Normal variant accessory pathway n Electrical alternans n Atrial pacing n Incorrect electrode n AV junctional escape complex Intraventricular Conduction Disturbances n Ventricular demand pacing placement or escape rhythm n Incomplete and complete left n Atrial triggered ventricular pacing n Artifact Ventricular Rhythms bundle-branch block n Atrioventricular dual pacing Atrial Abnormalities n Ventricular ectopic complexes n Incomplete and complete right n Biventricular pacing n Left atrial abnormality n Accelerated idioventricular rhythm bundle-branch block n Malfunctioning: demand acting n Right atrial abnormality n Ventricular tachycardia: uniform n Left anterior and left posterior as fixed rate, failure to sense, n Biatrial abnormality (monomorphic), multiform fascicular blocks slowing of rate, acceleration Sinoatrial Rhythm (pleomorphic or polymorphic), n Indeterminate (nonspecific) of rate, failure to capture, n Normal sinus rhythm sustained, nonsustained, intraventricular conduction defects failure to pace (inappropriate n Sinus tachycardia bidirectional, and torsades n Aberrant intraventricular conduction inhibition) n Sinus bradycardia de pointes (rate related; Ashman) Clinical Diagnoses (Selected) n Sinus arrhythmia n Ventricular flutter, ventricular n Ventricular pre-excitation syndromes n Hyperkalemia n Sinoatrial pause or arrest fibrillation (Wolff-Parkinson-White pattern) n Hypokalemia n Sinoatrial exit block n Ventricular escape complexes Myocardial Ischemia and Infarction n Hypercalcemia Atrial Rhythms or rhythm n ST-T wave changes due to ischemia n Hypocalcemia n Atrial premature complexes Atrioventricular Relationship n Acute current of injury n Long-QT syndromes (congenital (conducted; nonconducted) and Conduction n ST-elevation MI and acquired) n Atrial tachycardia (ectopic) Atrioventricular dissociation due to: n Q-wave MI n Atrial septal defect, secundum n Atrial tachycardia with n Slowing of dominant pacemaker n Abnormal Q waves not associated n Atrial septal defect, primum atrioventricular block n Acceleration of subsidiary pacemaker with infarction n Dextrocardia n Atrial fibrillation n Third-degree atrioventricular block n Time course of ECG changes n Mitral stenosis n Atrial flutter (typical and n Isorhythmic atrioventricular in MI (acute/recent; age n Acute cor pulmonale, including atypical forms) dissociation undetermined/old) pulmonary embolus n Atrial tachycardia, multifocal Atrioventricular Block n ECG localization of MI n Pericardial effusion AV Junctional Rhythms n First degree Miscellaneous ST-T, U-Wave Abnormalities n Acute pericarditis n Premature junctional complexes n Second degree: 2:1, Mobitz type I n Nonspecific ST-T wave abnormalities n Hypertrophic cardiomyopathy n Atrioventricular node re-entrant (Wenckebach), Mobitz type II, n Prolonged Q-T interval n Brugada disease tachycardia (AVNRT-common high-degree atrioventricular block n Prominent U waves n Arrhythmogenic right and uncommon types) n Third degree (complete) n ST-T wave abnormalities secondary ventricular dysplasia n Nonparoxysmal junctional QRS Voltage and Axis to hypertrophy n Central nervous system disorder tachycardia/accelerated n Low voltage n Myxedema junctional rhythm n Left axis deviation n Hypothermia n Right axis deviation n Sick sinus syndrome n Left ventricular hypertrophy n Digitalis effect n Digitalis toxicity n Effects of other drugs (e.g., tricyclic or antiarrhythmic agents)

ECG ¼ electrocardiogram; MI ¼ myocardial infarction.

APPENDIX 5. ABBREVIATION LIST

ABIM ¼ American Board of Internal Medicine ABMS ¼ American Board of Medical Specialties ACC ¼ American College of Cardiology ACGME ¼ Accreditation Council for Graduate Medical Education AHA ¼ American Heart Association COCATS ¼ Core Cardiovascular Training Statement ECG ¼ electrocardiography/electrocardiogram HIPAA ¼ Health Insurance Portability and Accountability Act JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL.65,NO.17,2015 ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00 PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacc.2015.03.024

TRAINING STATEMENT COCATS 4 Task Force 4: Training in Multimodality Imaging

Jagat Narula, MD, PHD, MACC, Chair Shaista Malik, MD, PHD, FACC Y.S. Chandrashekhar, MD, FACC Thomas Ryan, MD, FACC Vasken Dilsizian, MD, FACC Soma Sen, MBBS, FACC

Mario J. Garcia, MD, FACC Joseph C. Wu, MD, PHD, FACC Christopher M. Kramer, MD, FACC

1. INTRODUCTION ACC, and addressed the reviewers’ comments. The document was revised and posted for public comment 1.1. Document Development Process from December 20, 2014, to January 6, 2015. Authors 1.1.1. Writing Committee Organization addressed the additional comments from the public to complete the document. The final document was The Writing Committee was selected to represent approved by the Task Force, COCATS Steering Com- the American College of Cardiology (ACC) and included mittee, and ACC Competency Management Commit- the chairs of the COCATS 4 Imaging Task Forces tee, and ratified by the ACC Board of Trustees in on Cardiovascular Computed Tomography (CCT), February 2015. This document is considered current Cardiovascular Magnetic Resonance (CMR), Nuclear until the ACC Competency Management Committee Cardiology, and Echocardiography; a cardiovascular revises or withdraws it. training program director; early-career experts; highly experienced specialists practicing in both academic 1.2. Background and Scope and community-based settings; and members experi- The Task Force was charged with updating previously- enced in defining and applying training standards published standards for training fellows in clinical according to the core competencies structure promul- cardiology who are enrolled in ACGME–accredited fel- gated by the Accreditation Council for Graduate Med- lowships (1,2) on the basis of changes in the field ical Education (ACGME), American Board of Internal since 2008 and as part of a broader effort to establish Medicine (ABIM), and American Board of Medical consistent training criteria across all aspects of cardi- Specialties (ABMS). The ACC determined that re- ology. This document does not provide specific lationships with industry or other entities were not guidelines for training in advanced cardiovascular relevant to the creation of this general cardiovascular subspecialty areas because these are already defined training statement. Employment and affiliation details by individual modality-specifictaskforces,butitdoes for the authors and peer reviewers are provided in identify opportunities to obtain advanced training Appendixes 1 and 2, respectively, along with disclosure where appropriate. The Steering Committee and reporting categories. Comprehensive disclosure infor- Task Force recognize that implementation of these mation for the authors, including relationships with changes in training requirements will occur incre- industry and other entities, is available as an online mentally over time. supplement to this document. For most areas of adult cardiovascular medicine, 1.1.2. Document Development and Approval 3 levels of training are delineated:

The Writing Committee developed the document, n Level I training the basic training required of all approved it for review by individuals selected by the fellows to become competent consultants, is considered a foundation for further multimodality imaging (MMI) training and can be accomplished The American College of Cardiology requests that this document be cited during a standard 3-year training program in car- as follows: Narula J, Chandrashekhar YS, Dilsizian V, Garcia MJ, Kramer diology but does not qualify the trainee for inde- CM, Malik S, Ryan T, Sen S, Wu JC. COCATS 4 task force 4: training in multimodality imaging. J Am Coll Cardiol 2015;65:1778–85. pendent practice as an imager. JACC VOL. 65, NO. 17, 2015 Narula et al. 1779 MAY 5, 2015:1778– 85 COCATS 4 Task Force 4

n Level II training refers to the additional training in 1 or Trainees should develop competence in evidence-based more areas that enables cardiologists to perform or application of each of these imaging methods and in interpret specificdiagnostictestsandproceduresorto selecting the most appropriate imaging modality for com- render more specialized care for specific patients and mon clinical conditions. Furthermore, required compe- conditions. This level of training is recognized for those tence extends to integrating the results of noninvasive areas in which an accepted instrument or benchmark, imaging with other components of the patient evaluation such as a qualifying examination, is available to mea- in order to manage patients with known or suspected sure specific knowledge, skills, or competence. Level II cardiovascular disease. Yet, because noninvasive cardio- training in selected areas may be achieved by some vascular imaging modalities are increasingly complex and trainees during the standard 3-year cardiovascular expensive, appropriate use of the technologies is essential fellowship, depending on the trainees’ career goals and for the competent practice of clinical cardiology. This re- use of elective rotations. This level of training gener- quires that the cardiologist learn to identify complex set- ates the MMI specialists needed to provide the majority tings in which consultation with an advanced imaging of imaging services in routine patient care, particularly specialist can help in selection of the optimal imaging in the ambulatory arena, for diagnosis and surveillance approach for addressing questions relevant to an individ- of common cardiovascular conditions. ual patient most accurately and efficiently. These princi- n Level III training requires additional experience ples are equally pertinent when noninvasive imaging is beyond the standard 3-year cardiovascular fellowship employed in conjunction with surgical and catheter-based to acquire specialized knowledge and competencies in interventional or electrophysiological procedures and as performing, interpreting, and training others to per- newer applications are introduced, making the dynamic form specific procedures or render advanced, special- integration of MMI intrinsic to the continuing commitment ized care at a high level of skill. Level III training in of cardiologists to lifelong learning. MMI leads to the ability to direct an MMI center, train The core curriculum embraces these principles while others, and conduct advanced research in cardiovas- acknowledging that each of the 4 major noninvasive im- cular imaging. Level III training is described here only aging modalities (echocardiography, nuclear cardiology, in broad terms to provide context for trainees and CCT, and CMR) have evolved independently. Moreover, clarify that these advanced competencies are not as each modality has become more complex, few cardi- covered during the cardiovascular fellowship. The ologists now have the training or experience to function additional exposure and requirements for Level III at the current state of the art across the full multimodality training will be addressed in a subsequent, separately spectrum. Although specialization in 1 modality enhances published Advanced Training Statement. and focuses specific knowledge and skills, it may some- times limit one’s capacity to judiciously apply alternative modalities, each with its own unique set of strengths and 2. GENERAL STANDARDS weaknesses for particular clinical situations. The future of cardiac imaging will include enhanced integration across 2.1. Basic Clinical Training in Noninvasive Imaging modalities of critical information regarding cardiac (Level I Training) structure, function, physiology, and pathology. This The curriculum assumes that the typical fellow can ac- deeper integration will facilitate patient-centric imaging quire the requisite knowledge and skills for Level I by which cardiologists select the best test to achieve training in all noninvasive imaging modalities within optimal outcomes using an advanced toolbox to provide approximately 7 months. Development of Level II com- high-quality, efficient, cost-effective care. In short, petency requires additional training as described in the application of a given modality should be dictated by the COCATS 4 Task Force reports pertaining to the individual specific needs of a particular patient rather than the modalities. Level II competency in more than 2 imaging expertise of the cardiologist (3). Modalities should be modalities typically requires additional training beyond viewed as hierarchically complementary depending on the standard 3-year cardiovascular fellowship. the clinical problem. For any single patient or clinical Noninvasive imaging techniques are key components of scenario, there is almost always a best test (or best test the evaluation of patients with cardiovascular disease, and combination) most likely to answer the question safely every cardiovascular trainee should gain a basic under- and accurately. Good patient outcomes require under- standing of how to utilize them properly in patient care. In standing of the nuances of multiple modalities and line with this, every cardiovascular trainee should learn avoiding duplication to reduce cost, minimize risk and the principles underlying echocardiographic, nuclear, discomfort, and enhance value. Training programs are CCT, and CMR imaging modalities, including their encouraged to embrace these concepts and offer oppor- respective advantages, limitations, and potential risks. tunities for fellows at all levels of training to concurrently 1780 Narula et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 4 MAY 5, 2015:1778– 85

assess the findings generated by more than 1 imaging System, the ACC has adopted this format for its compe- modality, allowing them to experience firsthand how tency and training statements, career milestones, lifelong these can yield complementary information. learning, and educational programs. It is also developing tools to assist physicians in assessing, enhancing, and 2.2. Advanced Imaging Training for Selected Fellows documenting these competencies and delineated mile- (Levels II and III) stones in noninvasive cardiac imaging that identify Training should be flexible and aligned with future career particular behaviors and attributes within each compe- goals. Most trainees should develop independent com- tency domain to provide a developmental roadmap for petency (Level II) in echocardiography during the stan- fellowsastheyprogressthroughvariouslevelsof dard 3-year fellowship. Selected fellows, depending on training. their career objectives and educational experiences (including elective rotations), may develop independent 3.2. Structure of Training competency (Level II) in an additional imaging modality The reports of the COCATS 4 Task Forces addressing the (nuclear, CCT, or CMR) during the standard 3-year individual imaging modalities provide a general frame- fellowship. Level II competency in more than 2 modal- work for training in patient-centered noninvasive cardio- ities typically requires additional training beyond the vascular imaging organized around defining a central standard 3-year cardiovascular fellowship. An especially clinical question. The recommendations address: 1) the adept and committed fellow in a program well-equipped structure of the training program; 2) the need for emphasis with the faculty, facilities, case volume, and educational on a cross-modality curriculum; 3) real-time evaluation of infrastructure may accomplish competency in 3 modal- trainee progress; and 4) integration of modality-specific ities during the standard fellowship through flexible ro- training guidelines defined by specialty societies as stan- tations. Competency-based learning—which emphasizes dards for training and demonstrating competency. In successful graduation on the basis of articulated and general, training in MMI should not be provided in a rigorously evaluated competency rather than on the separate rotation, but should instead be offered as part of amount of time devoted to a particular skill or the number an integrated, correlative experience during rotations in of procedures performed or interpreted during training— the various component imaging modalities (see Table 1). will help ensure quality. The individual COCATS 4 Task Force reports emphasize Satisfactory acquisition of the knowledge and skills concurrent training and consolidation of common cur- corresponding to Level II competency should be ricula across modalities. Quality and appropriate use measured and documented by recognized methods, such measures are emphasized as they apply to each test as by meeting the criteria for the examinations offered by encountered during the training, and the effectiveness of the National Board of Echocardiography or the Certifica- training is evaluated in competency-based terms. Unify- tion Board of Nuclear Cardiology. More advanced com- ing imaging around image information rather than mode of petency (Level III) in 1 or more imaging modalities acquisition can generate creative ways of structuring requires additional training beyond the standard 3-year training time and competency-based evaluation. Length of cardiovascular fellowship. Advanced training in multi- training is not the primary determinant of quality. Hands- modality cardiovascular imaging results in a higher level on,supervisedparticipationin direct image acquisition, of competency and the ability to direct an MMI center and interpretation, and integration with other clinical data are train others in cardiovascular imaging. Except in selected essential elements of training in advanced imaging. areas, this advanced Level III training in cardiovascular imaging will generally entail training in more than 1 4. ADVANCED IMAGING TRAINING modality. Some cardiologists may seek advanced skills in more than 3. SUMMARY OF TRAINING REQUIREMENTS 1 imaging modality, although few will attain advanced skill levels in all imaging modalities. Program directors 3.1. Development and Evaluation of Core Competencies should consider the dynamic nature of this field when Training requirements in noninvasive cardiovascular im- advising fellows. During a standard 3-year fellowship, aging address the 6 general competency domains selected fellows, depending on their career focus, could promulgated by the ACGME/ABMS and endorsed by the obtain Level II competency in up to 2 imaging modalities. ABIM. These domains are: medical knowledge, patient Fellows interested in greater expertise in MMI may seek care and procedural skills, practice-based learning and Level III competency, which requires additional training improvement, systems-based practice, interpersonal and after the standard 3-year fellowship. Fellows interested in communication skills, and professionalism. In parallel procedural careers (interventional cardiology or electro- with the evolution of the ACGME’s Next Accreditation physiology) may modify training to align with their JACC VOL. 65, NO. 17, 2015 Narula et al. 1781 MAY 5, 2015:1778– 85 COCATS 4 Task Force 4

TABLE 1 Key Principles for Training in Multimodality Noninvasive Cardiovascular Imaging

1. Cardiovascular imaging techniques are key components in the evaluation of patients with known or suspected heart and vascular disease, and every cardiology trainee should have a basic understanding of their proper use in patient care. 2. Noninvasive cardiovascular imaging modalities are increasingly complex and expensive, making appropriate use of the technologies essential for the high- quality, efficient, and cost-effective practice of clinical cardiology. 3. All cardiovascular trainees should understand the basic principles underlying echocardiographic, nuclear cardiology, CCT, and CMR, along with their limitations and potential risks. 4. All cardiovascular trainees should achieve competence in evidence-based application of noninvasive cardiovascular imaging and selection of themost appropriate imaging modality for common clinical conditions. A guiding educational principle is that utilization of noninvasive imaging for a givenclinical situation should not be aligned with or committed to a specific or single modality but should instead involve selection of the optimum test to address the clinical situation at hand, within the setting of available technical resources and professional expertise. 5. Every standard 3-year cardiovascular fellow should understand the distinguishing concepts of echocardiography, nuclear cardiology, CCT, and CMR as the basis for Level I competency in all 4 modalities. Programs can provide this training through on-site facilities, off-site collaboration with other programs, and access to audiovisual resources and courses organized by subspecialty organizations. 6. Concurrent training across multiple imaging modalities is encouraged when possible. Topics common to multiple modalities (e.g., radiation physics, image processing) can be grouped to avoid duplication or repetition. 7. Trainee competency is the primary determinant of sufficient training, rather than the time, exposure, or volume of imaging studies performed or inter- preted. All cardiovascular trainees should become competent in integrating the results of noninvasive imaging with other components of clinical evaluation to manage patients with cardiovascular disease. Correlation of findings across multiple imaging modalities should be emphasized to enhance the understanding of the strengths and weaknesses of each modality. Common workstations that display images generated by multiple imaging modalities are useful for this purpose. 8. All cardiovascular trainees should be able to identify complex settings in which consultation with a specialist in advanced cardiovascular imaging can help in selecting the imaging approach that addresses the clinical questions most accurately and efficiently. 9. All standard 3-year cardiovascular fellows should gain a deep understanding of appropriate use criteria (AUC) and be encouraged to link all logged procedures to the corresponding AUC. 10. Programs should offer opportunities to facilitate Level II training in 1 or more modalities, which are to be selected on the basis of each fellow’saptitude, interests, and career goals. More advanced competency beyond Level II typically requires additional training beyond the standard 3-year cardiovascular fellowship. 11. Satisfactory acquisition of the knowledge and skills corresponding to Level II competency should be measured and documented by recognized methods, such as by meeting the criteria for the examinations offered by the National Board of Echocardiography and the Certification Board of Nuclear Cardiology and Cardiac Computed Tomography. 12. Cardiology programs should strongly consider providing standard 3-year cardiovascular fellows with independent competency (Level II) in echocardiography during the standard 3-year fellowship. 13. Advanced training in multimodality cardiovascular imaging (beyond that obtained during the general fellowship) results in a higher level of competency and the ability to both direct an MMI center and train others in noninvasive cardiovascular imaging. 14. As medical school and residency training provides more advanced imaging training and a wider array of modalities is introduced in the future, fellows in cardiology should be progressively better prepared to understand, utilize, and perform cardiac imaging.

AUC ¼ appropriate use criteria; CCT ¼ cardiovascular computed tomography; CMR ¼ cardiovascular magnetic resonance; MMI ¼ multimodality imaging.

choice. For instance, a higher level of understanding advancement in the form of a Health Insurance Portability regarding CCT angiography might be useful for those and Accountability Act (HIPAA)–compliant electronic undertaking careers in coronary intervention. An database or logbook that meets ACGME reporting stan- arrhythmia specialist might find it important to obtain a dards. These records should summarize pertinent clinical deeper understanding of CMR or CCT for prognostication, information (e.g., number of cases, diversity of referral localization of foci, and targeting catheter-based ablation sources, testing modalities, diagnoses, and findings). The procedures. Similarly, fellows interested in heart failure use of all tests should be aligned with both clinical need might choose to concentrate on echocardiography and and appropriate use criteria. Trainees should be prepared CMR imaging. to explain why a given procedure is better suited to the clinical question than another imaging option. Fellows 5. EVALUATION OF COMPETENCY should document clinical correlation with the other imaging, hemodynamic, invasive laboratory, surgical pa- Evaluation tools in noninvasive cardiovascular imaging thology, and outcomes data to enhance their under- include direct observation by instructors, in-training standing of the diagnostic utility and value of various examinations, case logbooks, conference and case pre- imaging procedures. Finally, imaging experiences should sentations, multisource evaluations, trainee portfolios, be assessed against measures of quality with regard to and simulation. Selection of the optimum modality on a test selection, performance, interpretation, and reporting case-by-case basis, judgment, acquisition, and interpre- (4,5) to ensure an appreciation of the potential adverse tive skills should be evaluated in every trainee. Interac- consequences of suboptimal, redundant, or unnecessary tion with other physicians, patients, and laboratory testing. support staff; initiative; reliability; decisions or actions Under the aegis of the program director and director that result in complications; and the ability to make of each imaging laboratory, facility, or program, the appropriate decisions independently and follow up faculty should record and verify each trainee’sexperi- appropriately should be considered in these assessments. ences, assess his or her performance, and document Trainees should maintain records of participation and satisfactory achievement. The program director is 1782 Narula et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 4 MAY 5, 2015:1778– 85

responsible for confirming trainees’ experience and to ensure achievement of selected training milestones competence and reviewing the overall progress of indi- and to identify areas in which additional focused training vidual trainees with the Clinical Competency Committee may be required.

REFERENCES

1. Beller GA, Bonow RO, Fuster V. ACCF 2008 recom- 3. Zoghbi WA, Narula J. Training in multimodality im- second American College of Cardiology–Duke mendations for training in adult cardiovascular medi- aging: challenges and opportunities. J Am Coll Cardiol University Medical Center Think Tank on Quality in cine core cardiology training (COCATS 3) (revision of Img 2009;2:249–50. Cardiovascular Imaging. J Am Coll Cardiol Img 2009;2: the 2002 COCATS training statement). J Am Coll Car- 231–40. diol 2008;51:335–8. 4. Douglas P, Iskandrian AE, Krumholz HM, et al. Achieving quality in cardiovascular imaging: pro- 2. Thomas JD, Zoghbi WA, Beller GA, et al. ACCF 2008 ceedings from the American College of Cardiology– KEY WORDS training statement on multimodality noninvasive car- Duke University Medical Center Think Tank on Quality ACC Training Statement, diovascular imaging: a report of the American College in Cardiovascular Imaging. J Am Coll Cardiol 2006;48: cardiovascular computed tomography, of Cardiology Foundation/American Heart Association/ 2141–51. cardiovascular magnetic resonance, clinical American College of Physicians Task Force on Clinical competence, COCATS, echocardiography, Competence and Training. J Am Coll Cardiol 2009;53: 5. Douglas PS, Chen J, Gillam L, et al. Achieving quality fellowship training, multimodality imaging, 125–46. in cardiovascular imaging II: proceedings from the nuclear cardiology JACC VOL. 65, NO. 17, 2015 Narula et al. 1783 MAY 5, 2015:1778– 85 COCATS 4 Task Force 4

APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 4: TRAINING IN MULTIMODALITY IMAGING

Institutional/ Ownership/ Organizational Speakers Partnership/ Personal or Other Expert Committee Member Employment Consultant Bureau Principal Research Financial Benefit Witness

Jagat Narula (Chair) Mount Sinai School of None None None None None None Medicine—Philip J. & Harriet L. Goodhart Chair in Cardiology; Professor of Medicine

Y. S. Chandrashekhar University of Minnesota, None None None None None None Division of Cardiology— Professor of Medicine

Vasken Dilsizian University of Maryland None None None None None None School of Medicine—Professor of Medicine/ Radiology; Director, Division of Nuclear Medicine

Mario J. Garcia Montefiore Medical Center, None None None None None None Albert Einstein College of Medicine—Chief of Cardiology; Professor of Medicine and Radiology

Christopher M. Kramer University of Virginia Health None None None None None None System—Ruth C. Heede Professor of Cardiology; Professor of Radiology

Shaista Malik University of California— None None None None None None Assistant Professor

Thomas Ryan Ross Heart Hospital—Director, None None None None None None Heart and Vascular Center; John G. and Jeanne Bonnet McCoy Chair in Cardiovascular Medicine

Soma Sen Park Nicollet Methodist None None None None None None Hospital—Cardiologist

Joseph C. Wu Stanford University School None None None None None None of Medicine—Professor of Medicine and Radiology; Stanford Cardiovascular Institute—Director

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects authors’ employment and reporting categories. To ensure complete transparency, authors’ comprehensive healthcare-related disclosure information—including relationships with industry not pertinent to this document—is available in an online data supplement. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/ relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional information about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology. 1784 Narula et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 4 MAY 5, 2015:1778– 85

APPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 4: TRAINING IN MULTIMODALITY IMAGING

Institutional/ Organizational Ownership/ or Other Speakers Partnership/ Personal Financial Expert Name Employment Representation Consultant Bureau Principal Research Benefit Witness

Richard Kovacs Indiana University, Official Reviewer, None None None None None None Krannert Institute of ACC Board of Trustees Cardiology—Q.E. and Sally Russell Professor of Cardiology

Dhanunjaya Kansas University Official Reviewer, None None None None None None Lakkireddy Cardiovascular Research ACC Board of Governors Institute

Howard Weitz Thomas Jefferson University Official Reviewer, None None None None None None Hospital—Director, Division Competency Management of Cardiology; Sidney Kimmel Committee Lead Reviewer Medical College at Thomas Jefferson University—Professor of Medicine

Dennis Calnon OhioHealth Heart and Vascular Organizational Reviewer, None None None None None None Physicians—Director, Cardiac ASNC Imaging; Riverside Methodist Hospital

Thomas Gerber Mayo Clinic—Professor, Organizational Reviewer, SAIP None None None None None None Medicine and Radiology

John Hodgson Metrohealth Medical Center Organizational Reviewer, SCAI None None None None None None

Allan Klein Cleveland Clinic—Professor, Organizational Reviewer, ASE None None None None None None Medicine and Director, Pericardial Center

Warren Manning Beth Israel Deaconess Organizational Reviewer, SCMR None None None None None None Medical Center, Division of Cardiology—Professor, Medicine and Radiology

Sherif Nagueh Methodist DeBakey Heart Organizational Reviewer, ASE None None None None None None and Vascular Center— Professor of Medicine

Brian D. Hoit University Hospitals Case Content Reviewer, None None None None None None Medical Center Cardiology Training and Workforce Committee

Andrew Kates Washington University Content Reviewer, None None None None None None School of Medicine Academic Cardiology Section Leadership Council

Nishant Shah Brigham and Women’s Content Reviewer, None None None None None None Hospital, Harvard Medical Imaging Council School—Cardiovascular Imaging Fellow

Prem Soman University of Pittsburgh Content Reviewer, None None None None None None Medical Center—Director, CV Imaging Summit Nuclear Cardiology and Steering Committee Associate Professor, Medicine

David Vorchheimer Montefiore-Einstein Center Content Reviewer, Individual None None None None None None for Heart & Vascular Care— Director, Clinical Cardiology; Professor, Clinical Medicine

Kim Williams Rush University Medical Center— Content Reviewer, None None None None None None James B. Herrick Professor; Cardiology Training and Chief, Division of Cardiology Workforce Committee

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects peer reviewers’ employment, representation in the review process, as well as reporting categories. Names are listed in alphabetical order within each category of review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional infor- mation about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology; ASE ¼ American Society of Echocardiography; ASNC ¼ American Society of Nuclear Cardiology; CV ¼ cardiovascular; SAIP ¼ Society of Atherosclerosis Imaging and Prevention; SCAI ¼ Society for Cardiovascular Angiography and Interventions; SCMR ¼ Society for Cardiovascular Magnetic Resonance. JACC VOL. 65, NO. 17, 2015 Narula et al. 1785 MAY 5, 2015:1778– 85 COCATS 4 Task Force 4

APPENDIX 3. ABBREVIATION LIST

ABIM ¼ American Board of Internal Medicine ABMS ¼ American Board of Medical Specialties ACC ¼ American College of Cardiology ACGME ¼ Accreditation Council for Graduate Medical Education CCT ¼ cardiovascular computed tomography CMR ¼ cardiovascular magnetic resonance COCATS ¼ Core Cardiovascular Training Statement HIPAA ¼ Health Insurance Portability and Accountability Act MMI ¼ multimodality imaging JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL.65,NO.17,2015 ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00 PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacc.2015.03.035

TRAINING STATEMENT COCATS 4 Task Force 5: Training in Echocardiography

Endorsed by the American Society of Echocardiography

Thomas Ryan, MD, FACC, FASE, Chair Sunil V. Mankad, MD, FACC, FASE* Kathryn Berlacher, MD, FACC Geoffrey A. Rose, MD, FACC, FASE Jonathan R. Lindner, MD, FACC, FASE Andrew Wang, MD, FACC

1. INTRODUCTION the ACC and ASE, and addressed the reviewers’ comments. The document was revised and posted 1.1. Document Development Process for public comment from December 20, 2014, to 1.1.1. Writing Committee Organization January 6, 2015. Authors addressed the additional comments from the public to complete the document. The writing committee was selected to represent The final document was approved by the Task the American College of Cardiology (ACC) and Amer- Force, COCATS Steering Committee, and ACC Com- ican Society of Echocardiography (ASE) and included petency Management Committee; ratified by the ACC a cardiovascular training program director, an echo- Board of Trustees in March, 2015; and endorsed by the cardiography training program director, early-career ASE. This document is considered current until the echocardiography experts, highly experienced speci- ACC Competency Management Committee revises or alists practicing in both the academic and community- withdraws it. based practice settings, and physicians experienced in defining and applying training standards according to the 6 general competency domains promulgated by the 1.2. Background and Scope Accreditation Council for Graduate Medical Education Echocardiography is the most widely used and readily (ACGME) and American Board of Medical Specialties available imaging technique for assessing cardiovas- (ABMS)andendorsedbytheAmericanBoardof cular anatomy and function. Clinical application of Internal Medicine (ABIM). The ACC determined that ultrasound encompasses M-mode, 2-dimensional (2D), relationships with industry or other entities were not 3-dimensional (3D), pulsed,tissue,andcontinuous- relevant to the creation of this general cardiovascular wave Doppler and color-flow imaging. Echocardiogra- training statement. Employment and affiliation details phy noninvasively provides diagnostic and prognostic for authors and peer reviewers are provided in information concerning cardiovascular anatomy, Appendixes 1 and 2, respectively, along with disclosure function (i.e., ejection fraction), hemodynamic vari- reporting categories. Comprehensive disclosure in- ables (i.e., gradient or pressure), and flow disturbances formation for all authors, including relationships by means of pulsed, continuous-wave, and color-flow with industry and other entities, is available as an Doppler imaging. Moreover, these cardiovascular pa- online supplement to this document. rameters can be assessed at rest, as well as during conditions of increased hemodynamic demand such as 1.1.2. Document Development and Approval exercise. The writing committee developed the document, The Task Force was charged with updating approved it for review by individuals selected by previously-published standards for training clinical adult cardiovascular fellows on the basis of changes in the field since 2008 and as part of a broader *American Society of Echocardiography Representative. effort to establish consistent training criteria across The American College of Cardiology requests that this document be cited all aspects of cardiology. The changes herein as follows: Ryan T, Berlacher K, Lindner JR, Mankad SV, Rose GA, Wang A. COCATS 4 task force 5: training in echocardiography. J Am Coll address the necessary balance between the devel- Cardiol. 2015;65:1786–99. opment of increasingly specialized and sophisticated JACC VOL. 65, NO. 17, 2015 Ryan et al. 1787 MAY 5, 2015:1786– 99 COCATS 4 Task Force 5

echocardiographic techniques and the need to provide trainothersinadvancedaspects of echocardiography. a broad and complete training experience within a These advanced competencies are usually not covered 3-year fellowship period. The Task Force also updated during the general cardiology fellowship, but require previously published standards to address the evolving additional training during which they are integrated framework of competency-based medical education with training in other imaging modalities. For described by the ACGME Outcomes Project and the 6 selected fellows wishing to attain advanced compe- general competencies endorsed by the ACGME and tencies in echocardiography, training beyond Level II ABMS. The background and overarching principles can be achieved either during the standard 3-year governing fellowship training are provided in the fellowship (for those individuals seeking dedicated COCATS 4 Introduction, and readers should become Level III training focused on echocardiography) or familiar with this foundation before considering the during an additional period of training beyond details of training in a subdiscipline like echocardiog- the standard 3-year fellowship for those desiring raphy. The Steering Committee and Task Force recog- advanced echocardiography competency as part of nize that implementation of these changes in training multimodality imaging training. Fellows pursuing this requirements will occur incrementally over time. advanced training during the 3-year fellowship will For most areas of adult cardiovascular medicine, devote all available elective time to echocardiogra- 3 levels of training are delineated: phy, precluding acquisition of Level II competency in any other imaging modality. In both pathways, n Level I training, the basic training required for trainees Level III training in echocardiography should take to become competent consultants, is required by all place in laboratories with Level III–trained faculty fellows in cardiology and can be accomplished as part and with the necessary infrastructure to provide the of a standard 3-year training program in cardiology. For advanced training experience. Level III training is echocardiography, Level I training is defined as an described here in relatively broad terms to provide introductory or early level of competency in performing context for trainees. The additional exposure and and interpreting transthoracic echocardiography (TTE) requirements for Level III training will be addressed that is achieved during fellowship training but not in a subsequent, separately published Advanced sufficient to provide independent interpretation of Training Statement. results. The numbers of cases, procedures, and experiences n Level II training refers to the additional training in 1 recommended are based on published guidelines, com- or more areas that enables some cardiovascular spe- petency statements, and the opinions of the members cialists to perform or interpret specificdiagnostic of the writing group. It is assumed that training tests and procedures or to render more specialized is directed by appropriately-trained mentors in an care for patients and conditions. This level of training ACGME–accredited program and that satisfactory com- is recognized for those areas in which an accepted pletion of training is documented by the program di- instrument or benchmark, such as a qualifying ex- rector. The number and types of encounters and the amination, is available to measure specificknowl- duration of training required for each level of training edge, skills, or competence. Level II training in are summarized in Section 4. selected areas may be achieved by trainees during the standard 3-year cardiovascular fellowship, depending 2. GENERAL STANDARDS on their career goals and use of elective rotations. Level II training in echocardiography is required Optimal training in echocardiography relies on the inter- to provide independent interpretation of play between the learner and the educational environ- echocardiograms. ment. Success depends on the background, abilities, and n Level III training usually requires additional experi- commitment of the trainee; the volume and variety of ence beyond the standard 3-year cardiology fellowship cases; the effectiveness of faculty; and the educational to acquire specialized knowledge and competencies culture of the laboratory. The current trend to introduce in performing, interpreting, and training others to the fundamental principles, indications, applications, and perform specific procedures or render advanced, limitations of echocardiography into the education of specialized care at a high level of skill and are defined medical students and residents is encouraged and will by competency components and outcome metrics. The facilitate subsequent mastery of this discipline. In skills and experience achieved during Level III training particular, experience at an early stage with hand-carried prepare the trainee to perform and interpret complex ultrasound (HCU) enhances the learning process and fa- studies in special populations, engage in research, cilitates an understanding of cardiovascular anatomy and direct an academic echocardiography laboratory, and hemodynamics. 1788 Ryan et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 5 MAY 5, 2015:1786– 99

2.1. Faculty 3.1. Didactic Program The echocardiographic laboratory in which training of Didactic instruction may occur in a variety of formats, cardiovascular fellows is undertaken should be under the including lectures, conferences, journal clubs, and clinical direct supervision of a full-time qualified director (or di- case conferences. A program of didactic instruction is rectors) who has achieved Level III training (1,2).Partici- intended to provide the trainee with an understanding of pation of additional full- or part-time faculty provides a the basic principles and appropriate clinical application diversity of experience and is highly desirable. Exposure of echocardiography. It should incorporate relevant by the trainee to faculty and sonographers with different knowledge of cardiac embryology, anatomy, pathology, strengths and interests ensures a range of experience and and physiology, and integrate clinical information gained a broader base of knowledge. from other imaging disciplines, such as cardiovascular computed tomography, cardiovascular magnetic reso- 2.2. Facilities and Equipment nance, angiography, and nuclear medicine. The program To provide acceptable fellowship training in echocardi- should also expose trainees to appropriate use criteria ography, a laboratory must have equipment capable of for ordering echocardiographic tests. With the increased providing comprehensive TTE and transesophageal role of echocardiography in guiding interventional pro- echocardiography (TEE), including M-mode and 2D and cedures, a specific program of instruction in the intra- 3D imaging, pulsed and continuous-wave Doppler echo- operative use of echocardiography and its role in guiding cardiography, tissue Doppler, stress echocardiography, management of structural/arrhythmic heart disease and color-flow imaging. The laboratory environment should be available for the advanced trainee. should offer a broad range of clinical material. The labo- The precise format for best achieving these educational ratory should conform to continuing quality improvement goals will vary from institution to institution; however, guidelines (3) and ideally perform at least 2,000 echo- given the increasing clinical application of other imaging cardiographic studies per year to give the fellow an modalities within cardiology, it is recommended that a appropriate variety of experience. Accreditation of the common element of any didactic program include specific laboratory through an organization such as the Interso- multimodality imaging conferences that address the cietal Accreditation Commission for Echocardiography appropriate use of echocardiography in clinical decision (IAC Echocardiography) is strongly encouraged. Intra- making. procedural (including intraoperative) echocardiography 3.2. Clinical Experience and an exposure to adults with structural and congenital heart disease should be available. Echocardiography plays an important role in the diag- A rich and diverse clinical milieu will provide an nosis and treatment of a wide variety of acquired and congenital cardiac disorders. Accordingly, exposure to the environment in which the echocardiographic findings entire spectrum of heart disease in a diverse patient can be correlated with other diagnostic data and patient population should be available to the trainee. Although a outcomes. Access during echocardiography training to other imaging modalities provides an opportunity to recommended number of clinical cases to encounter understand the strengths and limitations of echocardi- during training is provided (see Section 4.2), these criteria ography relative to other techniques. At an early stage, merely serve as proxies for clinical exposure. In terms of the trainee should be exposed to quality improvement the overall quality of the educational experience and initiatives, structured reporting, process improvement, depth of understanding, the number of echocardiographic studies in which the trainee participates is less important and appropriate use. For those fellows who plan to than the range of pathologies encountered and adequacy be involved in clinical research, formal training in of supervision and instruction. The criteria described modern research methodology, including biostatistics, clinical trial design, ethics, and grant writing, should be herein are similar to those in other publications on this – available. topic (1,2,6 9). If the case mix available for the trainee is skewed, additional cases beyond the numbers quoted may be required to ensure appropriate experience (10). 3. TRAINING COMPONENTS 3.3. Hands-On Experience Specific requirements for echocardiographic examination The echocardiographic examination is an exceedingly of pediatric patients have been published elsewhere operator-dependent procedure in which it is possible to (2,4,5). Training guidelines in the present document are introduce confounding artifacts or to omit data of diag- primarily directed to trainees performing echocardio- nostic importance. The echocardiographic examination is graphic examinations in adult patients with acquired and interactive, requiring the real-time recognition of specific congenital heart diseases. diagnostic findings to obtain a study that is of clinical JACC VOL. 65, NO. 17, 2015 Ryan et al. 1789 MAY 5, 2015:1786– 99 COCATS 4 Task Force 5

benefit. Therefore, fellowship training in echocardiogra- milestones for each competency and domain also provide phy must emphasize the ability of the trainee to perform a a developmental roadmap for fellows as they progress hands-on examination independently with understand- through various levels of training and serve as an un- ing of the results at the time of image acquisition. The derpinning for the ACGME/ABIM reporting milestones. trainee should develop sufficient technical skills in using The ACC has adopted this format for its competency and an echocardiographic instrument to answer common training statements, career milestones, lifelong learning, clinical questions. and educational programs. Additionally, it has developed Such training is important not so much to develop true tools to assist physicians in assessing, enhancing, and technical expertise as to better understand the diagnostic documenting these competencies. capabilities and potential pitfalls of the echocardio- Table 1 delineates each of the 6 competency domains, graphic examination. It also helps trainees to learn as well as their associated curricular milestones for tomographic cardiac anatomy and integrate planar views training in echocardiography. The milestones are cate- into a 3D framework. Highly skilled cardiac sonographers gorized into Level I, II, and III training (as previously with broad experience in performing echocardiographic defined in this document) and indicate the stage of examinations are necessary to facilitate this training. fellowship training (12, 24, or 36 months, and additional In contrast to transthoracic and stress echocardiogra- time points) by which the typical cardiovascular trainee phy, which are most often performed by sonographers, should achieve the designated level. Given that programs advanced echocardiographic modalities, such as TEE and may vary with respect to the sequence of clinical experi- 3D echocardiography, require the trainee to acquire ences provided to trainees, the milestones at which technical competency in image acquisition and image various competencies are reached may also vary. Level I presentation. Clinical exposure to a broad range of cardiac competencies may be achieved at earlier or later time pathologies and sufficient hands-on experience with the points. Acquisition of Level II skills requires additional technology are essential for the advanced trainee to gain training during the standard 3-year cardiovascular the requisite technical competency (see Section 4.2). fellowship. Level III skills may be attained during the As part of the hands-on aspect of the echocardiographic standard 3-year fellowship in a dedicated program training program, experience with HCU devices is desir- focused on advanced cardiac ultrasound imaging or may able. These devices extend the clinical utility of echo- be acquired during a period of additional training, typi- cardiography by allowing the operator to offer a “visual cally for those fellows seeking multimodality imaging physical examination” in a manner that can be applied training. The table also describes examples of evaluation practically in the clinical setting (11).HCUdevicesoffer tools suitable for assessing competence in each domain. capabilities similar to but less robust than their standard echocardiographic counterparts. Their appropriate appli- 4.2. Training Requirements cation nevertheless requires that the operator have a Echocardiography is integral to the practice of cardiology. fundamental understanding of echocardiographic princi- Because of the fundamental and essential nature of the ples, cardiac anatomy/physiology, and resultant echo- technique, all fellows should have the opportunity to cardiographic correlates. Therefore, participation in a achieve Level II competency, which would prepare them didactic echocardiographic educational program and to perform and interpret echocardiograms independently. hands-on training with conventional echocardiographic This varies from prior versions of COCATS in which Level equipment best prepares the cardiovascular fellow to II training was considered optional and was provided only utilize HCU in the clinical setting as an adjunct to physical to those fellows who desired such training. examination. Fellowship training in echocardiography should in- clude instruction in the basic aspects of ultrasound such 4. SUMMARY OF TRAINING REQUIREMENTS as the principles, technology, indications, and limitations of the techniques. Every trainee should be educated in the 4.1. Development and Evaluation of Core Competencies physical principles and instrumentation of ultrasound Training and requirements for echocardiography address and in cardiovascular anatomy, physiology, and patho- the 6 general competencies promulgated by the ACGME/ physiology, both with regard to the cardiovascular system ABMSandendorsedbytheABIM.Thesecompetencydo- in general and in relation to the echocardiogram in mains are: medical knowledge, patient care and proce- particular. Trainees at all levels should perform the dural skills, practice-based learning and improvement, echocardiographic and Doppler examination to integrate systems-based practice, interpersonal and communica- their understanding of tomographic and 3D cardiac anat- tion skills, and professionalism. The ACC has used this omy. Trainees should correlate the findings from the structure to define and depict the components of the core echocardiographic and Doppler examination with the re- clinical competencies for cardiology. The curricular sults of other imaging modalities and physical 1790 Ryan et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 5 MAY 5, 2015:1786– 99

examination. The trainee should master the relationships imaging should attain Level III competency in a program between the echocardiographic findings and results of that meets requirements addressed in a subsequent, other cardiovascular tests, such as catheterization, angi- separately published Advanced Training Statement ography, magnetic resonance imaging, and electrophysi- (formerly Clinical Competence Statement). ology. The trainee should also understand the impact of The requirements for each level of training are sum- the results of the echocardiographic examination on the marized in Table 2.Indefining these levels, it is recog- medical and surgical management of the patient. nized that specifying the duration of training and number Ultrasound imaging is an evolving technology experi- of procedures is both necessary and desirable. It should encing continued improvement with an expanding list of be emphasized, however, that the quality of experience, clinical indications. Every cardiovascular fellow should intensity of the educational environment, variety and become familiar with the technical performance, inter- complexity of cases, and commitment of both faculty and pretation, strengths, multiple clinical applications, and fellow are the primary determinants of the value of limitations of 2D echocardiographic/Doppler technology. fellowship training. As such, training duration and pro- Level I fellows should also be familiar with the risks cedure volume for each level are provided as a guide, and associated with intravenous administration of echocar- flexibility and the individual needs of the trainee must be diographic contrast agents and have a general under- considered as well. standing of their intended advantages to enhance image quality, particularly myocardial border definition. 4.2.1. Level I Training Requirements Within the scope of fellowship training, this document Level I training typically requires 3 months of full-time defines 3 levels of training (Table 2). Level I training pro- training or its equivalent devoted to understanding vides the basic or introductory exposure that should be functional anatomy and physiology in relation to the achieved by most trainees over the first 2 years of fellow- echocardiographic examination. The trainee should ship. This entails understanding the basic principles, participate in the interpretation of a minimum of 150 indications, appropriate use, applications, and technical complete (M-mode, 2D, and Doppler) examinations and limitations of echocardiography and the inter-relation of personally perform 75 of these studies under the super- this technique with other diagnostic methods. All fellows vision of the laboratory director, designated faculty, and should achieve Level I competency to perform and inter- cardiac sonographers. The Level I trainee should be able pret basic echocardiographic studies in the context of to recognize common cardiovascular pathologic entities. managing their patients. This level of training does not During Level I training, initial exposure to TEE and other qualify a trainee to perform echocardiography or to inde- special procedures may be appropriate, but full compe- pendently interpret complex echocardiograms or a full tence in these areas requires additional training. No other range of echocardiograms typically acquired in an echo- clinical or service responsibility, other than required cardiography laboratory. The competencies developed as outpatient clinic and routine night call duties, should be part of this level of exposure are described in Table 1. expected of the trainee during the dedicated period of Beyond the basic exposure provided by Level I training, Level I training in echocardiography. most cardiovascular fellows should attain Level II compe- tency. Level II training prepares the fellow to indepen- 4.2.2. Level II Training Requirements dently perform and interpret basic and comprehensive Level II training is intended to prepare trainees to perform echocardiographic studies, including resting transthoracic and interpret both basic and complex echocardiograms M-mode, 2D, and Doppler examinations, stress, and TEE independently. During Level II training, emphasis should in adults. Familiarity with published appropriate use be placed on the variety, quality, and completeness of criteria (12) should begin during Level I training and studies; quantification in diagnostic studies; and correla- continue throughout fellowship. tion with other diagnostic and clinical results in a broad Advanced (Level III) expertise requires additional range of clinical problems. To accomplish this, the typical experience during and, in some cases, beyond the general fellow will need an additional 3 months, or the equivalent, 3-year cardiology fellowship to acquire specialized of full-time training, interpreting an additional 150 (300 knowledge and competencies, including additional and total) complete ultrasound imaging and Doppler hemo- more specialized training in various ultrasound pro- dynamic examinations. Of these, at least 75 (150 total) cedures (i.e., transesophageal, stress, and intraoperative should be performed by the trainee under appropriate procedures). This level of training also prepares an indi- supervision. The fellow with Level II training should be vidual to direct an academic echocardiography laboratory able to perform an echocardiographic and Doppler study and pursue a research career in echocardiography. that is diagnostic, complete, and quantitatively accurate. Fellows who wish to incorporate advanced clinical Competence at this level implies sufficient experience to investigation in echocardiography or multimodality interpret echocardiographic examinations accurately and JACC VOL. 65, NO. 17, 2015 Ryan et al. 1791 MAY 5, 2015:1786– 99 COCATS 4 Task Force 5

TABLE 1 Core Competency Components and Curricular Milestones for Training in Echocardiography

Competency Component Milestones (Months) MEDICAL KNOWLEDGE 12 24 36 Add

1 Know the physical principles of ultrasound and the instrumentation used to obtain images. I

2 Know the appropriate indications, including the appropriate use criteria, for: M-mode, 2-dimensional, and I 3-dimensional transthoracic echocardiography; Doppler echocardiography and color-flow imaging; transesophageal echocardiography; tissue Doppler and strain imaging; and contrast echocardiography.

3 Know the limitations and potential artifacts of the echocardiographic examination. I

4 Know the standard views included in a comprehensive transthoracic echocardiogram. I

5 Know the standard views included in a comprehensive transesophageal echocardiogram. I

6 Know the techniques to quantify cardiac chamber sizes and evaluate left and right ventricular systolic and II diastolic function and hemodynamics.

7 Know the characteristic findings of cardiomyopathies. I

8 Know the use of echocardiographic and Doppler data to evaluate native and prosthetic valve function and diseases. II

9 Know the echocardiographic and Doppler findings of cardiac ischemia and infarction, and the complications of I myocardial infarction.

10 Know the echocardiographic findings of pericardial disease, pericardial effusion, and pericardial constriction. II

11 Know the characteristic findings of basic adult congenital heart disease. II

12 Know the findings of complex/postoperative adult congenital heart disease. III*† III*

13 Know the techniques to evaluate cardiac masses and suspected endocarditis. II

14 Know the techniques to evaluate diseases of the aorta. II

15 Know the techniques to assess pulmonary artery pressure and diseases of the right heart. II

16 Know the use and characteristic findings in the evaluation of patients with systemic diseases involving the heart. II

17 Know the indications for, and the echocardiographic findings in, patients with known or suspected cardioembolic II events.

18 Know key aspects of contrast echocardiography including interpretation, administration techniques, and safety II information.

19 Understand the principles and applications of 3-dimensional echocardiography. II

20 Recognize and treat the potential complications of stress, contrast, and transesophageal echocardiography. II

EVALUATION TOOLS: conference presentation, direct observation, and in-training examination.

PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

1 Skill to perform and interpret a basic transthoracic echocardiographic examination. I

2 Skill to perform and interpret a comprehensive transthoracic echocardiographic examination. II

3 Skill to perform and interpret a comprehensive transesophageal echocardiographic examination. II

4 Skill to recognize pathophysiology, quantify severity of disease, identify associated findings, and recognize II artifacts in echocardiography.

5 Skill to integrate echocardiographic findings with clinical and other testing results in the evaluation and I management of patients.

6 Skill to interpret stress echocardiography. II

7 Skill to incorporate stress hemodynamic information in the management of complex valve disease or hypertrophic II cardiomyopathy.

8 Skill to utilize echocardiographic techniques during cardiac interventions, including intraoperative transesophageal III† III echocardiography.

9 Skill to perform and interpret basic 3-dimensional echocardiography. II

10 Skill to utilize advanced 3-dimensional echocardiography during guidance of procedures and/or surgery. III† III

11 Skill to perform and interpret contrast echocardiographic studies. II

EVALUATION TOOLS: direct observation, logbook, and simulation. 1792 Ryan et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 5 MAY 5, 2015:1786– 99

TABLE 1 Core Competency Components, continued

Competency Component Milestones (Months) SYSTEMS-BASED PRACTICE 12 24 36 Add

1 Work effectively and efficiently with the echocardiography laboratory staff. I

2 Incorporate risk/benefit, safety, and cost considerations in the use of ultrasound techniques. I

3 Participate in echocardiographic quality monitoring and initiatives. II

EVALUATION TOOLS: direct observation and multisource evaluation.

PRACTICE-BASED LEARNING AND IMPROVEMENT 12 24 36 Add

1 Identify knowledge and performance gaps and engage in opportunities to achieve focused education and performance I improvement.

EVALUATION TOOLS: conference presentation and direct observation.

PROFESSIONALISM 12 24 36 Add

1 Know and promote adherence to guidelines and appropriate use criteria. I

2 Interact respectfully with patients, families, and all members of the healthcare team, including ancillary and support staff. I

EVALUATION TOOLS: conference presentation, direct observation, multisource evaluation, and reflection and self-assessment.

INTERPERSONAL AND COMMUNICATION SKILLS 12 24 36 Add

1 Communicate with and educate patients and families across a broad range of cultural, ethnic, and socioeconomic II backgrounds.

2 Communicate testing results to physicians and patients in an effective and timely manner. II

3 Communicate detailed information on cardiac anatomy for surgical planning or guidance of interventional procedures. II

EVALUATION TOOLS: direct observation and multisource evaluation.

*Because of its unique and specialized nature, competency in interpreting complex and postoperative congenital heart disease echocardiography studies will usually require training beyond Level II. †See definition of Level III training in Section 1.2. Add ¼ additional months beyond the 3-year cardiovascular fellowship.

independently. Continued experience in special echocar- Level III training is intended for those fellows who plan diographic procedures such as TEE, 3D, and stress echo- careers in echocardiography and should include exposure cardiography is appropriate during Level II training, but to echocardiographic laboratory administration, including full competence to perform these techniques indepen- quality improvement and the understanding and ability dently requires completion of Level II training and to incorporate new and evolving ultrasound technologies supervised performance of the requisite number of special and applications. To obtain Level III competence, the studies. Additional guidelines for training in these areas trainee should fulfill all of the previously described are described later in this document. Gaining experience requirements (including those delineated in Table 2)and intheappropriateuseofcontrast and the role of echo- develop additional experience in performing and inter- cardiography in congenital heart disease should also be preting special procedures, such as intraprocedural, 3D, part of Level II training. Additionally, Level II training strain, and contrast echocardiography in a program that should include recognition of the echocardiographic meets requirements that will be addressed in a subse- changes that can develop in highly conditioned athletes. quent, separately published Advanced Training State- This level of training is recognized by successful ment (formerly a Clinical Competence Statement). completion of a qualifying examination such as the National Board of Echocardiography examination. 4.3. Training in Multiple Imaging Modalities The recent emergence of other noninvasive imaging 4.2.3. Level III Training Requirements modalities, especially cardiovascular magnetic resonance Advanced expertise in echocardiography requires Level and computed tomography angiography, is having a pro- III training during, and in some cases, beyond the found impact on the practice of cardiology and the 36-month cardiovascular fellowship. To achieve Level III fellowship training experience. The cardiovascular competency during a 3-year fellowship period, all avail- medicine specialist is increasingly expected to provide able elective time must be devoted to echocardiography. expertise in 2 or more imaging techniques. Trainees JACC VOL. 65, NO. 17, 2015 Ryan et al. 1793 MAY 5, 2015:1786– 99 COCATS 4 Task Force 5

TABLE 2 Summary of Training Requirements for Echocardiography

Duration of Training* Cumulative Duration* Minimal No. of TTE Minimal No. of TTE TEE and Special Level (Months) of Training (Months) Examinations Performed Examinations Interpreted Procedures

I 3 3 75 150 Yes†

II 3 6 150 (75 Add) 300 (150 Add) Yes‡

III 3 9 300 (150 Add) 750 (450 Add) Yes

*Typical duration assuming acceptable progress toward milestones and demonstrated competency. †Exposure to TEE and other special procedures. ‡Completion of Level II and additional special training are needed to achieve full competence in TEE and other special procedures. Add ¼ additional; TEE ¼ transesophageal echocardiography; TTE ¼ transthoracic echocardiography. should, therefore, gain exposure to multiple imaging not limited to assessment of native and prosthetic valve modalities during the cardiovascular fellowship. To the disease, aortic disease, acquired or congenital structural degree possible, the training program should strive to heart disease, and evaluation of masses (e.g., thrombus or meet these needs by offering multimodality imaging ex- vegetation). Minimum training for independent perfor- periences (see COCATS 4 Task Force 4 report) that address mance and interpretation of TEE requires performance of each technique’s uses and clinical indications, strengths 25 esophageal intubations and 50 supervised complete and limitations, safety issues, and relevant guidelines and multiplanar diagnostic studies (2); however, in many in- appropriate use criteria, when available. stances, this level of expertise will be inadequate to expose the trainee to the full range of pathologies encountered in 4.4. Special Ultrasound Procedures the clinical practice of TEE. Therefore, continued instruc- Special procedures are those that require specialized tion under the supervision of an experienced operator for training. Exposure to these procedures may begin during an additional 50 studies is recommended. The growing Level I training, but competence requires at least availability of TEE simulation to supplement clinical completion of Level II and additional specialized training experience will likely make this an increasingly important as described in the following text. Some are covered under and practical way to enhance TEE skills. Level II training, such as stress echocardiography, TEE, Competence requires full knowledge of the indications, tissue Doppler, contrast echocardiography, and in some contraindications, and complications of TEE, which can cases, intraoperative TEE. Others generally require Level be achieved through both experiential and didactic edu- III training, such as evaluation of advanced myocardial cation. Independent performance of TEE also requires mechanics (strain echocardiography, dyssynchrony knowledge of and experience in the administration of assessment), 3D echocardiography, epicardial and epi- conscious sedation. For most cardiovascular training vascular echocardiography, and echocardiography during programs, initial exposure to TEE can begin during Level I catheter-based interventional procedures. Adequate training, with competence in nonintraoperative TEE training in special ultrasound procedures depends on a full being a component of Level II training. understanding of the principles, indications, risks, and technical limitations of the techniques. In addition to 4.4.2. Intraoperative TEE special expertise, mastery of these procedures involves Intraoperative TEE requires training in routine TEE the ability to integrate the information from the pro- followed by additional experience evaluating patients cedures into clinical practice. Each special procedure can undergoing a variety of cardiac procedures in the oper- only be learned at a high-volume reference laboratory with ating room (13,14). Experience in the operating room an adequate volume of cases under the supervision of should involve the evaluation and monitoring of patients fully-qualified physician experts who perform and inter- undergoing routine coronary bypass surgery, as well as pret a large number of the procedures annually according the examination of patients during valve replacement and to specific guidelines applicable to the procedure. Specific repair procedures. Published guidelines for training in recommendations for the various procedures follow. intraoperative TEE (15) have been developed primarily for the cardiovascular anesthesiologist who has not had prior 4.4.1. Transesophageal Echocardiography training in routine TEE. For cardiovascular fellows who TEE is best learned in a laboratory that performs at least 500 have achieved Level II training in echocardiography TEE studies annually. Although the technical expertise (having performed at least 50 TEE studies), competency needed to perform TEE may be acquired in a lower-volume in intraoperative TEE requires a minimum of 100 addi- setting, less volume limits exposure to the critical and tional intraoperative TEE studies supervised by a quali- unusual abnormalities uniquely identified by TEE. fied expert. Competency in intraoperative TEE also Training should include exposure to TEE examinations requires an understanding of the cardiac surgical pro- performed for a broad array of indications, including but cedures, cardiopulmonary bypass, and intraoperative 1794 Ryan et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 5 MAY 5, 2015:1786– 99

changesinhemodynamicsasassessedbyechocardiogra- stress test; and integration of stress echocardiographic phy. Intraoperative monitoring of procedures for patients results in clinical cardiovascular medicine. For indepen- with congenital heart disease requires specifictraining dent supervision and interpretation of stress echocardi- that is often best acquired in a pediatric training labora- ography, training must include participation in and tory (16). interpretation of a minimum of 100 stress echocardiograms under the supervision of a Level III–trained physician. 4.4.3. Echocardiography During Interventional Procedures Level III experience includes advanced training in and Echocardiography plays an essential role in the selection understanding of: 1) the application of stress echocardi- of patients with structural heart disease for catheter- ography for evaluation of abnormal hemodynamic re- based interventions, planning for these procedures, and sponses in patients with valvular heart disease such as intraprocedural monitoring (17,18). Interventional pro- aortic stenosis, mitral regurgitation, or mitral stenosis; cedures that are typically guided by echocardiography 2) the role of stress echocardiography in evaluation of (transthoracic, transesophageal, or intracardiac) include, patients with hypertrophic cardiomyopathy and pulmo- but are not limited to, transcatheter valve replacement or nary hypertension; and 3) the use of stress echocardiogra- repair and closure of atrial or ventricular septal defects, phy for assessment of myocardial viability (20). perivalvular sources of regurgitation, and the left atrial appendage. Training should occur in a center that per- 4.4.5. Intracardiac and Intravascular Ultrasound forms a high volume of interventional procedures for Intravascular ultrasound is a specialized procedure most structural heart disease. There are currently no guidelines often performed in conjunction with cardiac catheteriza- for training in echocardiographic guidance of inter- tion (21). It is increasingly used to guide interventional ventional procedures, although there are courses of and electrophysiology procedures (22). This procedure instruction on the echocardiographic guidance of trans- requires close collaboration with the interventional catheter valve devices. A high level of expertise in probe cardiologist to ensure proper interpretation of all avail- manipulation and advanced understanding of cardiac able imaging data. Because interpretation of these studies anatomy related to echocardiographic imaging are vital has the potential for immediate and significant impact on for these procedures. Accordingly, guidance of interven- patient management, communication among involved tional procedures requires Level III training and special parties is critical. Performance and interpretation of competency in 3D echocardiography. Competency for in- intravascular ultrasound requires specific, dedicated dependent performance is demonstrated by the ability to training in both image acquisition and interpretation in a completely characterize the cardiovascular anatomy and high-volume laboratory. Training in intracardiac echo- hemodynamics relevant to each specific interventional cardiography should be part of Level III training, and the procedure and to provide both immediate guidance to requisite skills can be obtained only in a reference labo- operators during device-related procedures and feedback ratory where this examination is performed routinely. regarding the satisfactory completion of the intervention. 4.4.6. Contrast Echocardiography 4.4.4. Stress Echocardiography Contrast echocardiography is a broad discipline. Encap- Training in stress echocardiography entails exposure to a sulated microbubble contrast agents that are stable in the mix of exercise and pharmacological stress testing, blood produce left-sided cavity opacification and can be including patient selection, stress modality selection, helpful for identification of endocardial borders and stress test supervision, and integration of all diagnostic detection of intracardiac thrombi and masses (23,24).The information (19,20). Exposure to stress echocardiography ability to supervise and interpret these studies is part of may begin during Level I training; however, because of Level II training in a laboratory that routinely in- the difficulty in interpreting segmental wall-motion ab- corporates agitated saline contrast in the evaluation of normalities developing during stress echocardiography, patients with suspected right-to-left shunts or unex- achieving basic competence in this area is an objective of plained hypoxemia. Training in contrast echocardiogra- Level II training and generally requires supervised inter- phy should include instruction on the composition and pretation of more than 100 stress echocardiographic safety of microbubble contrast agents, contrast-specific studies. For competence and independence in stress imaging methods, indications and contraindications, and echocardiography, additional training beyond Level II is specific scenarios in which contrast is likely to add value. recommended. In addition to supervised interpretation, The individual completing Level II training should the training experience should include both didactic and have the requisite skills to perform and interpret experiential training in the indications for stress echo- contrast-enhanced echocardiograms under the supervi- cardiography; the advantages, limitations, and risks of sion of a Level III echocardiographer trained in contrast different stress imaging approaches; monitoring of the imaging. Level III competency in echocardiography JACC VOL. 65, NO. 17, 2015 Ryan et al. 1795 MAY 5, 2015:1786– 99 COCATS 4 Task Force 5

includes more extensive exposure to rest and stress con- may have a role in selecting patients for resynchroniza- trast echocardiography as well as acquisition of advanced tion therapy. Training in echocardiographic assessment knowledge of microbubble administration protocols, of ventricular dyssynchrony should be obtained in a physical principles of contrast signal generation, and reference laboratory in which this examination is specific machine settings to optimize image quality. routinely performed and should include instruction in echocardiography-based optimization of resynchroniza- 4.4.7. Three-Dimensional Echocardiography tion of pacemakers. Three-dimensional echocardiography is a technically complex modality that has an increasing role in charac- 5. EVALUATION OF COMPETENCY terizing structural heart disease and is also used in planning and guiding certain interventional and surgical Evaluation tools in echocardiography include direct procedures (25). Level II training in echocardiography observation by instructors, in-training examinations, case should provide a basic understanding of the principles of logbooks, conference and case presentations, multisource 3D echocardiography and recognition of the clinical situ- evaluations, trainee portfolios, simulation, and reflection ations in which 3D representation can add incremental and self-assessment. Acquisition and interpretive skills value over 2D imaging. Level II training should prepare should be evaluated in every trainee. Interaction with fellows to apply 3D echocardiography appropriately and other physicians, patients, and laboratory support staff; expose them to basic image acquisition and interpreta- initiative; reliability; decisions or actions that result in tion. Because of the evolving nature and complexity of 3D clinical error; and the ability to make appropriate de- echocardiography, independent performance, processing, cisions independently and follow-up appropriately and interpretation of 3D echocardiography is part of Level should be considered in these assessments. Trainees III training under the supervision of a Level III expert. should maintain records of participation and advance- Training should be performed in a laboratory in which ment in the form of a Health Insurance Portability and 3D echocardiography is used in a variety of applications Accountability Act (HIPAA)–compliant electronic data- including, but not limited to, assessment of ventricular base or logbook that meets ACGME reporting standards volumes, valvular heart disease, and atrial septal defects. and summarizes pertinent clinical information (e.g., Competence to perform 3D echocardiography indepen- number of cases, diversity of referral sources, testing dently requires demonstration of skills in image acquisi- modalities, diagnoses, and findings). Every echocardio- tion, image processing (3D image set manipulation and graphic study should be justified, and during training display), interpretation of 3D transthoracic and trans- fellows should be required to link each procedure to the esophageal echocardiograms, and accurate communica- corresponding appropriate use criteria indication/code in tion of findings. their log book. Trainees should be prepared to explain why a given echocardiographic test is better suited to the 4.4.8. Strain Echocardiography and Myocardial Mechanics clinical question than another imaging option. Fellows Advanced methods have been developed for echocardio- should document clinical correlation with the other im- graphic assessment of globalorregionalmyocardial aging, hemodynamic, invasive laboratory, surgical pa- function, regional timing of myocardial contraction, thology, and outcomes data to enhance understanding of myocardial strain, strain rate, and deformation (26). the diagnostic utility and value of various studies. Finally, Although these techniques are not part of routine diag- experiences in echocardiography should be assessed nostic echocardiography, they enhance diagnostic capa- against measures of quality with regard to test selection, bilities and will likely play an increasing role in the future. performance, interpretation, and reporting (28,29) in the Level II training in echocardiography should include interest of appreciating the potential adverse conse- knowledge of the principles and potential applications of quences of suboptimal testing. strain echocardiography. Independent interpretation and The ACC, American Heart Association, and ASE have proper use of strain or strain rate echocardiography re- formulated a clinical competence statement on the per- quires Level III training under the supervision of an formance, interpretation, and reporting of ultrasound expert in a laboratory in which these procedures are studies (2). Self-assessment programs in echocardiography routinely performed. Training includes instruction in the are available through the ACCF and other organizations. physical principles of imaging cardiac mechanics, image Program directors and trainees are encouraged to incor- processing, and scenarios in which strain imaging may porate these resources in the course of training. In addi- contribute to clinical care. tion, objective examinations have been created by the Echocardiographic assessment of ventricular dyssyn- National Board of Echocardiography for physicians with chrony can contribute to understanding cardiovascular Level II training who want to test and demonstrate their pathophysiology and causes of symptoms (26,27) and competency. To confirm competency, trainees should 1796 Ryan et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 5 MAY 5, 2015:1786– 99

strongly consider preparing for and taking the appropriate achievement. The program director is responsible for National Board of Echocardiography examination. confirming experience and competence and reviewing the Under the aegis of the program director and director overall progress of individual trainees with the Clinical of each imaging laboratory, facility, or program, the Competency Committee to ensure achievement of faculty should record and verify each trainee’sexperi- selected training milestones and to identify areas in ences, assess performance, and document satisfactory which additional focused training may be required.

REFERENCES

1. DeMaria AN, Crawford MH, Feigenbaum H, et al. 17th Nomenclature and Standards Committee of the echocardiography. J Am Soc Echocardiogr 2007;20: Bethesda conference: adult cardiology training. Task American Society of Echocardiography. J Am Soc 1021–41. force IV: training in echocardiography. J Am Coll Car- Echocardiogr 2002;15:369–73. 21. McDaniel MC, Eshtehardi P, Sawaya FJ, et al. diol 1986;7:1207–8. 12. Douglas PS, Garcia MJ, Haines DE, et al. ACCF/ASE/ Contemporary clinical applications of coronary intra- 2. Quinones MA, Douglas PS, Foster E, et al. ACC/AHA AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 vascular ultrasound. J Am Coll Cardiol Intv 2011;4: clinical competence statement on echocardiography: a appropriate use criteria for echocardiography: a report 1155–67. report of the American College of Cardiology/American of the American College of Cardiology Foundation 22. Kim SS, Hijazi ZM, Lang RM, et al. The use of Heart Association/American College of Physicians– Appropriate Use Criteria Task Force, American Society intracardiac echocardiography and other intracardiac American Society of Internal Medicine Task Force of Echocardiography, American Heart Association, imaging tools to guide noncoronary cardiac in- on Clinical Competence. J Am Coll Cardiol 2003;41: American Society of Nuclear Cardiology, Heart Failure terventions. J Am Coll Cardiol 2009;53:2117–28. 687–708. Society of America, Heart Rhythm Society, Society 23. Mulvagh SL, Rakowski H, Vannan MA, et al. 3. Picard MH, Adams D, Bierig SM, et al. American for Cardiovascular Angiography and Interventions, American Society of Echocardiography consensus Society of Echocardiography recommendations for Society of Critical Care Medicine, Society of Cardio- statement on the clinical applications of ultrasonic quality echocardiography laboratory operations. J Am vascular Computed Tomography, and Society for Car- contrast agents in echocardiography. J Am Soc Echo- Soc Echocardiogr 2011;24:1–10. diovascular Magnetic Resonance. J Am Coll Cardiol cardiogr 2008;21:1179–201. 2011;57:1126–66. 4. Graham TP Jr., Beekman RH III, Allen HD, et al. 24. Kaufmann BA, Wei K, Lindner JR. Contrast echo- ACCF/AHA/AAP recommendations for training in pe- 13. Savage RM, Licina MG, Koch CG, et al. Educational cardiography. Curr Probl Cardiol 2007;32:51–96. diatric cardiology: a report of the American College of program for intraoperative transesophageal echocar- Cardiology Foundation/American Heart Association/ diography. Anesth Analg 1995;81:399–403. 25. Lang RM, Badano LP, Tsang W, et al. EAE/ASE American College of Physicians Task Force on Clinical recommendations for image acquisition and display 14. Aronson S, Thys DM. Training and certification in using three-dimensional echocardiography. Eur Heart J Competence (ACC/AHA/AAP Committee on Pediatric perioperative transesophageal echocardiography: a – Cardiovasc Imaging 2012;13:1–46. Cardiology). J Am Coll Cardiol 2005;46:1378 403. historical perspective. Anesth Analg 2001;93:1422–7. 5. Meyer RA, Hagler D, Huhta J, et al. Guidelines for 26. Mor-Avi V, Lang RM, Badano LP, et al. Current and 15. Cahalan MK, Stewart W, Pearlman A, et al. Amer- physician training in fetal echocardiography: recom- evolving echocardiographic techniques for the quanti- ican Society of Echocardiography and Society of Car- mendations of the Society of Pediatric Echocardiogra- tative evaluation of cardiac mechanics: ASE/EAE diovascular Anesthesiologists task force guidelines for phy Committee on Physician Training. J Am Soc consensus statement on methodology and indications training in perioperative echocardiography. J Am Soc – endorsed by the Japanese Society of Echocardiogra- Echocardiogr 1990;3:1 3. – Echocardiogr 2002;15:647 52. phy. J Am Soc Echocardiogr 2011;24:277–313. 6. Pearlman AS, Gardin JM, Martin RP, et al. Guidelines 16. Ayres NA, Miller-Hance W, Fyfe DA, et al. for physician training in transesophageal echocardiog- 27. Yu CM, Sanderson JE, Gorcsan J III Echocardiogra- Indications and guidelines for performance of trans- raphy: recommendations of the American Society of phy, dyssynchrony, and the response to cardiac esophageal echocardiography in the patient with Echocardiography Committee for Physician Training resynchronization therapy. Eur Heart J 2010;31: pediatric acquired or congenital heart disease: report – in Echocardiography. J Am Soc Echocardiogr 1992;5: 2326 37. from the task force of the Pediatric Council of the 187–94. 28. Douglas PS, Chen J, Gillam L, et al. Achieving American Society of Echocardiography. J Am Soc Quality in Cardiovascular Imaging II: proceedings from 7. Parmley WW. Changing requirements for training in Echocardiogr 2005;18:91–8. — cardiovascular diseases. J Am Coll Cardiol 1993;22: the Second American College of Cardiology Duke Zamorano JL, Badano LP, Bruce C, et al. EAE/ASE 1548. 17. University Medical Center Think Tank on Quality in recommendations for the use of echocardiography in Cardiovascular Imaging. J Am Coll Cardiol Img 2009;2: 8. Popp RL, Winters WL Jr. Clinical competence in new transcatheter interventions for valvular heart 231–40. adult echocardiography: a statement for physicians disease. Eur Heart J 2011;32:2189–214. from the ACP/ACC/AHA Task Force on Clinical Privi- 29. Douglas P, Iskandrian AE, Krumholz HM, et al. leges in Cardiology. J Am Coll Cardiol 1990;15:1465–8. 18. Silvestry FE, Kerber RE, Brook MM, et al. Echo- Achieving quality in cardiovascular imaging: pro- cardiography-guided interventions. J Am Soc Echo- ceedings from the American College of Cardiology– 9. Education and Training Subcommittee of the British cardiogr 2009;22:213–31. Duke University Medical Center Think Tank on Quality Society of Echocardiography. Training in echocardiog- in Cardiovascular Imaging. J Am Coll Cardiol 2006;48: raphy. Br Heart J 1994;71:2–5. 19. Popp R, Agatston A, Armstrong W, et al., Com- 2141–51. mittee on Physician Training and Education of the 10. Eisenberg MJ, Rice S, Schiller NB. Guidelines for American Society of Echocardiography. Recommenda- physician training in advanced cardiac procedures: the tions for training in performance and interpretation of importance of case mix. J Am Coll Cardiol 1994;23: stress echocardiography. J Am Soc Echocardiogr 1998; 1723–5. 11:95–6. KEY WORDS ACC Training Statement, 11. Seward JB, Douglas PS, Erbel R, et al. Hand-carried clinical competence, COCATS, echocardiography, 20. Pellikka PA, Nagueh SF, Elhendy AA, et al. Amer- cardiac ultrasound (HCU) device: recommendations fellowship training, stress echocardiography, ican Society of Echocardiography recommendations for regarding new technology. A report from the Echo- transesophageal echocardiography, performance, interpretation, and application of stress cardiography Task Force on New Technology of the transthoracic echocardiography JACC VOL. 65, NO. 17, 2015 Ryan et al. 1797 MAY 5, 2015:1786– 99 COCATS 4 Task Force 5

APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 5: TRAINING IN ECHOCARDIOGRAPHY

Institutional/ Ownership/ Organizational Speakers Partnership/ Personal or Other Expert Committee Member Employment Consultant Bureau Principal Research Financial Benefit Witness

Thomas Ryan (Chair) Ross Heart Hospital—Director, None None None None None None Heart and Vascular Center; John G. And Jeanne Bonnet McCoy Chair in Cardiovascular Medicine

Kathryn Berlacher University of Pittsburgh School None None None None None None of Medicine, Cardiovascular Fellowship Office—Assistant Professor, Associate Program Director

Jonathan R. Lindner Oregon Health & Science University None None None None None None Division of Cardiology—Associate Chief for Education

Sunil V. Mankad Mayo Clinic—Associate Professor None None None None None None of Medicine

Geoffrey A. Rose Sanger Heart and Vascular None None None None None None Institute/Carolinas Healthcare System—Professor of Medicine, Chief of Cardiology

Andrew Wang Duke University Medical Center None None None None None None Division of Cardiovascular Medicine—Professor of Medicine

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects authors’ employment and reporting categories. To ensure complete transparency, authors’ comprehensive healthcare-related disclosure information—including relationships with industry not pertinent to this document—is available in an online data supplement. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/ relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional information about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology. 1798 Ryan et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 5 MAY 5, 2015:1786– 99

APPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 5: TRAINING IN ECHOCARDIOGRAPHY

Institutional/ Organizational Ownership/ or Other Speakers Partnership/ Personal Financial Expert Name Employment Representation Consultant Bureau Principal Research Benefit Witness

Richard Kovacs Indiana University, Krannert Official Reviewer, None None None None None None Institute of Cardiology—Q.E. ACC Board of Trustees and Sally Russell Professor of Cardiology

Dhanunjaya Kansas University Cardiovascular Official Reviewer, None None None None None None Lakkireddy Research Institute ACC Board of Governors

Howard Weitz Thomas Jefferson University Official Reviewer, None None None None None None Hospital—Director, Division of Competency Management Cardiology; Sidney Kimmel Committee Lead Reviewer Medical College at Thomas Jefferson University— Professor of Medicine

Allan Klein Cleveland Clinic—Professor, Organizational Reviewer, None None None None None None Medicine and Director, ASE Pericardial Center

Sherif Nagueh Methodist DeBakey Heart Organizational Reviewer, None None None None None None and Vascular Center— ASE Professor, Medicine

Kim Williams Rush University Medical Organizational Reviewer, None None None None None None Center—James B. Herrick ASE Professor and Chief, Division of Cardiology

Anna Lisa Duke University Medical Content Reviewer, None None None None None None Crowley Center Cardiology Training and Workforce Committee

Kenneth VCU Medical Center—Director, Content Reviewer, None None None None None None Ellenbogen Clinical Electrophysiology Cardiology Training and Laboratory Workforce Committee

Michael Emery Greenville Health System Content Reviewer, None None None None None None Sports and Exercise Cardiology Section Leadership Council

Brian D. Hoit University Hospitals Case Content Reviewer, None None None None None None Medical Center Cardiology Training and Workforce Committee

Larry Jacobs Lehigh Valley Health Network, Content Reviewer, None None None None None None Division of Cardiology; Cardiology Training and University of South Florida— Workforce Committee Professor, Cardiology

Andrew Kates Washington University Content Reviewer, None None None None None None School of Medicine Academic Cardiology Section Leadership Council

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects peer reviewers’ employment, representation in the review process, as well as reporting categories. Names are listed in alphabetical order within each category of review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional infor- mation about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology; ASE ¼ American Society of Echocardiography; VCU ¼ Virginia Commonwealth University. JACC VOL. 65, NO. 17, 2015 Ryan et al. 1799 MAY 5, 2015:1786– 99 COCATS 4 Task Force 5

APPENDIX 3. ABBREVIATION LIST

ABIM ¼ American Board of Internal Medicine ABMS ¼ American Board of Medical Specialties ACC ¼ American College of Cardiology ACGME ¼ Accreditation Council for Graduate Medical Education ASE ¼ American Society of Echocardiography COCATS ¼ Core Cardiovascular Training Statement HCU ¼ hand-carried ultrasound HIPAA ¼ Health Insurance Portability and Accountability Act TEE ¼ transesophageal echocardiography TTE ¼ transthoracic echocardiography JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL.65,NO.17,2015 ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00 PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacc.2015.03.019

TRAINING STATEMENT COCATS 4 Task Force 6: Training in Nuclear Cardiology

Endorsed by the American Society of Nuclear Cardiology

Vasken Dilsizian, MD, FACC, Chair Todd D. Miller, MD, FACC James A. Arrighi, MD, FACC* Allen J. Solomon, MD, FACC Rose S. Cohen, MD, FACC James E. Udelson, MD, FACC, FASNC

1. INTRODUCTION ACC and ASNC, and addressed their comments. The document was revised and posted for public comment 1.1. Document Development Process from December 20, 2014, to January 6, 2015. Authors 1.1.1. Writing Committee Organization addressed additional comments from the public to complete the document. The final document was The Writing Committee was selected to represent the approved by the Task Force, COCATS Steering Com- American College of Cardiology (ACC) and the Amer- mittee, and ACC Competency Management Commit- ican Society of Nuclear Cardiology (ASNC) and tee; ratified by the ACC Board of Trustees in March, included a cardiovascular training program director; a 2015; and endorsed by the ASNC. This document is nuclear cardiology training program director; early- considered current until the ACC Competency Man- career experts; highly experienced specialists in agement Committee revises or withdraws it. both academic and community-based practice set- tings; and physicians experienced in defining and applying training standards according to the 6 general 1.2. Background and Scope competency domains promulgated by the Accredita- Nuclear cardiology provides important diagnostic and tion Council for Graduate Medical Education (ACGME) prognostic information that is an essential part of the and American Board of Medical Specialties (ABMS), knowledge base required of the well-trained cardiol- and endorsed by the American Board of Internal ogist for optimal management of the cardiovascular Medicine (ABIM). The ACC determined that relation- patient (Table 1). ships with industry or other entities were not relevant The Task Force was charged with updating to the creation of this general cardiovascular training previously published standards for training fellows in statement. Employment and affiliation details for adult nuclear cardiology on the basis of changes in the authors and peer reviewers are provided in field since 2008 and as part of a broader effort to Appendixes 1 and 2, respectively, along with disclo- establish consistent training criteria across all aspects sure reporting categories. Comprehensive disclosure of cardiology. This document does not provide spe- information for all authors, including relationships cific guidelines for training in advanced cardiovascu- with industry and other entities, is available as an lar subspecialty areas but identifies opportunities to online supplement to this document. obtain advanced training where appropriate. The Task Force also updated previously published standards to 1.1.2. Document Development and Approval address the evolving framework of competency-based The Writing Committee developed the document, medical education described by the ACGME Outcomes approved it for review by individuals selected by the Project and the 6 general competencies endorsed by the ACGME and ABMS. The background and over- arching principles governing fellowship training are *American Society of Nuclear Cardiology Representative. provided in the COCATS 4 Introduction, and readers The American College of Cardiology requests that this document be cited should become familiar with this foundation before as follows: Dilsizian V, Arrighi JA, Cohen RS, Miller TD, Solomon AJ, Udelson JE. COCATS 4 task force 6: training in nuclear cardiology. J Am considering the details of training in a subdiscipline Coll Cardiol 2015;65:1800–9. like nuclear cardiology. The Steering Committee and JACC VOL. 65, NO. 17, 2015 Dilsizian et al. 1801 MAY 5, 2015:1800– 9 COCATS 4 Task Force 6

Classification of Nuclear Cardiology Procedures procedures with appropriate additional clinical TABLE 1 and Skills training and experience. n A. Procedures in which competency should be achieved during Level II training Level III training requires additional experience 1. Myocardial perfusion imaging beyond the 3-year cardiovascular fellowship dedicated a. SPECT, with or without attenuation correction b. ECG-gated perfusion images to acquiring specialized knowledge and competencies c. Stress protocols (exercise and pharmacologic) in performing, interpreting, and training others to d. Viability assessment using SPECT and/or PET fi 2. Radionuclide angiography perform speci c procedures or to render advanced, 3. Use of methods for acquisition, reconstruction, and quantitative analysis specialized care at a high level of skill. Level III training of images 4. Appropriate radiation safety and quality improvement programs is described here only in broad terms to provide context 5. Use of radiation monitoring instruments for trainees and clarify that these advanced compe- B. Procedures in which medical knowledge should be demonstrated and tencies are not covered during the cardiovascular achievement of competency may be accomplished during or after fellowship fellowship and require additional training and desig- 1. PET myocardial perfusion imaging 2. Myocardial blood flow quantification nation by an independent certification board, often 3. Cardiac planar imaging coupled with a certifying examination. Level III 4. Hybrid PET/CT and SPECT/CT 5. Myocardial innervation training cannot be obtained during the standard 3-year 6. Myocardial metabolism cardiovascular fellowship and requires additional CT ¼ computed tomography; ECG ¼ electrocardiogram; PET ¼ positron emission exposure in a program that meets requirements that tomography; SPECT ¼ single-photon computed tomography. will be addressed in a subsequent, separately published Advanced Training Statement (formerly in Clinical Task Force recognize that implementation of these Competence Statement). changes in training requirements will occur incrementally over time. It is assumed that training at all levels is directed by For most areas of adult cardiovascular medicine, 3 appropriately trained mentors in an ACGME–accredited levels of training are delineated: program and that satisfactory completion of training is documented by the program director. The number and n Level I training, the basic training required of trainees types of encounters and duration of training required for to become competent consultant cardiologists, is re- trainees are summarized in Section 4. quired of all fellows in cardiology and can be accom- plished as part of a standard 3-year training program in 2. GENERAL STANDARDS cardiology. For nuclear cardiology, Level I training enables trainees to become conversant with the field of Three organizations—the ACC, American Heart Associa- nuclear cardiology for application in general clinical tion, and ASNC—have addressed training requirements management of cardiovascular patients. and guidelines for patient selection, imaging protocols, n Level II training refers to the additional training in 1 or interpretation, correlation with coronary anatomy, follow- more areas that enables some cardiologists to perform up, and prognosis. The recommendations are congruent or interpret specific procedures or render more and address faculty, facility requirements, emerging specialized care for patients and conditions. This level technologies, and clinical practice. We recommend of training is recognized for those areas in which an strongly that candidates for the ABIM examination for accepted instrument or benchmark, such as a quali- certification in cardiovascular diseases who seek compe- fying examination, is available to measure specific tency in nuclear cardiology, as well as those seeking cer- knowledge, skills, or competence. Level II training in tificationandAuthorizedUserstatusfornuclear selected areas may be achieved by some trainees cardiology procedures, review the specific requirements of during the standard 3-year cardiovascular fellowship, the Certification Board of Nuclear Cardiology (CBNC) and depending on the trainees’ career goals and use of Nuclear Regulatory Commission (NRC) (1,2). elective rotations. In the case of nuclear cardiology, Cardiovascular fellowship programs should satisfy the Level II training provides trainees with expertise requirements regarding facilities and faculty for training to practice clinical nuclear cardiology as a sub- in nuclear cardiology as defined in the following text. specialty by providing supervision and interpretation Eligibility for the CBNC examination requires that training of the following: myocardial perfusion single-photon take place in a cardiology, radiology, or nuclear medicine emission computed tomography (SPECT) and/or posi- training program that is accredited by the ACGME. The tron emission tomography (PET); cardiac function intensity of training and required resources vary accord- assessment with gated SPECT and/or PET; and gated ing to the level of training. equilibrium radionuclide angiography. Additionally, To have an adequate understanding of the clinical Level II training will provide the requisite training for applications of nuclear cardiology and to perform clinicians to learn emerging nuclear cardiology tests safely, the cardiovascular trainee must acquire 1802 Dilsizian et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 6 MAY 5, 2015:1800– 9

knowledge and competency in the following areas of 3. TRAINING COMPONENTS general cardiology: 3.1. Didactic Program 1. Coronary angiography and physiology 2. Cardiac physiology and pathophysiology 3.1.1. Lectures, Radiation Safety, Radiopharmacy, and Self-Study 3. Rest and exercise electrocardiography This component consists of lectures on the basic aspects 4. Exercise physiology of nuclear cardiology and parallel self-study material 5. Pharmacology of standard cardiovascular drugs consisting of reading and viewing case files. The material 6. Cardiopulmonary resuscitation and treatment of other presented should integrate the role of nuclear cardiology cardiac emergencies into total patient management. Such information can be 7. Pharmacology and actions of commonly used stress included within the didactic curriculum of the training agents, such as dipyridamole, adenosine, regadenoson, program and should include presentation and discussion and dobutamine of nuclear cardiology image data as it relates to diagnostic 8. Clinical outcomes assessment and therapeutic management. In addition, there should be a didactic program on radiation safety and radio- pharmacy, which should provide the fellow with an un- 2.1. Faculty derstanding of radiation safety as it relates to patient Faculty should include specialists skilled in adminis- selection and risk/benefit assessment of diagnostic tests tering and interpreting stress testing (exercise and that utilize ionizing radiation. pharmacological), performing and interpreting radionu- 3.2. Clinical Experience clide cardiac imaging, and assessing the potential risks of radiation exposure to patients and medical personnel. At least 2 months of the cardiovascular fellowship training Theremustbeaminimumof1facultymemberwhois should be dedicated to nuclear cardiology. Fellows should the Authorized User at the training institution. Clinical actively participate in daily nuclear cardiology study faculty should be certified by CBNC or possess equiva- interpretation (at least 100 cases). Experience in as many lent board qualifications from the American Board of areas as possible from those listed in Table 1 is recom- Nuclear Medicine or American Board of Radiology. A mended. If some procedures are not available or are per- physician is considered to have equivalent qualifications formed in low volume, an adequate background for fi if he or she trained in a similar environment for a similar fellowship training can be satis ed by appropriate reading fi fi duration of time and performed the required number of or review of case les. The teaching le should consist procedures. of perfusion and ventricular function studies with angio- graphic/cardiac catheterization documentation of disease.

2.2. Facilities 3.3. Hands-On Experience Facilities should be adequate to ensure a safe, secure, and 3.3.1. Clinical Cases effective environment for noninvasive radionuclide All fellows should perform complete nuclear cardiology SPECT and/or PET studies. The facilities should maintain studies alongside a qualified technologist or other quali- allRadiationSafety,NRC,andJointCommissionre- fied laboratory personnel. They should, under supervi- quirements. Accreditation of the facility through the sion, observe and participate in a large number of the Intersocietal Commission for the Accreditation of Nuclear standard procedures and as many of the less commonly- Medicine Laboratories or American College of Radiology performed procedures as possible. Fellows should have is strongly encouraged. experience in the practical aspects of radiation safety associated with performing clinical patient studies. 2.3. Equipment 3.3.2. Radiation Safety Nuclear laboratories should be equipped with at least 1 All Level I fellows need to be familiar with radiation SPECT camera. Additional attenuation correction capa- biology and the regulations governing the use of radio- bility, hybrid SPECT/computed tomography (CT), PET, active materials and ionizing radiation for performing and hybrid PET/CT cameras are optional. diagnostic nuclear cardiology and hybrid CT studies. This knowledge includes details for protecting patients, the 2.4. Ancillary Support public, and the user from the effects of radiation. Ancillary support should be available to perform nuclear cardiology procedures, including nuclear technologists, 3.3.3. Additional Training nurses to perform stress testing, a physicist, and a radia- The requirements for Level II training in nuclear cardiol- tion safety officer. ogy are delineated in Section 4. JACC VOL. 65, NO. 17, 2015 Dilsizian et al. 1803 MAY 5, 2015:1800– 9 COCATS 4 Task Force 6

4. SUMMARY OF TRAINING REQUIREMENTS safety and regulations, interpretation of nuclear cardiol- ogy studies, and hands-on experience. 4.1. Development and Evaluation of Core Competencies 4.2.2. Level II Training Requirements Training and requirements in nuclear cardiology address the 6 general competencies promulgated by the ACGME/ Fellows who wish to practice the specialty of nuclear ABMSandendorsedbytheABIM.Thesecompetencydo- cardiology are required to have at least 4 months of mains are: medical knowledge, patient care and proce- training. Level II training includes a minimum of 700 dural skills, practice-based learning and improvement, hours of work experience in nuclear cardiology, inclusive systems-based practice, interpersonal and communica- of radiation safety. This requirement is based in part on tion skills, and professionalism. The ACC has used this NRC regulations. Didactic instruction, clinical study structure to define and depict the components of the core interpretation, and hands-on involvement in clinical clinical competencies for cardiology. The curricular cases are all required. In training programs with a high milestones for each competency and domain also provide volume of procedures, clinical experience may be ac- a developmental roadmap for fellows as they progress quired in as little as 4 months during fellowship. In pro- through various levels of training and serve as an un- grams with a lower volume of procedures, at least 6 derpinning for the ACGME/ABIM reporting milestones. months of clinical experience will be necessary to achieve The ACC has adopted this format for its competency and Level II competency. The additional training required of training statements, career milestones, lifelong learning, Level II trainees is intended to enhance their clinical and educational programs. Additionally, it has developed skills, knowledge, and hands-on experience in radiation tools to assist physicians in assessing, enhancing, and safety and to qualify them to become authorized users of documenting these competencies. radioactive materials in accordance with the regulations Table 2 delineates each of the 6 competency domains, of the NRC and/or the Agreement States. as well as their associated curricular milestones for The various nuclear cardiology procedures are listed in training in nuclear cardiology. The milestones are cate- Table 1. It is recommended that all fellows receive training gorized into Level I, II, and III training (as previously aligned with achieving competency in the procedures defined in this document) and indicate the stage of listed in Section A of this table. For procedures listed in fellowship training (12, 24, or 36 months, and additional Section B, which may not be widely available, fellows time points) by which the typical cardiovascular trainee should receive at minimum didactic instruction and, should achieve the designated level. Given that pro- when available, clinical experience to achieve compe- grams may vary with respect to the sequence of clinical tency. For Level II training in cardiac PET, direct patient experiences provided to trainees, the milestones at experience with at least 40 patient studies of myocardial which various competencies are reached may also vary. perfusion, metabolism, or both, is required. Level II Level I competencies may be achieved at earlier or later training must also provide experience in computer time points. Acquisition of Level II skills requires addi- methods for analysis. This should include perfusion and tional training. The table also describes examples of functional data derived from thallium or technetium evaluation tools suitable for assessing competence in agents and ejection fraction and regional wall motion each domain. measurements from radionuclide angiographic studies. The didactic training required to develop Level II 4.2. Number of Procedures and Duration of Training competence should include in-depth details of all aspects The specific competencies for Levels I and II are delineated of the procedures listed in Table 1.Thisprogrammaybe in Table 2. The minimum duration of training and volume scheduled over a 12- to 24-month period concurrent and of procedures required for each level of training in nuclear integrated with other fellowship assignments. Alterna- cardiology are summarized in Table 3. A brief discussion tively, a fellow may choose to fulfill the advanced pro- of the competencies and training requirements follows. cedures of Table 1 by pursuing an additional year of fellowship dedicated to nuclear cardiology. 4.2.1. Level I Training Requirements Classroom and laboratory training needs to include The trainee is exposed to the fundamentals of nuclear extensive review of radiation physics and instrumenta- cardiology for at least 2 months during training. This tion, radiation protection, mathematics pertaining to the 2-month experience provides familiarity with nuclear use and measurement of radioactivity, chemistry of cardiology technology and its clinical applications in the byproduct material for medical use, radiation biology, generalclinicalpracticeofadultcardiology,butitisnot effects of ionizing radiation, and radiopharmaceuticals in sufficient for the specific practice of nuclear cardiology. order to meet the NRC requirements and qualifications for The 3 components of training include a didactic program becoming an authorized user. There should be a thorough that involves lectures, self-study, instruction in radiation review of regulations dealing with radiation safety for 1804 Dilsizian et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 6 MAY 5, 2015:1800– 9

TABLE 2 Core Competency Components and Curricular Milestones for Training in Nuclear Cardiology

Competency Component Milestones (Months) MEDICAL KNOWLEDGE 12 24 36 Add

1 Know the principles of SPECT and radionuclide ventriculography image acquisition and display, including I the standard tomographic planes and views.

2 Know the properties and use of standard perfusion tracers. I

3 Know the principles of radiation safety and how to minimize radiation exposure. II

4 Know the indications for myocardial perfusion imaging and the appropriate selection of exercise versus I pharmacologic stress testing.

5 Know the principles and use of pretest probability and sequential probability analysis to assess post-test I probability.

6 Know the mechanism of pharmacologic stress agents, methods of their administration, and safety issues in I using the agents.

7 Know the protocols for administration of standard perfusion agents and the influence of the clinical I situation on choice of imaging protocol.

8 Know the quality control issues, how to review raw data, and recognize artifacts. II

9 Know the use of nuclear cardiology in the assessment of ventricular function. I

10 Know the protocols for the use of perfusion imaging to assess myocardial viability. I

11 Know the indications for PET imaging and use of PET tracers. II

EVALUATION TOOLS: direct observation and in-training examination.

PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

1 Skill to select the appropriate imaging study. I

2 Skill to integrate perfusion imaging findings with clinical and other test results in the evaluation and I management of patients.

3 Skill to identify results that indicate a high-risk state. I

4 Skill to perform and interpret gated stress-rest perfusion study. II

5 Skill to perform and interpret a radionuclide ventriculography study. II

6 Skill to perform and interpret hybrid SPECT/CT and PET/CT imaging. III

7 Skill to perform and quantify PET absolute myocardial blood flow and metabolism. III

8 Skill to perform and interpret cardiac innervation, first pass, and planar studies. III

EVALUATION TOOLS: conference presentation, direct observation, and logbook.

SYSTEMS-BASED PRACTICE 12 24 36 Add

1 Work effectively and efficiently with the nuclear laboratory staff. II

2 Incorporate risk/benefit and cost considerations in the use of radionuclide imaging techniques. I

3 Participate in laboratory quality monitoring and initiatives. II

EVALUATION TOOLS: chart-stimulated recall, conference presentation, direct observation, and multisource evaluation.

PRACTICE-BASED LEARNING AND IMPROVEMENT 12 24 36 Add

1 Identify knowledge and performance gaps and engage in opportunities to achieve focused education and I performance improvement.

EVALUATION TOOLS: conference presentation and direct observation. JACC VOL. 65, NO. 17, 2015 Dilsizian et al. 1805 MAY 5, 2015:1800– 9 COCATS 4 Task Force 6

TABLE 2 Core Competency Components, continued

Competency Component Milestones (Months) PROFESSIONALISM 12 24 36 Add

1 Know and promote adherence to guidelines and appropriate use criteria. I

2 Interact respectfully with patients, families, and all members of the healthcare team—including ancillary and support I staff.

EVALUATION TOOLS: chart-stimulated recall, conference presentation, and direct observation.

INTERPERSONAL AND COMMUNICATION SKILLS 12 24 36 Add

1 Communicate effectively and timely with patients, families, and referring physicians. III

2 Communicate test results in a comprehensive and user-friendly manner. II

EVALUATION TOOLS: direct observation and multisource evaluation.

Add ¼ additional months beyond the 3-year cardiovascular fellowship; CT ¼ computed tomography; PET ¼ positron emission tomography; SPECT ¼ single-photon computed tomography. the use of radiopharmaceuticals and ionizing radiation. interpretation and technicalaspectsasassessedbythe This experience should total at least 80 hours and be outcomes evaluation measures, fellows will be eligible for documented separately. This experience may include the CBNC examination. web-based didactics. The CBNC was established jointly by the ACC and It is expected that the foundation of Level II nuclear ASNC and assesses knowledge and mastery in the areas cardiology training, including didactic instruction, radia- of radiation safety and the technical and clinical per- tion safety training, and clinical experience during formance of nuclear cardiology procedures. The CBNC is fellowship, is required to achieve competency after recognized by the NRC as a certification pathway for formal fellowship training for those emerging procedures obtaining authorized user status for administering ra- listed in Table 1. Didactic instruction in those procedures diotracers that are specifictothefield of cardiology. listed in Table 1 should include the topics listed in Table 4. Information concerning the eligibility requirements for Fellows seeking Level II training should participate in the examination can be obtained from the CBNC. Privi- the interpretation of nuclear cardiology imaging data for a leges to interpret nuclear cardiology studies should be minimum of 4 months. It is imperative that the fellows basedmainlyonsatisfactorycompletionofthetraining have experience in correlating catheterization or CT outlined in this document, including demonstration of angiographic data with radionuclide-derived data for a competence and technical expertise. The issues of minimum of 30 patients. A teaching conference in which ongoing clinical competence and training or retraining of the fellow presents the clinical material and nuclear car- practicing cardiologists are beyond the scope of this diology results is an appropriate forum for such experi- document.* ence. A minimum of 300 cases should be interpreted Fellows acquiring Level II training should have hands- under preceptor supervision from direct patient studies. on, supervised imaging experience with a minimum of 30 Upon satisfactory completion of Level II training, which patients: 25 patients with myocardial perfusion imaging includes demonstration of competency in both clinical and 5 patients with radionuclide angiography. Such experience should include pretest patient evaluation; radiopharmaceutical preparation (including experience with relevant radionuclide generators and CT systems); Summary of Training Requirements for Nuclear TABLE 3 performance of studies with and without attenuation Cardiology correction; administration of the dosage, calibration, and Minimum Duration of Training Minimum No. of setup of the gamma camera and CT system; setup of the Level (Months)* Examinations imaging computer; processing the data for display; I 2 100† interpretation of the studies; and generating clinical II 4* 300† reports. *Refer to COCATS 4 Task Force 4 Multimodality Imaging report for guidelines regarding the number of months that may be shared with training in other imaging modalities. †These are approximate cumulative numbers of examinations. At least 30 cases with hands-on experience must be performed and interpreted under supervision, with a greater emphasis on demonstrating competency in both clinical interpretation and *For additional information, contact CBNC at 101 Lakeforest Boulevard, Suite technical aspects as assessed by the outcomes evaluation measures. 401, Gaithersburg, Maryland 20877; http://www.cccvi.org/cbnc/. 1806 Dilsizian et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 6 MAY 5, 2015:1800– 9

Didactic Instruction in Procedures in Which imaging training and requires additional training beyond Medical Knowledge Should be Demonstrated the standard 3-year cardiovascular fellowship. In addition TABLE 4 and Achievement of Level II Competency May Be to the recommended program for Level II, the Level III Accomplished During or After Fellowship program should include advanced quality control of nu- Cardiac PET clear cardiology studies and active participation and re- a. Production and use of positron-emitted radiotracers b. Instrumentation and physics of PET sponsibility in ongoing laboratory or clinical research. In c. Radiation safety and regulatory requirements unique to PET parallelwithparticipationinaresearchprogram,the d. Range of PET cardiac studies (e.g., myocardial perfusion, metabolism, innervation) trainee should participate in clinical imaging activities;

Hybrid SPECT/CT and PET/CT some of these experiences may involve concurrent a. Use for attenuation correction training in other imaging modalities as defined in the b. Coronary calcium scoring c. Combined anatomic/physiologic imaging guidelines for the COCATS 4 Task Force 4 Multimodality Imaging report. Fellows pursuing Level III training should Myocardial Innervation a. I-123 MIBG imaging already be eligible for the CBNC on the basis of their prior Level II training. Level III training should include both Abbreviations as in Table 1. hands-on experience and supervised interpretative Level II trainees must acquire 620 hours of work experience greater than that required for Level II training. experience inclusive of radiation safety (in addition to the Additional training in nuclear cardiology may include 80 hours of classroom and laboratory experience) during quantification of absolute myocardial blood flow, assess- training in the clinical environment where radioactive ment of coronary artery disease and myocardial perfusion materials are being used. This training should take place using hybrid PET/CT and/or SPECT/CT protocols, patient under the supervision of an authorized user who preparation and imaging protocols for planar imaging, meets the NRC requirements of Part 35.290 or Part first-pass radionuclide angiography, myocardial meta- 35.290(c)(ii)(G) and Part 35.390 or the equivalent Agree- bolism, and innervation. ment State requirements and must include the following: 4.2.4. Training in Multiple Imaging Modalities a. Ordering, receiving, and unpacking radioactive mate- The recent emergence of other noninvasive imaging mo- rials safely and performing the related radiation dalities, especially cardiovascular magnetic resonance surveys. andCTangiography,ishavingaprofoundimpactonthe b. Performing quality control procedures on instruments practice of cardiology and the fellowship training expe- used to determine the activity of dosages as well as rience. The cardiovascular medicine specialist is increas- performing checks for proper operation of survey ingly expected to provide expertise in 2 or more of the meters. imaging techniques. It is understandable that trainees c. Calculating, measuring, and safely preparing patient or will desire the opportunity togainexposuretomultiple human research subject dosages. imaging modalities during their fellowship experience. To d. Using administrative controls to prevent a medical the degree possible, the training program should strive to event that involves the use of unsealed byproduct meet these needs by offering a “multimodality” imaging material. experience (see COCATS 4 Task Force 4 Multimodality e. Using procedures to safely contain spilled radioac- Imaging report). This might include an appreciation for tive material and using proper decontamination each technique’s uses and clinical indications, strengths procedures. and limitations, safety issues, and relevant guidelines and f. Administering dosages of radioactive material to pa- appropriateness criteria, when available. tients or human research subjects. g. Eluting generator systems appropriate for preparation 5. EVALUATION OF COMPETENCY of radioactive drugs for imaging and localization studies; measuring and testing the eluate for radionu- Evaluation tools in nuclear cardiology include direct clide purity; and processing the eluate with reagent observation by instructors, in-training examinations, case kits to prepare labeled radioactive drugs. logbooks, conference and case presentations, multisource evaluations, trainee portfolios, and simulation. Acquisi- 4.2.3. Level III Training Requirements tion and interpretive skills should be evaluated in every For fellows planning an academic career in nuclear car- trainee. Interaction with other physicians, patients, and diology or a career directing a clinical nuclear cardiology laboratory support staff; initiative; reliability; decisions laboratory, an extended program is required. More or actions that result in clinical error; and the ability to advanced competency (Level III) in nuclear cardiology is make appropriate decisions independently and follow-up generally obtained within the context of multimodality appropriately should be considered in these assessments. JACC VOL. 65, NO. 17, 2015 Dilsizian et al. 1807 MAY 5, 2015:1800– 9 COCATS 4 Task Force 6

Trainees should maintain records of participation and studies. Finally, experiences in nuclear cardiology should advancement in the form of a Health Insurance Portability be assessed against measures of quality with regard to and Accountability Act (HIPAA)–compliant electronic test selection, performance, interpretation, and reporting database or logbook that meets ACGME reporting stan- in the interest of appreciating the potential adverse con- dards and summarizes pertinent clinical information sequences of suboptimal testing (3–5). (e.g., number of cases, diversity of referral sources, Under the aegis of the program director and director of testing modalities, diagnoses, and findings). The use of each imaging laboratory, facility, or program, the faculty nuclear cardiology should be aligned with clinical need should record and verify each trainee’s experiences, and appropriate use criteria. Trainees should be prepared assess performance, and document satisfactory achieve- to explain why a given nuclear cardiology test is better ment. The program director is responsible for confirming suited to the clinical question than another imaging op- experience and competence and reviewing the overall tion. Fellows should document clinical correlation with progress of individual trainees with the Clinical Compe- the other imaging, hemodynamic, invasive laboratory, tency Committee to ensure achievement of selected surgical pathology, and outcomes data to enhance un- training milestones and identify areas in which additional derstanding of the diagnostic utility and value of various focused training may be required.

REFERENCES

1. Certification Board of Nuclear Cardiology. Certifica- 4. Hendel RC, Berman DS, Di Carli MF, et al. ACCF/ 5. Tilkemeier PL, Cooke CD, Ficaro EP, Glover DK, tion Board of Nuclear Cardiology certification re- ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appro- Hansen CL, McCallister BD Jr. American Society of quirements. Available at: http://www.cccvi.org/cbnc. priate use criteria for cardiac radionuclide imaging: a Nuclear Cardiology information statement: stan- Accessed September 26, 2014. report of the American College of Cardiology Foun- dardized reporting matrix for radionuclide myocar- dation Appropriate Use Criteria Task Force, the Amer- dial perfusion imaging. J Nucl Cardiol 2006;13: 2. U.S. Nuclear Regulatory Commission. x35.290 ican Society of Nuclear Cardiology, the American e157–71. Training for imaging and localization studies. Available College of Radiology, the American Heart Association, at: http://www.nrc.gov/reading-rm/doc-collections/ the American Society of Echocardiography, the Society cfr/part035/part035-0290.html. Accessed September of Cardiovascular Computed Tomography, the Society 26, 2014. for Cardiovascular Magnetic Resonance, and the Soci- KEY WORDS ACC Training Statement, 3. DePuey EG, Mahmarian JJ, Miller TD, et al. Patient- ety of Nuclear Medicine. J Am Coll Cardiol 2009;53: cardiovascular imaging, clinical competence, centered imaging. J Nucl Cardiol 2012;19:185–215. 2201–29. COCATS, fellowship training, nuclear cardiology

APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 6: TRAINING IN NUCLEAR CARDIOLOGY

Institutional/ Organizational Ownership/ or Other Speakers Partnership/ Personal Financial Expert Committee Member Employment Consultant Bureau Principal Research Benefit Witness

Vasken Dilsizian (Chair) University of Maryland School of Medicine—Professor None None None None None None of Medicine and Radiology; Director, Division of Nuclear Medicine

James A. Arrighi Rhode Island Hospital, Brown University—Program None None None None None None Director, Cardiology Fellowship and Associate Professor of Medicine

Rose S. Cohen Contra Costa Regional Medical Center, None None None None None None Department of Cardiology—Physician Advisor

Todd D. Miller Mayo Clinic—Professor of Medicine None None None None None None

Allen J. Solomon The George Washington University, None None None None None None Division of Cardiology—Associate Professor of Medicine

James E. Udelson Tufts Medical Center—Chief, None None None None None None Division of Cardiology

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects authors’ employment and reporting categories. To ensure complete transparency, authors’ comprehensive healthcare-related disclosure information—including relationships with industry not pertinent to this document—is available in an online data supplement. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/ relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional information about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology. 1808 Dilsizian et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 6 MAY 5, 2015:1800– 9

APPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 6: TRAINING IN NUCLEAR CARDIOLOGY

Institutional/ Organizational Ownership/ or Other Speakers Partnership/ Personal Financial Expert Name Employment Representation Consultant Bureau Principal Research Benefit Witness

Richard Kovacs Indiana University, Krannert Official Reviewer, ACC None None None None None None Institute of Cardiology— Board of Trustees Q.E. and Sally Russell Professor of Cardiology

Dhanunjaya Kansas University Official Reviewer, ACC None None None None None None Lakkireddy Cardiovascular Research Board of Governors Institute

Howard Weitz Thomas Jefferson University Official Reviewer, None None None None None None Hospital—Director, Competency Division of Cardiology; Management Committee Sidney Kimmel Medical Lead Reviewer College at Thomas Jefferson University—Professor of Medicine

Dennis Calnon OhioHealth Heart and Organizational Reviewer, None None None None None None Vascular Physicians—Director, American Society of Cardiac Imaging; Riverside Nuclear Cardiology Methodist Hospital

Kenneth VCU Medical Center—Director, Content Reviewer, None None None None None None Ellenbogen Clinical Electrophysiology Cardiology Training Laboratory and Workforce Committee

Brian D. Hoit University Hospitals Case Content Reviewer, None None None None None None Medical Center Cardiology Training and Workforce Committee

Larry Jacobs Lehigh Valley Health Network, Content Reviewer, None None None None None None Division of Cardiology; Cardiology Training University of South and Workforce Florida—Professor, Committee Cardiology

Andrew Kates Washington University Content Reviewer, None None None None None None School of Medicine Academic Cardiology Section Leadership Council

Nishant Shah Brigham and Women’s Content Reviewer, None None None None None None Hospital, Harvard Medical Imaging Council School—Cardiovascular Imaging Fellow

Prem Soman University of Pittsburgh Content Reviewer, None None None None None None Medical Center—Director, Cardiovascular Imaging Nuclear Cardiology and Summit Steering Associate Professor, Committee Medicine

Kim Williams Rush University Medical Content Reviewer, None None None None None None Center—James B. Herrick Cardiology Training Professor and Chief, and Workforce Division of Cardiology Committee

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects peer reviewers’ employment, representation in the review process, as well as reporting categories. Names are listed in alphabetical order within each category of review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional infor- mation about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology; VCU ¼ Virginia Commonwealth University. JACC VOL. 65, NO. 17, 2015 Dilsizian et al. 1809 MAY 5, 2015:1800– 9 COCATS 4 Task Force 6

APPENDIX 3. ABBREVIATION LIST

ABIM ¼ American Board of Internal Medicine ABMS ¼ American Board of Medical Specialties ACC ¼ American College of Cardiology ACGME ¼ Accreditation Council for Graduate Medical Education ASNC ¼ American Society of Nuclear Cardiology CBNC ¼ Certification Board of Nuclear Cardiology COCATS ¼ Core Cardiovascular Training Statement CT ¼ computed tomography HIPAA ¼ Health Insurance Portability and Accountability Act NRC ¼ Nuclear Regulatory Commission PET ¼ positron emission tomography SPECT ¼ single-photon emission computed tomography JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL.65,NO.17,2015 ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00 PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacc.2015.03.028

TRAINING STATEMENT COCATS 4 Task Force 7: Training in Cardiovascular Computed Tomographic Imaging

Endorsed by the American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Atherosclerosis Imaging and Prevention, and the Society of Cardiovascular Computed Tomography

Mario J. Garcia, MD, FACC, Chair John R. Lesser, MD, FACC Ron Blankstein, MD, FACC Maleah Grover-McKay, MD, FACC, FASNC Matthew J. Budoff, MD, FACC, FSCAI* Jeffrey M. Schussler, MD, FACC, FSCAIy John M. Dent, MD, FACC Szilard Voros, MD, FACCz Douglas E. Drachman, MD, FACC L. Samuel Wann, MD, MACC, FASNCx

1. INTRODUCTION Board of Medical Specialties (ABMS), and endorsed by the American Board of Internal Medicine (ABIM). The 1.1. Document Development Process ACC determined that relationships with industry or 1.1.1. Writing Committee Organization other entities were not relevant to the creation of this general cardiovascular training statement. Employ- The Writing Committee was selected to represent ment and affiliation details for authors and peer re- the American College of Cardiology (ACC), American viewers are provided in Appendixes 1 and 2, Society of Nuclear Cardiology (ASNC), Society for respectively, along with disclosure reporting cate- Cardiovascular Angiography and Interventions (SCAI), gories. Comprehensive disclosure information for all Society of Atherosclerosis Imaging and Prevention authors, including relationships with industry and (SAIP), and Society of Cardiovascular Computed other entities, is available as an online supplement to Tomography (SCCT), and included a cardiovascular this document. training program director, a cardiovascular com- puted tomography (CCT) training program director, 1.1.2. Document Development and Approval an advanced-multimodality cardiovascular imaging training program director, an early-career cardiologist, The writing committee developed the document; highly experienced specialists practicing in both approved it for review by individuals selected by the academic and community-based settings, and physi- ACC, ASNC, SAIP, SCAI, and SCCT; and addressed the ’ cians experienced in defining and applying training reviewers comments. The document was revised and standards according to the 6 general competency do- posted for public comment from December 20, 2014, mains promulgated by the Accreditation Council for to January 6, 2015. Authors addressed additional Graduate Medical Education (ACGME) and American comments from the public to complete the document. The final document was approved by the Task Force, COCATS SC, and ACC Competency Management Committee. It was then ratified by the ACC Board of *Society of Cardiovascular Computed Tomography Representative. Trustees in March, 2015, and endorsed by ASNC, SAIP, y Society for Cardiovascular Angiography and Interventions SCAI, and SCCT. This document is considered current Representative. zSociety of Atherosclerosis Imaging and Prevention Representative. until the ACC Competency Management Committee xAmerican Society of Nuclear Cardiology Representative. revisesorwithdrawsit. The American College of Cardiology requests that this document be cited as follows: Garcia MJ, Blankstein R, Budoff MJ, Dent JM, Drachman DE, 1.2. Background and Scope Lesser JR, Grover-McKay M, Schussler JM, Voros S, Wann LS. COCATS 4 task force 7: training in cardiovascular computed tomographic imaging. CCT is a rapidly evolving technique for assessing J Am Coll Cardiol 2015;65:1810–21. cardiovascular anatomy. The anatomic detail, JACC VOL. 65, NO. 17, 2015 Garcia et al. 1811 MAY 5, 2015:1810– 21 COCATS 4 Task Force 7

complex imaging devices, protocols, and evolving clinical technology in a rapid phase of development and improve- applications of this modality require that all cardiovas- ment, with an expanding list of clinical indications. cular trainees receive training in CCT imaging during The Task Force was charged with updating previously- fellowship. Clinical application of CCT encompasses published standards for training fellows in clinical cardi- noncontrast (coronary calcium evaluation), contrast (CCT ology enrolled in ACGME–accredited fellowship programs angiography and function), and hybrid studies (2) on the basis of : 1) changes in the field since 2008; and (combining nuclear cardiology techniques with CCT). 2) the evolving framework of competency-based medical Computed tomography, like catheterization, provides education described by the ACGME Outcomes Project and anatomic and functional information (e.g., coronary the 6 general competencies endorsed by ACGME and anatomy and left ventricular ejection fraction, respec- ABMS. The updating effort was also convened as part of a tively). Hybrid devices incorporate high-speed multi- broader effort to establish consistent training criteria detector computed tomography (MDCT) technology, across all aspects of cardiology. The background and positron emission tomography (PET), and single-photon overarching principles governing fellowship training are emission computed tomography (SPECT) detector sys- provided in the COCATS 4 Introduction, and readers tems. Current hybrid systems (MDCT plus nuclear) should become familiar with this foundation before provide attenuation correction for SPECT and PET, considering the details of training in a subdiscipline like further improving the diagnostic accuracy of traditional CCT. The Steering Committee and Task Force recognize radionuclide techniques. that implementation of these changes in training re- This training statement has been designed for fellows- quirements will occur incrementally over time. in-training and is not intended for physicians already in For most areas of cardiovascular imaging, 3 levels of practice (1). Fellows-in-training are expected to gain training are delineated: exposure to CCT during their fellowship years and combine this experience with knowledgeofechocardiography,nu- n Level I training defines the fundamental level of clear cardiology, cardiovascular magnetic resonance, and experience required of all fellows-in-training in order cardiac catheterization, as appropriate. All fellows should to be considered competent to practice cardiology be exposed to the fundamental aspects of CCT, but only independently. Level I training should be accomplished those who achieve levels of experience beyond Level I will during every standard 3-year training program in be sufficiently qualified to interpret CCT scans indepen- cardiology. This entails understanding the basic prin- dently. At the conclusion of training, all fellows should be ciples, indications, applications, and technical limita- familiar with CCT assessment of cardiovascular anatomy, tions of CCT, as well as the inter-relationship between physiology, and pathophysiology and know the clinical CCT and other diagnostic methods. Level I training application of CCT and the principles of CCT physics and does not qualify a trainee to perform or interpret CCT radiation generation and exposure. Because many CCT studies independently. studies require the administration of intravenous iodin- n Level II training refers to the additional training in 1 or ated contrast, fellows should be familiar with the protocols more areas that enables a cardiologist to perform or for contrast administration and subsequent contrast ki- interpret specific procedures or render more specialized netics, as well as the potential adverse events resulting care for patients and conditions. This level of training is from contrast exposure and appropriate treatment. In recognized for those areas in which an accepted instru- particular, fellows should be able to define the methods for ment or benchmark, such as a qualifying examination, is contrast-enhanced CCT imaging of the pericardium, right available to measure specific knowledge, skills, or and left heart chambers, and the great vessels. Given the competence. Level II training in selected areas may be potential hazards of exposure to medical radiation, achieved by some trainees during the standard 3-year trainees should become familiar with appropriate patient cardiovascular fellowship, depending on the trainees’ selection, dose reduction techniques, and the principle of career goals and use of elective rotations. It is antici- maintaining radiation exposure at the lowest level pated that during a standard 3-year cardiovascular reasonably achievable. fellowship training program, sufficient time will be Every cardiovascular fellow should develop familiarity available for the trainee to receive Level II training in a with the technical performance, interpretation, strengths, specific subspecialty. In the case of CCT, Level II is and limitations of CCT and its multiple clinical applica- defined as the minimum level of experience required to tions. In addition, every cardiovascular fellow should gain perform and interpret CCT independently. an understanding of how to effectively use the information n Level III training in CCT, as in other noninvasive provided by CCT, together with other clinical and imaging imaging modalities, should include the principles of tests (when available), in making patient management multimodality imaging (see COCATS 4 Task Force 4 decisions. It is recognized that CCT is an evolving report). This requires additional training and experience 1812 Garcia et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 7 MAY 5, 2015:1810– 21

beyond the cardiovascular fellowship to allow the qualifications. A physician is considered to have equiva- trainee to acquire specialized knowledge and experi- lent qualifications if he or she trained in a similar envi- ence in performing, interpreting, and training others to ronment for a similar duration of time, supervised the perform specificproceduresorrenderadvanced required number of studies, and performed both super- specialized care at a high level of skill. In the case of CCT, vised and independent interpretations. Faculty must Level III expertise would enable the trainee to direct a participate with trainees in imaging acquisition, process- CCT laboratory, train others in CCT, and conduct ing, and interpretation. advanced imaging research. Level III training is described here only in broad terms to provide context for 2.2. Facilities trainees. The additional exposure and requirements for Facilities must be adequate to ensure a safe and effective Level III training will be addressed in a subsequent, environment for conducting diagnostic CCT studies and separately published Advanced Training Statement. providing didactic instruction to fellows-in-training. Appropriate infrastructure, personnel, and equipment The number of cases, procedures, and experiences should be available to enable image processing, inter- recommended is based on published guidelines, compe- pretation, and didactic interactions between faculty and tency statements, and the opinions of the members of the trainees. writing group. It is assumed that training is directed by The CCT laboratory in which training is undertaken appropriately trained mentors in an ACGME–accredited should be under the direct supervision of a full-time program and that satisfactory completion of training is qualified director (or directors) with Level III training or documented by the program director. The number and equivalent. The training guidelines set forth in this types of encounters and the duration of training typically document pertain primarily to trainees performing CCT required are summarized in Section 4. examinations in adult patients with acquired or congen- 2. GENERAL STANDARDS ital heart disease.

Three organizations—the ACC, AmericanHeartAssocia- 2.3. Equipment tion, and SCCT—have addressed training requirements CCT laboratories require specialized equipment for the and guidelines for patient selection (1,3);clinicalin- safe performance and interpretation of diagnostic studies. dications (4,5); study performance, interpretation, and This equipment includes a multislice CCT scanner with a reporting (6,7); and educational objectives (2) for fellow- minimum of 64-slice and electrocardiographic-gating ca- ship training in CCT. The recommendations are congruent pabilities; specialized equipment for contrast adminis- and address faculty, facility requirements, emerging tration and patient monitoring; and computer network technologies, and practice. Cardiovascular fellowship infrastructure for data storage, transmission, processing, programs should satisfy the requirements regarding fa- study interpretation, and reporting (8). cilities and faculty for training in CCT. Candidates for the ABIM examination for certification in cardiovascular dis- 2.4. Ancillary Support eases should review the specificABIMrequirements,and Ancillary support should be available to obtain intrave- those seeking certification in CCT should review the nous access, administer intravenous medications, specific requirements of the Certification Board of monitor patients after procedures, and treat potential Cardiovascular Computed Tomography (8). complications, including performance of emergency car- To be eligible to sit for the CBCCT examination, U.S.- diopulmonary resuscitation. trained cardiovascular fellows must have undergone 3. TRAINING COMPONENTS training in a program accredited by the ACGME (8) and have met Level II training requirements. The intensity and depth of training and required resources may vary 3.1. Didactic Program according to the level of training provided. The educational curriculum in CCT should include di- dactic lectures, reference reading material, case discus- 2.1. Faculty sions,andformalcasepresentations.Thecurriculum Faculty should include cardiovascular imaging specialists should supplement the hands-on and clinical case inter- who are knowledgeable about the risks to the patient as pretation experiences to ensure that the medical knowl- well as medical personnel associated with radiation edge milestones detailed in Section 4.1 are met. exposure and skilled in performing and interpreting Consequently, knowledge pertaining to CCT should be CCT studies. The program must have at least 2 key clinical acquired in the following areas: epidemiology, CCT CCT faculty members, including the program director, who physics, image processing, pathophysiology, and man- are board-certified in CCT or possess equivalent agement of coronary artery disease. In addition, didactic JACC VOL. 65, NO. 17, 2015 Garcia et al. 1813 MAY 5, 2015:1810– 21 COCATS 4 Task Force 7

sessions should include discussions of the diagnostic ac- should learn to recognize appropriate image quality and curacy of CCT, including sensitivity and specificity, when understand the source of—and recognize techniques for compared with the reference standard of invasive angi- avoiding—artifacts (e.g., breath-holding, gating, and ography or myocardial perfusion imaging, as well as arrhythmias). knowledge of the advantages and disadvantages of CCT 4. SUMMARY OF TRAINING REQUIREMENTS compared with other cardiovascular imaging modalities. Didactic teaching should address appropriate utilization of CCT and integration of the CCT results with other data 4.1. Development and Evaluation of Core Competencies to enhance patient management. Training and requirements for CCT address the 6 general Each fellow should receive documented training from a competencies promulgated by the ACGME/ABMS and CCT mentor and/or physicist in the basic physics of endorsed by the ABIM. These competency domains are: computed tomography in general and CCT in particular. medicalknowledge,patientcare and procedural skills, Lectures should include training in principles of radiation practice-based learning and improvement, systems-based protection, hazards of radiation exposure to both patients practice, interpersonal and communication skills, and and personnel, and techniques for reporting and professionalism. The ACC has used this structure to define measuring radiation doses. The CCT mentor should also and depict the components of the core clinical compe- discuss cardiac and great-vessel anatomy, contrast tencies for cardiology. The curricular milestones for each administration and kinetics, principles of 3-dimensional competency and domain also provide a developmental imaging and postprocessing, and appropriate post- roadmap for fellows as they progress through various procedural patient monitoring. levels of training and serve as an underpinning for the ACGME/ABIM reporting milestones. The ACC has adopted 3.2. Clinical Experience this format for its competency and training statements, Interpretation of a designated minimum number of CCT career milestones, lifelong learning, and educational studies will typically be required to approach Level I programs. Additionally, it has developed tools to assist competency (see Section 4.2). In addition, for a certain physicians in assessing, enhancing, and documenting number of cases, the trainee should be present and these competencies. participate in image acquisition. For these cases, the Table 1 delineates each of the 6 competency domains, following 3 conditions must be met: as well as their associated curricular milestones for training in CCT. The milestones are categorized into 1. The trainee must be present in the scanning control Levels I and II (as previously defined in this document) room. and indicate the stage of fellowship training (12, 24, or 36 2. For Level I or II training, the fellow must participate months, and additional time points) by which the typical interactively in manipulation of the processed images cardiovascular trainee should achieve the designated for evaluation of the study. Interpretation of each case level. Given that programs may vary with respect to the should include all components of cardiac structure and sequence of clinical experiences provided to trainees, the function (when available), as well as noncardiac milestones at which various competencies are reached structures. may also vary. Level I competencies may be achieved at 3. During this image evaluation process, there must be an earlier or later time points. Acquisition of Level II skills opportunity for interaction between the trainee and requires additional training, and acquisition of Level III the trainer. skills requires training in a dedicated CCT program. The The CCT program should expose trainees to a wide table also describes examples of evaluation tools suitable array of CCT indications and imaging protocols and to a for assessing competence in each domain. varied patient population, including patients with com- plex congenital heart disease. It is important to empha- 4.2. Number of Procedures and Duration of Training size that merely completing a certain number of studies The specific competencies for Levels I and II are delin- does not equate to competency, which instead must be eated in Table 1. The minimum volume of procedures assessed individually by supervising faculty. typically required to achieve competence at each level of training in CCT is summarized in Table 2. 3.3. Hands-On Experience Although approximate numbers of procedures are lis- Hands-on training is important, not only to develop ted, it is more important to assess achievement by eval- technical expertise regarding image acquisition and uation of outcome measures. Requirements for Level II interpretation, but also as a valuable aid to learning training may be satisfied, for example, by supervised tomographic and 3-dimensional cardiac anatomy. time, courses, case studies, CD/DVD training, participa- Through acquisition and interpretation of data, trainees tion in major medical meetings devoted to CCT, or other 1814 Garcia et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 7 MAY 5, 2015:1810– 21

TABLE 1 Core Competency Components and Curricular Milestones for Training in Cardiovascular Computed Tomography

Competency Component Milestones (Months) MEDICAL KNOWLEDGE 12 24 36 Add

1 Know the principles of cardiovascular computed tomographic scanning and the scanning modes. I

2 Know the risks and safety measures for cardiovascular computed tomographic scanning, including radiation I reduction strategies.

3 Know the appropriate indications for cardiovascular computed tomography for screening or evaluating I symptoms in patients with suspected cardiac disease.

4 Know the indications, potential adverse effects, prevention, and treatment of complications of iodinated I contrast agent use in cardiovascular computed tomographic studies.

5 Know the indications and protocols for beta-adrenergic blocking drugs and nitroglycerin during II cardiovascular computed tomographic studies.

6 Know the principles of cardiovascular computed tomographic scan collimation, temporal resolution, table II speed, field of view, and window and level view settings.

7 Know the principles of postprocessing methods for cardiovascular computed tomographic scanning. II

8 Know the algorithms used for reconstruction, and recognize and isolate causes of artifacts. II

9 Know the principles of quantitative coronary artery calcium scoring. II

10 Know normal chest anatomy and common incidental extra cardiac findings. II

11 Know the characteristic cardiovascular computed tomographic images of normal cardiac chambers and I great vessels, normal coronary arteries and veins, and normal variants.

12 Know the characteristic cardiovascular computed tomographic findings of coronary atherosclerosis II including plaque morphology and assessment of stenosis severity.

13 Know the characteristic cardiovascular computed tomographic findings of anomalous coronary arteries and II other common congenital anomalies.

14 Know the characteristic cardiovascular computed tomographic findings in postoperative cardiac surgical II patients including internal mammary artery and saphenous vein bypass grafts.

15 Know the characteristic cardiovascular computed tomographic findings of acquired and congenital valvular II disease.

16 Know the characteristic cardiovascular computed tomographic findings of left atrial and pulmonary and II coronary venous abnormalities.

17 Know the characteristic cardiovascular computed tomographic findings of pericardial disease. II

18 Know the characteristic cardiovascular computed tomographic findings of cardiomyopathies and infiltrative II myocardial diseases.

19 Know the differential diagnosis of cardiac masses identified by cardiovascular computed tomography. II

20 Know the characteristic cardiovascular computed tomographic findings of common diseases of the aorta II and great vessels.

21 Know the characteristic cardiovascular computed tomographic findings of pulmonary embolism and II primary and acquired pulmonary vascular diseases.

22 Know when to request help with interpretation of difficult studies, such as patients with complex I congenital heart disease.

EVALUATION TOOLS: conference presentation, direct observation, and in-training examination.

PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

1 Skill to appropriately utilize cardiovascular computed tomography in the evaluation and management of I patients with known or suspected cardiovascular disease.

2 Skill to integrate cardiovascular computed tomographic findings with other clinical information in patient I evaluation and management.

3 Skill to recognize and treat contrast-related adverse reactions. I

4 Skill to independently perform and interpret cardiovascular computed tomography. II

5 Skill to perform and interpret hybrid CT/SPECT and CT/PET imaging. III

EVALUATION TOOLS: conference presentation, direct observation, and logbook. JACC VOL. 65, NO. 17, 2015 Garcia et al. 1815 MAY 5, 2015:1810– 21 COCATS 4 Task Force 7

TABLE 1 Core Competency Components, continued

Competency Component Milestones (Months) SYSTEMS-BASED PRACTICE 12 24 36 Add

1 Incorporate appropriate use criteria, risk/benefit, and cost considerations in the use of cardiovascular I computed tomography and alternative imaging modalities.

EVALUATION TOOLS: conference presentation, direct observation, and multisource evaluation.

PRACTICE-BASED LEARNING AND IMPROVEMENT 12 24 36 Add

1 Identify knowledge and performance gaps and engage in opportunities to achieve focused education I and performance improvement.

2 Utilize point-of-care educational resources (e.g., guidelines, appropriate use criteria, and clinical trial I results).

EVALUATION TOOLS: conference presentation, direct observation, and reflection and self-assessment.

PROFESSIONALISM 12 24 36 Add

1 Work effectively in an interdisciplinary cardiovascular computed tomographic imaging environment. I

2 Reliably obtain patient informed consent, ensuring that patients understand the risks and benefits of, I and alternatives to, cardiovascular computed tomographic testing.

3 Know and promote adherence to clinical practice guidelines. I

EVALUATION TOOLS: conference presentation, direct observation, and multisource evaluation.

INTERPERSONAL AND COMMUNICATION SKILLS 12 24 36 Add

1 Communicate testing results to physicians and patients in an effective and timely manner. I

EVALUATION TOOLS: direct observation and multisource evaluation.

Add ¼ additional months beyond the 3-year cardiovascular fellowship; CT ¼ computed tomography; PET ¼ positron emission tomography; SPECT ¼ single-photon emission computed tomography.

relevant educational training activities. The caseload For all levels of competence, the trainee should attend lec- recommendations may include studies from an estab- tures on the basic concepts of CCT and, in parallel, utilize self- lished teaching file, previous CCT cases, and electronic/ study reading material. A basic understanding of CCT includes online learning tools or courses. the physics of CCT imaging; basics of CCT scan acquisition; safety issues; recognition and management of side effects of 4.2.1. Level I Training Requirements medications administered in the course of CCT, including Level I training is the minimal introductory experience betablockers and nitrates in addition to iodinated contrast; necessary to gain familiarity with CCT but does not postprocessing methods; and basics of CCT interpretation provide sufficient competence for independent inter- compared with other cardiovascular imaging modalities, pretation of CCT images. The trainee should obtain including echocardiography, nuclear cardiology, cardiovascu- intensive exposure to the methodology and multiple lar magnetic resonance, and invasive cardiovascular x-ray applications of CCT for approximately 1 month. This angiography. Ancillary cardiac diagnostic studies should exposure may occur in conjunction with other training evaluate ventricular hypertrophy; dilation; valvular pathology activities. During this cumulative experience, individuals such as mitral stenosis/annular and leaflet calcification; cardiac should be actively involved in CCT interpretation under masses; aortic valve pathology (number of cusps, calcification, the direction of a qualified (at minimum Level II–,but and stenosis); pericardial and infiltrative myocardial diseases; preferably Level III–trained) physician-mentor (1).There internal mammary arteries; left atrial, pulmonary, and coro- should be a mentored interpretative experience of at nary venous abnormalities; thoracic aortic pathology; and least 50 studies for which other correlative cardiovas- saphenous vein grafts. cular imaging data are also available. The mentored interpretive experience may include studies from an 4.2.2. Level II Training Requirements established teaching file of CCT cases, CD/DVD, and on- Level II training is defined as the minimum experience line training. necessary for a physician to independently perform and 1816 Garcia et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 7 MAY 5, 2015:1810– 21

Requirements for CCT Study Performance and A fellow with Level II training should demonstrate a TABLE 2 Interpretation to Achieve Level I and II clear understanding of the various types of CCT scanners Clinical Competence available for cardiovascular imaging and understand, at a

Minimum Number of Minimum Number of minimum, common issues related to imaging, post- Mentored Examinations Mentored Examinations processing, and scan interpretation. Present During Performance Interpreted

Level I 15 50 4.2.2.1. Incidental Noncardiac Findings Level II 65 250 CCT cases* During a CCT examination, the standard use of a small *Cumulative numbers; caseload recommendations may include studies from an estab- field of view (e.g., limited lung fields) precludes complete lished teaching file, previous CCT cases, journals and/or textbooks, and electronic/on- line courses/continuing medical education. evaluation of the entire thorax. To address the possibility CCT ¼ cardiovascular computed tomography. that significant noncardiac imaging findings,(e.g.,aortic disease, hilar adenopathy, large pulmonary nodules, pulmonary emboli) might be present on a CCT scan, spe- interpret CCT. To accomplish this, the fellow should cific interpretation of the extracardiac fields should be devote an additional 1 month or equivalent and interpret performed as discussed below. The patient, referring a minimum of 200 additional contrast studies. Non- physician, and trainee should understand that the focus contrast and contrast-enhanced studies may be evaluated of the CCT examination is the detection of cardiac dis- in the same patients. Of these, at least 65 should be per- ease, and that the scan does not encompass the entire formed with the fellow present under appropriate super- lung field. Fellows should be trained to recognize inci- vision. Competence at this level implies that the fellow is dental findings in the interest of providing high-quality sufficiently experienced to help acquire, if necessary, and care. Cases in which these extracardiac findings are interpret the CCT examination accurately and indepen- identified require referral to a specialist with expertise dently. Continued exposure to special CCT procedures, in chest imaging. To this end, Level II and III training such as hybrid studies with nuclear imaging and inte- should encompass review of all cardiovascular cases for gration of images into electrophysiological procedures, is noncardiac findings. The review of 150 CCT cases for appropriate during Level II training. incidental findings should include studying a dedicated To qualify for Level II certification, the trainee should teaching file of CCT cases featuring significant extrac- be exposed to an additional 200 cases, demonstrate ardiac pathology, and the core curricula for Levels II competency for independent performance and interpre- and III should include specific didactic training in the tation, and meet the following components: extracardiac pathology often encountered during diag- nostic CCT. 1. The trainee must be present in the scanning suite control room and actively participate in the acquisition 4.2.3. Level III Training Requirements of 50 cases. 2. A trainee may view a maximum of 50 cases from an Level III training enables a physician to direct an aca- educational CD or presentation granting continuing demic CCT section, independent CCT facility, or clinic. medical education credit that contains CCT data re- This individual would be responsible for quality control, view, clinical information, and appropriate clinical training technologists, and mentoring other physicians in correlative information (e.g., invasive coronary angio- training. In addition to the requirements for Level I and II graphic images). training, Level III training requires training devoted 3. At least 150 cases must involve interactive manipula- to CCT beyond the standard 3-year cardiovascular tion of reconstructed datasets using a 3-dimensional fellowship and training in at least 1 other imaging imaging workstation. modality, because Level III training in any noninvasive 4. At least 20 cases must include evaluation of cardiac modality requires training in more than 1 noninvasive function. imaging modality. Level III trainees in CCT should be 5. At least 20 cases should involve evaluation of struc- involved in the acquisition and interpretation of imaging tural and/or congenital heart disease. examinations and demonstrate the ability to over-read 6. At least 15 cases must involve evaluation of bypass CCT studies independently. Level III training should graft vessels. include participation in research, teaching, and the 7. At least 40 cases should be correlated with invasive administrative aspects of laboratory operations, including angiography and/or myocardial perfusion imaging. data management, report generation and distribution, 8. In at least 50 cases, the trainee should be actively quality improvement, and accreditation as well as devel- involved and demonstrate competency in acquisition, opment of an understanding of evolving multimodality interpretation, and reporting of CCT images. imaging technologies. JACC VOL. 65, NO. 17, 2015 Garcia et al. 1817 MAY 5, 2015:1810– 21 COCATS 4 Task Force 7

4.2.4. Training in Multiple Imaging Modalities initiative; reliability; decisions or actions that result in The recent emergence of noninvasive imaging modalities, clinical error; and the ability to make appropriate especially cardiovascular magnetic resonance and decisions independently and follow-up appropriately computed tomography angiography, is having a profound should be considered in these assessments. Trainees impact on the practice of cardiology and the fellow- should maintain records of participation and advance- ship training experience. The cardiovascular medicine ment in the form of a Health Insurance Portability – specialist is increasingly expected to provide expertise in and Accountability Act (HIPAA) compliant electronic 2 or more of the imaging techniques. It is understandable, database or logbook that meets ACGME reporting stan- then, that trainees will desire the opportunity to gain dards and summarizes pertinent clinical information exposure to multiple imaging modalities during their (e.g., number of cases, diversity of referral sources, fi fellowship experience. To the degree possible, the testing modalities, diagnoses, and ndings). The use of training program should strive to meet these needs by CCT should be aligned with both clinical need and offering a “multimodality” imaging experience (see appropriate use criteria. Trainees should be prepared to COCATS 4 Task Force 4 report). This might include an explain why a given CCT test is better suited to the appreciation for each technique’susesandclinicalin- clinical question than is another imaging option. Fellows dications, strengths and limitations, safety issues, and the should document clinical correlation with the other im- relevant guidelines and appropriate use criteria, when aging and with hemodynamic, invasive laboratory, sur- available. gical pathology, and outcomes data to enhance understanding of the diagnostic utility and value of 4.2.5. Vascular Computed Tomography Imaging various studies. Finally, experiences in CCT should be Vascular computed tomography represents an optional assessed against measures of quality with regard to test portion of training. As a cardiovascular specialist, the selection, performance, interpretation, and reporting in cardiovascular fellow should acquire skills beyond the interest of appreciating the potential adverse con- thosepertainingtocardiacstructureandthecoronary sequences of suboptimal testing (2). vasculature. Among the advantages of newer MDCT The ACC, American Heart Association, and SCCT have equipment is its capacity for very rapid imaging of the formulated a clinical competence statement on the per- carotid, renal, or peripheral vessels with small contrast formance, interpretation, and reporting of CCT studies requirements and high spatial resolution. The physics, (5). Self-assessment programs and competence examina- acquisition parameters, and reconstruction techniques tions in CCT are available through the ACC and other are similar, but vascular imaging requires additional organizations. Program directors and trainees are knowledge of the anatomy and pathophysiology specific encouraged to incorporate these resources in the course to each vascular territory. Level I, II, or III CCT training of training. We strongly encourage the use of examina- does not imply that trainees have acquired the vascular tions (e.g., the Cardiac Computed Tomography Self- imaging expertise associated with the corresponding Assessment Program [CCTSAP]) at the end of CCT levels of CCT training. training. Under the aegis of the program director and director of 5. EVALUATION OF COMPETENCY each imaging laboratory, facility, or program, the faculty should record and verify each trainee’s experiences, Evaluation tools in CCT include direct observation by assess performance, and document satisfactory achieve- instructors, in-training examinations, case logbooks, ment. The program director is responsible for confirming conference and case presentations, multisource evalua- experience and competence and reviewing the overall tions, trainee portfolios, simulation, and reflection progress of individual trainees with the Clinical Compe- and self-assessment. Acquisition and interpretive skills tency Committee to ensure achievement of selected should be evaluated in every trainee. Interaction with training milestones and identify areas in which additional other physicians, patients, and laboratory support staff; focused training may be required.

REFERENCES

1. Budoff MJ, Cohen MC, Garcia MJ, et al. ACCF/ Clinical Competence and Training. J Am Coll Cardiol 3. Pelberg R, Budoff M, Goraya T, et al. Training, compe- AHA clinical competence statement on cardiac im- 2005;46:383–402. tency, and certification in cardiac CT: a summary statement aging with computed tomography and magnetic from the Society of Cardiovascular Computed Tomogra- 2. Budoff MJ, Achenbach S, Berman DS, et al. Task resonance: a report of the American College of phy. J Cardiovasc Comput Tomogr 2011;5:279–85. force 13: training in advanced cardiovascular imaging Cardiology Foundation/American Heart Association/ (computed tomography). J Am Coll Cardiol 2008;51: 4. Budoff MJ, Achenbach S, Blumenthal RS, et al. American College of Physicians Task Force on 409–14. Assessment of coronary artery disease by cardiac 1818 Garcia et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 7 MAY 5, 2015:1810– 21

computed tomography: a scientific statement from Consensus Documents. J Am Coll Cardiol 2010;55: 8. Certification Board of Cardiovascular Computed the American Heart Association Committee on 2663–99. Tomography. About CBCCT. Available at: http://www. Cardiovascular Imaging and Intervention, Council on cccvi.org/cbcct/content_81.cfm?navID¼12. Accessed 6. Abbara S, Arbab-Zadeh A, Callister TQ, et al. SCCT Cardiovascular Radiology and Intervention, and September 27, 2014. guidelines for performance of coronary computed tomo- Committee on Cardiac Imaging, Council on graphic angiography: a report of the Society of Cardio- Clinical Cardiology. Circulation 2006;114: vascular Computed Tomography Guidelines Committee. 1761–91. KEY WORDS ACC Training Statement, J Cardiovasc Comput Tomogr 2009;3:190–204. 5. Mark DB, Berman DS, Budoff MJ, et al. ACCF/ cardiovascular computed tomography, ACR/AHA/NASCI/SAIP/SCAI/SCCT 2010 expert 7. Raff GL, Abidov A, Achenbach S, et al. SCCT guide- cardiovascular imaging, cardiovascular magnetic consensus document on coronary computed tomo- lines for the interpretation and reporting of coronary resonance, COCATS, positron emission graphic angiography: a report of the American Col- computed tomographic angiography. J Cardiovasc tomography, single-photon emission computed lege of Cardiology Foundation Task Force on Expert Comput Tomogr 2009;3:122–36. tomography JACC VOL. 65, NO. 17, 2015 Garcia et al. 1819 MAY 5, 2015:1810– 21 COCATS 4 Task Force 7

APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 7: TRAINING IN CARDIOVASCULAR COMPUTED TOMOGRAPHY

Institutional/ Ownership/ Organizational Committee Speakers Partnership/ Personal or Other Expert Member Employment Consultant Bureau Principal Research Financial Benefit Witness

Mario J. Garcia (Chair) Montefiore Medical Center, None None None None None None Albert Einstein College of Medicine—Chief of Cardiology; Professor of Medicine and Radiology

Ron Blankstein Brigham and Women’s None None None None None None Hospital—Director, Cardiac CT; Co-Director, Cardiovascular Imaging Training Program; and Cardiovascular Division & Department of Radiology; Harvard Medical School— Assistant Professor in Medicine and Radiology

Matthew J. Budoff Los Angeles Biomedical None None None None None None Research Institute—Program Director, Division of Cardiology

John M. Dent University of Virginia Health None None None None None None System Department of Medicine—Professor of Medicine (Cardiology)

Douglas E. Drachman Massachusetts General None None None None None None Hospital—Training Director, Division of Cardiology

John R. Lesser Minneapolis Heart Institute— None None None None None None Director of Cardiovascular CT and MRI

Maleah Grover-McKay DaVita Healthcare Partners— None None None None None None Director, Plaza Cardiology

Jeffrey M. Schussler Baylor University Medical None None None None None None Center—Medical Director, Cardiovascular ICU; Texas A&M College of Medicine— Professor of Medicine

Szilard Voros Stony Brook University Medical None None None None None None Center, State University of New York—Visiting Professor of Radiology and Medicine/ Cardiology; Global Genomics Group—Founder, Chief Executive Officer; Health Diagnostic Laboratory—Executive Vice President, Chief Clinical Strategy Officer

L. Samuel Wann University of Wisconsin, None None None None None None Madison, and Medical College of Wisconsin, Milwaukee—Clinical Professor of Medicine

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects authors’ employment and reporting categories. To ensure complete transparency, authors’ comprehensive healthcare-related disclosure information—including relationships with industry not pertinent to this document—is available in an online data supplement. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/ relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional information about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology; CT ¼ computed tomography; ICU ¼ intensive care unit; MRI ¼ magnetic resonance imaging. 1820 Garcia et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 7 MAY 5, 2015:1810– 21

APPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 7: TRAINING IN CARDIOVASCULAR COMPUTED TOMOGRAPHY

Institutional/ Organizational Ownership/ or Other Speakers Partnership/ Personal Financial Expert Name Employment Representation Consultant Bureau Principal Research Benefit Witness

Richard Kovacs Indiana University, Official Reviewer, None None None None None None Krannert Institute of ACC Board of Trustees Cardiology—Q.E. and Sally Russell Professor of Cardiology

Dhanunjaya Kansas University Official Reviewer, None None None None None None Lakkireddy Cardiovascular ACC Board of Governors Research Institute

Howard Weitz Thomas Jefferson Official Reviewer, None None None None None None University Hospital—Director, Competency Management Division of Cardiology; Committee Lead Reviewer Sidney Kimmel Medical College at Thomas Jefferson University— Professor of Medicine

Kiran Musunuru Brigham and Women’s Organizational Reviewer, AHA None None None None None None Hospital, Harvard University

Dennis Calnon OhioHealth Heart and Organizational Reviewer, ASNC None None None None None None Vascular Physicians— Director, Cardiac Imaging, Riverside Methodist Hospital

Thomas Gerber Mayo Clinic—Professor, Organizational Reviewer, SAIP None None None None None None Medicine, Radiology

John Hodgson Metrohealth Medical Center Organizational Reviewer, SCAI None None None None None None

Suhny Abbara UT Southwestern Medical Organizational Reviewer, SCCT None None None None None None Center—Chief, Cardiothoracic Imaging Division

Brian D. Hoit University Hospitals Case Content Reviewer, None None None None None None Medical Center Cardiology Training and Workforce Committee

Larry Jacobs Lehigh Valley Health Network, Content Reviewer, None None None None None None Division of Cardiology; Cardiology Training and University of South Florida— Workforce Committee Professor, Cardiology

Andrew Kates Washington University Content Reviewer, None None None None None None School of Medicine Academic Cardiology Section Leadership Council

Nishant Shah Brigham and Women’s Content Reviewer, None None None None None None Hospital, Harvard Medical Imaging Council School—Cardiovascular Imaging Fellow

Kim Williams Rush University Medical Content Reviewer, None None None None None None Center—James B. Herrick Cardiology Training and Professor and Chief, Workforce Committee Division of Cardiology

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects peer reviewers’ employment, representation in the review process, as well as reporting categories. Names are listed in alphabetical order within each category of review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional infor- mation about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology; AHA ¼ American Heart Association; ASNC ¼ American Society of Nuclear Cardiology; SAIP ¼ Society of Atherosclerosis Imaging and Pre- vention; SCAI ¼ Society for Cardiovascular Angiography and Interventions; SCCT ¼ Society of Cardiovascular Computed Tomography. JACC VOL. 65, NO. 17, 2015 Garcia et al. 1821 MAY 5, 2015:1810– 21 COCATS 4 Task Force 7

APPENDIX 3. ABBREVIATION LIST

ABIM ¼ American Board of Internal Medicine ABMS ¼ American Board of Medical Specialties ACC ¼ American College of Cardiology ACGME ¼ Accreditation Council for Graduate Medical Education CCT ¼ cardiovascular computed tomography COCATS ¼ Core Cardiovascular Training Statement HIPAA ¼ Health Insurance Portability and Accountability Act PET ¼ positron emission tomography SAIP ¼ Society of Atherosclerosis Imaging and Prevention SCCT ¼ Society of Cardiovascular Computed Tomography JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL.65,NO.17,2015 ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00 PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacc.2015.03.022

TRAINING STATEMENT COCATS 4 Task Force 8: Training in Cardiovascular Magnetic Resonance Imaging

Endorsed by the Society for Cardiovascular Magnetic Resonance

Christopher M. Kramer, MD, FACC, Chair Matthew W. Martinez, MD, FACC W. Gregory Hundley, MD, FACC Subha V. Raman, MD, FACC* Raymond Y. Kwong, MD, MPH R. Parker Ward, MD, FACC

1. INTRODUCTION 1.1.2. Document Development and Approval The Writing Committee developed the document, 1.1. Document Development Process approved it for review by individuals selected by the 1.1.1. Writing Committee Organization ACC and SCMR, and then addressed the reviewers’ The Writing Committee was selected to represent the comments. The document was revised and posted for American College of Cardiology (ACC) and the Society public comment from December 20, 2014, to January 6, for Cardiovascular Magnetic Resonance (SCMR) and 2015. Authors addressed these additional comments fi included a cardiovascular training program director, a from the public to complete the document. The nal cardiovascular magnetic resonance (CMR) training document was approved by the Task Force, COCATS program director, early-career experts, highly experi- Steering Committee, and ACC Competency Manage- fi enced specialists representing both the academic and ment Committee; rati ed by the ACC Board of Trustees community-based practice settings, and physicians in March, 2015; and endorsed by the SCMR. This experienced in defining and applying training stan- document is considered current until the ACC Compe- dards according to the 6 general competency domains tency Management Committee revises or withdraws it. promulgated by the Accreditation Council for Graduate Medical Education (ACGME) and American Board of 1.2. Background and Scope Medical Specialties (ABMS)andendorsedbythe The Task Force was charged with updating previously American Board of Internal Medicine (ABIM). The ACC published standards for training fellows in clinical determined that relationships with industry or other cardiology enrolled in ACGME–accredited fellowships entities were not relevant to the creation of this general (1) on the basis of: 1) changes in the field since 2008; and cardiovascular training statement. Employment and 2) the evolving framework of competency-based med- affiliation details for authors and peer reviewers are ical education described by the ACGME Outcomes provided in Appendixes 1 and 2, respectively, along Project and the 6 general competencies endorsed by with disclosure reporting categories. Comprehensive ACGME and ABMS. The updating effort was also disclosure information for all authors, including re- convened as part of a broader effort to establish lationships with industry and other entities, is avail- consistent training criteria across all aspects of cardi- able as an online supplement to this document. ology. The background and overarching principles governing fellowship training are provided in the COCATS 4 Introduction, and readers should become familiar with this foundation before considering *Society for Cardiovascular Magnetic Resonance Representative. the details of training in a subdiscipline like CMR. The American College of Cardiology requests that this document be The Steering Committee and Task Force recognize cited as follows: Kramer CM, Hundley WG, Kwong RY, Martinez MW, that implementation of these changes in training Raman SV, Ward RP. COCATS 4 task force 8: training in cardiovascular magnetic resonance imaging. J Am Coll Cardiol 2015;65:1822–31. requirements will occur incrementally. JACC VOL. 65, NO. 17, 2015 Kramer et al. 1823 MAY 5, 2015:1822– 31 COCATS 4 Task Force 8

CMR, one of the newest cardiovascular imaging modal- by appropriately trained mentors in an ACGME–accredi- ities, often provides useful and unique information with ted program and that satisfactory completion of training which all cardiologists should be conversant. Accordingly, is documented by the program director. The number and all standard 3-year cardiovascular trainees should receive types of encounters and the duration of training required training that would provide at least a basic understanding for trainees are summarized in Section 4. of the methods and utility of CMR in the practice of cardiology. To provide fellows with different levels of 2. GENERAL STANDARDS interest in CMR with such an understanding, training in CMR should be provided at 3 levels—basic, specialized, Three organizations—the ACC, the American College of and advanced, as described in the following text. Radiology, and the SCMR—have addressed training re- For most areas of adult cardiovascular medicine, quirements for CMR (2–4). The recommendations address 3 levels of training are delineated: faculty, facility requirements, emerging technologies, and practice. We strongly recommend that candidates for n Level I training is the basic training required of all certification in cardiovascular diseases, as well as those trainees to become competent consultant cardiologists seeking certification of subspecialty qualification in CMR, and must be accomplished during a standard 3-year review the specific requirements of other organizations. training program in cardiology. Cardiovascular fellowship programs should satisfy the n Level II training refers to the additional training in 1 or requirements regarding facilities and faculty for training more areas that enables some cardiologists to perform in CMR. Eligibility for supplemental subspecialty CMR or interpret specific procedures or render more examination training requires that training take place in a specialized care for specific patients and conditions. cardiovascular disease program accredited by the ACGME. This level of training is recognized for those areas in The intensity of training and required resources vary ac- which an accepted instrument or benchmark, such as a cording to the levels of certification desired. qualifying examination, is available to measure specific An examination of core competency in CMR is currently knowledge, skills, or competence. Level II training under development by the CMR Exam Board in collabora- in selected areas may be achieved by some trainees tion with SCMR. This group is under agreement to develop during the standard 3-year cardiovascular fellowship, the examination with the Council for Certification in depending on the trainees’ career goals and use of Cardiovascular Imaging, which comprises the former elective rotations. It is anticipated that during a stan- certification boards for nuclear cardiology and computed dard 3-year cardiovascular fellowship training program, tomography. Thus, examinations for 3 of the 4 imaging sufficient time will be available to receive Level II modalities will be housed within the same organization. training in a specificsubspecialty.InthecaseofCMR, Level II training is required for individuals who wish to 2.1. Faculty perform and interpret CMR examinations as part of CMR training faculty should include specialists who are their practice of cardiovascular medicine. skilled in CMR image acquisition, interpretation, and n Level III training requires additional training and reporting and are knowledgeable about the risks to the experience beyond the standard 3-year cardiovascular patient and medical personnel associated with magnetic fellowship to acquire specialized knowledge and com- resonance procedures. There should be at least 1 key petencies in performing, interpreting, and training clinical CMR faculty member with Level II or (preferably) others to perform specific procedures or render ad- Level III certification in CMR. Occasionally, a Level II– or vanced specialized care at a high level of skill. In the case III–trained CMR mentor will not be available in the insti- of CMR, Level III training would enable the trainee to tution housing the standard 3-year fellowship program direct a CMR laboratory or train others in CMR. As for but will be available at a nearby nonacademic medical other noninvasive imaging modalities, Level III training center accredited for CMR by an organization such as the in CMR requires training in multimodality imaging (see Intersocietal Accreditation Commission for Magnetic COCATS 4 Task Force 4 report). Level III training is Resonance Imaging. Under these circumstances, it is described here only in broad terms to provide context for acceptable to provide all levels of CMR training at such a trainees. The additional exposure and requirements for medical center. Level III training will be addressed in a subsequent, separately published Advanced Training Statement. 2.2. Facilities The number of cases, procedures, and experiences This training should generally be acquired through an recommended is based on published guidelines, compe- ACGME–approved cardiovascular or radiology program tency statements (2), and the opinions of the members of with expertise in CMR and under the aegis of a Level II– or the writing group. It is assumed that training is directed (preferably) a Level III–qualified mentor in a laboratory 1824 Kramer et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 8 MAY 5, 2015:1822– 31

accredited by an organization such as the Intersocietal Classification of Basic Cardiovascular TABLE 1 Accreditation Commission for Magnetic Resonance Im- Magnetic Resonance Techniques

aging. Facilities should be adequate to ensure a safe and Morphological imaging effective environment for the performance of diagnostic Still-frame imaging (black or bright blood) CMR procedures. Systolic and diastolic function imaging

2.3. Equipment Cine imaging Cine myocardial tagging or equivalent for quantitative regional strain CMR laboratories require not only the magnet, but also Blood-flow imaging specialized equipment for the safe monitoring and per- formance of diagnostic procedures, particularly stress Velocity-encoded phase contrast imaging testing. This magnetic resonance safe equipment may Stress testing include monitoring and recording systems, power in- First-pass myocardial perfusion imaging during pharmacological stress and at rest jectors for administering contrast, and systems to provide Cine imaging of left ventricular structure/function with exercise or inhalational as well as intravenous medications. dobutamine

Myocardial tissue characterization 2.4. Ancillary Support LGE imaging for myocardial infarction, fibrosis, or infiltration Ancillary support should be available to perform the CMR T2-weighted imaging for myocardial edema/inflammation/injury procedures, including individuals trained in general Myocardial T2* myocardial iron content imaging anesthesia for those centers performing procedures under Quantitative tissue mapping (T1 and/or T2) high levels of sedation. Angiography

3. TRAINING COMPONENTS Magnetic resonance coronary angiography

Left atrial and pulmonary vein magnetic resonance angiography

3.1. Didactic Program Magnetic resonance angiography of the aorta, peripheral arteries, and venous system Lectures and self-study in CMR: Didactic training consists of lectures on the basic aspects of CMR and parallel LGE ¼ late gadolinium enhancement. reading material comprising selected articles, digital training programs, or CMR text. The lectures and reading should provide the fellow with a basic understanding of content should include the materials noted in Table 3. CMR imaging techniques (Table 1) and applications These lectures may be web-based, if available. (Table 2). Specificity, sensitivity, diagnostic accuracy, utility in assessing prognosis, costs, appropriate use 3.2. Clinical Experience criteria, artifacts, indications, contraindications, and pit- Level I training should include exposure to the methods falls must be included for each cardiovascular diagnostic and applications of CMR for a period of not less than 1 subset. Such information could be effectively transmitted month or its equivalent when integrated with other within a weekly noninvasive or clinical teaching confer- training activities. During the 1 month of training, the ence during which CMR data are presented. Mentored trainee should actively participate in daily CMR study interpretation of CMR studies should be coupled with interpretation under the direction of CMR faculty. Studies comparison and integration of CMR results with other should incorporate the range of techniques and pro- relevant clinical, imaging, and laboratory test results. cedures listed in Tables 1 and 2, including exposure to a Additional training should include an understanding of: minimum of 25 cases, some of which may come from an 1) sources of artifacts, including motion, arrhythmias, and established CMR teaching file. metal objects; 2) the safety of implanted devices (e.g., pace- makers, automatic implantable cardioverter-defibrillators), 3.3. Hands-On Experience external ferromagnetic devices, and gadolinium-based Hands-on experience is not necessary for Level I training contrast agents (for a summary of safety issues in CMR, but is an integral part of Level II training, as discussed in see www.mrisafety.com); 3) basic post-processing ap- the previous text. The trainee should take an active role in proaches and analyses; 4) noncardiac incidental findings planning and implementing protocol decision making. and an approach to their recognition; and 5) appropriate 4. SUMMARY OF TRAINING REQUIREMENTS use criteria as they relate to CMR. Trainees should receive didactic lectures from CMR faculty and/or physicists on the basic physics of magnetic 4.1. Development and Evaluation of Core Competencies resonance in general and physics that relate to CMR and Training and requirements for CMR address the 6 general to patients with cardiovascular disease in particular. The competencies promulgated by the ACGME/ABMS and JACC VOL. 65, NO. 17, 2015 Kramer et al. 1825 MAY 5, 2015:1822– 31 COCATS 4 Task Force 8

TABLE 2 Classification of Common CMR Applications

CMR Study Indications Cardiac Features of Interest Key CMR Techniques

Myocardial viability n Left ventricular function n Cine imaging n Infarct transmurality for recovery of systolic function n LGE imaging n Contractile reserve of heart function n Cine imaging with low-dose dobutamine

Myocardial ischemia n Left ventricular function n Cine imaging n Presence and extent of ischemia n Eithercineimagingduringdobutamineor n Presence and extent of infarction exercise, or myocardial perfusion imaging during vasodilator stress and at rest n LGE imaging

Acute myocardial infarction n Left and right ventricular function n Cine imaging n Myocardial edema and hemorrhage n T2- and T2*-weighted imaging n Infarct size and microvascular obstruction n LGE imaging n Imaging of complications (e.g., ventricular septal n Cine imaging, still-frame imaging (black or defect, pericardial disease, acute mitral regurgitation) bright blood), velocity-encoded imaging

Detecting acute coronary syndrome n Left and right ventricular function n Cine imaging or determining other causes of n Myocardial edema/inflammation n T2-weighted imaging myocardial injury n Presence and extent of ischemia n Myocardial perfusion imaging at rest and n Myocardial infarction and myocarditis during vasodilator stress n LGE imaging

Assessing cardiomyopathy or n Left and right ventricular function n Cine imaging new-onset heart failure of n Myocardial edema n T2-weighted imaging unknown cause n Myocardial iron content n T2* imaging n Myocardial fibrosis n Quantitative tissue mapping (T1 and/or T2) n Myocardial blood flow n Myocardial perfusion imaging at rest n Myocardial infarction or infiltration n LGE imaging

Pericardial disease n Left and right ventricular function n Cine imaging n Ventricular interdependence n Real-time cine imaging n Pericardial thickening n Still-frame imaging (black or bright blood) n Pericardial inflammation n LGE imaging n Pericardial adhesions n Cine myocardial tagging

Valvular heart disease n Left and right ventricular function n Cine imaging (including real-time imaging) n Flow volume and velocity across valves n Velocity-encoded imaging n Great vessel anatomy (e.g., aorta for n Still-frame imaging (black or bright blood) bicuspid aortic valve) and/or MR angiography

Cardiac mass/thrombus n Location, size, attachment, and motion n Cine imaging n Tissue characteristics n T1-, T2-weighted black blood imaging n Vascularity and fibrotic contents without and with fat saturation n Tumor necrosis and suspected thrombus n First-pass perfusion imaging at rest and T1-weighted imaging precontrast and postcontrast n LGE imaging

Left atrial mapping and pulmonary n Left and right ventricular function n Cine imaging vein ablation n Left atrial volume and pulmonary venous anatomy n MR angiography of the left atrium

Congenital heart disease n Left and right ventricular function n Cine imaging n Great vessel anatomy n MR angiography of the great vessels n Anomalous coronary artery anatomy n MR coronary angiography n Flow volume and velocity across heart n Velocity-encoded imaging valves and shunt ratio n LGE imaging n Myocardial fibrosis

Aorta and peripheral artery disease n Aortic anatomy (intramural hematoma, n T1-, T2-weighted black blood imaging dissection, coarctation, aneurysm) n MR angiography n Anatomy of peripheral arterial stenosis n Velocity-encoded imaging n Severity of peripheral artery stenosis n Anatomy of venous system

CMR ¼ cardiovascular magnetic resonance; LGE ¼ late gadolinium enhancement; MR ¼ magnetic resonance. endorsed by the ABIM. These competency domains are: the ACGME/American Board of Internal Medicine medical knowledge, patient care and procedural skills, reporting milestones. The ACC has adopted this format practice-based learning and improvement, systems-based for its competency and training statements, career practice, interpersonal and communication skills, and milestones, lifelong learning, and educational programs. professionalism. The ACC has used this structure to define Additionally, it has developed tools to assist phy- and depict the components of the core clinical compe- sicians in assessing, enhancing, and documenting these tencies for cardiology. The curricular milestones for each competencies. competency and domain also provide a developmental Table 4 delineates each of the 6 competency domains roadmap for fellows as they progress through various as well as their associated curricular milestones for levels of training and serve as an underpinning for training in CMR. The milestones are categorized as Level 1826 Kramer et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 8 MAY 5, 2015:1822– 31

fi I, II, or III training (as previously de ned in this docu- Classification of Basic Cardiovascular TABLE 3 ment) and indicate the stage of fellowship training (12, 24, Magnetic Resonance Physics Principles

or 36 months, and additional time points) by which the Image contrast typical cardiovascular disease trainee should achieve the T1, T2, proton density T2* designated level. Given that programs may vary with Image formation respect to the sequence of clinical experiences provided k-space, gradient echo, spin echo, fast spin echo, spiral, steady-state free to trainees, the milestones at which various competencies precession, and parallel imaging

are reached may also vary. Level I competencies may be Pulse sequence parameters

achieved at earlier or later time points. Acquisition of Slice selection, frequency and phase encoding, flip angle, repetition time, Level II skills requires additional training that can usually echo time, field of view, matrix size be obtained during elective time in the standard 3-year Hardware

cardiovascular fellowship, whereas Level III skills Field strength, gradient coil design, receiver coils, and digital sampling

require an additional period of training in a dedicated Specialized sequences

CMR program beyond the cardiovascular fellowship. The T1 and T2 mapping, velocity-encoded imaging, noncontrast and contrast table also describes examples of evaluation tools suitable angiography, strain imaging, dark blood preparation, T2 preparation, saturation recovery perfusion, inversion recovery gradient echo, for assessing competence in each domain. phase-sensitive inversion recovery, fat–water separation

Contrast agents 4.2. Number of Cases and Duration of Training Gadolinium-based agents, iron-based agents Although the training duration and numbers of pro- Image acquisition parameters cedures stated previously are typically required to obtain Electrocardiography gating, peripheral pulse gating, breath-holding, competency, there must also be a demonstration of navigator sequences achievement of the competencies as assessed by the outcomes evaluation measures. troubleshooting through formal CMR physics lectures 4.2.1. Level I Training Requirements when possible. These lectures should include the topics Level I training should be required of all 3-year cardio- listed in Table 3 and may be web-based, if this is available. vascular fellows and includes exposure to the methods During the 3 or more months of experience necessary and the applications of CMR (Tables 1 and 2)foraperiodof to develop Level II competence, trainees should actively not less than 1 month or its equivalent when integrated participate in daily CMR study interpretation under the with other training activities. This experience should direction of Level II or (preferably) Level III CMR fac- provide basic background knowledge in CMR sufficient ulty. In addition to Level I requirements, the trainee for the practice of adult cardiology and appropriate should interpret at least 150 CMR examinations during referral for CMR evaluation and for report interpretation, this training period, including 50 for which the trainee but not for the practice of or independent clinical inter- is present during the scanning procedure, directs the pretation of CMR. It is expected that trainees will be imaging acquisition, and serves as the primary inter- exposed to at least 25 mentored cases. As a practical preter.Upto50ofthe100examinationsforwhichthe matter, many fellowship programs in cardiovascular trainee is not the primary interpreter can be derived medicine may not be able to fulfill CMR training re- from established teaching files, journals and/or text- quirements. In these instances, fellows should be en- books, or electronic/online courses. Careful documen- couraged to obtain experience in an alternate program tation of all case material and the details of the way in with appropriate training and accreditation in the per- which the case was derived are essential. For all studies formance of CMR studies. in which other cardiac imaging data are available, such information should be correlated with CMR data. Rather 4.2.2. Level II Training Requirements than seeking a certain number of case experiences, Level II is for trainees who wish to practice the clinical trainees should seek competency in performing and subspecialty of CMR, including independent interpreta- managing CMR. tion of CMR studies. Level II trainees must have at least 3 months of dedicated CMR training (where 1 month is 4.2.3. Training in Multiple Imaging Modalities defined as 4 weeks and 1 week is defined as 35 hours), The cardiovascular medicine specialist is increasingly including familiarity with the CMR techniques and ap- expected to provide expertise in 2 or more of the nonin- plications listed in Tables 1 and 2, respectively. In addition vasive cardiovascular imaging techniques. It is under- to Level I requirements, the Level II trainee should have standable, then, that trainees will desire the opportunity a clear understanding of CMR physics and how it to gain exposure to multiple imaging modalities during relates to image acquisition, sequence building, and their fellowship experience. To the degree possible, the JACC VOL. 65, NO. 17, 2015 Kramer et al. 1827 MAY 5, 2015:1822– 31 COCATS 4 Task Force 8

TABLE 4 Core Competency Components and Curricular Milestones for Training in Cardiovascular Magnetic Resonance

Competency Component Milestones (Months) MEDICAL KNOWLEDGE 12 24 36 Add

1 Know the principles of cardiovascular magnetic resonance image acquisition. I

2 Know the principles of safety and contraindications for cardiovascular magnetic resonance imaging. I

3 Know the uses, potential side effects, and contraindications of using gadolinium-based contrast agents in I cardiovascular magnetic resonance imaging.

4 Know the indications for cardiovascular magnetic resonance to assess left and right heart chamber sizes and function. I

5 Know the cardiovascular magnetic resonance indications for assessment of myocardial viability. I

6 Know the cardiovascular magnetic resonance indications and characteristic findings of myocardial ischemia. I

7 Know the cardiovascular magnetic resonance indications and characteristic findings of acute myocardial infarction. I

8 Know the cardiovascular magnetic resonance indications and characteristic findings of acute coronary syndromes and I other causes of myocardial injury.

9 Know the cardiovascular magnetic resonance indications and differential findings in cardiomyopathies of uncertain cause. I

10 Know the cardiovascular magnetic resonance indications to assess diseases of the pericardium. I

11 Know the cardiovascular magnetic resonance indications to evaluate valvular heart disease. I

12 Know the cardiovascular magnetic resonance indications and characteristic findings of myocardial masses and thrombi. I

13 Know the cardiovascular magnetic resonance indications for left atrial and pulmonary vein mapping prior to ablation I of atrial fibrillation.

14 Know the cardiovascular magnetic resonance indications for evaluation of adult congenital heart disease including I identification of coronary artery anomalies.

15 Know the cardiovascular magnetic resonance indications to detect and evaluate diseases of the aorta and peripheral I arteries.

EVALUATION TOOLS: conference presentation, direct observation, and in-training examination.

PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

1 Skill to appropriately order and integrate the results of cardiovascular magnetic resonance testing with other clinical I findings in the evaluation and management of patients.

2 Skill to interpret cardiovascular magnetic resonance tissue characterization (late gadolinium enhancement) to I distinguish the etiology of cardiomyopathy and acute myocardial injury.

3 Skill to interpret regional and global left and right ventricular wall motion and ejection fraction. II

4 Skill to interpret vascular diseases of the aorta (e.g., intramural hematoma, dissection, coarctation, and aneurysm). II

5 Skill to identify and characterize myocardial masses. II

6 Skill to identify and characterize pericardial disease. II

7 Skill to identify and diagnose basic congenital heart disease in adults. II

8 Skill to identify and diagnose complex adult congenital heart disease, including quantification of intracardiac II shunting, and anomalous coronary arteries.

9 Skill to perform and interpret cardiovascular magnetic resonance stress testing. II

10 Skill to interpret vascular diseases of the peripheral arteries. III

EVALUATION TOOLS: conference presentation, direct observation, and logbook.

SYSTEMS-BASED PRACTICE 12 24 36 Add

1 Incorporate risk/benefit and cost considerations in the use of cardiovascular magnetic resonance testing. I

2 Participate in cardiovascular magnetic resonance quality monitoring and initiatives. II

EVALUATION TOOLS: chart-stimulated recall, conference presentations, direct observation, and multisource evaluation. 1828 Kramer et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 8 MAY 5, 2015:1822– 31

TABLE 4 Core Competency Components, continued

Competency Component Milestones (Months) PRACTICE-BASED LEARNING AND IMPROVEMENT 12 24 36 Add

1 Identify knowledge and performance gaps and engage in opportunities to achieve focused education and I performance improvement.

EVALUATION TOOLS: chart-stimulated recall, conference presentations, direct observation, and reflection and self-assessment.

PROFESSIONALISM 12 24 36 Add

1 Practice within the scope of expertise and technical skills. I

2 Know and promote adherence to guidelines and appropriate use criteria. I

EVALUATION TOOLS: chart-stimulated recall, conference presentations, direct observation, and multisource evaluation.

INTERPERSONAL AND COMMUNICATION SKILLS 12 24 36 Add

1 Communicate testing results to physicians and patients in an effective and timely manner. II

EVALUATION TOOLS: direct observation and multisource evaluation.

Add ¼ additional months beyond the 3-year cardiovascular fellowship.

training program should strive to meet these needs by evaluations, trainee portfolios, simulation, and reflection offering a “multimodality” imaging experience (see and self-assessment. Acquisition and interpretive skills COCATS4TaskForce4report).Thismightincludean should be evaluated in every trainee. Interaction with appreciation for each technique’s uses and indications, other physicians, patients, and laboratory support staff; strengths and limitations, safety issues, and relevant initiative; reliability; decisions or actions that result in guidelines and appropriate use criteria, when available. clinical error; and the ability to make appropriate de- cisions independently and follow up appropriately 4.2.4. Level III Training Requirements should be considered in these assessments. Trainees Level III training enables a physician to direct an aca- should maintain records of participation and advance- demic CMR section, independent CMR facility, or CMR ment in the form of a Health Insurance Portability and clinic. This individual would be responsible for quality Accountability Act (HIPAA)–compliant electronic database control, training technologists, and mentoring other or logbook that meets ACGME reporting standards and physicians in training. In addition to the requirements for summarizes pertinent clinical information (e.g., number of Level I and II training, Level III training requires training cases, diversity of referral sources, testing modalities, di- devoted to CMR beyond the standard 3-year cardiovas- agnoses, and findings). The use of CMR should be aligned cular fellowship and training in at least 1 other imaging with both clinical need and appropriate use criteria. modality, because Level III training in any noninvasive Trainees should be prepared to explain why a given CMR modality requires training in more than 1 noninvasive test is better suited to the clinical question than is another imaging modality. Level III trainees in CMR should be imaging option. Fellows should document clinical corre- involved in the acquisition and interpretation of imaging lation with the other imaging, hemodynamic, invasive examinations and demonstrate the ability to over-read laboratory, surgical pathology, and outcomes data to CMR studies independently. Level III training should enhance their understanding of the diagnostic utility and include participation in research, teaching, and the value of various studies. Finally, experiences in CMR administrative aspects of laboratory operations, including should be assessed against measures of quality with regard data management, report generation and distribution, to test selection, performance, interpretation, and report- quality improvement, accreditation, and understanding ing in the interest of appreciating the potential adverse of evolving multimodality imaging technologies. consequences of suboptimal testing (5–7). The ACC, American Heart Association, and SCMR have 5. EVALUATION OF COMPETENCY formulated a clinical competence statement on the per- formance, interpretation, and reporting of CMR studies, Evaluation tools in CMR include direct observation by as well as an expert consensus document (2,8).Program instructors, in-training examinations, case logbooks, directors and trainees are encouraged to incorporate conference and case presentations, multisource these resources in the course of training. JACC VOL. 65, NO. 17, 2015 Kramer et al. 1829 MAY 5, 2015:1822– 31 COCATS 4 Task Force 8

Under the aegis of the program director and director of experience and competence and reviewing the overall each imaging laboratory, facility, or program, the faculty progress of individual trainees with the Clinical Compe- should record and verify each trainee’sexperiences, tency Committee to ensure achievement of selected assess performance, and document satisfactory achieve- training milestones and identify areas in which additional ment. The program director is responsible for confirming focused training may be required.

REFERENCES

1. Pohost GM, Kim RJ, Kramer CM, et al. Task Force 12: 4. Woodard PK, Bluemke DA, Cascade PN, et al. ACR 7. Hundley WG, Bluemke D, Bogaert JG, et al. Society training in advanced cardiovascular imaging (cardio- practice guideline for the performance and interpre- for Cardiovascular Magnetic Resonance guidelines for vascular magnetic resonance [CMR]). J Am Coll Cardiol tation of cardiac magnetic resonance imaging (MRI). reporting cardiovascular magnetic resonance exami- 2008;51:404–8. J Am Coll Radiol 2006;3:665–76. nations. J Cardiovasc Magn Reson 2009;11:5.

2. Budoff MJ, Cohen MC, Garcia MJ, et al. ACCF/AHA 5. Kramer CM, Barkhausen J, Flamm SD, et al. Stan- 8. Hundley WG, Bluemke DA, Finn JP, et al. ACCF/ACR/ clinical competence statement on cardiac imaging with dardized cardiovascular magnetic resonance (CMR) AHA/NASCI/SCMR 2010 expert consensus document computed tomography and magnetic resonance: a protocols 2013 update. J Cardiovasc Magn Reson 2013; on cardiovascular magnetic resonance: a report of the report of the American College of Cardiology Foun- 15:91. American College of Cardiology Foundation Task Force dation/American Heart Association/American College on Expert Consensus Documents. J Am Coll Cardiol 6. Schulz-Menger J, Bluemke DA, Bremerich J, et al. of Physicians Task Force on Clinical Competence and 2010;55:2614–62. Standardized image interpretation and post processing Training. J Am Coll Cardiol 2005;46:383–402. in cardiovascular magnetic resonance: Society for 3. Kim RJ, de Roos A, Fleck E, et al. Guidelines for Cardiovascular Magnetic Resonance (SCMR) Board of KEY WORDS ACC Training Statement, training in cardiovascular magnetic resonance (CMR). Trustees Task Force on Standardized Post Processing. cardiovascular imaging, cardiovascular magnetic J Cardiovasc Magn Reson 2007;9:3–4. J Cardiovasc Magn Reson 2013;15:35. resonance, COCATS, steady-state free precession

APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 8: TRAINING IN CARDIOVASCULAR MAGNETIC RESONANCE IMAGING

Institutional/ Ownership/ Organizational or Speakers Partnership/ Personal Other Financial Expert Committee Member Employment Consultant Bureau Principal Research Benefit Witness

Christopher University of Virginia Health System—Ruth C. None None None None None None M. Kramer (Chair) Heede Professor of Cardiology, Professor of Radiology

W. Gregory Hundley Wake Forest University School of None None None None None None Medicine—Professor, Internal Medicine (Cardiology) and Radiology

Raymond Y. K. Kwong Brigham & Women’s Hospital Medicine, None None None None None None Cardiovascular Division—Instructor of Medicine

Matthew W. Martinez Lehigh Valley Health Network—Associate None None None None None None Professor of Medicine

Subha V. Raman Ohio State University—Professor of Internal None None None None None None Medicine, Biomedical Informatics, and Radiology

R. Parker Ward University of Chicago Medicine—Professor None None None None None None of Medicine

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects authors’ employment and reporting categories. To ensure complete transparency, authors’ comprehensive healthcare-related disclosure information—including relationships with industry not pertinent to this document—is available in an online data supplement. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/ relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional information about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology. 1830 Kramer et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 8 MAY 5, 2015:1822– 31

APPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 8: TRAINING IN CARDIOVASCULAR MAGNETIC RESONANCE IMAGING

Institutional/ Ownership/ Organizational or Speakers Partnership/ Personal Other Financial Expert Name Employment Representation Consultant Bureau Principal Research Benefit Witness

Richard Kovacs Indiana University, Official Reviewer, None None None None None None Krannert Institute of ACC Board of Trustees Cardiology—QE and Sally Russell Professor of Cardiology

Dhanunjaya Kansas University Official Reviewer, None None None None None None Lakkireddy Cardiovascular ACC Board of Governors Research Institute

Howard Weitz Thomas Jefferson Official Reviewer, None None None None None None University Hospital— Competency Director, Division of Management Committee Cardiology; Sidney Lead Reviewer Kimmel Medical College at Thomas Jefferson University—Vice Chair, Department of Medicine

Warren Beth Israel Deaconess Organizational None None None None None None Manning Medical Center, Division Reviewer, SCMR of Cardiology—Professor, Medicine and Radiology

Michael Emery Greenville Health System Content Reviewer, None None None None None None Sports and Exercise Cardiology Section Leadership Council

Brian D. Hoit University Hospitals Case Content Reviewer, None None None None None None Medical Center Cardiology Training and Workforce Committee

Larry Jacobs Lehigh Valley Health Content Reviewer, None None None None None None Network, Division of Cardiology Training and Cardiology; University of Workforce Committee South Florida—Professor, Cardiology

Andrew Kates Washington University Content Reviewer, None None None None None None School of Medicine Academic Cardiology Section Leadership Council

Nishant Shah Brigham and Women’s Content Reviewer, None None None None None None Hospital, Harvard Medical Imaging Council School—Cardiovascular Imaging Fellow

Kim Williams Rush University Medical Content Reviewer, None None None None None None Center—James B. Herrick Cardiology Training Professor and Chief, and Workforce Division of Cardiology Committee

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects peer reviewers’ employment, representation in the review process, as well as reporting categories. Names are listed in alphabetical order within each category of review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional infor- mation about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology; SCMR ¼ Society for Cardiovascular Magnetic Resonance. JACC VOL. 65, NO. 17, 2015 Kramer et al. 1831 MAY 5, 2015:1822– 31 COCATS 4 Task Force 8

APPENDIX 3. ABBREVIATION LIST

ABIM ¼ American Board of Internal Medicine ABMS ¼ American Board of Medical Specialties ACC ¼ American College of Cardiology ACGME ¼ Accreditation Council for Graduate Medical Education CMR ¼ cardiovascular magnetic resonance COCATS ¼ Core Cardiovascular Training Statement HIPAA ¼ Health Insurance Portability and Accountability Act SCMR ¼ Society for Cardiovascular Magnetic Resonance JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL.65,NO.17,2015 ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00 PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacc.2015.03.025

TRAINING STATEMENT COCATS 4 Task Force 9: Training in Vascular Medicine

Endorsed by the Society for Vascular Medicine

Mark A. Creager, MD, FACC, MSVM, Chair William F. Iobst, MDz Heather L. Gornik, MD, FACC, FSVM* Emile R. Mohler III, MD, FACC, FSVM Bruce H. Gray, DO, MSVMy Christopher J. White, MD, FACC Naomi M. Hamburg, MD, FACC, FSVM

1. INTRODUCTION with industry and other entities, is available as an online supplement to this document. 1.1. Document Development Process 1.1.2. Document Development and Approval 1.1.1. Writing Committee Organization The writing committee developed the document, The writing committee was selected to represent the approved it for review by individuals selected by the American College of Cardiology (ACC), Society for ACC and SVM, and then addressed the peer reviewers’ Vascular Medicine (SVM), American Board of Internal comments. The document was revised and posted for Medicine (ABIM), and American Board of Vascular public comment from December 20, 2014, to January 6, Medicine (ABVM), and included a cardiovascular 2015. Authors addressed the additional comments training program director, a vascular medicine pro- from the public to complete the document. The final gram training director, early-career vascular medicine document was approved by the Task Force, COCATS experts, and highly experienced specialists repre- Steering Committee, and ACC Competency Manage- senting both the academic and community-based ment Committee; ratified by the ACC Board of Trustees practice settings. The committee also included phy- in March, 2015; and endorsed by the SVM. This docu- sicians experienced in defining and applying training ment is considered current until the ACC Competency standards according to the 6 general competency do- Management Committee revises or withdraws it. mains promulgated by the Accreditation Council for Graduate Medical Education (ACGME) and American 1.2. Background and Scope Board of Medical Specialties (ABMS) and endorsed by Cardiovascular physicians frequently encounter pa- the ABIM. The ACC determined that relationships tients with peripheral vascular diseases. Athero- with industry or other entities were not relevant to thrombosis, in particular, is a systemic disorder with the creation of this general cardiovascular training clinical manifestations in the peripheral circulation. statement. Employment and affiliation details for These and other vascular diseases account for sub- authors and peer reviewers are provided in stantial cardiovascular morbidity and mortality. Appendixes 1 and 2, respectively, along with disclo- Moreover, technological advances in imaging tech- sure reporting categories. Comprehensive disclosure niques and endovascular therapies have brought the information for all authors, including relationships management of vascular diseases firmly into the sphere of the cardiovascular medicine specialist. As part of a broader effort to standardize training criteria for all aspects of cardiovascular medicine, this Task Force was charged with updating previously- *Society for Vascular Medicine Representative. yAmerican Board of Vascular Medicine Representative. published adult vascular medicine training guide- zAmerican Board of Internal Medicine Representative. lines (1,2) on the basis of changes in the field since The American College of Cardiology requests that this document be cited 2008. One modification presented by this update is the as follows: Creager MA, Gornik HL, Gray BH, Hamburg NM, Iobst WF, Mohler ER III, White CJ. COCATS 4 task force 9: training in vascular transfer of the training recommendations on catheter- medicine. J Am Coll Cardiol 2015;65:1832–43. based peripheral vascular interventions to the COCATS JACC VOL. 65, NO. 17, 2015 Creager et al. 1833 MAY 5, 2015:1832– 43 COCATS 4 Task Force 9

4 Task Force 10 report, thus integrating the recommenda- medicine, Level III training pertains to advanced tions with other cardiovascular interventional training knowledge in diagnostic and therapeutic modalities for components. The Task Force also updated previously evaluating and managing vascular disease and leads to published standards to address the evolving framework of the ability to direct a vascular laboratory, train others, competency-based medical education described by the and conduct advanced research in vascular medicine. ACGME Outcomes Project and by the 6 general compe- Level III training is described here only in broad terms tencies endorsed by the ACGME and ABMS. The back- to provide context for trainees and clarify that these ground and overarching principles governing fellowship advanced competencies are not covered during the training are provided in the COCATS 4 Introduction, and cardiovascular fellowship. The additional exposure and readers should become familiar with this foundation requirements for Level III training will be addressed in a before considering the details of training in a subdiscipline subsequent, separately published Advanced Training like vascular medicine. The Steering Committee and Task Statement. Force recognize that implementation of these changes in The knowledge and competencies recommended at training requirements will occur incrementally. each level of training are based on published guidelines, For most areas of cardiovascular medicine, 3 levels of competency statements, and the experience and opinions training are delineated: of the writing group. It is assumed that training is directed by appropriately trained mentors and that satisfactory n Level I training, the basic training required to become a completion of training is documented by the program competent cardiovascular consultant, is required of all director. The milestones required for each level of cardiovascular fellows and can be accomplished as part training are summarized in Section 4. of a standard 3-year training program in cardiovascular medicine. All cardiovascular fellows should receive 2. GENERAL STANDARDS basic training in vascular medicine and acquire suffi- cient knowledge to care for most patients with vascular disease. The ACC and the SVM have addressed training re- quirements and guidelines for vascular medicine training n Level II training refers to the additional training in 1 or more areas that enables some cardiovascular specialists (1,2). The recommendations are congruent and address to perform or interpret specificdiagnostictestsand faculty, facility requirements, emerging technologies, and procedures or render more specialized care for patients clinical practice. We strongly recommend that candidates fi and conditions. This level of training is recognized for for the ABIM examination for certi cation in cardiovas- fi those areas in which an accepted instrument or cular diseases, as well as those seeking certi cation from fi benchmark, such as a qualifying examination, is avail- the ABVM, review the speci c examination requirements able to measure specific knowledge, skills, or compe- (3). Cardiovascular fellowship programs should satisfy the tence. Level II training in selected areas may be requirements regarding faculty and facilities for training achieved by some trainees during the standard 3-year in vascular medicine (1,2). The intensity of training and cardiovascular fellowship, depending on their career required resources vary according to the level of training goals and use of elective rotations. It is anticipated that provided. during a standard 3-year cardiovascular fellowship 2.1. Faculty and Facilities training program, sufficient time will be available for the trainee to receive Level II training in a specific 2.1.1. Faculty subspecialty. In the case of vascular medicine, Level II Trainees should be exposed to individuals with special training can be elected by fellows seeking additional training in vascular medicine. In some institutions, lead- expertise in interpreting noninvasive diagnostic tests ership of the vascular medicine component of training and evaluating and managing patients with peripheral will come from vascular medicine specialists. In other vascular diseases. Level II training is also recom- programs, training in vascular medicine will be guided by mended prior to or in conjunction with training in faculty in other disciplines such as general cardiology, catheter-based peripheral vascular intervention (see hematology,neurology,vascularsurgery,andvascularor COCATS 4 Task Force 10 report). interventional radiology. All faculty members responsible n Level III training requires additional training and for training fellows in vascular medicine should be board experience beyond the cardiovascular fellowship to certified or board eligible in their subspecialties. acquire specialized knowledge and competencies in Ideally, faculty will include individuals certified in performing, interpreting, and training others to perform vascular medicine by the ABVM. Recognizing that this specific procedures or render advanced specialized may not be possible at all institutions, cardiovascular care at a high level of skill. In the case of vascular fellows may spend time in other departments or divisions 1834 Creager et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 9 MAY 5, 2015:1832– 43

to gain the expertise necessary to interpret noninvasive and formal lectures that review diagnostic and therapeutic vascular studies and to evaluate and manage patients approaches to vascular diseases. Case presentations with vascular disease. Faculty with expertise in disci- should illustrate the use of clinical tools, including plines relevant to vascular medicine, such as vascular noninvasive laboratory testing, magnetic resonance, surgery, vascular radiology, hematology, neurology, computedtomographicandcatheter-basedangiography, dermatology, and rheumatology, play important roles in and therapeutic approaches for patients with vascular training cardiovascular fellows. Faculty should provide diseases. Lectures should provide information regarding didactic and practical education to fellows and deliver vascular anatomy, pathobiology, and pathophysiology; appropriate feedback about the performance of trainees. epidemiology and the natural history of peripheral vascular disorders; diagnostic evaluation; perioperative 2.2. Facilities evaluation and management; and therapeutic options, The training institution should provide comprehensive including the risks and benefits of medical, endovascular, facilities for the care of patients with vascular disease and and surgical approaches to vascular disease to comple- include offices for outpatient evaluation and treatment, ment teaching in the clinic and at the bedside. inpatient vascular consultative services, a noninvasive In addition to the lectures and case presentations vascular laboratory accredited by the Intersocietal described in the previous text for Level I trainees, didactic Accreditation Commission (Intersocietal Accreditation activities for Level II and III trainees should include a Commission Vascular Testing Division, formerly comprehensive longitudinal conference series on vascular Intersocietal Commission for the Accreditation of Vascular topics, including peripheral artery disease; renal artery Laboratories) (4), facilities for computed tomographic stenosis; mesenteric vascular disease and extracranial angiography and magnetic resonance angiography, a pe- cerebrovascular disease; aneurysmal disease of the aorta ripheral vascular catheterization laboratory, and compre- and peripheral arteries; vasculitis; vasospastic and hensive vascular surgery and wound care programs. temperature-related diseases; venous thromboembolism; chronic venous insufficiency and varicose veins; lym- 2.3. Equipment phedema; less-common disorders such as fibromuscular Noninvasive vascular laboratories require dedicated dysplasia and arteriopathies associated with inherited equipment to perform diagnostic studies, including duplex diseases of connective tissue; congenital vascular mal- ultrasound units capable of high-resolution B-mode formations and arterial entrapment syndromes; leg ul- (grayscale) imaging as well as color and spectral Doppler cers;andthepreoperativeevaluationandperioperative analysis, equipment for physiological testing with appro- management of patients undergoing vascular surgery. priately sized cuffs to measure blood pressure at multiple Conferences should also cover the noninvasive vascular sites in the limbs, Doppler and plethysmographic devices laboratory, including principles of vascular physiology, (e.g., pulse volume recordings, photoplethysmographic vascular ultrasound imaging and Doppler flow velocity sensors), and equipment for digital image recording and measurements, ultrasound physics, blood pressure mea- archiving. Equipment required for cardiovascular surement and pulse volume recordings, transducer tech- computed tomography, cardiovascular magnetic reso- nology, imaging artifacts, and reviews of the noninvasive nance, and catheter-based angiography is discussed in the evaluation of specific vascular diseases. Lectures and COCATS 4 Task Force 7, 8, and 10 reports, respectively. case presentations should cover other vascular imaging modalitiessuchasmagneticresonance,computedtomo- 2.4. Ancillary Support graphic, and catheter-based angiography. The lecture se- Ancillary support should be available to facilitate ries should include regularly scheduled patient safety or appointment scheduling and follow-up; manage clinical quality improvement conferences, journal clubs, or other and financial records; retrieve laboratory and other clin- fora for interactive discussion of the established literature ical reports; enable telephone communications between and emerging scientific advances. Interaction with patients and providers (e-mailing optional); provide vascular specialists from other disciplines at these con- clean, prepared examination and consultation rooms; and ferences is recommended. properly contain, control, and remove medical waste. 3.2. Clinical Experience 3. TRAINING COMPONENTS Level I trainees should gain experience in vascular disease management in both the inpatient and outpatient settings, 3.1. Didactic Program assisting in patient care in a manner that provides patient- 3.1.1. Lectures and Conferences centered education. It is important that Level I trainees Conferences for Level I training in vascular medicine for evaluate and manage patients with arterial, venous, and cardiovascular fellows should include case presentations lymphatic disorders. Training in vascular medicine may JACC VOL. 65, NO. 17, 2015 Creager et al. 1835 MAY 5, 2015:1832– 43 COCATS 4 Task Force 9

occureitherindedicatedrotationsorthroughoutthecar- complete vascular examination and measure the ankle- diovascular clinical training period. During the course of brachial index using a hand-held Doppler device and patient-based rotations, Level I trainees should encounter should become familiar with the interpretation of and receive instruction in the bedside evaluation of pa- vascular laboratory reports as they apply to the nonin- tients with peripheral (limb) artery disease, renal and vasive assessment of obstructive arterial and venous mesenteric artery disease, extracranial carotid artery dis- thromboembolic diseases affecting the vessels of the ease, thoracic and abdominal aortic aneurysms, acute lower extremities. aortic syndromes, deep vein thrombosis, pulmonary em- Level II and III trainees should independently perform bolism, and chronic venous insufficiency. Program activity and interpret arterial physiological studies of the limbs should include appropriate use of vascular diagnostic and vascular ultrasound examinations of the veins and modalities (physiological testing; duplex ultrasound im- arteries of the limbs, abdominal vessels, and extracranial aging; and magnetic resonance, computed tomographic, carotid arteries. Additional experience in the vascular and catheter-based angiography); indications for and use laboratory during Level III training may include trans- of pharmacotherapy to prevent and treat atherosclerosis, cranial Doppler examinations, treatment of femoral artery venous thromboembolism, and their risk factors; the role pseudoaneurysms with ultrasound-guided compression of endovascular and surgical revascularization; assess- or thrombin injection, and ultrasound-guided treatment ment of cardiovascular risk; and periprocedural/perioper- of varicose veins. Level III training may include training ative management of patients undergoing endovascular in wound care techniques, including debridement and procedures and vascular surgery. application of appropriate dressings. Level II training for a cardiovascular specialist 4. SUMMARY OF TRAINING REQUIREMENTS concentrating in vascular medicine should include the evaluation and management of patients with vascular disease in both the outpatient clinic and the hospital, 4.1. Development and Evaluation of Core Competencies extending the skills acquired during Level I training. Training and requirements in vascular medicine address Level II training must include performance and interpre- the 6 general competencies promulgated by the ACGME/ tation of noninvasive vascular tests. Trainees should un- ABMS and endorsed by the ABIM. These competency do- derstand physiological and ultrasound vascular testing mains are: medical knowledge, patient care and procedural and should perform and interpret segmental pressure skills, practice-based learning and improvement, systems- measurements, pulse volume recordings, and duplex ul- based practice, interpersonal and communication skills, trasonography for venous thrombosis, venous insuffi- and professionalism. The ACC has used this structure to ciency, peripheral artery disease, abdominal aortic define and depict the components of the core clinical aneurysm, renal and mesenteric artery disease, and ca- competencies for cardiovascular medicine. The curricular rotid artery disease. milestones for each competency and domain also provide a Level III training in vascular medicine should provide developmental roadmap for fellows as they progress the knowledge and skills to function as a vascular through various levels of training and serve as an under- specialist, including the ability to interpret patients’ pinning for the ACGME/ABIM reporting milestones. The clinical presentation, plan diagnostic testing, apply clin- ACC has adopted this format for its competency and ical and laboratory information, and develop appropriate training statements, career milestones, lifelong learning, management plans for patients across the entire range of and educational programs. Additionally, it has developed vascular diseases, including but not limited to peripheral tools to assist physicians in assessing, enhancing, and artery disease, renal artery disease, mesenteric vascular documenting these competencies. disease, extracranial cerebrovascular disease, aneurysmal Table 1 delineates each of the 6 competency domains as disease of the aorta and peripheral arteries, vasculitis, well as their associated curricular milestones for training venous thromboembolism, chronic venous insufficiency, in vascular medicine. The milestones are categorized into varicose veins, lymphedema, leg ulcers, and Raynaud’s Level I, II, and III training (as previously defined in this phenomenon and other vasospastic and temperature- document) and indicate the stage of fellowship training related disorders. Trainees should also acquire skills to (12, 24, or 36 months, and additional time points) by evaluate patients before and after interventional periph- which the typical cardiovascular trainee should achieve eral vascular procedures. the designated level. Given that programs may vary with respect to the sequence of clinical experiences provided 3.3. Hands-On Experience to trainees, the milestones at which various competencies Trainees should perform physical examinations and are reached may also vary. Level I competencies may be noninvasive vascular testing appropriate to their level of achieved at earlier or later time points. Acquisition of training. Level I trainees should be able perform a Level II skills requires additional training that may be 1836 Creager et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 9 MAY 5, 2015:1832– 43

completed during the standard 3-year cardiovascular to a vascular specialist for further evaluation and fellowship. Level III skills require additional training in a intervention. dedicated advanced vascular medicine program after completion of the general cardiovascular fellowship. The 4.2.2. Level II Training Requirements table also describes examples of evaluation tools suitable Level I training in vascular medicine is a prerequisite for for assessing competence in each domain. Level II training. In addition to the 24 months of clinical training required for board eligibility in cardiovascular 4.2. Duration and Structure of Training medicine, further training, typically during the third Level I competencies must be obtained by all fellows year, should enable the fellow to become more know- during the 3-year cardiovascular disease fellowship ledgeable and skilled in vascular medicine and non- training program. Level II competencies may be obtained invasive vascular laboratory procedures (1,2).At by selected fellows during the cardiovascular disease completion of Level II training, the trainee should be fellowship depending on their career focus and elective able to perform and interpret noninvasive vascular experiences. Level III competencies are noted as addi- diagnostic examinations. In addition to interpretation, tional requirements for advanced training beyond the hands-on experience and familiarity with scanning pro- standard 3-year fellowship. The duration and structure tocolsarerequired.Completionofthevascularlabora- of training required for the typical fellow to gain com- tory curriculum during Level II or III training should petencies in Levels I, II, and III training in vascular make the trainee eligible for the Physicians’ Vas- medicine are summarized in the following text. In cular Interpretation Examination (5) and meet the re- all cases, achievement of the competencies must be quirements to serve as medical staff or medical director assessed. of an accredited vascular laboratory. Trainees seeking additional competency in vascular medicine during car- 4.2.1. Level I Training Requirements diovascular fellowship should participate in additional Level I training typically requires 2 months of exposure to inpatient and outpatient vascular medicine consulta- vascular medicine services, either as dedicated rotations tions and noninvasive vascular laboratory activities, and or in aggregate, to provide the knowledge, skills, and should observe magnetic resonance, tomographic, and attitudes required for diagnosis and management of catheter-based angiography and interventions. patients with vascular diseases (Table 1). Training should focus on the value of the clinical history and examination for diagnosis, and exposure to bedside testing, vascular 4.2.3. Level II and III Noninvasive Vascular Laboratory Training physiologic testing, duplex ultrasound imaging, and Expertise in the noninvasive vascular laboratory is other noninvasive angiographic imaging modalities important for vascular medicine specialists and required (computed tomographic and magnetic resonance angiog- for Level II and III trainees. The curriculum should raphy). The curriculum should include testing methods, include diagnostic testing procedures and equipment, indications, diagnostic criteria, and technical limitations. indications, diagnostic criteria, and technical limitations. Level I trainees should understand the advantages and In addition to the curricular components, Level II and disadvantages of the various vascular testing modalities III trainees should have extensive mentored experience for specific clinical conditions. Sufficient exposure to in interpreting vascular studies. The Physicians’ Vascular catheter-based angiography and endovascular procedures Interpretation Examination should be successfully com- should be provided to allow understanding of the roles of pleted after either Level II or III training. Interpreta- these modalities in diagnosis and management. The Level tion under faculty supervision of at least 500 studies I trainee should understand basic concepts of surgical and distributed across the vascular testing areas is a prereq- endovascular treatments, including indications, contra- uisite for the Physicians’ Vascular Interpretation Exami- indications, and potential complications. Level I trainees nation (5). These areas include duplex ultrasonography should also be instructed in the comprehensive evalua- of limb veins, limb arteries (including bypass grafts and tion of patients undergoing vascular surgery, including stents), carotid arteries, renal and mesenteric arteries, indications and risks of preoperative testing and man- and the abdominal aorta; physiological testing for pe- agement of perioperative cardiovascular problems and ripheral artery disease; and transcranial Doppler exami- complications. They should learn to recognize and nation. The vascular laboratory curriculum for the Level manage disorders associated with vascular diseases, III trainee should include laboratory quality and including hypertension, hypercholesterolemia, and dia- accreditation processes, a review of correlation studies, betes mellitus, throughout the cardiovascular fellowship and participation in quality improvement activities, such and should know when it is appropriate to refer patients as peer review and cross-modality correlation studies. JACC VOL. 65, NO. 17, 2015 Creager et al. 1837 MAY 5, 2015:1832– 43 COCATS 4 Task Force 9

TABLE 1 Core Competency Components and Curricular Milestones for Training in Vascular Medicine

Competency Component Milestones (Months) MEDICAL KNOWLEDGE 12 24 36 Add

1 Know the anatomy of the peripheral arterial and venous systems. I

2 Know the causes and clinical epidemiology of atherosclerotic peripheral vascular disease, including the incidence I and prevalence, sex and ethnic differences, role of genetics, and the influence of traditional risk factors and demographics on outcomes.

3 Know the pathophysiology of peripheral artery disease, including atherosclerosis, thrombosis, embolism, I entrapment, vasculitis, and vasospasm.

4 Know the pathophysiology, causes, and clinical epidemiology of aortic aneurysms. I

5 Know the pathophysiology, causes, and clinical epidemiology of acute aortic syndromes such as dissection and I intramural hematoma.

6 Know the pathophysiology, causes, and clinical epidemiology of deep vein thrombosis and pulmonary embolism. I

7 Know the pathophysiology, causes, and clinical epidemiology of cerebrovascular disease. I

8 Know the pathophysiology, causes, and clinical epidemiology of chronic venous insufficiency and varicose veins. I

9 Know the pathophysiology, causes, and clinical epidemiology of lymphedema. II

10 Know the cardinal symptoms and physical findings of peripheral atherosclerotic vascular diseases, including I peripheral artery disease, renal and mesenteric artery disease, extracranial cerebrovascular disease, and abdominal aortic aneurysm.

11 Know the cardinal symptoms and physical findings of venous diseases including venous thromboembolism, I chronic venous insufficiency, and varicose veins.

12 Know the differentiating characteristics between arterial, venous, and neurotrophic lower extremity ulcers. II

13 Know the natural history and prognosis of deep vein thrombosis and pulmonary embolism. I

14 Know the natural history and prognosis of peripheral atherosclerotic vascular diseases including peripheral I artery disease, renal and mesenteric artery disease, extracranial carotid artery disease, and abdominal aortic aneurysm.

15 Know the indications for noninvasive screening for abdominal aortic aneurysm. I

16 Know the indications for duplex ultrasound of the peripheral veins and carotid arteries and for duplex and I physiological testing of the peripheral arteries.

17 Know the indications for duplex ultrasonography of the renal and mesenteric arteries, arterial bypass grafts II and stents, aortic endografts, and intracranial vessels (i.e., transcranial Doppler).

18 Know the indications and contraindications for computed tomographic angiography and magnetic resonance I angiography in patients with suspected vascular disease.

19 Know the appropriate indications and laboratory tests to assess for inherited and acquired thrombophilia. I

20 Know the appropriate indications and laboratory tests to assess for vasculitis. I

21 Know the indications, contraindications, risks, clinical pharmacology, and interactions of drugs used to treat I atherosclerotic vascular diseases.

22 Know the indications, contraindications, risks, clinical pharmacology, and interactions of drugs used to treat I thrombotic disorders.

23 Know the indications, contraindications, risks, and expected outcomes for thrombolytic therapy for venous I thromboembolism (pulmonary embolism and deep vein thrombosis).

24 Know the indications and risks for surgical and endovascular treatments for acute aortic syndromes and the I expected outcomes.

25 Know the indications and risks for surgical and endovascular treatments for aortic aneurysm and the expected I outcomes.

26 Know the indications and risks for surgical and endovascular treatments for peripheral atherosclerotic I vascular diseases, including peripheral artery disease, renal and mesenteric artery disease, and extracranial cerebrovascular disease, and the expected outcomes.

EVALUATION TOOLS: chart-stimulated recall, global evaluation, and in-training examination. 1838 Creager et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 9 MAY 5, 2015:1832– 43

TABLE 1 Core Competency Components, continued

Competency Component Milestones (Months) PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

1 Skill to perform the comprehensive physical examination of the peripheral arteries, including palpation of the I abdominal aorta and peripheral pulses and auscultation for bruits.

2 Skill to perform physical examination for suspected peripheral venous disorders, including deep vein I thrombosis, varicose veins, and chronic venous insufficiency.

3 Skill to perform and interpret an ankle-brachial index measurement. I

4 Skill to perform physical examination maneuvers for arterial compression syndromes (e.g., thoracic outlet, III median arcuate ligament, and popliteal artery entrapment syndromes).

5 Skill to interpret limb segmental blood pressure measurements, pulse volume recordings and Doppler II waveforms, and treadmill vascular exercise tests.

6 Skill to interpret duplex ultrasound examinations of the extracranial carotid arteries, peripheral arteries, II abdominal aorta, renal and mesenteric arteries, and peripheral veins.

7 Skill to evaluate and manage aortic aneurysms including identification of patients for whom surgical or I endovascular repair is indicated.

8 Skill to evaluate and manage acute aortic syndromes including identification of patients for whom surgical or I endovascular therapy is indicated.

9 Skill to evaluate and manage patients with deep venous thrombosis and pulmonary embolism, including I identification of patients for whom thrombolytic therapy is indicated.

10 Skill to perform preoperative risk assessment and manage patients undergoing vascular surgery. I

11 Skill to evaluate and manage lower extremity peripheral artery disease. I

12 Skill to evaluate and manage extracranial carotid artery disease. I

13 Skill to evaluate and manage patients with chronic venous insufficiency and varicose veins, including use of III compression therapy and identification of patients for whom additional venous procedures are indicated (i.e., sclerotherapy, ablation, or surgery).

14 Skill to evaluate lymphedema. II

15 Skill to manage lymphedema. III

16 Skill to diagnose and manage arterial access complications, including arteriovenous fistula and arterial III pseudoaneurysms.

17 Skill to evaluate and manage lower extremity wounds, including indications for adjunctive imaging and biopsy, III indications and techniques for debridement, and selection of appropriate dressings.

18 Skill to evaluate and manage Raynaud’s phenomenon. III

19 Skill to evaluate and manage other temperature related disorders, including acrocyanosis, pernio, and III erythromelalgia.

20 Skill to evaluate and manage uncommon vascular disorders, including vascular compression syndromes III (e.g., thoracic outlet, popliteal entrapment), fibromuscular dysplasia, arteriopathies associated with inherited disorders of connective tissue, and congenital vascular malformations.

21 Skill to evaluate and manage peripheral and visceral artery aneurysms including identification of patients for III whom surgical or endovascular repair is indicated.

EVALUATION TOOLS: chart-stimulated recall, direct observation, and global evaluation.

SYSTEMS-BASED PRACTICE 12 24 36 Add

1 Practice in a manner that balances appropriate utilization of finite resources with the net clinical benefit for I the individual patient.

2 Utilize an interdisciplinary, coordinated approach for patient management. II

3 Utilize a coordinated approach for patient management, including coordination with rehabilitation services, III physical and occupational therapy, and consideration of employment-related issues.

4 Know the components of quality assurance in the noninvasive vascular laboratory, including certification of II technical and medical personnel, laboratory accreditation, and internal quality improvement initiatives.

EVALUATION TOOLS: chart-stimulated recall, direct observation, and multisource evaluation. JACC VOL. 65, NO. 17, 2015 Creager et al. 1839 MAY 5, 2015:1832– 43 COCATS 4 Task Force 9

TABLE 1 Core Competency Components, continued

Competency Component Milestones (Months) PRACTICE-BASED LEARNING AND IMPROVEMENT 12 24 36 Add

1 Identify knowledge and performance gaps and engage in opportunities to achieve focused education and I performance improvement.

2 Utilize decision support tools for accessing guidelines and pharmacologic information at the point of care. I

EVALUATION TOOLS: chart-stimulated recall, conference presentation, and global evaluation.

PROFESSIONALISM 12 24 36 Add

1 Forego recommending unvalidated diagnostic testing or treatments. I

2 Demonstrate a commitment to carry out professional responsibilities, appropriately refer patients, and II respond to patient needs in a way that supersedes self-interest.

3 Know and promote adherence to guidelines and appropriate use criteria. I

4 Interact respectfully with patients, families, and all members of the healthcare team, including ancillary and I support staff.

EVALUATION TOOLS: chart-stimulated recall, direct observation, and multisource evaluation.

INTERPERSONAL AND COMMUNICATION SKILLS 12 24 36 Add

1 Communicate with and educate patients and families across a broad range of cultural, ethnic, and I socioeconomic backgrounds.

2 Communicate with other specialists for optimal interdisciplinary management of patients. II

EVALUATION TOOLS: direct observation and multisource evaluation.

Add ¼ additional months beyond the 3-year cardiovascular fellowship.

4.2.4. Level III Training Requirements certification examination offered by the ABVM (3).Fel- Level III training should provide trainees with the lows seeking training in peripheral vascular interventions knowledge and skills to interpret the clinical presenta- should consult the COCATS 4 Task Force 10 report, which tion, plan diagnostic testing, apply clinical and laboratory integrates peripheral endovascular intervention with information, and develop appropriate management plans other cardiovascular interventional training components. for patients with a variety of vascular disorders as a vascular medicine specialist. This extends the knowledge and skills acquired during Level I training to the entire 5. EVALUATION OF COMPETENCY range of vascular diseases, as described in Sections 3.2 and 3.3 and outlined in Table 1, and includes perfor- A key characteristic of the competency- and curricular mance and interpretation of noninvasive vascular diag- milestone–based system is integration with outcomes- nostic examinations, as described in Section 4.2.3. based evaluations. For training programs, evaluation Fellows planning careers as vascular medicine special- tools include a variety of modalities, such as direct ists require advanced training beyond the 24 months of observation by instructors, in-training examinations, clinical training required for board eligibility in cardio- procedure logbooks, conference and case presentations, vascular medicine, typically during a 4th year dedicated multisource evaluations, trainee portfolios, and simula- to this field (1,2). Level I training in vascular medicine is a tion. Case management, judgment, and interpretive and prerequisite for Level III training, and Level II training can technical skills must be evaluated in every trainee. An be applied to Level III training, decreasing the time optimum training environment includes bidirectional required to gain Level III competence. Level III training evaluations in which faculty evaluate and provide posi- cannot be obtained during the standard 3-year cardio- tive or negative feedback to trainees, and trainees eval- vascular fellowship and requires additional exposure in a uate faculty after each rotation. The program director program meeting requirements that will be addressed in a should review these evaluations with the trainee and subsequent, separately published Advanced Training faculty individually. Mechanisms should be incorporated Statement (formerly Clinical Competence Statement) so that the fellow who performs suboptimally can be (1,2). The Level III trainee is expected to pass the counseled and further action can be taken if necessary. 1840 Creager et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 9 MAY 5, 2015:1832– 43

Within a given clinical area, achievement of compe- of individual trainees and achievement of selected tence is expected for each of the specific Level I curricular training milestones and identify areas in which additional milestones. It is not expected, however, that the training focused training is required. program formally evaluate each component (curricular Along with other professional organizations, including milestone) individually. Rather, evaluation tools may the SVM, the ACC has formulated a clinical competence focus on representative components in a given area. The statement on vascular medicine and catheter-based program director should record each trainee’sexperi- vascular interventions (2).TheSVMhasdefined the ences and performance of various patient care skills to essential components of a specialized program for document satisfactory achievement at each level of training in vascular medicine (1). Self-assessment pro- training. Trainees should maintain records of participa- grams are available through the ACC. Training directors tion and advancement in the form of a Health Insurance and trainees are encouraged to incorporate these re- Portability and Accountability Act (HIPAA)–compliant sources in the course of training. electronic database or logbook that meets ACGME Evidence of competence can be ascertained by several reporting standards and summarizes pertinent clinical certification examinations. The American Registry for information (e.g., number of cases, diagnoses, disease Diagnostic Medical Sonography (ARDMS) offers a certi- severity, outcomes, and disposition). The program direc- fying examination for physicians performing and inter- tor is responsible for confirming the experience and preting noninvasive vascular examinations (the competence of trainees. Under the aegis of the program Physicians’ Vascular Interpretation Examination) for in- director,thefacultyshouldrecordeachtrainee’sexperi- dividuals completing the noninvasive vascular labora- ences and assess performance to document satisfactory tory prerequisites during Level II or III training. achievement. The fund of knowledge regarding vascular Information concerning the eligibility and prerequisites disease must be evaluated in every trainee. Quality of for this examination can be obtained from the American clinical skills; reliability; judgment; actions that result in Registry for Diagnostic Medical Sonography (5).The complications; and interactions with other physicians, ABVM offers an examination for certification in vascular patients, and laboratory support staff are key components medicine for individuals completing Level III training. of the evaluation. Initiative and the ability to make in- Information concerning eligibility requirements can be dependent and appropriate decisions should also be obtained from the ABVM (3). Additional information assessed. The program director and Clinical Competency regarding peripheral intervention is discussed in the Committee should specifically review the overall progress COCATS 4 Task Force 10 report.

REFERENCES

1. Creager MA, Hirsch AT, Cooke JP, et al. Postgraduate Statement on Peripheral Vascular Disease). J Am Coll 5. American Registry of Diagnostic Medical Sonography. training in vascular medicine: proposed requirements Cardiol 2004;44:941–57. Physicians’ Vascular Interpretation (PVI) examinations. and standards. Vasc Med 2003;8:47–52. Available at: http://www.ardms.org/credentials_ 3. American Board of Vascular Medicine. American examinations/physicians_vascular_interpretation_pvi_ Board of Vascular Medicine certification requirements. 2. Creager MA, Goldstone J, Hirshfeld JW Jr., et al. examination. Accessed September 18, 2014. Available at: http://www.vascularboard.org/cert_reqs. ACC/ACP/SCAI/SVMB/SVS clinical competence state- cfm. Accessed September 18, 2014. ment on vascular medicine and catheter-based pe- ripheral vascular interventions: a report of the 4. Intersocietal Accreditation Commission. IAC stan- American College of Cardiology/American Heart dards and guidelines for vascular testing accreditation. KEY WORDS ACC Training Statement, COCATS, Association/American College of Physicians Task Force Available at: http://www.intersocietal.org/vascular/ computed tomography angiography, peripheral on Clinical Competence (ACC/ACP/SCAI/SVMB/SVS standards/IACVascularTestingStandards2015.pdf. Accessed vascular catheter-based intervention, peripheral Writing Committee to Develop a Clinical Competence March 25, 2015. vascular intervention, vascular medicine JACC VOL. 65, NO. 17, 2015 Creager et al. 1841 MAY 5, 2015:1832– 43 COCATS 4 Task Force 9

APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 9: TRAINING IN VASCULAR MEDICINE

Institutional/ Ownership/ Organizational Speakers Partnership/ Personal or Other Expert Committee Member Employment Consultant Bureau Principal Research Financial Benefit Witness

Mark A. Creager (Chair) Brigham & Women’s Hospital, None None None None None None Harvard Medical School Cardiovascular Division—Professor of Medicine

Heather L. Gornik Cleveland Clinic Foundation None None None None None None Cardiovascular Medicine—Medical Director, Noninvasive Vascular Laboratory; Staff Physician, Vascular Medicine

Bruce H. Gray University of South Carolina None None None None None None School of Medicine/Greenville— Professor of Surgery/Vascular Medicine; Upstate Vascular Specialists— Vascular Medicine Specialist

Naomi M. Hamburg Boston Medical Center Cardiovascular None None None None None None Medicine—Associate Professor of Medicine

William F. Iobst The Commonwealth Medical College, None None None None None None Vice Dean and Vice President for Academic and Clinical Affairs; Former employment during writing effort: American Board of Internal Medicine—Vice President, Academic Affairs

Emile R. Mohler, III University of Pennsylvania None None None None None None Health System—Associate Professor of Medicine

Christopher J. White The Ochsner Clinical School, None None None None None None University of Queensland—Professor and Chairman of Medicine

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects authors’ employment and reporting categories. To ensure complete transparency, authors’ comprehensive healthcare-related disclosure information—including relationships with industry not pertinent to this document—is available in an online data supplement. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/ relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional information about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology. 1842 Creager et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 9 MAY 5, 2015:1832– 43

APPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 9: TRAINING IN VASCULAR MEDICINE

Institutional/ Organizational Ownership/ or Other Speakers Partnership/ Personal Financial Expert Name Employment Representation Consultant Bureau Principal Research Benefit Witness

Richard Kovacs Indiana University, Krannert Official Reviewer, None None None None None None Institute of Cardiology—Q.E. ACC Board of Trustees and Sally Russell Professor of Cardiology

Dhanunjaya Kansas University Official Reviewer, None None None None None None Lakkireddy Cardiovascular Research Institute ACC Board of Governors

Howard Weitz Thomas Jefferson University Official Reviewer, None None None None None None Hospital—Director, Division Competency Management of Cardiology; Sidney Kimmel Committee Lead Reviewer Medical College at Thomas Jefferson University—Professor of Medicine

Furman McDonald American Board of Internal Organizational Reviewer, None None None None None None Medicine—Vice President, ABIM Graduate Medical Education, Department of Academic Affairs and Professor, Medicine

Kiran Musunuru Brigham and Women’s Hospital, Organizational Reviewer, None None None None None None Harvard University AHA

Aditya M. Sharma University of Virginia Health Organizational Reviewer, None None None None None None System, Cardiovascular Division— SCAI Assistant Professor, Medicine

Kanwar Singh University of Virginia Health Organizational Reviewer, None None None None None None System—Cardiovascular Division SCAI

Geoffrey Barnes University of Michigan Frankel Organizational Reviewer, None None None None None None Cardiovascular Center— SVM Cardiovascular Medicine and Vascular Medicine

Esther S.H. Kim Cleveland Clinic—Staff Physician, Organizational Reviewer, None None None None None None Department of Cardiovascular SVM Medicine

Brian D. Hoit University Hospitals Case Content Reviewer, None None None None None None Medical Center Cardiology Training and Workforce Committee

Larry Jacobs Lehigh Valley Health Network, Content Reviewer, None None None None None None Division of Cardiology; University Cardiology Training and of South Florida—Professor, Workforce Committee Cardiology

Andrew Kates Washington University Content Reviewer, None None None None None None School of Medicine Academic Cardiology Section Leadership Council

Gregory Piazza Brigham and Women’s Content Reviewer, None None None None None None Hospital/Harvard Medical PVD Council School—Cardiovascular Division

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects peer reviewers’ employment, representation in the review process, as well as reporting categories. Names are listed in alphabetical order within each category of review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional infor- mation about the ACC Disclosure Policy for Writing Committees. ABIM ¼ American Board of Internal Medicine; ACC ¼ American College of Cardiology; AHA ¼ American Heart Association; PVD ¼ peripheral vascular disease; SCAI ¼ Society for Cardiovascular Angiography and Interventions; SVM ¼ Society for Vascular Medicine. JACC VOL. 65, NO. 17, 2015 Creager et al. 1843 MAY 5, 2015:1832– 43 COCATS 4 Task Force 9

APPENDIX 3. ABBREVIATION LIST

ABIM ¼ American Board of Internal Medicine ABMS ¼ American Board of Medical Specialties ABVM ¼ American Board of Vascular Medicine ACC ¼ American College of Cardiology ACGME ¼ Accreditation Council for Graduate Medical Education ARDMS ¼ American Registry for Diagnostic Medical Sonography COCATS ¼ Core Cardiovascular Training Statement HIPAA ¼ Health Insurance Portability and Accountability Act PVI ¼ Physicians’ Vascular Interpretation SVM ¼ Society for Vascular Medicine JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL.65,NO.17,2015 ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00 PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacc.2015.03.026

TRAINING STATEMENT COCATS 4 Task Force 10: Training in Cardiac Catheterization

Endorsed by the Society for Cardiovascular Angiography and Interventions

Spencer B. King III, MD, MACC, FSCAI, Chair George D. Dangas, MD, FACC, FSCAI Joseph D. Babb, MD, FACC, FSCAI* Michele D. Voeltz, MD, FACC Eric R. Bates, MD, FACC, FSCAI Christopher J. White, MD, FACC, FSCAI Michael H. Crawford, MD, FACC

1. INTRODUCTION 1.1.2. Document Development and Approval The writing committee developed the document, 1.1. Document Development Process approved it for review by individuals selected by the 1.1.1. Writing Committee Organization ACC and SCAI, and addressed the peer reviewers’ The writing committee was selected to represent the comments. The document was revised and posted for American College of Cardiology (ACC) and the Society public comment from December 20, 2014, to January for Cardiovascular Angiography and Interventions 6, 2015. Authors addressed the additional comments fi (SCAI) and included a cardiovascular training pro- from the public to complete the document. The nal gram director, an interventional cardiology training document was approved by the Task Force, COCATS program director, an early-career cardiologist, highly- Steering Committee, and ACC Competency Manage- fi experienced specialists representing both the aca- ment Committee; rati ed by the ACC Board of demic and community-based practice settings, and Trustees in March, 2015; and endorsed by the SCAI. physicians experienced in defining and applying This document is considered current until the ACC training standards according to the 6 general compe- Competency Management Committee revises or tency domains promulgated by the Accreditation withdraws it. CouncilforGraduateMedicalEducation(ACGME)and American Board of Medical Specialties (ABMS) and 1.2. Background and Scope endorsed by the American Board of Internal Medicine The role of the cardiac catheterization laboratory in (ABIM). The ACC determined that relationships with trainee education and clinical care continues to industry or other entities were not relevant to the evolve. The cardiac catheterization laboratory serves creation of this general cardiovascular training state- as both a diagnostic and therapeutic facility. This ment. Employment and affiliation details for authors document addresses training in diagnostic cardiac and peer reviewers are provided in Appendixes 1 and 2, catheterization (invasive cardiology) as distinct from respectively, along with disclosure reporting cate- therapeutic catheterization (interventional cardiol- gories. Comprehensive disclosure information for all ogy). The catheterization laboratory has an important authors, including relationships with industry and diagnostic role in the evaluation and management of other entities, is available as an online supplement to all types of cardiovascular disease (i.e., coronary, this document. structural heart, primary myocardial, peripheral, and cerebrovascular diseases). This role includes inva- sive hemodynamic measurements and angiographic delineation of cardiovascular anatomy and pathology. The information derived from these studies overlaps *Society for Cardiovascular Angiography and Interventions Representative. with and complements that derived from noninvasive The American College of Cardiology requests that this document be cited diagnostic modalities such as echocardiography, nu- as follows: King SB III, Babb JD, Bates ER, Crawford MH, Dangas GD, Voeltz MD, White CJ. COCATS 4 task force 10: training in cardiac clear imaging, computed tomography, and magnetic catheterization. J Am Coll Cardiol 2015;65:1844–53. resonance imaging. This relationship has value in JACC VOL. 65, NO. 17, 2015 King III et al. 1845 MAY 5, 2015:1844– 53 COCATS 4 Task Force 10

both enhancing diagnostic accuracy and fostering the document are consistent with the requirements of the understanding of cardiovascular anatomy, pathology, ABIM, ACGME, and ABMS. This document covers training physiology, and pathophysiology. The widespread use of in cardiac catheterization, and the ACC/American Heart echocardiography in addition to the growing use Association (AHA)/American College of Physicians clin- of cardiovascular magnetic resonance and computed ical competence statement on coronary artery inter- tomography angiography has also changed the practice of ventional procedures covers training in interventional invasive and interventional cardiology. Patients with cardiology (5). diagnostic, echocardiographic, or hemodynamic assess- Training in diagnostic cardiac catheterization must ment of valvular or myocardial/pericardial disease may be occur and be able to be completed within a cardiovascular referred for diagnostic coronary angiography only; how- training program that is fully accredited by the ACGME. If ever, patients in whom echocardiographic findings are the program does not include an accredited training pro- inconclusive are still referred to the catheterization lab- gram in interventional cardiology, exposure to an active oratory for hemodynamic assessment. These patients are interventional cardiovascular program should be pro- often exceedingly complex. Thus, even in this era of vided. All invasive cardiovascular training programs in enhanced noninvasive imaging, the understanding and the United States must satisfy the basic standards devel- proper performance of detailed hemodynamic evaluation oped by the ACGME in order for the candidates to be in such patients remains critical. eligible for the ABIM’s clinical cardiovascular certificate. The therapeutic role of the cardiac catheterization The ACGME standards represent the qualifying re- laboratory continues to grow as interventional cardio- quirements. COCATS 4 endorses the ACGME standards for vascular procedures are applied to increasingly complex program accreditation and makes additional recommen- and critically ill patients. Urgent catheterization and dations over and above those standards. percutaneous revascularization are now considered the The ultimate goal of a cardiac catheterization training standard of care for patients with acute coronary syn- program is to teach the requisite cognitive and technical dromes, ST-elevation myocardial infarction, and cardio- knowledge of invasive cardiology. This includes in- genic shock. Furthermore, new adjunctive pharmacologic dications and contraindications for the procedures, pro- regimens and interventional diagnostic and therapeutic cedural skills, preprocedure and postprocedure care, devices have emerged. In addition, many noncoronary management of complications, and analysis and inter- therapeutic procedures—including percutaneous closure pretation of hemodynamic and angiographic data. The of atrial septal defects, valve repair or replacement, cardiac catheterization laboratory provides a platform for alcohol septal ablation, and peripheral vascular pro- teachingthecoreknowledgebaseofcardiacanatomy, cedures—are performed frequently. These procedures, pathology, physiology, and pathophysiology that all car- together with the use of left ventricular assist and support diologists should possess regardless of whether they devices, have significantly expanded the scope of inter- perform invasive cardiovascular procedures. In addition, ventional cardiology. This evolution has increased the it is this experience that provides the basic intravascular cognitive and technical knowledge base required of catheter insertion and manipulation skills needed to care invasive and interventional cardiologists. It is essential for cardiac patients in critical care environments. that all cardiologists understand the appropriate appli- The Task Force was charged with updating previously cations of invasive and interventional cardiology and that published standards for training fellows in cardiology those planning to practice these disciplines achieve the enrolled in cardiac fellowship programs on the basis of knowledge and skills needed for advanced training. changes in the field since 2008 (1) and as part of a broader Consequently, this document revises and updates the effort to establish consistent training criteria across all standards for training in cardiac catheterization during aspects of cardiology. The Task Force also updated the3-yearcardiovasculardiseasetrainingprogram(1). previously published standards to address the evolving In addition to the cardiovascular disease examination, framework of competency-based medical education the ABIM provides a certifying examination in interven- described by the ACGME Outcomes Project and the 6 tional cardiology (2), and the Residency Review Com- generalcompetenciesendorsedbyACGMEandABMS. mittee of the ACGME has a formal accreditation The background and overarching principles governing mechanism for interventional cardiovascular training fellowship training are provided in the COCATS 4 Intro- programs (3). In 1999, the ACC published a training duction, and readers should become familiar with this statement on recommendations for the structure of an foundation before considering the details of training in a optimal adult interventional cardiovascular training subdiscipline like cardiac catheterization. The Steering program (4), and the recommendations to prepare for Committee and Task Force recognize that implementation advanced training in interventional cardiology are of these changes in training requirements will occur updated in this document. The recommendations in this incrementally. 1846 King III et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 10 MAY 5, 2015:1844– 53

For most areas of adult cardiovascular medicine, separately published Advanced Training Statement 3 levels of training are delineated: (formerly Clinical Competence Statement).

In the case of interventional cardiology, Level III n Level I training, the basic training required of trainees training is for those who will practice diagnostic, inter- to become competent consultant cardiologists, is ventional cardiac, and peripheral vascular catheterization required of all cardiovascular fellows and can be and is undertaken during a dedicated interventional car- accomplished as part of a standard 3-year training diovascular training program. Level II training in vascular program in cardiology. In the case of cardiac catheter- medicine (see COCATS 4 Task Force 9 report) is also ization, Level I represents training for those who will suggested prior to or in conjunction with Level III training practice noninvasive cardiology and whose invasive in catheter-based peripheral vascular intervention. activities will be confined to critical care unit pro- The number of procedures recommended at each cedures. This level will also provide training in the in- level of training is based on published guidelines (6), dications for the procedure and in the accurate competency statements (5,7), and the experience and interpretation of data obtained in the catheterization opinions of the writing group. It is assumed that training is laboratory. directed by appropriately qualified mentors in an ACGME– n Level II training refers to the additional training in 1 or accredited program and that satisfactory completion of more areas that enables some cardiologists to perform training is documented by the program director. The or interpret specific procedures or render more number of procedures and duration of training required for specialized care for patients and conditions. This level each level of training are summarized in Section 4. of training is recognized for those areas in which an accepted instrument or benchmark, such as a qualifying 2. GENERAL STANDARDS examination, is available to measure specificknowl- edge, skills, or competence. Level II training in selected Several organizations, such as the ACC, AHA, American areas may be achieved by some trainees during the College of Physicians, and SCAI, have addressed training standard 3-year cardiovascular fellowship, depending requirements and guidelines for interventional cardiology. ’ on the trainees career goals and use of elective rota- The recommendations are congruent and address faculty, tions. It is anticipated that during a standard 3-year facility requirements, emerging technologies, and prac- fi cardiovascular fellowship training program, suf cient tice. We recommend strongly that candidates for the ABIM time will be available for the trainee to receive Level II examination for certification in cardiovascular diseases, as fi training in a speci c subspecialty. In the case of cardiac well as those seeking certification in interventional cardi- catheterization and peripheral angiography, Level II is ology, review the specificrequirementsoftheABIM(2). defined as training for those who will either practice diagnostic cardiovascular catheterization or pursue 2.1. Faculty further training in interventional cardiology. Level II Faculty must be experienced and committed to the training may also be sought by those who aspire to teaching program. All requirements for faculty are out- advanced training in heart failure or electrophysiology. lined in ABMS and ACGME documents (3).Exposureto Notably, no certification examination currently exists multiple faculty mentors substantially enhances the to assess Level II competency in this field. quality of a training experience. The faculty should n Level III training requires additional training and consist of a full-time training director, key faculty, and experience beyond the cardiovascular fellowship in otherassociatedfaculty.Anoptimalprogramshouldhave order for the trainee to acquire specialized knowledge at least 3 key faculty members, 1 of whom is the training and competencies in performing, interpreting, and director, who devotes at least 20 hours per week to the training others to perform specificproceduresorrender program. Associated faculty may have varying levels of advanced specialized care at a high level of skill. Level commitment and involvement in the program. III training is described here only in broad terms to provide context for trainees and clarify that these 2.1.1. Training Director advanced competencies are not covered during the The training director for the diagnostic catheterization cardiovascular fellowship and require additional train- curriculum must be certified in cardiovascular medicine ing and designation by an independent certification by the ABIM and should be recognized as an expert in board, often coupled with a certifying examination. cardiac catheterization. Preferably, the director should be Level III training cannot be obtained during the stan- a full-time faculty member of the overall cardiovascular dard 3-year cardiovascular fellowship and requires training program, committed to medical education and additional exposure in a program that meets require- teaching. If the director also serves as training director of ments that will be addressed in a subsequent, interventional cardiology, certification in interventional JACC VOL. 65, NO. 17, 2015 King III et al. 1847 MAY 5, 2015:1844– 53 COCATS 4 Task Force 10

cardiology is required. The director should be responsible physiology, such as fractional flow reserve, and coronary for the invasive teaching curriculum and overall teaching and structural heart anatomy, such as intravascular and program in addition to trainee evaluation. If the program intracardiac ultrasound, is strongly recommended. director is also the director of the catheterization labora- tory, this individual should also be responsible for the 2.4. Ancillary Support administration of the laboratory, quality assurance, and The program must have on-site access to all core cardio- radiation safety. vascular services, including a cardiac critical care facility, and echocardiography and stress testing with nuclear 2.1.2. Other Key Faculty imaging. Complete electrophysiological testing onsite is Key faculty members should be certified in cardiovascular desirable, but alternatively, it may be arranged by referral medicine by the ABIM and have expertise in all aspects to an affiliated institution. On-site support services for of diagnostic procedures, including the evaluation of interventional cardiovascular training include cardiac coronary, valvular, congenital, cardiomyopathic and pe- surgery, anesthesia, vascular and interventional radi- ripheral vascular disease, and should be familiar with ology, vascular surgery, vascular medicine, neurology, complex hemodynamics in patients with all types of heart nephrology, and hematology. disease. The program faculty should include individuals with expertise in the performance of trans-septal cathe- 3. TRAINING COMPONENTS terization, the interpretation and performance of intra- vascular imaging, and physiological assessment. If the 3.1. Didactic Program program also provides training in interventional cardiol- For Level I and II training, all trainees must attend a weekly ogy, its faculty must satisfy the requirements for pro- cardiac catheterization conference. This may be a com- grams in interventional cardiology by the ACGME (3) and bined medical/surgical conference. The conference must the requirements outlined in the previously published present hemodynamic and angiographic data that are dis- ACC training statement (1).Ideally,theprogramshould cussedincontextwithhistory,physicalexamination,and include faculty who possess skills in advanced interven- noninvasive findings. Indications, complications, and tional cardiovascular techniques, including interven- management strategies should also be discussed. It is tional therapy of structural heart, peripheral arterial, and particularly important that the Level I and II curricula carotid artery disease. should focus on teaching hemodynamics, cardiovascular physiology, and the pathophysiology of the major cardio- 2.2. Facilities vascular disorders in addition to coronary and peripheral All training facilities must be equipped and staffed to vascular pathoanatomy. In this role, it is important that the function in accordance with the ACC/AHA/SCAI clinical cardiac catheterization program establish a close liaison expert consensus document on cardiac catheterization with other noninvasive diagnostic laboratories. The laboratory standards (7). educational program should emphasize relationships be- tween the findings provided by the different diagnostic 2.3. Equipment modalities in order to create a clear picture of the physi- 2.3.1. X-Ray Imaging Equipment ology and pathophysiology of the various cardiovascular The cardiac catheterization laboratory must generate disorders. A regular patient safety or quality improvement high-quality x-ray digital images during diagnostic and conference, either as part of the cardiac catheterization interventional catheterization procedures. Laboratories conference or as a separate conference, is also required. performing peripheral and carotid angiography must have Additionally, exposure to and participation in regular digital subtraction angiography and appropriately sized catheterization laboratory peer review conferences is image intensifiers (i.e., 12 in to 16 in). The laboratory must strongly recommended to educate trainees in focused and have access to the support personnel needed to ensure functional practices in peer review using random case se- that image quality is optimal and that radiation exposure lection, anonymization, and concordance with guidelines. to patients and staff is both monitored and minimized. Radiation exposure to trainees must be carefully moni- 3.2. Clinical Experience tored on a monthly basis. Level I and II training require exposure to the wide vari- ety of cardiovascular disorders and clinical procedures. 2.3.2. Hemodynamic Monitoring and Recording Equipment This experience is importanttoprovidenotonlydirect The facility must have high-quality physiological moni- hands-on training, but also the requisite material for toring and recording equipment to permit accurate clinical conferences. In addition to becoming familiar assessment of complex hemodynamic conditions. The with the many manifestations of coronary artery disease, presence of equipment for assessing both coronary all trainees should also acquire experience in the 1848 King III et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 10 MAY 5, 2015:1844– 53

hemodynamic assessment, evaluation, and management 4. Active involvement in pre- and postprocedural man- of patients with valvular, myocardial, peripheral vascular, agement inside and outside of the catheterization labo- and congenital heart disease. ratory. After the procedure, a note should be placed in the medical record. The trainee should monitor the 3.3. Hands-On Experience patient and be available to respond to adverse re- Thenatureofatrainee’s participation in a given proce- actions or complications that may arise, such as hy- dure will vary depending on the procedure’s complexity potension, vascular complications, bleeding, heart and the trainee’s experience level. Requisite participation failure, renal failure, or myocardial ischemia. A final in a procedure includes the following elements: report should be completed within the time frame stipulated by local institutional policy and regulatory 1. Preprocedural evaluation to assess appropriateness and standards. If a complication occurs, the trainee should plan procedure strategy. Before the procedure, it is participate in the follow-up and management of the expected that the trainee will review the patient’s complication. medical record and obtain a confirmatory history and physical examination, giving specific attention to fac- 4. SUMMARY OF TRAINING REQUIREMENTS tors known to increase the risk of the procedure, such as vascular disease, renal failure, history of contrast reaction, congestive heart failure, anemia, active 4.1. Development and Evaluation of Core Competencies infection, and conditions known to increase the risk of Training and requirements in invasive cardiology address bleeding. The trainee should also obtain informed the 6 general competencies promulgated by the ACGME/ consent and document a preprocedural note that in- ABMS and endorsed by the ABIM. These competency do- cludes indications for the procedure, opportunities for mains are: medical knowledge, patient care and proce- the findings to influencethecareofthepatient,risksof dural skills, systems-based practice, practice-based the procedure, alternatives to the procedure, and un- learning and improvement, professionalism, and inter- derstanding by the patient. This should be done and personal and communication skills. The ACC has used this documented in conjunction with the supervising fac- structure to define and depict the components of the core ulty member. clinical competencies for cardiology. The curricular 2. Performance of the procedure by the trainee at a level milestones for each competency and domain also provide appropriate to experience, always (at all levels) under a developmental roadmap for fellows as they progress the direct supervision of a program faculty member. through various levels of training and serve as an un- Level I trainees will begin in a mostly observational derpinning for the ACGME/ABIM reporting milestones. role and assume greater participation as experience is The ACC has adopted this format for its competency and gained. Level II trainees will assume progressive re- training statements, career milestones, lifelong learning, sponsibility for conducting diagnostic procedures and and educational programs. Additionally, it has developed coordinating the various functions of ancillary staff in tools to assist physicians in assessing, enhancing, and the room (e.g., directing nurses, hemodynamic tech- documenting these competencies. nicians, and junior fellows) as they acquire skills. Table 1 delineates each of the 6 general competency Highly experienced Level II (or Level III) trainees may domains, as well as their associated curricular mile- collaborate in a procedure with Level I trainees under stones for training in invasive cardiology. The mile- the direct supervision of a program faculty member. In stones are categorized into Level I, II, and III training this circumstance, both Level I and II (or Level III) (as previously defined in this document), and indicate trainees may claim credit for participation in the the stage of fellowship training (12, 24, or 36 months, procedure. and additional time points) by which the typical car- 3. Participation in analyzing the hemodynamic and diovascular trainee should achieve the designated level. angiographic data obtained during the procedure and Given that programs may vary with respect to the preparation of the procedure report as well as formula- sequence of clinical experiences provided to trainees, tion of treatment plans and relevant communication the milestones at which various competencies are back to the referring doctors. Trainees should partici- reached may also vary. Level I competencies may be pate in the creation of the procedure report, including achieved at earlier or later time points. Acquisition of drawing appropriate conclusions and making recom- Level II skills requires additional training, and Level III mendations to ordering physicians and care teams. skills require training in a dedicated interventional Procedure results should be communicated to care cardiovascular program. The table also describes exam- teams clearly and concisely by the fellow and/or su- ples of evaluation tools suitable for assessment of pervising physician. competence in each domain. JACC VOL. 65, NO. 17, 2015 King III et al. 1849 MAY 5, 2015:1844– 53 COCATS 4 Task Force 10

TABLE 1 Core Competency Components and Curricular Milestones for Training in Invasive Cardiology

Competency Component Milestones (Months) MEDICAL KNOWLEDGE 12 24 36 Add

1 Know the indications/contraindications and potential complications of cardiac catheterization for assessment of I coronary, valvular, myocardial, and basic adult congenital heart diseases.

2 Know the principles of radiation safety. I

3 Know the use and complications of contrast media and the role of renal protection measures. I

4 Know the indications for, and clinical pharmacology of, antiplatelet and anticoagulant drugs and vasopressor and I vasodilator agents used in the cardiac catheterization laboratory.

5 Know normal cardiovascular hemodynamics and the principles and interpretation of waveforms, pressure, flow, I resistance, and cardiac output measurements.

6 Know the characteristic hemodynamic findings with myocardial, valvular, pericardial, and pulmonary vascular diseases. I

7 Know the methods to detect and estimate the magnitude of intracardiac and extracardiac shunts. I

8 Know coronary anatomy, its variations and congenital abnormalities, and its coronary blood flow physiology. I

9 Know the angiographic features of coronary artery disease and how to assess the anatomic and physiologic severity. I

10 Know the vascular anatomy and the indications and contraindications for, and complications of, peripheral vascular I angiography.

11 Know the indications and potential complications of percutaneous coronary, peripheral, valvular, and structural I heart interventions.

12 Know the indications and contraindications for, and the complications of, endomyocardial biopsy and pericardiocentesis. I

13 Know the indications for, and the mechanisms of action of, mechanical circulatory support devices. I

14 Know the indications for, and complications of, vascular access and closure strategies and devices. I

EVALUATION TOOLS: conference presentation, direct observation, in-training examination, logbook, and simulation.

PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

1 Skill to perform preprocedural evaluation, assess appropriateness, obtain informed consent, and plan procedure strategy. I

2 Skill to perform venous and arterial access and obtain hemostasis. I

3 Skill to perform right heart catheterization. I

4 Skill to analyze hemodynamic, ventriculographic, and angiographic data and to integrate with clinical findings for I patient management.

5 Skill to manage postprocedural patients, including complications and coordination of care. I

6 Skill to perform endomyocardial biopsy. II

7 Skill to perform pericardiocentesis. II

8 Skill to perform diagnostic left heart catheterization, ventriculography, and coronary angiography. II

9 Skill to place an intra-aortic balloon pump emergently. II

10 Skill to perform diagnostic peripheral (excluding carotid) angiography. II

11 Skill to perform percutaneous coronary interventions. III

12 Skill to perform peripheral, carotid, valvular, and structural heart interventions. III

13 Skill to insert and manage percutaneous left ventricular support devices. III

EVALUATION TOOLS: chart-stimulated recall, conference presentation, direct observation, logbook, and simulation.

SYSTEMS-BASED PRACTICE 12 24 36 Add

1 Coordinate care in an interdisciplinary approach for patient management, including transition of care. I

2 Utilize cost-awareness and risk/benefit analysis in patient care. I

EVALUATION TOOLS: chart-stimulated recall, conference presentation, direct observation, and logbook. 1850 King III et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 10 MAY 5, 2015:1844– 53

TABLE 1 Core Competency Components, continued

Competency Component Milestones (Months) PRACTICE-BASED LEARNING AND IMPROVEMENT 12 24 36 Add

1 Locate, appraise, and assimilate information from scientific studies, guidelines, and registries in order to identify I knowledge and performance gaps.

2 Document number and outcomes of diagnostic and therapeutic procedures. I

EVALUATION TOOLS: conference presentation, direct observation, logbook, and reflection and self-assessment.

PROFESSIONALISM 12 24 36 Add

1 Practice within the scope of expertise and technical skills. I

2 Know and promote adherence to guidelines and appropriate use criteria. I

3 Interact respectfully with patients, families, and all members of the healthcare team, including ancillary and support staff. I

EVALUATION TOOLS: conference presentation, direct observation, multisource evaluation, and reflection and self-assessment.

INTERPERSONAL AND COMMUNICATION SKILLS 12 24 36 Add

1 Communicate with and educate patients and families across a broad range of socioeconomic, ethnic, and cultural I backgrounds, including obtaining informed consent.

2 Communicate and work effectively with physicians and other professionals on the healthcare team regarding I procedure findings, treatment plans, and follow-up care coordination.

3 Complete procedure records and communicate testing results to physicians and patients in an effective and I timely manner.

EVALUATION TOOLS: direct observation and multisource evaluation.

Add ¼ additional months beyond the 3-year cardiovascular fellowship.

4.2. Structure and Duration of Training congenital disease. Only 1 Level I trainee may claim credit The specific competencies for Levels I, II, and III are for participation in a given procedure; however, a Level delineated in Table 1.LevelIcompetenciesmustbeob- I and a Level II (or III) trainee may claim credit for the tained by all fellows during the cardiovascular disease same procedure if they perform different functions, fellowship training program. Level II competencies may applicable to their training levels and expertise. An be obtained during the cardiovascular disease fellowship essential part of Level I training is instruction in evaluating by selected fellows depending on their career focus and hemodynamic data and reading cardiac and coronary elective experiences. Level III competencies are noted so angiographic studies. that fellows are aware of the competencies for which 4.2.2. Level II Training Requirements additional, advanced training beyond the standard 3-year Level II training generally requires a total of approxi- fellowship is required. A brief discussion of the compe- mately 6 months in the cardiac catheterization labora- tencies and training requirements for Levels I, II, and III tory and participation in the performance (under direct follow. Although the training duration and numbers of supervision) of approximately 300 diagnostic cardiac procedures are typically required to obtain competency, catheterization procedures. For competency in periph- trainees must also demonstrate achievement of the eral vascular angiography, the typical candidate should competencies as assessed by the outcomes evaluation participate in the performance (under direct supervision) measures. of approximately 100 invasive diagnostic peripheral 4.2.1. Level I Training Requirements vascular (not carotid) angiographic procedures. This Level I training requires approximately 4 months of competency may not be acquired by all Level II trainees experience in the cardiac catheterization laboratory. Dur- and is further addressed in the COCATS 4 Task Force 9 ing this period, a trainee should generally participate in a report. Only 1 Level II trainee may claim credit for minimum of 100 diagnostic cardiac catheterization pro- participationinagivendiagnosticprocedure.ALevelII cedures. At least 50 of these procedures should involve trainee may claim 1 cardiac procedure and 1 peripheral coronary angiography, and 25 should involve hemody- vascular diagnostic procedureforthesamepatientwhen namic assessment of valvular, myocardial, pericardial, or appropriate. JACC VOL. 65, NO. 17, 2015 King III et al. 1851 MAY 5, 2015:1844– 53 COCATS 4 Task Force 10

4.2.3. Level III Training Requirements considered. Trainees should maintain records of partici- Level III training must be performed during additional pation and advancement in the form of a Health – year(s) of fellowship dedicated to cardiovascular inter- Insurance Portability and Accountability Act (HIPAA) ventional training (2). Level II training in vascular medi- compliant electronic database or logbook that meets cine (COCATS 4 Task Force 9 report) is suggested prior to ACGME/ABIM reporting standards and summarizes or in conjunction with training in catheter-based periph- pertinent clinical information (e.g., number of cases, eral vascular intervention. Level III training leads to the diversity of referral sources, diagnoses, disease severity, ability to direct a cardiac catheterization laboratory, train outcomes, and disposition). others, and conduct advanced research in interventional The ACC, AHA, and SCAI have formulated a clinical cardiology. competence statement on invasive and interventional cardiovascular procedures (5). Self-assessment programs 5. EVALUATION OF COMPETENCY and competence examinations are available through the ACC and other organizations. Training directors and Evaluation tools in cardiac catheterization include direct trainees are encouraged to incorporate these resources in observation by instructors, in-training examinations, case the course of training. logbooks, conference and case presentations, multisource The faculty, under the aegis of the program director, evaluations, trainee portfolios, simulation, and reflection should record and verify each trainee’s experiences, and self-assessment. Case management, judgment, assess performance, and document satisfactory achieve- interpretive, and bedside skills must be evaluated in ment. The program director is responsible for confirming every trainee. Quality of care and follow-up; reliability; experience and competence and for reviewing the overall judgment, decisions, or actions that result in complica- progress of individual trainees with the Clinical Compe- tions; interaction with other physicians, patients, and tency Committee to ensure achievement of selected laboratory support staff; initiative; and the ability to training milestones and to identify areas in which addi- make appropriate decisions independently should be tional focused training may be required.

REFERENCES

1. Jacobs AK, Babb JD, Hirshfeld JW Jr., et al. Task force the structure of an optimal adult interventional cardi- intervention: a report of the American College of Car- 3: training in diagnostic and interventional cardiac ology training program: a report of the American diology Foundation/American Heart Association Task catheterization. J Am Coll Cardiol 2008;51:355–61. College of Cardiology Task Force on Clinical Expert Force on Practice Guidelines and the Society for Car- Consensus Documents. J Am Coll Cardiol 1999;34: diovascular Angiography and Interventions. J Am Coll 2. American Board of Internal Medicine. ABIM inter- 2141–7. Cardiol 2011;58:e44–122. ventional cardiology policies. Available at: http://www. fi abim.org/certi cation/policies/imss/icard.aspx. Accessed 5. Harold JG, Bass TA, Bashore TM, et al. ACCF/AHA/ 7. Bashore TM, Balter S, Barac A, et al. 2012 ACCF/SCAI September 27, 2014. SCAI 2013 update of the clinical competence statement expert consensus document on cardiac catheterization laboratory standards update: a report of the American 3. Accreditation Council for Graduate Medical Educa- on coronary artery interventional procedures: a report College of Cardiology Foundation Task Force on Expert tion. ACGME program requirements for graduate of the American College of Cardiology Foundation/ Consensus Documents. J Am Coll Cardiol 2012;59: medical education in interventional cardiology (inter- American Heart Association/American College of Phy- 2221–305. nal medicine). Available at: http://www.acgme.org/ sicians Task Force on Clinical Competence and Training acgmeweb/Portals/0/PFAssets/2013-PR-FAQ-PIF/152_ (Writing Committee to Revise the 2007 Clinical interventional_card_int_med_07132013_1-YR.pdf. Accessed Competence Statement on Cardiac Interventional September 27, 2014. Procedures). J Am Coll Cardiol 2013;62:357–96. KEY WORDS ACC Training Statement, cardiac 4. Hirshfeld JW Jr., Banas JS Jr., Brundage BH, et al. 6. Levine GN, Bates ER, Blankenship JC, et al. 2011 catheterization, clinical competence, COCATS, ACC training statement on recommendations for ACCF/AHA/SCAI guideline for percutaneous coronary fellowship training 1852 King III et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 10 MAY 5, 2015:1844– 53

APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 10: TRAINING IN CARDIAC CATHETERIZATION

Institutional/ Ownership/ Organizational Speakers Partnership/ Personal or Other Expert Committee Member Employment Consultant Bureau Principal Research Financial Benefit Witness

Spencer B. King III (Chair) Saint Joseph’s Heart and None None None None None None Vascular Institute—Professor of Medicine (Emeritus), Emory University

Joseph D. Babb East Carolina University None None None None None None Cardiovascular Sciences— Professor of Medicine

Eric R. Bates University of Michigan Hospitals None None None None None None and Health Centers—Professor of Medicine

Michael H. Crawford University of California None None None None None None San Francisco Medical Center—Professor of Medicine, Chief of Clinical Cardiology

George D. Dangas Mount Sinai Medical Center— None None None None None None Program Director, Interventional Cardiology

Michele D. Voeltz Henry Ford Hospital—Director, None None None None None None Interventional Cardiology Fellowship Training Program

Christopher J. White The Ochsner Clinical School, None None None None None None University of Queensland— Professor and Chairman of Medicine

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects authors’ employment and reporting categories. To ensure complete transparency, authors’ comprehensive healthcare-related disclosure information—including relationships with industry not pertinent to this document—is available in an online data supplement. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/ relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional information about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology. JACC VOL. 65, NO. 17, 2015 King III et al. 1853 MAY 5, 2015:1844– 53 COCATS 4 Task Force 10

APPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 10: TRAINING IN CARDIAC CATHETERIZATION

Institutional/ Organizational Ownership/ or Other Speakers Partnership/ Personal Financial Expert Name Employment Representation Consultant Bureau Principal Research Benefit Witness

Richard Kovacs Indiana University, Krannert Official Reviewer, None None None None None None Institute of Cardiology—Q.E. ACC Board of Trustees and Sally Russell Professor of Cardiology

Dhanunjaya Kansas University Official Reviewer, None None None None None None Lakkireddy Cardiovascular Research ACC Board of Governors Institute

Howard Weitz Thomas Jefferson University Official Reviewer, None None None None None None Hospital—Director, Division Competency Management of Cardiology; Sidney Kimmel Committee Lead Reviewer Medical College at Thomas Jefferson University—Professor of Medicine

J. Dawn Abbott Warren Alpert Medical School Organizational Reviewer, SCAI None None None None None None of Brown University—Director, Interventional Cardiology Fellowship; Associate Professor of Medicine

Michael Ragosta University of Virginia Health Organizational Reviewer, SCAI None None None None None None System—Cardiovascular Division

Brian D. Hoit University Hospitals Case Content Reviewer, Cardiology None None None None None None Medical Center Training and Workforce Committee

Larry Jacobs Lehigh Valley Health Network, Content Reviewer, Cardiology None None None None None None Division of Cardiology; Training and Workforce University of South Florida— Committee Professor, Cardiology

Andrew Kates Washington University Content Reviewer, None None None None None None School of Medicine Academic Cardiology Section Leadership Council

Lloyd W. Klein Rush University Content Reviewer, Interventional None None None None None None Section Leadership Council

Robert Piana Vanderbilt University Medical Content Reviewer, Interventional None None None None None None Center—Professor, Medicine, Section Leadership Council Cardiology

Tanveer Rab Emory University School of Content Reviewer, Interventional None None None None None None Medicine—Associate Professor, Section Leadership Council Medicine, Cardiology/ Interventional Cardiology

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects peer reviewers’ employment, representation in the review process, as well as reporting categories. Names are listed in alphabetical order within each category of review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional infor- mation about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology; SCAI ¼ Society for Cardiovascular Angiography and Interventions.

APPENDIX 3. ABBREVIATION LIST

ABIM ¼ American Board of Internal Medicine ABMS ¼ American Board of Medical Specialties ACC ¼ American College of Cardiology ACGME ¼ Accreditation Council for Graduate Medical Education AHA ¼ American Heart Association COCATS ¼ Core Cardiovascular Training Statement HIPAA ¼ Health Insurance Portability and Accountability Act SCAI ¼ Society for Cardiovascular Angiography and Interventions JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL.65,NO.17,2015 ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00 PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacc.2015.03.029

TRAINING STATEMENT COCATS 4 Task Force 11: Training in Arrhythmia Diagnosis and Management, Cardiac Pacing, and Electrophysiology

Endorsed by the Heart Rhythm Society

Hugh Calkins, MD, FACC, FHRS, Chair Sanjay Kaul, MBBS, FACC Eric H. Awtry, MD, FACC John M. Miller, MD, FACC, FHRS

Thomas Jared Bunch, MD, FACC Usha B. Tedrow, MD, FHRS, MSC*

1. INTRODUCTION 1.1.2. Document Development and Approval The writing committee developed the document, 1.1. Document Development Process approved it for review by individuals selected by the 1.1.1. Writing Committee Organization ACC and HRS, and addressed the reviewers’ comments. The writing committee was selected to represent the The document was revised and posted for public American College of Cardiology (ACC) and the Heart comment from December 20, 2014, to January 6, 2015. Rhythm Society (HRS) and included a cardiovascular Authors addressed the additional comments to com- fi training program director, an electrophysiology (EP) plete the document. The nal document was approved program training director, early-career experts, by the Task Force, COCATS Steering Committee, and fi highly experienced specialists representing both the ACC Competency Management Committee; rati ed academic and community-based practice settings, by the ACC Board of Trustees in March, 2015; and and physicians experienced in defining and applying endorsed by the Heart Rhythm Society. This document training standards according to the 6 general compe- is considered current until the ACC Competency tency domains promulgated by the Accreditation Management Committee revises or withdraws it. CouncilforGraduateMedicalEducation(ACGME)and the American Board of Medical Specialties (ABMS) and 1.2. Background and Scope endorsed by the American Board of Internal Medicine The diagnosis and management of cardiac arrhyth- (ABIM). The ACC determined that relationships with mias and conduction disorders are common and industry or other entities were not relevant to the important components of the practice of clinical car- creation of this general cardiovascular training state- diology and are thus part of the core competency ment. Employment and affiliation details for authors training of a clinical cardiologist. Clinical cardiac and peer reviewers are provided in Appendixes 1 and 2, electrophysiologists are responsible for the compre- respectively, along with disclosure reporting cate- hensive care of patients with more complex arrhyth- gories. Comprehensive disclosure information for all mias, along with advanced testing and invasive authors, including relationships with industry and therapies. Clinical cardiac electrophysiologists are other entities, is available as an online supplement to trained to implant cardiac electrical devices, perform this document. diagnostic EP procedures and therapeutic catheter ablation procedures, and employ pharmacological agents to treat patients with complex arrhythmias *Heart Rhythm Society Representative. and conduction disturbances. Cardiac implantable The American College of Cardiology requests that this document be cited electrical devices (CIEDs) include pacemakers, im- as follows: Calkins H, Awtry EH, Bunch TJ, Kaul S, Miller JM, Tedrow UB. fi COCATS 4 task force 11: training in arrhythmia diagnosis and management, plantable cardioverter-de brillators (ICDs), cardiac cardiac pacing, and electrophysiology. J Am Coll Cardiol 2015;65:1854–65. resynchronization therapy (CRT) devices, implantable JACC VOL. 65, NO. 17, 2015 Calkins et al. 1855 MAY 5, 2015:1854– 65 COCATS 4 Task Force 11

hemodynamic monitors, and implantable loop recorders specific subspecialty. In the case of EP, Level II training (ILRs). For this document, implantable hemodynamic is required for individuals to provide specialized monitors and ILRs are excluded from the minimum arrhythmia and CIED management, including implan- training requirements. All cardiovascular trainees are tation, interrogation, and programming of pacemakers expected to understand their indications for clinical use andILRs,andinterrogationandprogrammingof and to learn how to interpret the generated results in implanted defibrillators. Those cardiovascular fellows providing clinical care as part of their basic training. seeking to implant ICDs and CRT devices without sub- The Task Force was charged with updating previously specialty board certification in CCEP are required to published standards for training fellows in cardiology take an additional year of dedicated training beyond enrolled in cardiac fellowship programs (1–4) on the basis of the 3 years required for cardiovascular training. changes in the field since 2008 (2) and as part of a broader n Level III training requires additional training and effort to establish consistent training criteria across all as- experience beyond the cardiovascular fellowship for the pects of cardiology. This document does not provide spe- trainee to acquire specialized knowledge and experience cific guidelines for advanced cardiac electrophysiology in performing, interpreting, and training others to training. Recommendations for advanced training in clin- perform specific procedures or render advanced ical cardiac electrophysiology (CCEP) are provided in the specialized care for specific procedures at a high level of 2006 Clinical Competence Statement (5). The 2006 Clinical skill. In the case of EP, Level III training is required of Competence Statement is currently being revised and individuals seeking subspecialty board certification retitled as the Electrophysiology Advanced Training (CCEP). As noted previously, those cardiovascular fel- Statement. In its revised form, it will provide detailed lows seeking to implant ICDs and CRT devices without recommendations for the electrophysiology training subspecialty board certification in CCEP are required to required to obtain ABIM certification. The Task Force also take an additional year of dedicated training beyond the updated previously published standards to address the 3 years required for cardiovascular training. evolving framework of competency-based medical educa- The recommended number of cases, procedures, and tion described by the ACGME Outcomes Project and the 6 experiences is based on published guidelines, compe- general competencies endorsed by ACGME and ABMS. The tency statements, and the experience and opinions of the background and overarching principles governing fellow- members of the writing group. It is assumed that training ship training are provided in the COCATS 4 Introduction, is directed by appropriately trained mentors in and readers should become familiar with this foundation an ACGME–accredited program and that satisfactory before considering the details of training in a subdisci- completion of training is documented by the program pline like electrophysiology. The Steering Committee director. The number and types of encounters and the and Task Force recognize that implementation of these duration of training required for fellows are summarized changes in training requirements will occur incrementally. in Section 4. Level III training is described here only in For most areas of adult cardiovascular medicine, 3 broad terms to provide context for trainees and clarify levels of training are delineated: that these advanced competencies are not covered during the cardiovascular fellowship. The additional exposure n Level I training, the basic training required of trainees to and requirements for Level III training will be addressed become competent consultant cardiologists, is required in a subsequent, separately published, Advanced Training of all fellows in cardiology, and can be accomplished as Statement, previously described in the 2006 Clinical part of a standard 3-year training program in cardiology. Competency Statement (5). n Level II training refers to additional training in 1 or more areas that enables some cardiologists to perform 2. GENERAL STANDARDS or interpret specific procedures or render more specialized care for patients and conditions. This level Three organizations—the ACC, American Heart Associa- of training is recognized for those areas in which an tion, and HRS—have addressed training requirements and accepted instrument or benchmark, such as a qualifying guidelines for the following topic areas: permanent pace- examination, is available to measure specificknowl- maker selection, implantation, and follow-up (6,7);im- edge, skills, or competence. Level II training in selected plantation and follow-up of ICDs (8,9); training in catheter areas may be achieved by some trainees during the ablation procedures (10,11); and educational objectives for standard 3-year cardiovascular fellowship, depending fellowship training in CCEP (2,12,13). The recommenda- on the trainees’ careergoalsanduseofelectiverota- tions are congruent and address faculty, facility require- tions. It is anticipated that during a standard 3-year ments, emerging technologies, and practice. We strongly cardiovascular fellowship training program, sufficient recommend that candidates for the ABIM examination for time will be available to receive Level II training in a certification in cardiovascular diseases, as well as those 1856 Calkins et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 11 MAY 5, 2015:1854– 65

seeking certification of added qualifications in CCEP, re- journal clubs, grand rounds, clinical case presentations, view the specificrequirementsoftheABIM(14,15). and patient safety or quality improvement conferences. The intensity of training and required resources The electrocardiographic (ECG) manifestations of ar- vary according to the level of training provided. Cardio- rhythmias should be taught on a regular basis during vascular fellowship programs do not have to satisfy the formal ECG conferences. requirements regarding facilities and faculty for training in EP (10,11) unless they also have an ABIM–accredited EP 3.2. Clinical Experience training program designed to provide Level III training. Rotation on an arrhythmia service is an essential Eligibility for the ABIM CCEP examination requires component of all levels of EP training. A Level I trainee that training take place in a program accredited by the should gain first-hand experience as a consultant in ACGME (14). arrhythmia management. It is important that the arrhythmia consultation servicehavearobustpatientmix 2.1. Faculty and acuity level. During the required 2 months on the Faculty involved in training in arrhythmia diagnosis and consultation arrhythmia service, Level I trainees should management, cardiac pacing, and electrophysiology evaluate 1 or more inpatient arrhythmia consultations should include specialists who are skilled in the phar- daily in addition to providing follow-up care after initial macological, catheter-based, and surgical aspects of pac- consultation. In addition to participating in arrhythmia ing and EP and are knowledgeable about the risks to the consultations, it is also important for Level I trainees to patient and medical personnel associated with radiation observe EP procedures including diagnostic EP studies, exposure. This faculty should include at least 1 board- placement of ILRs, catheter ablation procedures including fi certi ed electrophysiologist (CCEP) or 1 who possesses atrial fibrillation ablation procedures, and device im- fi equivalent quali cations. A physician is considered to plantation procedures (permanent pacemakers, ICDs, and fi have equivalent quali cations if he or she trained in a CRTs). Level I trainees should also observe a number of similar environment for a similar period of time and interrogations of implanted devices (permanent pace- performed the required number of procedures. makers, ICDs, and CRTs) and gain a basic understanding of concepts involved in programming and interrogating 2.2. Facilities implantable devices. Facilities should include a cardiac EP laboratory that Level II and III training require robust clinical experi- provides a safe, sterile, and effective environment for ences in the outpatient setting, inpatient and inpatient invasive diagnostic EP studies, catheter ablation pro- consultation setting, and EP laboratory. In each of these cedures, and CIED implantation. In addition, outpatient clinical settings, trainees assist in patient care in a su- clinical facilities should be available for implantation of pervised setting that provides for patient-centered edu- CIEDs, training in the consultative aspects of arrhythmia cation in all aspects of arrhythmia management. management, and device therapy. 3.3. Hands-On Experience 2.3. Equipment Hands-on experience is important for training in EP laboratories require fluoroscopy and specialized arrhythmia and CIED management. Trainees in cardiology equipment for the safe performance of diagnostic pro- should spend a minimum of 2 months on an arrhythmia cedures, catheter ablation procedures, and CIED implan- service to acquire the core competencies (Level I). During tation. This equipment includes EP pacing and recording this period or during rotations in the coronary care unit systems, radiofrequency generators, and defibrillators. and cardiac catheterization laboratory, trainees should Additional equipment is needed in programs performing perform cardioversion procedures; implant, evaluate, and lead extraction (16). adjust temporary pacemakers; and interpret the results of 2.4. Ancillary Support tilt-table testing. Ancillary support should be available to perform EP and Level II knowledge and skills can typically be obtained ablation procedures and to implant CIEDs, including within 6 months dedicated training by the arrhythmia general anesthesia and surgical backup in the event of service. During this additional training, trainees should complications requiring surgical intervention. perform cardioversion procedures; implant, evaluate, and adjust temporary pacemakers; learn how to interrogate 3. TRAINING COMPONENTS and troubleshoot implantable devices (permanent pace- makers, ICDs, and CRTs); perform and interpret the re- 3.1. Didactic Program sults of tilt-table testing; implant ILRs; and spend time in Didactic instruction may take place in a variety of for- the device and arrhythmia clinic. Level II trainees may mats, including but not limited to lectures, conferences, use part of this dedicated training period to learn to JACC VOL. 65, NO. 17, 2015 Calkins et al. 1857 MAY 5, 2015:1854– 65 COCATS 4 Task Force 11

implant permanent pacemakers safely and appropriately. obtained by all fellows during the 3-year cardiovas- The minimum number of such procedures is provided cular disease fellowship training program. Level II com- later in this document. petencies may be obtained during the cardiovascular Level III training in cardiac EP requires additional disease fellowship by selected fellows depending on their training beyond the standard 3-year cardiovascular career focus and elective experiences. Level III compe- fellowship and typically requires 24 months of exposure to tencies are noted so that fellows are aware of the com- advanced cardiac electrophysiology, including a consid- petencies for which additional, advanced training beyond erable amount of time in the EP laboratory performing the standard 3-year fellowship is required. Details for specific procedures. Level III training is required of in- advanced training will be included in an updated version dividuals seeking subspecialty board certification in CCEP. of the 2006 Clinical Competence Statement on Invasive Electrophysiology Studies, Catheter Ablation, and Car- 4. SUMMARY OF TRAINING REQUIREMENTS dioversion (5), which is currently under revision. The minimum duration of training and volume of procedures 4.1. Development and Evaluation of Core Competencies required for Level I and II training in CCEP are summa- Training and requirements in cardiac arrhythmia diag- rized in Tables 2 and 3. Although these minimum training nosis, pacing, and electrophysiology address the 6 general durations and numbers of procedures are typically competency domains promulgated by the ACGME/ required to obtain the competency levels, trainees must American Board of Medical Specialties and endorsed by the also demonstrate achievement of the competencies as ABIM. These competency domains are: medical knowl- assessed by the outcomes evaluation measures. A brief edge, patient care and procedural skills, practice-based discussion of the competencies and training requirements learning and improvement, systems-based practice, follows. interpersonal and communication skills, and profession- alism. The ACC has used this structure to define the com- 4.2.1. Level I Training Requirements ponents of the core clinical competencies for cardiology. Level I training should occupy at least 2 months on a CCEP The curricular milestones for each competency and rotation designed to acquire knowledge, skills, and domain also provide a developmental roadmap for fellows experience in the diagnosis and management of arrhyth- as they progress through various levels of training and mias (Table 1). Level I training should focus on the value serve as an underpinning for the ACGME/ABIM reporting of the clinical history in the diagnosis of cardiac milestones. The ACC has adopted this format for its com- arrhythmias and the ECG interpretation of arrhythmias, petency and training statements, career milestones, life- including differentiation of supraventricular from ven- long learning, and educational programs. Additionally, it tricular tachycardia. Also important for Level I training is has developed tools to assist physicians in assessing, exposure to the noninvasive diagnosis of cardiac ar- enhancing, and documenting these competencies. rhythmias, including ambulatory ECG monitoring (see Table 1 delineates each of the 6 competency domains as COCATS 4 Task Force 2 report), event recorders, ILRs, well as their associated curricular milestones for training exercise testing for arrhythmia assessment, and tilt-table in cardiac arrhythmias and electrophysiology. The mile- testing. Exposure to invasive EP studies (including mea- stones are categorized into Level I, II, and III training (as surements of AH and HV intervals, and basic activation previously defined in this document) and indicate the sequences) should be provided in Level I training to allow stage of fellowship training (12, 24, or 36 months, and understanding of the role of invasive EP testing in diag- additional time points) by which the typical cardiovas- nosis of cardiac arrhythmias. The Level I trainee should cular trainee should achieve the designated level. Given understand the basic concepts of catheter ablation, that programs may vary with respect to the sequence of including indications, contraindications, techniques, and clinical experiences provided to trainees, the milestones potential complications. Similarly, the Level I trainee at which various competencies are reached may also vary. should understand the basic concepts of CIEDs, including Level I competencies may be achieved at earlier or later the indications, techniques, and potential complications time points. Acquisition of Level II skills requires addi- of ICDs and biventricular pacemakers. Knowledge of the tional training, and acquisition of Level III skills requires fundamentals of cardiac pacing should encompass training in a dedicated CCEP program. The table also de- recognition of normal and abnormal pacemaker function scribes examples of evaluation tools suitable for assess- (2);pacingmodes;andtechniques of interrogation, pro- ment of competence in each domain. gramming, and surveillance of pacemakers and ICDs. Instruction in cardiac pacing should emphasize the 4.2. Number of Procedures and Duration of Training indications, cost-effective use, and limitations of The specific competencies for Levels I, II, and III are these devices. Level I trainees should understand the delineated in Table 1. Level I competencies must be proper use of anticoagulant and antiarrhythmic agents, 1858 Calkins et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 11 MAY 5, 2015:1854– 65

TABLE 1 Core Competency Components and Curricular Milestones for Training in Cardiac Arrhythmias and Electrophysiology

Competency Component Milestones (Months) MEDICAL KNOWLEDGE 12 24 36 Add

1 Know the mechanism and characteristics of normal sinus rhythm and of sinus node dysfunction. I

2 Know the pathophysiology, differential diagnosis, clinical significance, and approach to management of I re-entrant tachycardia (atrioventricular nodal re-entrant tachycardia; atrioventricular reciprocating tachycardia), ectopic atrial tachycardias, and accelerated atrioventricular junctional rhythm.

3 Know the pathophysiology, differential diagnosis, clinical significance, and approach to management of I atrial fibrillation and flutter, including the assessment of stroke and bleeding risk, indications of anticoagulation, and selection of anticoagulant medications.

4 Know the risk factors for stroke and for bleeding in patients with atrial fibrillation or atrial flutter, as well as I the indications for, and use of, anticoagulant medications.

5 Know the pathophysiology, differential diagnosis, clinical significance, and approach to management of I sustained and nonsustained ventricular tachyarrhythmias.

6 Know the pathophysiology, differential diagnosis, and approaches to risk stratification and management of I sudden cardiac death and cardiac arrest, including sudden cardiac death in athletes.

7 Know the types, mechanisms, differential diagnosis, clinical significance, and approach to management of I atrioventricular dissociation and atrioventricular heart blocks (first, second, and third degree).

8 Know the physical examination characteristics of arrhythmias (e.g., findings of atrioventricular I dissociation).

9 Know the significance of underlying structural or congenital heart disease in the likelihood and significance I of cardiac arrhythmias, including sudden death risk, and their impact in clinical management decisions.

10 Know the indications, contraindications, and clinical pharmacology of antiarrhythmic medications, I including drug–drug and drug–device interactions and proarrhythmia potential (including acquired long QT syndrome).

11 Know the indications and limitations of noninvasive testing in the diagnosis and management of patients I with arrhythmias: electrocardiogram, ambulatory, event, implantable loop recorder, and tilt-table testing.

12 Know the indications for, and limitations and complications of, invasive electrophysiological testing, as I well as catheter ablation for cardiac arrhythmias.

13 Know the indications and contraindications for permanent pacemaker placement, cardiac resynchronization I therapy, and implantable cardioverter-defibrillator placement.

14 Know the pathophysiology, differential diagnosis, natural history, and approach to management of I syncope, including neurocardiogenic causes and syncope in athletes.

15 Know the mechanisms, findings, clinical significance, and approach to management of ventricular pre- I excitation.

16 Know the pathology, clinical significance, and approach to evaluation (including the role of genetic testing) I and management of inherited diseases that may cause cardiac arrhythmias due to ion channel abnormalities or structural changes in the heart (including the long QT syndrome, Brugada syndrome, arrhythmogenic right ventricular dysplasia, hypertrophic dilated cardiomyopathy, and myotonic dystrophy).

17 Know the principles and practice of radiation safety as applied to the evaluation and management of I cardiac electrical disorders.

18 Know the basic principles of programming and interrogating implanted devices (permanent pacemakers, I implantable cardioverter-defibrillators, cardiac resynchronization therapies, and implantable monitors)

EVALUATION TOOLS: chart-stimulated recall, global evaluation, and in-training examination.

PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

1 Skill to evaluate and manage patients with palpitations. I

2 Skill to evaluate and manage patients with syncope. I

3 Skill to evaluate and manage patients with supraventricular tachyarrhythmias. I

4 Skill to evaluate and manage patients with atrial fibrillation and flutter (including rate and rhythm control I and anticoagulation strategies).

5 Skill to evaluate and manage patients with wide-QRS tachycardia. I JACC VOL. 65, NO. 17, 2015 Calkins et al. 1859 MAY 5, 2015:1854– 65 COCATS 4 Task Force 11

TABLE 1 Core Competency Components, continued

Competency Component Milestones (Months) PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

6 Skill to manage patients with nonsustained and sustained ventricular arrhythmias. I

7 Skill to evaluate and manage patients with bradycardia and/or heart block. I

8 Skill to perform electrical cardioversion. I

9 Skill to perform defibrillation. I

10 Skill to perform tilt-table testing. II

11 Skill to perform temporary pacemaker placement. I

12 Skill to select and manage patients requiring a permanent pacemaker, implantable cardioverter- I defibrillator, or biventricular pacing.

13 Skill to integrate the information provided in cardiac electrophysiology consultation, and reports of I procedures and device interrogation, into the overall clinical assessment of the patient and plan of management.

14 Skill to perform pacemaker and implantable cardioverter-defibrillator interrogation, programming, and II surveillance.

15 Skill to perform single- and dual-chamber permanent pacemaker implantation and manage complications, II including device infections and chronic lead failure.

16 Skill to perform implantation of implantable loop recorders, interpret results to guide patient II management, and manage complications.

17 Skill to perform implantable cardioverter-defibrillator and biventricular device implantation and manage III complications.

18 Skill to perform and interpret invasive electrophysiological testing and carry out ablation therapy. III

19 Skill to utilize magnetic resonance imaging, computed tomography, and intracardiac echocardiography in III facilitating invasive electrophysiology and ablation therapies.

20 Skill to follow-up, interrogate, and troubleshoot patients with implanted devices (permanent pacemakers, II implantable cardioverter-defibrillators, cardiac resynchronization therapies), including remote interrogation.

21 Skill to evaluate and manage patients with cardiac arrest. I

22 Skill to prescribe and interpret the results of electrocardiographic recording devices. I

EVALUATION TOOLS: chart-stimulated recall, patient safety or quality improvement conference presentation, direct observation, global evaluation, logbook, and simulation.

SYSTEMS-BASED PRACTICE 12 24 36 Add

1 Utilize an interdisciplinary coordinated approach for patient management, including transfer of care and I employment-related issues.

2 Use technology and available registries to assess appropriateness, performance, and safety of implanted I devices.

3 Incorporate risk/benefit analysis and cost considerations in diagnostic and treatment decisions. I

EVALUATION TOOLS: chart-stimulated recall, direct observation, and multisource evaluation.

PRACTICE-BASED LEARNING AND IMPROVEMENT 12 24 36 Add

1 Identify knowledge and performance gaps and engage in opportunities to achieve focused education and I performance improvement.

2 Utilize decision support tools for accessing guidelines and pharmacologic information at the point of care. I

EVALUATION TOOLS: chart-stimulated recall, conference presentation, direct observation, and logbook.

PROFESSIONALISM 12 24 36 Add

1 Demonstrate sensitivity to patient preferences and end-of-life issues. I

2 Practice within the scope of expertise and technical skills. I 1860 Calkins et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 11 MAY 5, 2015:1854– 65

TABLE 1 Core Competency Components, continued

Competency Component Milestones (Months) PROFESSIONALISM 12 24 36 Add

3 Interact respectfully with patients, families, and all members of the healthcare team, including ancillary I and support staff.

EVALUATION TOOLS: chart-stimulated recall, conference presentation, and direct observation.

INTERPERSONAL AND COMMUNICATION SKILLS 12 24 36 Add

1 Communicate with and educate patients and families across a broad range of cultural, ethnic, and I socioeconomic backgrounds.

2 Engage in shared decision-making with patients, including decisions regarding options for diagnosis and I treatment.

EVALUATION TOOLS: direct observation and multisource evaluation.

Add ¼ additional months beyond the 3-year cardiovascular fellowship.

including their toxicity and drug–drug and drug–device criteria detailed in Table 3. These experiences and skills interactions. should be obtained throughout the cardiovascular clinical The cardiovascular trainee should be instructed in training period and be integrated with formal didactic ECG and gain experience with the indications for insertion, conferences, core curriculum sessions, and rotation on the management, and follow-up of temporary pacemakers arrhythmia consultation service. (2), including measurement of pacing and sensing thresholds, recording of intracardiac electrograms, and 4.2.2. Level II Training Requirements recognition of procedure-related complications. The Trainees who wish to have more training in cardiac EP cardiovascular trainee should also be instructed in and should be enrolled in programs that include specific gain experience with cardioversion and cardiac defibril- inpatient services and outpatient clinics designed for lation (17). Temporary pacemaker and cardioversion pro- patients requiring therapy for cardiac arrhythmias and cedures may be performed in the cardiac catheterization conduction disorders, as described for Level I; however, laboratory, electrophysiology laboratory, cardiac care unit, in addition to ensuring a curriculum that satisfies the or other critical care settings. Instruction leading to specifics of Level I training, such programs must offer acquisition of the core competencies required of Level I greater intensity and exposure to a broader spectrum of trainees should meet the minimum procedural volume therapeutic modalities. Level II training can be accom- plished within the scope of the 3 years of initial cardio- vascular training. Trainees in a Level II curriculum should actively participate in didactic activities relating more Cardiac Arrhythmia and Electrophysiology TABLE 2 Curriculum Training Summary for 3-Year specifically to EP, including research conferences, semi- Cardiovascular Fellowship Training Program nars, and journal clubs with cardiac electrophysiological

Optional Training disordersasaprimaryfocus. in Device Level II training involves more advanced knowledge Level Curriculum/Skills Time Requirement Implantation and skills than Level I training but less than the I Cardiac arrhythmia and 2 months (in addition to No comprehensive training in cardiac EP required for Level electrophysiology COCATS 4 Task Force 2 core training requirements) III training. Level II training typically involves 6 months II Advanced noninvasive 6 months Level II trainees of training in mechanisms of arrhythmia; pharmacology arrhythmia who wish of antiarrhythmic and anticoagulant drugs; and nonin- management to implant permanent vasive and invasive techniques of diagnosis, treatment, pacemakers and longitudinal care of patients with complex and ILRs may receive this arrhythmias. training The Level II trainee should acquire the skills and during this 6-month experience to manage patients with CIEDs, including period of time. permanent pacemakers, ICDs, biventricular pacemakers, ILR ¼ implantable loop recorder. and ILRs. Level II trainees who wish to implant JACC VOL. 65, NO. 17, 2015 Calkins et al. 1861 MAY 5, 2015:1854– 65 COCATS 4 Task Force 11

Core Cardiac Arrhythmia and Electrophysiology privileges to implant CIEDs, including ICDs and biven- TABLE 3 Curriculum Training for 3-Year Cardiovascular tricular devices. It is recommended that this type of Fellowship Training Program training for CIED implantation follow the aforementioned

Cumulative COCATS requirements. Although these individuals are not Duration eligible for the ABIM EP Board Examination, they may be Level Minimum Number of Procedures of Training candidates for the International Board of Heart Rhythm I 5 temporary pacemakers 2 months 20 cardioversions Examiners physician examination (18).

II For Level II training alone (without training in 6 months pacemaker implantation) 4.2.3. Level III Training Requirements n 100 CIED interrogations/programming fi n 25 remote device interrogations The ACGME has de ned the essential components of a For Level II training, including pacemaker implantation specialized program for training in CCEP; the ABIM offers n 40 permanent pacemaker implantations with fi at least 20 single-chamber and 20 dual-chamber an examination for this additional certi cation. Informa- pacemakers tion concerning the eligibility requirements for the ex-

CIED ¼ cardiac implantable electrical device. amination can be obtained from the ABIM. Privileges to perform invasive procedures should be based mainly on satisfactory completion of the training outlined in this permanent pacemakers may spend time during their 6 document, including demonstration of competence and months of dedicated Level II training in implanting per- technical expertise. manent pacemakers. Level II training obtained during a Level III training prepares the physician to specialize in standard 3-year clinical cardiovascular fellowship does invasive CCEP (5,19,20). Level III trainees should meet all not qualify the trainee to implant defibrillators or biven- Level II training requirements and obtain additional, tricular devices. Rather, defibrillator and biventricular advanced training in performing diagnostic EP pro- device implantation requires Level III training in invasive cedures, catheter-based ablation procedures, and im- CCEP or an additional 12 months of dedicated training in plantation of ICDs and biventricular pacemakers. The ICD and biventricular device implantation and manage- minimal procedure volume requirements are provided in ment. During this additional 12-month period, the volume the Clinical Competency Statement (5,19,20). The Clinical requirements for device programming and ICD and Competency Statement for training in electrophysiology biventricular device implants must be met. The core will be replaced by an ACC/American Heart Association/ competencies appropriate for Level II training, including HRS Electrophysiology Advanced Training Statement minimum procedural volume criteria, are outlined in currently under development. The appropriate use, safe Table 3. performance, and judicious interpretation of these com- plex procedures require highly specialized training for 4.2.2.1. Optional Training in Pacemaker Implantation competencetobeachieved.Advancedunderstandingof (Level II) CCEP and cardiac pharmacology is required along with the Those who have obtained Level II training and wish to technical and cognitive skills to manage patients with implant permanent single- and dual-chamber pacemakers complex arrhythmias. should spend time implanting permanent pacemakers Level III training should include performing diagnostic during the 3-year cardiovascular fellowship program if 6 EP procedures for a variety of indications, including months is dedicated to acquiring the knowledge and skills evaluation of syncope, determination of the precise pertaining to permanent pacemaker implantation and mechanism of supraventricular arrhythmias, and risk- related patient management and follow-up. Competence stratification in patients with malignant arrhythmias. In in the indications for, implantation techniques, and many patients, these diagnostic EP procedures may be follow-up of ILRs is desirable. This training does not performed in conjunction with planned catheter ablation satisfy the ABIM requirements for admission to the CCEP procedures for treatment of supraventricular arrhyth- examination and is not considered adequate training to mias. Level III training in EP requires experience in left fi implant implantable de brillators. ventricular lead implantation procedures, ICD implanta- tion, and performance of pacing and defibrillation fi 4.2.2.2. Training in De brillator Implantation threshold testing at the time of implantation and during Individuals who spend an additional 12 months (beyond a follow-up. standard 3-year cardiovascular fellowship) obtaining Level III training in preparation for the CCEP board ex- additional training in ICD, biventricular device, and amination includes training in implantable defibrillator pacemaker implantation without satisfying the full re- implantation, during which the physician should develop quirements for Level III training in advanced cardiac expertise in the placement of permanent atrial, right and electrophysiology (Level III training) can be granted left ventricular, and ICD leads. Trainees should also 1862 Calkins et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 11 MAY 5, 2015:1854– 65

develop expertise in the implantation and testing of evaluated in every trainee. Quality of care and follow-up; subcutaneous ICDs. This entails adhering to principles reliability; judgment, decisions, or actions that result in of surgical asepsis, mastering surgical implantation tech- complications; interaction with other physicians, pa- niques, and managing implant-related complications. tients, and laboratory support staff; initiative; and the Trainees in implantable defibrillator implantation should ability to make appropriate decisions independently acquire extensive knowledge of the indications for and should be considered. Trainees should maintain records contraindications to ICDs; thorough understanding of of participation and advancement in the form of a Health advanced ICD electrocardiography; knowledge of drug– Insurance Portability and Accountability Act (HIPAA)– device interactions; competency in interrogation and compliant electronic database or logbook that meets programming of complex pacemaker and ICD systems; ACGME reporting standards and summarizes pertinent expertise in threshold testing, ventricular fibrillation in- clinical information (e.g., number of cases, diversity of duction, and defibrillator testing; experience in managing referral sources, diagnoses, disease severity, outcomes, device-related complications; and competence in man- and disposition). aging high pacing, defibrillation thresholds, and device The ACC, American Heart Association, and HRS have malfunction. Level III trainees gain extensive knowledge formulated a clinical competence statement on invasive of the indications for placement of left ventricular EP studies, catheter ablation, and cardioversion (5). leads, contraindications, and management of biven- Self-assessment programs and competence examina- tricular device malfunctions and interactions. Because tions in ECG are available through the ACC and other competency in these procedures is related to caseload, organizations. Training directors and trainees are minimal procedural volumes must be satisfied during encouraged to incorporate these resources in the course Level III training. of training. Under the aegis of the program director, the faculty 5. EVALUATION OF COMPETENCY should record and verify each trainee’s experiences, assess performance, and document satisfactory achieve- Evaluation tools in cardiac arrhythmia diagnosis, pacing, ment. The program director is responsible for confirming and electrophysiology include direct observation by in- experience and competence and reviewing the overall structors, in-training examinations, case logbooks, con- progress of individual trainees, with the Clinical Compe- ference and case presentations, multisource evaluations, tency Committee ensuring achievement of selected trainee portfolios, and simulation. Case management, training milestones and identifying areas in which addi- judgment, interpretive, and bedside skills must be tional focused training may be required.

REFERENCES

1. Flowers NC, Abildskov JA, Armstrong WF, et al. ACC 2006 update of the clinical competence statement and recommendations for follow-up of implantable policy statement: recommended guidelines for training on invasive electrophysiology studies, catheter abla- cardioverter-defibrillators. North American Society of in adult clinical cardiac electrophysiology. Elec- tion, and cardioversion: a report of the American Electrophysiology and Pacing. Pacing Clin Electro- trophysiology/ Electrocardiography Subcommittee, College of Cardiology/American Heart Association/ physiol 2001;24:262–9. American College of Cardiology. J Am Coll Cardiol American College of Physicians Task Force on Clinical 10. Scheinman MM, North American Society of Pacing 1991;18:637–40. Competence and Training. J Am Coll Cardiol 2006; and Electrophysiology Ad Hoc Committee on Catheter 48:1503–17. 2. Naccarelli GV, Conti JB, DiMarco JP, Tracy CM. Task Ablation. Catheter ablation for cardiac arrhythmias, force 6: training in specialized electrophysiology, car- 6. Gregoratos G, Abrams J, Epstein AE, et al. ACC/AHA/ personnel, and facilities. Pacing Clin Electrophysiol – diac pacing, and arrhythmia management. J Am Coll NASPE 2002 guideline update for implantation of 1992;15:715 21. – Cardiol 2006;47:904 10. cardiac pacemakers and antiarrhythmia devices— 11. American College of Cardiology Cardiovascular 3. Josephson ME, Maloney JD, Barold SS, et al. summary article: a report of the American College of Technology Assessment Committee. Catheter ablation Guidelines for training in adult cardiovascular medi- Cardiology/American Heart Association Task Force on for cardiac arrhythmias: clinical applications, personnel – cine: Core Cardiology Training Symposium (COCATS). Practice Guidelines (ACC/AHA/NASPE Committee to and facilities. J Am Coll Cardiol 1994;24:828 33. Update the 1998 Pacemaker Guidelines). J Am Coll Task force 6: training in specialized electrophysiology, 12. Mitchell LB, Dorian P, Gillis A, Kerr C, Klein G, Cardiol 2002;40:1703–19. cardiac pacing and arrhythmia management. J Am Coll Talajic M, Canadian Cardiovascular Society Committee. Cardiol 1995;25:23–6. 7. Hayes DL, Naccarelli GV, Furman S, et al. NASPE Standards for training in adult clinical cardiac electro- – 4. Zipes DP, DiMarco JP, Gillette PC, et al. Guidelines training requirements for cardiac implantable elec- physiology. Can J Cardiol 1996;12:476 80. tronic devices: selection, implantation, and follow-up. for clinical intracardiac electrophysiological and cath- 13. Scheinman M, Akhtar M, Brugada P, et al. Teaching Pacing Clin Electrophysiol 2003;26:1556–62. eter ablation procedures: a report of the American objectives for fellowship programs in clinical electro- College of Cardiology/American Heart Association Task 8. Curtis AB, Langberg JJ, Tracy CM. Clinical compe- physiology. Pacing Clin Electrophysiol 1988;11:989–96. Force on Practice Guidelines (Committee on Clinical tency statement: implantation and follow-up of car- 14. Accreditation Council for Graduate Medical Intracardiac Electrophysiologic and Catheter Ablation dioverter defibrillators. J Cardiovasc Electrophysiol Education. Program requirements for residency Procedures). J Am Coll Cardiol 1995;26:555–73. 2001;12:280–4. programs in clinical cardiac electrophysiology. Avail- 5. Tracy CM, Akhtar M, DiMarco JP, et al. American 9. Winters SL, Packer DL, Marchlinski FE, et al. able at: http://www.acgme.org/acgmeweb/Portals/0/ College of Cardiology/American Heart Association Consensus statement on indications, guidelines for use, PFAssets/2013-PR-FAQ-PIF/154_clinical_card_electrophys_ JACC VOL. 65, NO. 17, 2015 Calkins et al. 1863 MAY 5, 2015:1854– 65 COCATS 4 Task Force 11

int_med_07132013_1-YR.pdf. Accessed September 25, AHA Task Force on Clinical Privileges in Cardiology. Heart Association clinical competence statement on 2014. J Am Coll Cardiol 1993;22:336–9. invasive electrophysiology studies, catheter ablation, and cardioversion: a report of the American College of 18. International Board of Heart Rhythm Examiners 15. Zipes DP, Downing SM, Kangilaski R, Norcini JJ Jr. Cardiology/American Heart Association/American Col- fi was formerly named NAPSExAM. This physician exam is The rst cardiac electrophysiology examination for lege of Physicians—American Society of Internal Med- fi given at least twice a year. Available at: http://www. added quali cations: American Board of Internal icine Task Force on Clinical Competence. J Am Coll – ibhre.org/Exam-Information/Physician-Exams#axzz3 Medicine. J Cardiovasc Electrophysiol 1994;5:641 4. Cardiol 2000;36:1725–36. VRdQ76Hi. Accessed September 25, 2014. 16. Wilkoff BL, Byrd CL, Love C. NASPE guidelines for 19. Akhtar M, Achord JL, Reynolds WA. Clinical compe- lead extraction. Pacing Clin Electrophysiol 2000;23: tence in invasive cardiac electrophysiological studies. 544–51. ACP/ACC/AHA Task Force on Clinical Privileges in Car- KEY WORDS ACC Training Statement, diology. J Am Coll Cardiol 1994;23:1258–61. 17. Yurchak PM, Williams SV, Achord JL, et al. Clinical cardiac arrhythmias, clinical competence, competence in elective direct current (DC) cardiover- 20. Tracy CM, Akhtar M, DiMarco JP, Packer DL, COCATS, electrophysiology, fellowship training, sion: a statement for physicians from the ACP/ACC/ Weitz HH. American College of Cardiology/American implantable defibrillators, pacemakers

APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 11: TRAINING IN SPECIALIZED ELECTROPHYSIOLOGY, CARDIAC PACING, AND ARRHYTHMIA MANAGEMENT

Institutional/ Organizational Ownership/ or Other Speakers Partnership/ Personal Financial Expert Committee Member Employment Consultant Bureau Principal Research Benefit Witness

Hugh Calkins (Chair) John Hopkins Hospital—Professor None None None None None None of Medicine, Director of Electrophysiology

Eric H. Awtry Boston Medical Center, None None None None None None Cardiovascular Section—Vice Chair for Clinical Affairs; Boston University School of Medicine— Associate Professor of Medicine

Thomas Jared Bunch Intermountain Heart Institute, None None None None None None Intermountain Medical Center—Medical Director of Electrophysiology

Sanjay Kaul Cedars-Sinai Medical Center, None None None None None None Division of Cardiology—Professor of Medicine, UCLA

John M. Miller Indiana University School of None None None None None None Medicine, Clinical Cardiac Electrophysiology—Professor of Medicine; Director, Clinical Cardiac Electrophysiology

Usha B. Tedrow Brigham and Women’s Hospital None None None None None None Cardiovascular Division, Arrhythmia Unit, Harvard Medical School—Director, Clinical Cardiac Electrophysiology Program; Assistant Professor

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects authors’ employment and reporting categories. To ensure complete transparency, authors’ comprehensive healthcare-related disclosure information—including relationships with industry not pertinent to this document—is available in an online data supplement. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/ relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional information about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology. 1864 Calkins et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 11 MAY 5, 2015:1854– 65

APPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 11: TRAINING IN SPECIALIZED ELECTROPHYSIOLOGY, CARDIAC PACING, AND ARRHYTHMIA MANAGEMENT

Institutional/ Organizational Ownership/ or Other Speakers Partnership/ Personal Financial Expert Name Employment Representation Consultant Bureau Principal Research Benefit Witness

Richard Kovacs Indiana University, Krannert Official Reviewer, None None None None None None Institute of Cardiology— ACC Board of Trustees Q.E. and Sally Russell Professor of Cardiology

Dhanunjaya Kansas University Official Reviewer, None None None None None None Lakkireddy Cardiovascular Research ACC Board of Governors Institute

Howard Weitz Thomas Jefferson University Official Reviewer, None None None None None None Hospital—Director, Competency Management Division of Cardiology; Committee Lead Reviewer Sidney Kimmel Medical College at Thomas Jefferson University—Vice Chair, Department of Medicine

Bradley P. Knight Northwestern Medical Center Organizational Reviewer, None None None None None None Division of Cardiology— Heart Rhythm Society Director, Clinical Cardiac Electrophysiology

Kousik Krishnan Rush University Medical Organizational Reviewer, None None None None None None Center—Associate Heart Rhythm Society Professor, Medicine; Director, Arrhythmia Device Clinic

Kenneth Ellenbogen VCU Medical Center—Director, Content Reviewer, Cardiology None None None None None None Clinical Electrophysiology Training and Workforce Laboratory Committee

Michael Emery Greenville Health System Content Reviewer, Sports and None None None None None None Exercise Cardiology Section Leadership Council

N.A. Mark Estes Tufts University School of Content Reviewer, Individual None None None None None None Medicine—Professor, Medicine

Bulent Gorenek Eskisehir Osmangazi Content Reviewer, None None None None None None University Medical School Electrophysiology Section Leadership Council

Larry Jacobs Lehigh Valley Health Network, Content Reviewer, Cardiology None None None None None None Division of Cardiology; Training and Workforce University of South Committee Florida—Professor, Cardiology

Andrew Kates Washington University Content Reviewer, Academic None None None None None None School of Medicine Cardiology Section Leadership Council

Kristen Patton University of Washington Content Reviewer, None None None None None None Electrophysiology Section Leadership Council

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects peer reviewers’ employment, representation in the review process, as well as reporting categories. Names are listed in alphabetical order within each category of review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional infor- mation about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology; VCU ¼ Virginia Commonwealth University. JACC VOL. 65, NO. 17, 2015 Calkins et al. 1865 MAY 5, 2015:1854– 65 COCATS 4 Task Force 11

APPENDIX 3. ABBREVIATION LIST

ABIM ¼ American Board of Internal Medicine ABMS ¼ American Board of Medical Specialties ACC ¼ American College of Cardiology ACGME ¼ Accreditation Council for Graduate Medical Education CCEP ¼ clinical cardiac electrophysiology CIED ¼ cardiac implantable electrical device COCATS ¼ Core Cardiovascular Training Statement CRT ¼ cardiac resynchronization therapy ECG ¼ electrocardiographic EP ¼ electrophysiology HIPAA ¼ Health Insurance Portability and Accountability Act HRS ¼ Heart Rhythm Society ICD ¼ implantable cardioverter-defibrillator ILR ¼ implantable loop recorder JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL.65,NO.17,2015 ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00 PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacc.2015.03.031

TRAINING STATEMENT COCATS 4 Task Force 12: Training in Heart Failure

Endorsed by the Heart Failure Society of America

Mariell Jessup, MD, FACC, Chair Michael A. Mathier, MD, FACC

Reza Ardehali, MD, PHD, FACC John A. McPherson, MD, FACC

Marvin A. Konstam, MD, FACC* Nancy K. Sweitzer, MD, PHD, FACC Bruno V. Manno, MD, FACC

1. INTRODUCTION 1.1.2. Document Development and Approval The writing committee developed the document, 1.1. Document Development Process approved it for review by individuals selected by the 1.1.1. Writing Committee Organization ACC and HFSA, and then addressed the reviewers’ The Writing Committee was selected to represent comments. The document was revised and posted the American College of Cardiology (ACC) and for public comment from December 20, 2014, to the Heart Failure Society of America (HFSA) and January 6, 2015. Authors addressed the additional fi included a cardiovascular training program director, a comments to complete the document. The nal docu- heart failure training program director, an HFSA ment was approved by the Task Force, COCATS Steer- representative, an early-career cardiologist, highly- ing Committee, and ACC Competency Management fi experienced specialists representing both the aca- Committee; rati ed by the ACC Board of Trustees in demic and community-based practice settings, and March 2015; and endorsed by the HFSA. This document physicians experienced in defining and applying is considered current until the ACC Competency training standards according to the 6 general compe- Management Committee revises or withdraws it. tency domains promulgated by the Accreditation 1.2. Background and Scope CouncilforGraduateMedicalEducation(ACGME)and The Task Force was charged with updating published American Board of Medical Specialties (ABMS) and standards for training fellows in clinical cardiology endorsed by the American Board of Internal Medicine enrolled in fellowship programs (1–4) on the basis (ABIM). The ACC determined that relationships with of changes in the field since 2008 (3) and as part industry or other entities were not relevant to the of a broader effort to establish consistent train- creation of this general cardiovascular training state- ing criteria across all aspects of cardiology. This ment. Employment and affiliation details for authors document does not provide specific guidelines for and peer reviewers are provided in Appendixes 1 and training advanced cardiovascular subspecialty areas 2, respectively, along with disclosure reporting cate- but identifies opportunities to obtain advanced gories. Comprehensive disclosure information for all training where appropriate. The Task Force also authors, including relationships with industry and updated previously published standards to address other entities, is available as an online supplement to the evolving framework of competency-based medi- this document. cal education described by the ACGME Outcomes Project and the 6 general competencies endorsed by theACGMEandABMS.Thebackgroundandover- arching principles governing fellowship training are *Heart Failure Society of America Representative. provided in the COCATS 4 Introduction, and readers The American College of Cardiology requests that this document be cited should become familiar with this foundation before as follows: Jessup M, Ardehali R, Konstam MA, Mathier MA, Manno BV, McPherson JA, Sweitzer NK. COCATS 4 task force 12: training in heart considering the details of training in a subdiscipline failure. J Am Coll Cardiol 2015;65:1866–76. like heart failure. The Steering Committee and JACC VOL. 65, NO. 17, 2015 Jessup et al. 1867 MAY 5, 2015:1866– 76 COCATS 4 Task Force 12

Task Force recognize that implementation of these sufficient to perform an initial screen for advanced changes in training requirements will occur incrementally therapies of individuals cared for at nontransplant/ over time. nondurable MCS facilities, in collaboration with Level For most areas of adult cardiovascular medicine, 3 III–trained individuals at advanced therapy sites. levels of training are delineated: n Level III training requires additional training and experience beyond the cardiovascular fellowship for the n Level I training is the basic training required for trainee to acquire specialized knowledge and experi- trainees to become competent consultant cardiologists. ence in performing, interpreting, and training others to It is required of all fellows in cardiology and can be perform specific procedures or render advanced accomplished as part of a standard 3-year training specialized care for specific procedures at a high level of program in cardiology. In the case of heart failure, Level skill. In the case of heart failure, Level III training is I training will provide an understanding of the depth directed at those who anticipate focusing the majority of and breadth of the heart failure syndrome, as well as their clinical or research activities on the syndromes of nuances of diagnosis and management, including the heart failure, with a curriculum requiring additional important topic of heart failure prevention. Trainees fellowship training beyond that required for cardiovas- should understand which heart failure patients cular specialization board examination. It is recognized should be considered for implantable cardioverter- that not all cardiovascular fellowship training programs defibrillators, cardiac resynchronization therapies, or are capable of providing the most intense Level III more advanced therapies such as cardiac transplant or training curriculum. Level III training is covered in a mechanical circulatory support (MCS). (In this docu- range of programs that might include heart trans- ment, MCS represents both durable ventricular assist plantation, mechanical circulatory support devices, devices and temporary mechanical support, such as advanced heart failure electrophysiology, and end-of- intra-aortic balloon pumps or the Impella device.) The life management skills, although not necessarily all of trainee should be able to delineate the potential risks these. See further resources for ABIM policies and and benefits of these therapies for heart failure patients ACGME training requirements (5). Level III training is and provide appropriate referral. described here only in broad terms to provide context n Level II training refers to additional training in 1 or more for trainees and clarify that these advanced compe- areas that enables some cardiologists to perform or tencies are not covered during the cardiovascular interpret specific procedures or render more specialized fellowship. The additional exposure and requirements care for patients and conditions. This level of training is for Level III training will be addressed in a subsequent, recognized for those areas in which an accepted instru- separately published Advanced Training Statement. ment or benchmark, such as a qualifying examination, is available to measure specificknowledge,skills,or 2. GENERAL STANDARDS competence. Level II training in selected areas may be achieved by some trainees during the standard 3-year Three organizations—the ACC, American Heart Associa- cardiovascular fellowship, depending on the trainee’s tion, and HFSA—have addressed training requirements career goals and use of elective rotations. It is antici- and guidelines for the management of patients with heart pated that during a standard 3-year cardiovascular failure in both inpatient and outpatient settings (2,4,6). fellowship training program, sufficient time will be The recommendations are congruent and address faculty, available to receive Level II training in a specificsub- system requirements, management, emerging technolo- specialty. In the case of heart failure, Level II training gies, and practice. We recommend strongly that candi- will be for those individuals who wish to develop dates for the ABIM examination for certification in expertise in caring for heart failure patients, particularly cardiovascular diseases, as well as those seeking certifi- those with more advanced and challenging syndromes. cation of added qualifications in Advanced Heart Failure This curriculum can, in particular, provide the oppor- and Transplantation (AHFT), review the specificre- tunity to learn to manage devices (other than durable quirements of the ABIM documents (5,7). MCS) implanted for heart failure therapy, arrhythmia, or Cardiovascular fellowship programs should satisfy the hemodynamic monitoring. Level II will also emphasize requirements regarding facilities and faculty for training more detailed hemodynamic assessment of these pa- in heart failure. Eligibility for the ABIM AHFT examina- tients and will focus on transitions of care for heart tion requires that training take place in a program failurepatientsaswellasthesystemsofcarethatare accredited by the ACGME. The intensity of training necessary to avoid hospital admission and/or read- and required resources vary according to the level of mission. Level II training also prepares individuals with training provided. The recommended number of cases, a focused interest in heart failure to develop expertise procedures, and experiences is based on published 1868 Jessup et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 12 MAY 5, 2015:1866– 76

guidelines (2,4), competency statements (6),andthe care team; 3) assessment for quality of life, psychological experience and opinions of the writing group. It is problems (e.g., anxiety and depression), cognitive assumed that training is directedbyappropriatelytrained impairment, literacy problems, social isolation, financial mentorsinanACGME–accredited program (7) and that problems, and other barriers to adherence and risk factors satisfactory completion of training is documented by the for rehospitalization; 4) management of heart failure with program director. The number and types of encounters multiple comorbidities; 5) collaboration and skill as a and the duration of training required for trainees are team leader with nurses, dietitians, social workers, summarized in Section 4. pharmacists, and other health professionals in the man- agement of patients to stabilize or improve health status 2.1. Faculty and prevent hospitalization; and 6) transitional care Faculty should include specialists skilled in evaluating principles, that is, facilitating communication between heart failure patients and in the pharmacological, caregivers and physician extenders. catheter-based, and surgical aspects of heart failure care. For a program to be accredited to train candidates for 3.2. Clinical Experience AHFT, there must be a minimum of 2 key clinical, board- Trainees must have formal instruction and clinical expe- certified, AHFT faculty members, including the program rience in the following specificareastoattainLevelI director. To provide Level I training in heart failure, curricular milestones: however, faculty need not be board-certified in AHFT. 1. Basic disease mechanisms leading to syndromes of 2.2. Facilities acute and chronic systolic and diastolic heart failure. 2. Clinical trial evidence relevant to heart failure Facilities should be adequate to ensure a safe, sterile, management. and effective environment for the optimal management 3. Indication, prescription, pharmacology, adverse ef- of patients with heart failure of all etiologies and fects, and appropriate monitoring of all classes of drugs severity. In addition, outpatient clinical facilities should relevant to the heart failure patient, including those be available for training in the consultative aspects of known to benefit patients with heart failure, those heart failure management, including appropriate referral suspected of benefiting patients with heart failure, and for advanced therapies such as transplant or MCS those known or suspected of adversely affecting pa- devices. tients with heart failure, in both the acute and chronic 3. TRAINING COMPONENTS settings. 4. Indication and prescription of nonpharmacological/ 3.1. Didactic Program nondevice treatment modalities in heart failure, including diet, exercise, and the patient’s involvement During training, fellows should actively participate in in daily clinical assessment such as weight, fluid didactic activities relating specifically to heart failure. The intake, and exercise capacity. core curriculum of the fellowship program should include 5. Indications for cardiac transplantation and both dura- didactics focused on providing the trainee with appro- ble and nondurable mechanical circulatory support priate medical knowledge in heart failure. At a minimum, devices. such a program should provide the trainee with knowl- 6. Recognition of differences in appropriate management edge of current heart failure guidelines as well as an and response to therapy based on differences in etiol- understanding of the medical knowledge milestones ex- ogy, cardiac structure and function, age, sex, ethnic pected for Level I training. Additionally, didactic oppor- background, and genetics. tunities to acquire Level II medical knowledge should be 7. Impact of psychosocial factors on the manifestations, available to interested trainees. In addition to the core expression, and management of heart failure. curriculum, the didactic portion of training should 8. Existence, importance, and management of common include research conferences and journal clubs with the comorbidities encountered in patients with heart fail- heart failure syndrome as their primary focus and include ure, including but not limited to obesity, metabolic topics related to enhancement of patient safety and syndrome, diabetes mellitus, sleep breathing disor- resource management. ders, depression, anxiety, and sexual dysfunction.

3.1.1. Heart Failure Disease Management These scenarios represent a broad and basic spectrum Education and counseling strategies include: 1) the of clinical heart failure. It is accepted that for some spe- importance of nonpharmacological as well as pharmaco- cific situations (i.e., heart failure patients with congenital logical management; 2) end-of-life care, including care heart disease or pregnancy-related heart failure states), options and participation in an interdisciplinary palliative clinical material may not be readily available. In those JACC VOL. 65, NO. 17, 2015 Jessup et al. 1869 MAY 5, 2015:1866– 76 COCATS 4 Task Force 12

specific situations, didactic and interactive, case-based Table 1 delineates each of the 6 competency domains as training would be an acceptable substitute for formal well as their associated curricular milestones for training inpatient or outpatient clinical exposure. in heart failure. The milestones are categorized into Level I, II, and III training (as previously defined in this docu- 3.2.1. Prevention of Heart Failure ment) and indicate the stage of fellowship training (12, 24, With respect to heart failure prevention, trainees must or 36 months, and additional time points) by which the have formal instruction regarding conditions and factors typical cardiovascular trainee should achieve the desig- known to predispose patients to, or exacerbate, heart nated level. Given that programs may vary with respect to failure syndromes. Specifically, a curriculum that em- the sequence of clinical experiences provided to trainees, phasizes comprehensive cardiovascular risk factor modi- the milestones at which various competencies are reached fication more generally (e.g., primary and secondary may also vary. Level I competencies may be achieved at prevention of coronary artery disease, treatment of earlier or later time points. Acquisition of Level II skills hypertension), and with respect to the heart failure syn- requires additional training that may be completed during drome specifically, will be required. Trainees are ex- the standard 3-year cardiovascular fellowship. Level III pected to know the risk factors associated with the skills require additional training in a dedicated advanced development of heart failure and the pathophysiology of heart failure program after completion of the general myocardial cellular dysfunction, ventricular remodeling, cardiovascular fellowship. The table also describes ex- and ventricular dysfunction. amples of evaluation tools suitable for assessment of competence in each domain. 3.3. Hands-On Experience 4.2. Number of Procedures, Cases, and Duration of Training Hands-on experience is required for effective training in The goals of the heart failure milestones and compe- heart failure management. During rotations in the cardiac tencies are to ensure that cardiovascular medicine care unit, trainees should assess and manage the variety traineesacquireanappropriatedegreeofskilland of heart failure patients referred to in the previous text, knowledge in the care of patients with heart failure at including appropriately referring heart failure patients for basic (Level I) or more refined levels (Levels II and III). surgery, devices, and advanced therapies. In addition to Training directors and trainees are encouraged to incor- inpatient experience, Level I and II trainees are expected porate this resource in the course of training. The specific to gain experience managing outpatients with mild- competencies for Levels I, II, and III are delineated in to-moderate chronic heart failure and to determine the Table 1. Trainees in cardiology should spend a minimum appropriate medical and device therapies for these of 2 months on a heart failure consultation service to ac- patients. quire the core competencies identified in Table 1. Level I competencies must be obtained by all fellows during the 4. SUMMARY OF TRAINING REQUIREMENTS 3-year cardiovascular disease fellowship training pro- gram. Level II competencies may be obtained during the 4.1. Development and Evaluation of Core Competencies cardiovascular disease fellowship by selected fellows Training and requirements in heart failure address the depending on their career focus and elective experiences. 6 general competencies promulgated by the ACGME/ Level III competencies are noted so that fellows are ABMSandendorsedbytheABIM.Thesecompetencydo- aware of the competencies for which additional, ad- mains are: medical knowledge, patient care and proce- vanced training beyond the standard 3-year fellowship is dural skills, practice-based learning and improvement, required. A brief discussion of the competencies and systems-based practice, interpersonal and communica- training requirements for Levels I, II, and III follow. There tion skills, and professionalism. The ACC has used this are no volume or procedural requirements for heart fail- structure to define the components of the core clinical ure training at Levels I and II. Please refer to the ACGME competencies for cardiology. The curricular milestones program requirements for an outline of procedures for each competency and domain also provide a devel- and volume requirements for Level III training. Although opmentalroadmapforfellowsastheyprogressthrough the training duration and numbers of procedures are various levels of training and serve as an underpinning for typically required to obtain competency, trainees must the ACGME/ABIM reporting milestones. The ACC has also demonstrate achievement of the competencies as adopted this format for its competency and training assessed by the outcomes evaluation measures. statements, career milestones, lifelong learning, and This training scheme recognizes that there is an ever- educational programs. Additionally, it has developed increasing number of treatments and interventions that tools to assist physicians in assessing, enhancing, and improve outcomes and significantly alter the course of the documenting these competencies. heart failure syndrome. These treatments have generally 1870 Jessup et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 12 MAY 5, 2015:1866– 76

TABLE 1 Core Competency Components and Curricular Milestones for Training in Heart Failure

Competency Component Milestones (Months) MEDICAL KNOWLEDGE 12 24 36 Add

1 Know the pathophysiology, differential diagnosis, stages, and natural history of heart failure. I

2 Know the characteristic history and physical examination findings, and their limitations, in evaluation of I heart failure syndromes.

3 Know the pathophysiology of heart failure at the molecular, cellular, organ, and organismal levels, with I emphasis on the roles of neurohormonal activation and left ventricular remodeling in disease progression.

4 Know the indications, contraindications, and clinical pharmacology for drugs used for treatment of heart I failure, including adverse effects.

5 Know the indications, contraindications, and clinical pharmacology for the drugs used for the treatment of II heart failure of all etiologies and degrees of severity and in special populations.

6 Know the indications and clinical rationale for the pharmacological management of patients implanted III with mechanical circulatory support.

7 Know the indications, contraindications, and clinical pharmacology for intravenous, vasoactive, and I inotropic drugs used for cardiovascular support in advanced/refractory heart failure.

8 Know the appropriate pharmacological or nonpharmacological treatment for the prevention of heart I failure in patients with either “pre” or “established” heart failure.

9 Know the clinical pharmacology and use of immunosuppressive medications and other interventions in II heart transplant patients in the treatment of acute rejection.

10 Know the types of and indications for mechanical circulatory support. II

11 Know the effects and interactions of heart failure with other organ systems (kidney, nutritional, metabolic) I and in the setting of other systemic disease.

12 Know the management of cardiac arrhythmias in heart failure patients, as well as the indications and risks I of use of implantable cardioverter-defibrillator and cardiac resynchronization therapies.

13 Know the indications for referral for cardiac transplantation. I

14 Know the late stage complications of heart failure in patients with congenital heart disease. III

15 Know the management and diagnostic strategies for populations with heart failure not due to ischemic II heart disease, including infiltrative and restrictive cardiomyopathies, inherited cardiomyopathies, and those associated with pregnancy and chemotherapy.

16 Know the management strategies for highly specialized populations with heart failure, including those III associated with congenital heart disease and chronic pulmonary disease.

EVALUATION TOOLS: chart-stimulated recall, direct observation, in-training examination.

PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

1 Skill to evaluate and manage patients with new-onset, chronic, and acute decompensated heart failure. I

2 Skill to evaluate and manage patients with severe heart failure despite treatment. II

3 Skill to evaluate and manage patients with mechanical circulatory support or after heart transplant. III

4 Skill to appropriately obtain and incorporate data from the history, laboratory studies, and imaging I modalities in evaluation and management of heart failure patients.

5 Skill to interpret imaging results in the evaluation of heart failure patients. I

6 Skill to interpret imaging results found in advanced, rare, or uncommon forms of heart failure. III

7 Skill to use history and physical examination findings to accurately assess volume status and perfusion in II patients with heart failure.

8 Skill to perform invasive hemodynamic monitoring. I

9 Skill to incorporate the results of hemodynamic measurements and monitoring to make appropriate II management decisions in heart failure patients of all etiologies and severity.

10 Skill to incorporate results of hemodynamic measurements and monitoring to make appropriate III management decisions in complex or advanced heart failure patients of all etiologies and severity or in patients with mechanical circulatory support. JACC VOL. 65, NO. 17, 2015 Jessup et al. 1871 MAY 5, 2015:1866– 76 COCATS 4 Task Force 12

TABLE 1 Core Competency Components, continued

Competency Component Milestones (Months) PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

11 Skill to identify appropriate candidates for palliative care and hospice. I

12 Skill to recognize and manage cardiac arrhythmias, including the identification of appropriate candidates I for implantable cardioverter-defibrillators, cardiac resynchronization therapy, or arrhythmia ablation.

13 Skill to select and implement appropriate arrhythmia management, including utilization of implantable II cardioverter-defibrillators, cardiac resynchronization therapy, and ablation of arrhythmias in patients with heart failure of all etiologies and severity.

14 Skill to manage patients with advanced heart failure and complex arrhythmias, including patients with III mechanical circulatory support, in conjunction with clinical cardiac electrophysiologists.

15 Skill to recognize and manage comorbidities in heart failure patients. I

16 Skill to manage heart failure patients with complex contributing comorbidities. II

17 Skill to identify and manage patients who require transition from hospital to home or to a care facility while II on infusion of inotropic or vasoactive agents.

18 Skill to identify and manage patients who require transition from hospital to home or to a care facility after III heart transplant or permanent mechanical circulatory support.

19 Skill to appropriately utilize initial screening studies to determine patient eligibility for advanced therapies II of individuals cared for at nontransplant/nonventricular assist device facilities, in collaboration with Level III–trained individuals, who work at advanced therapy sites.

20 Skill to evaluate, order all appropriate testing, and determine the appropriateness of a patient for cardiac III transplant or mechanical circulatory support.

21 Skill to interpret and incorporate results of cardiopulmonary exercise testing into management of heart II failure patients, including physical activity and exercise recommendations.

22 Skill to recognize, manage, and seek appropriate consultation for depression or undue anxiety in heart I failure patients as part of their overall care.

EVALUATION TOOLS: chart-stimulated review, direct observation, and multisource evaluation.

SYSTEMS-BASED PRACTICE 12 24 36 Add

1 Utilize appropriate care settings and teams for various levels and stages of heart failure. I

2 Incorporate risk/benefit analysis and cost considerations in diagnostic and treatment decisions. I

3 Identify and address financial, cultural, and social barriers to diagnostic and treatment recommendations. I

4 Utilize an interdisciplinary, coordinated, team approach for patient management, including care transitions, I palliative care, and employment-related issues.

5 Effectively utilize an interdisciplinary approach to monitor the progress of ambulatory patients with heart II failure to maintain stability and avoid preventable hospitalization.

6 Identify the financial, social, and emotional barriers to successful outcomes after surgery. III

EVALUATION TOOLS: chart-stimulated recall, direct observation, and multisource evaluation.

PRACTICE-BASED LEARNING AND IMPROVEMENT 12 24 36 Add

1 Identify knowledge and performance gaps and engage in opportunities to achieve focused education and I performance improvement.

2 Utilize decision support tools for accessing guidelines and pharmacological information at the point of II care.

EVALUATION TOOLS: conference presentation, direct observation, global evaluation, and reflection and self-assessment.

PROFESSIONALISM 12 24 36 Add

1 Show compassion and effective management of end-of-life issues, including family meetings across the I spectrum of patients with heart failure.

2 Clearly and objectively discuss the therapies available for advanced heart failure, including palliative care, III transplant, or mechanical circulatory support. 1872 Jessup et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 12 MAY 5, 2015:1866– 76

TABLE 1 Core Competency Components, continued

Competency Component Milestones (Months) PROFESSIONALISM 12 24 36 Add

3 Interact respectfully with patients, families, and all members of the healthcare team, including ancillary I and support staff.

EVALUATION TOOLS: conference presentation, direct observation, multisource evaluation, and reflection and self-assessment.

INTERPERSONAL AND COMMUNICATION SKILLS 12 24 36 Add

1 Communicate with and educate patients and families across a broad range of cultural, ethnic, and I socioeconomic backgrounds.

2 Engage in shared decision making with patients, including options for diagnosis and treatment. I

3 Effectively lead and communicate with the interdisciplinary team involved in heart transplant and III mechanical circulatory support.

EVALUATION TOOLS: direct observation and multisource evaluation.

Add ¼ additional months beyond the 3-year cardiovascular fellowship.

increased the complexity of care. Thus, additional and The fundamental concepts of heart failure’spatho- special expertise are needed to best effect and improve physiology and its treatment should be understood by all utilization of many heart failure evaluation and treatment trainees in cardiovascular medicine as part of the Level I strategies. It is also recognized that a significant portion training curriculum. Training in the clinical management of initial and follow-up care for heart failure patients will of heart failure should include supervised experience in continue to be under the purview of cardiologists and both inpatient and outpatient settings and expose the primary care clinicians; however, the more advanced trainee to a broad spectrum of underlying causes of Level II and III programs will provide increased sophisti- heart failure. Trainees should be well acquainted with cation and more skills necessary to manage advanced the nuances of therapy for heart failure that are specific heart failure syndromes. to different etiologies and should be well informed about ItisimportanttopointoutthatLevelIIItrainingand the pharmacology of standard cardiovascular drugs subsequent competency do not necessarily equate with used to treat heart failure. Trainees should also be the level of experience in cardiac transplantation required aware of the treatment strategies for patients with both for qualification as a heart transplant physician under chronic disease and acute exacerbations. An important United Network of Organ Sharing (UNOS) criteria (8).Itis element of the curriculum will be to train clinicians to anticipated that a much broader group of individuals will appropriately refer heart failure patients for pacemaker, be interested in establishing competency in advanced defibrillator, and percutaneous cardiovascular inter- heart failure cardiology than will be directly managing ventions; surgical procedures (including insertion of patients undergoing cardiac transplantation. Nonethe- mechanical circulatory support devices); and cardiac less, many programs will offer an experience within the transplantation. Through interaction with this variety of Level III curriculum that can establish heart transplant patients, the trainee will acquire necessary competence physician competency according to United Network of and subsequent expertise as outlined in the milestones Organ Sharing criteria. table (Table 1).

4.2.1. Level I Training Requirements 4.2.2. Level II Training Requirements The heart failure training Level I curriculum must ensure Traineeswhowishtohavemoretraininginadvanced that trainees have formal instruction and clinical experi- heart failure should be enrolled in programs that ence in the evaluation and management of a full spec- include specific outpatient clinics and inpatient services trum of heart failure patients within the first 2 years of designed for patients requiring therapy for heart failure, training. The fellow must have access to a patient popu- as described for Level I; however, in addition to lation with a variety of clinical problems and stages of ensuring a curriculum that satisfies the specifics of diseases. The patient population must include patients of Level I training, such programs must offer a greater each sex and a broad age range, including geriatric intensity and exposure to a broader spectrum of heart patients. failure therapy modalities. Level II training can be JACC VOL. 65, NO. 17, 2015 Jessup et al. 1873 MAY 5, 2015:1866– 76 COCATS 4 Task Force 12

accomplished within the scope of the 3 years of initial Level III training requires further demonstration of cardiovascular training, generally during the third year proficiency in additional arenas that include exposure to of the cardiovascular training program. Trainees in patients with more advanced or challenging heart failure a Level II curriculum should actively participate in conditions. Level III trainees should spend a considerable didactic activities relating more specifically to heart amount of time acquiring expertise in the evaluation and failure, including research conferences, seminars, and management of patients with advanced heart failure, journal clubs, with the heart failure syndrome as the including the hemodynamic evaluation of such inpatients primary focus. andoutpatients,referralfordevicessuchasimplantable In addition to satisfying all Level I competencies out- cardioverter-defibrillators or cardiac resynchronization lined in Table 1, trainees should have experiences in therapies, and the appropriate selection of patients for interpreting the hemodynamic data of advanced heart transplant or MCS devices. failure patients during acute and chronic interventions and Level III training requires an additional 12 months of during prognosis assessment. Alternatively, they might training beyond that required for basic cardiovascular spend more time in the outpatient heart failure clinics, fellowship. A variety of curricula can be created to satisfy where exposure to a broader range of patients with heart Level III training requirements. The competencies identi- failure will occur. Level II trainees should develop a fied in Table 1 represent the core expectations or mile- fundamental understanding of emerging genetic risk fac- stones. Detailed components of Level III training will be tors and biomarkers for the development of heart failure addressed in a subsequent, separately published Advanced and the use of genetic markers and biomarkers as strategies Training Statement. for heart failure prevention (9). 5. EVALUATION OF PROFICIENCY 4.2.3. Level III Training Requirements In addition to the curriculum specifiedinLevelIandII Evaluation tools in heart failure include direct observation training, fellows should have formal instruction and by instructors, in-training examinations, case logbooks, attain understanding of the following for Level III conference and case presentations, multisource evalua- competency: tions, trainee portfolios, simulation, and reflection and self-assessment. Case management, judgment, interpre- 1. Advanced training in cellular, cardiomyocyte, and tive, and bedside skills must be evaluated in every trainee. extracellular matrix biology, including calcium dysre- Quality of care and follow-up; reliability; judgment, de- gulation; mechanisms of arrhythmia generation; beta- cisions, or actions that result in complications; interaction receptor abnormalities; mechanisms of apoptosis, with other physicians, patients, and laboratory support stem cells, and regeneration; metabolic abnormalities staff; initiative; and the ability to make appropriate de- of the failing myocyte; and the roles of matrix remod- cisions independently should be considered. Trainees eling in the progression of heart failure. should maintain records of participation and advancement 2. Genetics, including common mutations leading to hy- in the form of a Health Insurance Portability and pertrophic and dilated cardiomyopathies and an un- Accountability Act (HIPAA)–compliant electronic database derstanding of genetic polymorphisms related to both or logbook that meets ACGME reporting standards and myocardial disease and targeted heart failure treatment. summarizes pertinent clinical information (number of To qualify for heart failure Level III training, fellows cases, diversity of referral sources, diagnoses, disease must have a more in-depth and formal instruction in heart severity, outcomes, and disposition) for each encounter. failure disease management, have clinical experience, The ACC, American Heart Association, American Col- and demonstrate proficiency as part of an interdisci- lege of Physicians, HFSA, and International Society for plinary care team in a clinical setting dedicated to heart Heart and Lung Transplantation have formulated a failure. Managing interdisciplinary heart failure clinics clinical competence statement on the management of and home-based care services is envisioned as a primary patients with advanced heart failure (10). role of the advanced heart failure cardiologist, who Under the aegis of the program director, the faculty should achieve proficiency in: 1) specificbehavioralstra- should record and verify each trainee’s experiences, assess tegies to enhance adherence to a heart failure therapeutic performance, and document satisfactory achievement. regimen; 2) supervision of home-based titration and The program director is responsible for confirming expe- monitoring of diuretics and evidence-based medications, rience and competence and reviewing the overall progress with surveillance for renal dysfunction and electrolyte of individual trainees with the Clinical Competency Com- disturbances; and 3) the comprehensive education and mittee at least twice annually to ensure achievement of counseling needs of heart failure patients and family selected training milestones and identify areas in which members. additional focused training may be required. 1874 Jessup et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 12 MAY 5, 2015:1866– 76

REFERENCES

1. Liu P, Arnold JM, Belenkie I, et al. The 2002/3 5. American Board of Internal Medicine. ABIM Certifica- 9. Schocken DD, Benjamin EJ, Fonarow GC, et al. Pre- Canadian Cardiovascular Society consensus guideline tion in Advanced Heart Failure & Transplant Cardiology. vention of heart failure: a scientific statement from the update for the diagnosis and management of heart Available at: http://www.abim.org/certification/policies/ American Heart Association Councils on Epidemiology and failure. Can J Cardiol 2003;19:347–56. imss/ahftc.aspx. Accessed September 27, 2014. Prevention, Clinical Cardiology, Cardiovascular Nursing, and High Blood Pressure Research; Quality of Care and 2. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA 6. Young JB, Abraham WT, Bourge RC, et al. Task force 8: Outcomes Research Interdisciplinary Working Group; and guideline for the management of heart failure: a report training in heart failure. J Am Coll Cardiol 2008;51:383–9. Functional Genomics and Translational Biology Interdis- of the American College of Cardiology Foundation/ 7. Accreditation Council for Graduate Medical ciplinary Working Group. Circulation 2008;117:2544–65. American Heart Association Task Force on Practice Education. ACGME Program Requirements for Grad- Guidelines. J Am Coll Cardiol 2013;62:e147–239. 10. Francis GS, Greenberg BH, Hsu DT, et al. ACCF/ uate Medical Education in Advanced Heart Failure and AHA/ACP/HFSA/ISHLT 2010 clinical competence 3. Swedberg K, Cleland J, Dargie H, et al. Guidelines for Transplant Cardiology (Internal Medicine). Available at: statement on management of patients with advanced the diagnosis and treatment of chronic heart failure: http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ heart failure and cardiac transplant: a report of the executive summary (update 2005): the Task Force for 2013-PR-FAQ-PIF/159_advHeartFailure_transplantCard_ ACCF/AHA/ACP Task Force on Clinical Competence and the Diagnosis and Treatment of Chronic Heart Failure 07132013_1-YR.pdf. Accessed September 30, 2014. Training. J Am Coll Cardiol 2010;56:424–53. of the European Society of Cardiology. Eur Heart J 8. United Network for Organ Sharing. UNOS Desig- 2005;26:1115–40. nated Transplant Program Criteria Bylaw, Appendix B, 4. Heart Failure Society of America. HFSA 2006 Attachment I, Section VII. Available at: http://www. KEY WORDS ACC Training Statement, comprehensive heart failure practice guideline. J Card unos.org/about/index.php?topic¼bylaws. Accessed clinical competence, COCATS, fellowship Fail 2006;12:e1–2. September 27, 2014. training, heart failure JACC VOL. 65, NO. 17, 2015 Jessup et al. 1875 MAY 5, 2015:1866– 76 COCATS 4 Task Force 12

APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 12: TRAINING IN HEART FAILURE

Institutional/ Organizational Ownership/ or Other Speakers Partnership/ Personal Financial Expert Committee Member Employment Consultant Bureau Principal Research Benefit Witness

Mariell Jessup (Chair) University of Pennsylvania School None None None None None None of Medicine—Professor of Medicine

Reza Ardehali University of California Los None None None None None None Angeles—Assistant Professor of Medicine (Cardiology)

Marvin A. Konstam Tufts University School of None None None None None None Medicine—Professor; Director, Cardiovascular Center

Bruno V. Manno Pennsylvania Heart and Vascular None None None None None None Group, P.C.—Cardiologist

Michael A. Mathier University of Pittsburgh Medical None None None None None None Center Heart and Vascular Institute—Assistant Professor of Medicine; Associate Director, Cardiovascular Fellowship Program

John A. McPherson Vanderbilt University School of None None None None None None Medicine—Associate Professor of Medicine; Vice-Chair for Education, Department of Medicine

Nancy K. Sweitzer Sarver Heart Center, University None None None None None None of Arizona—Director; Professor; Chief, Division of Cardiology

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects authors’ employment and reporting categories. To ensure complete transparency, authors’ comprehensive healthcare-related disclosure information—including relationships with industry not pertinent to this document—is available in an online data supplement. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/ relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional information about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology. 1876 Jessup et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 12 MAY 5, 2015:1866– 76

APPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 12: TRAINING IN HEART FAILURE

Institutional/ Organizational Ownership/ or Other Speakers Partnership/ Personal Financial Expert Name Employment Representation Consultant Bureau Principal Research Benefit Witness

Richard Kovacs Indiana University, Krannert Official Reviewer, None None None None None None Institute of Cardiology— ACC Board of Trustees Q.E. and Sally Russell Professor of Cardiology

Dhanunjaya Kansas University Official Reviewer, None None None None None None Lakkireddy Cardiovascular Research ACC Board of Governors Institute

Howard Weitz Thomas Jefferson University Official Reviewer, None None None None None None Hospital—Director, Competency Management Division of Cardiology; Committee Lead Reviewer Sidney Kimmel Medical College at Thomas Jefferson University—Professor of Medicine

Kiran Musunuru Brigham and Women’s Organizational Reviewer, None None None None None None Hospital, Harvard University AHA

Richard Patten Lahey Hospital And Medical Organizational Reviewer, None None None None None None Center, Division of HFSA Cardiovascular Medicine

Michael Emery Greenville Health System Content Reviewer, Sports and None None None None None None Exercise Cardiology Section Leadership Council

Brian D. Hoit University Hospitals Case Content Reviewer, Cardiology None None None None None None Medical Center Training and Workforce Committee

Larry Jacobs Lehigh Valley Health Network, Content Reviewer, Cardiology None None None None None None Division of Cardiology; Training and Workforce University of South Committee Florida—Professor, Cardiology

Howard M. Thomas Jefferson University Content Reviewer, HF&T None None None None None None Julien Hospital—Director, Council Division of Cardiology; Sidney Kimmel Medical College at Thomas Jefferson University—Vice Chair, Department of Medicine

Andrew Kates Washington University School Content Reviewer, Academic None None None None None None of Medicine Cardiology Section Leadership Council

Wayne Miller Mayo Clinic Content Reviewer, HF&T None None None None None None Council

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects peer reviewers’ employment, representation in the review process, as well as reporting categories. Names are listed in alphabetical order within each category of review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional infor- mation about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology; AHA ¼ American Heart Association; HF&T ¼ Heart Failure and Transplant; HFSA ¼ Heart Failure Society of America.

APPENDIX 3. ABBREVIATION LIST

ABIM ¼ American Board of Internal Medicine COCATS ¼ Core Cardiovascular Training Statement ABMS ¼ American Board of Medical Specialties HFSA ¼ Heart Failure Society of America ACC ¼ American College of Cardiology HIPAA ¼ Health Insurance Portability and Accountability Act ACGME ¼ Accreditation Council for Graduate Medical MCS ¼ mechanical circulatory support Education UNOS ¼ United Network of Organ Sharing AHFT ¼ Advanced Heart Failure and Transplantation JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 65, NO. 17, 2015 ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00 PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacc.2015.03.027

TRAINING STATEMENT COCATS 4 Task Force 13: Training in Critical Care Cardiology

Patrick T. O’Gara, MD, MACC, Chair Kyle W. Klarich, MD, FACC Jesse E. Adams III, MD, FACC L. Kristin Newby, MD, MHS, FACC

Mark H. Drazner, MD, MSC, FACC Benjamin M. Scirica, MD, MPH, FACC Julia H. Indik, MD, FACC Thoralf M. Sundt III, MD, FACC Ajay J. Kirtane, MD, SM, FACC

1. INTRODUCTION ACC, and then addressed the reviewers’ comments. The document was revised and posted for public 1.1. Document Development Process comment from December 20, 2014, to January 6, 2015. 1.1.1. Writing Committee Organization Authors addressed these additional comments from the public to complete the document. The final The writing committee was selected to represent the document was approved by the Task Force, COCATS American College of Cardiology (ACC) and included a Steering Committee, and ACC Competency Manage- cardiovascular training program director; a director of a ment Committee, and ratified by the ACC Board of coronary care unit; experts in advanced interventional Trustees in March, 2015. This document is considered procedures, cardiothoracic surgery, electrophysiology, current until the ACC Competency Management and heart failure; early-career experts; highly Committee revises or withdraws it. experienced specialists representing both the aca- demic and community-based practice settings; and physicians experienced in defining and applying 1.2. Background and Scope training standards according to the 6 general compe- The field of critical care cardiology has evolved tency domains promulgated by the Accreditation considerably over the past 2 decades. The coronary Council for Graduate Medical Education (ACGME) and care unit of the 1970s and 1980s was populated most American Board of Medical Specialties (ABMS) and frequently by patients with acute—and often uncom- endorsed by the American Board of Internal Medicine plicated—myocardial infarction or unstable angina. (ABIM).TheACCdeterminedthatrelationshipswith Detection and rapid treatment of arrhythmias were industry or other entities were not relevant to the cre- the primary goals of therapy. Today, patients with ation of this cardiology training statement. Employ- acute coronary syndromes, including those with ST- ment and affiliation details for authors and peer elevation myocardial infarction who have undergone reviewers are provided in Appendixes 1 and 2,respec- primary percutaneous coronary intervention, may be tively, along with disclosure reporting categories. managed at some institutions in step-down units with Comprehensive disclosure information for all authors, continuous telemetry monitoring. At all institutions, including relationships with industry and other en- contemporary critical care cardiology is increasingly tities, is available as an online supplement to this focused on the management of patients with document. advanced hemodynamic compromise, complex ven- tricular arrhythmias, and established or incipient 1.1.2. Document Development and Approval multiorgan failure, thus demanding a broader and The writing committee developed the document, more in-depth knowledge base and refined skill set approved it for review by individuals selected by the than that expected of care providers in years past. In addition, at many institutions, increasing numbers of patients undergoing transcatheter valve therapies or The American College of Cardiology requests that this document be cited ventricular assist devices are cared for in cardiac as follows: O’Gara PT, Adams JE III, Drazner MH, Indik JH, Kirtane AJ, Klarich KW, Newby LK, Scirica BM, Sundt TM III. COCATS 4 task force 13: intensivecareunits.Apremiumisplaced,notonlyon training in critical care cardiology. J Am Coll Cardiol 2015;65:1877–86. the ability to participate in or lead interdisciplinary 1878 O’Gara et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 13 MAY 5, 2015:1877– 86

care teams in this environment, but also on the skills some fellows may obtain enhanced procedural skills in needed to ensure orderly transitions of care once patients the context of a 3-year cardiovascular medicine are ready for transfer to less intensive hospital units or fellowship by spending additional time (3 to 6 months) directly to a rehabilitation facility. The competencies dedicated to critical care cardiology experiences, there important for the cardiovascular medicine fellow to ach- is currently no Level II designation in this field of ieve during critical care cardiology training have not been cardiology. included in previous iterations of COCATS and are pro- n Level III training requires advanced training and vided here in recognition of the need to define them experience beyond the cardiovascular fellowship to ac- within the context of this evolving and complex field. quire specialized knowledge and competencies in per- Many of the competencies pertinent to critical care car- forming, interpreting, and training others to perform diology will be acquired during other rotations; these specific procedures or render advanced specialized care include cardiac catheterization, electrophysiology, and at a high level of skill. For critical care cardiology, Level advanced heart failure. III training involves completion of a 1-year clinical In addition, this report addresses the evolving frame- fellowship in critical care medicine within the Depart- work of competency-based medical education described ment of Medicine in addition to the 3-year cardiovas- by the ACGME Outcomes Project and the 6 general com- cular medicine fellowship (1). petenciesendorsedbyACGMEandABMS.Thebackground and overarching principles governing fellowship training 2. GENERAL STANDARDS are provided in the COCATS 4 Introduction, and readers should become familiar with this foundation before Theessentialsofcriticalcarecardiologyshouldbetaught considering the details of training in a subdiscipline like toallfellows.Criticalcaretrainingshouldbeintegrated critical care cardiology. The Steering Committee and Task into the fellowship program and should include the Force recognize that implementation of these changes in evaluation and management of patients with acute, life- training requirements will occur incrementally. threatening cardiovascular illnesses; exposure to nonin- For most areas of cardiovascular medicine, 3 levels of vasive and invasive diagnostic modalities commonly used training are delineated: in the evaluation of such patients; familiarity with both temporary and long-term mechanical circulatory support n Level I training is the basic training required to become a devices; and an understanding of the management of competent cardiovascular consultant. This level of critically ill patients. The majority of critical care cardiol- training is required of all cardiovascular fellows and can ogy training will occur duringdedicatedrotationsinthe be accomplished as part of a standard 3-year training cardiac intensive care unit as well as in the cardiac surgical program in cardiovascular medicine. Cardiovascular intensive care unit; however, knowledge and skills rele- fellows should be well equipped to manage the majority vant to critical care cardiology will also be integral com- of patients in a critical care cardiology environment. ponents of other rotations, such as electrophysiology (see n Level II training refers to additional training in 1 COCATS 4 Task Force 11 report), advanced heart failure and or more areas that enables some cardiovascular spe- transplantation (2) (see COCATS 4 Task Force 12 report), cialists to perform or interpret specificdiagnostictests cardiac catheterization (see COCATS 4 Task Force 10 and procedures or render more specialized care for report), and imaging (see COCATS 4 Task Force 4 to 8 re- patients and conditions. This level of training is ports). Acquiring this fundamental knowledge will permit recognized for those areas in which an accepted in- the fellow to diagnose a broad array of cardiovascular dis- strument or benchmark, such as a qualifying exami- orders, initiate appropriate medical management, and nation, is available to measure specificknowledge, consult when necessary with other specialists to enable skills, or competence. Level II training in selected areas further evaluation and treatment. Importantly, the fellow may be achieved by some trainees during the standard will acquire the skills necessary to work with other care 3-year cardiology fellowship, depending on the team members in the interdisciplinary management of trainee’scareergoalsanduseofelectiverotations.Itis critically ill patients and demonstrate competency in anticipated that during a standard 3-year cardiovascu- ensuring safe and orderly transitions of care. These rec- lar fellowship training program, sufficient time will be ommendations are congruent with other training docu- available for trainees to receive Level II training in a ments and address faculty and facility requirements, specific subspecialty. Additional training of this type emerging technologies, and practice (1,3,4).Werecom- would signify a strong career interest in critical care mend that candidates for the ABIM examination for certi- cardiology. There are currently challenges to mea- fication in cardiovascular diseases, as well as those seeking surement and verification of these additional compe- certification of added qualifications in critical care, review tencies that require further adjudication. Although the specific requirements of the ABIM. JACC VOL. 65, NO. 17, 2015 O’Gara et al. 1879 MAY 5, 2015:1877– 86 COCATS 4 Task Force 13

Cardiovascular fellowship programs should satisfy the population. The cardiac care unit must be of sufficient requirements regarding faculty and facilities for training in size to serve the patient load, with adequate space in each critical care cardiology. Eligibility for the ABIM examina- room as determined by staff and equipment needs. tion requires that training take place in a program Providing separate rooms for each patient is optimal and accredited by the ACGME. The intensity of training and isolation rooms either within or immediately available to required resources vary with the level of training provided. the unit should be utilized as necessary. Sufficient workspace to accommodate staff functions, preferably in 2.1. Faculty a centralized location allowing direct or indirect visuali- Faculty should include dedicated cardiovascular special- zation of all patients at all times, is necessary. To augment ists with extensive critical care experience as well as routine monitoring of each patient, facilities should representatives from several cardiovascular specialty includeappropriateequipmentineachroomandatthe disciplines necessary for an interdisciplinary approach to nursing station. Additional space and resources required critical care. Cardiovascular critical care specialists should for the safe performance of invasive procedures in the possess adequate knowledge of pharmacological, device- cardiac critical care unit (e.g., pulmonary artery catheter based, and surgical therapies relevant to the field of or temporary pacemaker placement) should be available. critical care cardiology. Relevant faculty from various cardiovascular specialties participating in critical care 2.3. Equipment training should include general cardiologists, electro- The critical care unit should be equipped to provide physiologists, coronary and structural interventionists, comprehensive bedside monitoring and support. Re- heart failure specialists, and surgeons (including those quirements include continuous electrocardiographic with knowledge of or specialization in the application of monitoring; invasive arterial, venous, and pulmonary advanced hemodynamic support of critically ill patients). arterial pressure monitoring; oxygen saturation moni- Other faculty expected to contribute to the care of criti- toring; bedside imaging; mechanical circulatory support cally ill cardiovascular patients include those with devices; and mechanical ventilator support devices. expertise in nephrology, neurology, pulmonary medicine, Equipment should be available for systemic cooling as part infectious diseases, gastroenterology, hematology, and of hypothermia protocols and for renal replacement ther- anesthesiology. The cardiovascular critical care team also apy when required. Electronic health record resources includes representation from nursing, pharmacy, respi- should be available to organize patient-related data effi- ratory care, nutrition, dialysis, physical/occupational ciently and enhance communication among members of therapy, social work, and hospital ethics committees, the critical care team. among others. All team members contribute to training the cardiovascular fellow in this environment. 2.4. Ancillary Support Capabilities There must be at least 1 key clinical faculty member Ancillary support should be available to care for critically dedicated to training fellows in critical care cardiology. ill cardiovascular patients, including on-site access to all This faculty member should be board-certified in cardiol- core cardiovascular and imaging services. These services ogy and demonstrate that she/he is meeting requirements include cardiac catheterization, echocardiography, and for maintenance of certification. In most instances, this electrophysiology facilities, as well as comprehensive individual will serve as the medical director of the critical radiology services for brain, vascular, thoracic, abdom- care cardiology unit and will assume responsibility for inal, and pelvic imaging. Required support services also curriculum development and oversight, working in include cardiac surgery, anesthesia, endovascular and collaboration with the training program director. Sufficient interventional radiology, vascular surgery, neurology, numbers of qualified faculty experts in critical care cardi- nephrology, pulmonary, social work, ethics, palliative ology must exist to provide direct supervision of all fellows care, and pharmacy services with “24/7/365” availability. as fellows rotate through the cardiac critical care unit. 3. TRAINING COMPONENTS Critical care faculty should have sufficient experience with the indications for and contraindications to bedside diag- nostic and treatment procedures to allow them to inde- 3.1. Didactic Program pendently supervise fellows in their performance (see An important aspect of training in critical care cardiology COCATS 4 Task Force 10 and 11 reports). is didactic instruction. Didactic sessions can occur in a variety of formats, including but not limited to lectures, 2.2. Facilities conferences, journal clubs, grand rounds, and clinical Facilities should be adequate to ensure a safe, supportive, case presentations. The majority of case-based teaching efficient, and effective environment for the provision of for critical care cardiology will occur during scheduled critical care services to an increasingly complex patient rotations in the critical care unit, but such teaching need 1880 O’Gara et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 13 MAY 5, 2015:1877– 86

not be limited to this care site. Rather, teaching that is and ventricular assist devices (5,6).Thesetrainees relevant to the care of critically ill patients will occur should have the skill to utilize therapeutic hypothermia throughout the fellowship training program. for victims of out-of-hospital cardiac arrest, should demonstrate an understanding of how to integrate 3.2. Clinical Cases palliative and hospice care, and identify when further Trainees should gain firsthand experience in the evalua- care is futile. Trainees should also develop the knowledge tion and management of critically ill cardiac patients and skills needed to ensure appropriate transitions during unit rotations that include a minimum exposure of of care. 8 (not necessarily consecutive) weeks during the first 24 4. SUMMARY OF TRAINING REQUIREMENTS months of training. Exposure should allow the trainee to obtain the knowledge and skills required to manage the broad spectrum of acute coronary syndromes, mechanical 4.1. Development and Evaluation of Core Competencies complications of myocardial infarction, acutely decom- Training and requirements in critical care cardiology pensated severe heart failure, severe pulmonary hyper- address the 6 general competencies promulgated by the tension with/without right ventricular failure, circulatory ACGME/ABMS and endorsed by the ABIM. These compe- collapse/shock, acute severe heart valve disorders, peri- tency domains are: medical knowledge, patient care and cardial tamponade, aortic dissection, hypertensive emer- procedural skills, practice-based learning and improve- gencies, massive or submassive pulmonary embolism, ment, systems-based practice, interpersonal and and life-threatening arrhythmias and cardiac conduction communication skills, and professionalism. The ACC has disorders. During this exposure, the trainee is expected to used this structure to define and depict the components demonstrate understanding of and apply the findings of the core clinical competencies for cardiology. The from invasive hemodynamic monitoring to patient care curricular milestones for each competency and domain and to recognize the indications for advanced interven- also provide a developmental roadmap for fellows as they tional or surgical treatments, including mechanical cir- progress through various levels of training and serve as an culatory support, coronary artery bypass grafting, underpinning for the ACGME/ABIM reporting milestones. percutaneous coronary intervention, heart valve repair/ The ACC has adopted this format for its competency and replacement (including transcatheter techniques), peri- training statements, career milestones, lifelong learning, cardiocentesis, open or endovascular aortic repair, and and educational programs. Additionally, it has developed pulmonary embolectomy or fragmentation. The cardiac tools to assist physicians in assessing, enhancing, and critical care unit experience should include opportunities documenting these competencies. to participate in and, when appropriate, lead interdisci- Table 1 delineates each of the 6 competency domains as plinary care teams, as noted in Section 2.1. well as their associated curricular milestones for training in critical care cardiology. The milestones are categorized into Level I and III training (as previously defined in this 3.3. Hands-On Experience document) and indicate the stage of fellowship training Level 1 trainees should demonstrate knowledge and make (12, 24, or 36 months, and additional time points) by appropriate use of medications necessary for the treat- which the typical cardiovascular trainee should achieve ment of critically ill cardiac patients, including but not the designated level. Given that programs may vary with limited to inotropic, vasopressor, vasodilator, fibrinolytic, respect to the sequence of clinical experiences provided anticoagulant, antiplatelet, antiarrhythmic, sedative, to trainees, the milestones at which various competencies analgesic, and paralytic agents. In addition, over the are reached may also vary. Level I competencies may be 24 months of clinical training—and in sequence with achieved at earlier or later time points. Acquisition of cardiac catheterization laboratory rotations—all trainees Level III skills requires training in a dedicated critical care should develop the skills necessary to insert central cardiology program. The table also describes examples of venous lines, temporary transvenous pacemakers, radial evaluation tools suitable for assessment of competence in arterial lines, and balloon-flotation pulmonary artery each domain. catheters. All of these procedures may be performed at the bedside. Trainees should recognize the indications for 4.2. Number of Procedures and Duration of Training endotracheal intubation, mechanical ventilation, and The specific competencies for Levels I and III are delin- renal replacement therapy and demonstrate the skills eated in Table 1. Level I competencies must be obtained needed to evaluate and treat spontaneous or treatment- by all fellows during the 3-yearcardiovasculardisease related acute bleeding complications. Level I trainees fellowship training program. The minimum duration of should know the indications for mechanical circulatory training for Level I competencies is 8 weeks over the support, including intra-aortic balloon counterpulsation course of the first 24 months of training. Specific JACC VOL. 65, NO. 17, 2015 O’Gara et al. 1881 MAY 5, 2015:1877– 86 COCATS 4 Task Force 13

TABLE 1 Core Competency Components and Curricular Milestones for Training in Critical Care Cardiology

Competency Components Milestones (Months) MEDICAL KNOWLEDGE 12 24 36 Add

1 Know the pathophysiology, differential diagnosis, and characteristic clinical, hemodynamic, radiographic, and I laboratory findings of cardiogenic, hypovolemic, septic, and mixed circulatory shock, and of the systemic inflammatory response syndrome.

2 Know the indications for, and characteristic findings with, bedside invasive and noninvasive hemodynamic I monitoring.

3 Know the indications, contraindications, and clinical pharmacology for vasoactive and inotropic medications used I in the treatment of patients with advanced heart failure, hypotension, or shock.

4 Know the indications, contraindications, and clinical pharmacology for anticoagulant, antiplatelet, and fibrinolytic I agents.

5 Know the indications for, contraindications to, and clinical pharmacology of agents used to treat hypertensive I urgencies and emergencies.

6 Know the indications, contraindications, and clinical pharmacology for agents used to treat pulmonary hypertension, I including intravenous, inhalational, and oral agents.

7 Know the indications, contraindications, and clinical pharmacology for agents used to treat supraventricular and I ventricular arrhythmias.

8 Know the indications for, contraindications to, and risks of catheter-based techniques to treat supraventricular and I ventricular arrhythmias.

9 Know the characteristic clinical, electrocardiographic, echocardiographic, and radiographic findings with pulmonary I embolism, aortic dissection, pericardial tamponade, acute decompensated severe heart failure, severe valvular heart disease, and myocardial infarction.

10 Know the indications for oxygen supplementation, endotracheal intubation, and mechanical ventilator support for I patients with hypoxia and/or respiratory failure.

11 Know the differential diagnosis and characteristic laboratory findings of oliguria and acute kidney injury. I

12 Know the characteristic physical examination, echocardiographic, angiographic, and hemodynamic findings of I mechanical complications of myocardial infarction (e.g., ventricular septal defect, mitral regurgitation, and right ventricular infarction).

13 Know the types of, and indications for, mechanical circulatory support, including intra-aortic balloon I counterpulsation, ventricular assist (both percutaneous and surgical) devices, and extracorporeal membrane oxygenation.

14 Know the principles of treatment of hypotension in special populations, including patients with cardiogenic shock, I hypertrophic obstructive cardiomyopathy, right ventricular infarction, massive pulmonary embolism, pericardial tamponade, and distributive shock.

15 Know the indications for emergency surgery in patients with aortic dissection. I

16 Know the indications for emergent/urgent surgery and transcatheter valve replacement/repair in patients with I severe valvular heart disease.

17 Know the differential diagnosis of heart failure or shock in cardiac transplant patients. I

18 Know the elements of risk scoring systems for the assessment of prognosis in acute coronary syndrome, advanced I heart failure, and pulmonary hypertension, including demographics and findings from the clinical examination, electrocardiogram, biomarker testing, angiography, echocardiography, and invasive hemodynamic assessment.

19 Know the indications for use of hypothermia protocols and the principles of postresuscitation bundled care. I

20 Know the elements of scoring systems for assessment of the risk of major bleeding in patients treated with I antithrombotic medications.

EVALUATION TOOLS: conference presentation, direct observation, in-training examination, and simulation.

PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

1 Skill to manage patients with acute myocardial infarction and any associated rhythm, conduction, or mechanical I complications.

2 Skill to evaluate and manage acutely unstable cardiac patients by integrating the findings from clinical, I electrocardiographic, telemetry, imaging, and hemodynamic assessment—and to develop a plan for bedside intervention. 1882 O’Gara et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 13 MAY 5, 2015:1877– 86

TABLE 1 Core Competency Components, continued

Competency Components Milestones (Months) PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

3 Skill to place arterial, central venous, and pulmonary artery catheters and temporary transvenous pacemakers in I sequence with cardiac catheterization laboratory rotations.

4 Skill to recognize when renal replacement therapy is indicated, and to manage in conjunction with nephrology I consultants.

5 Skill to appropriately utilize therapeutic hypothermia protocols in survivors of cardiac arrest in conjunction with I neurological consultants.

6 Skill to evaluate and manage patients with hemodynamic instability following cardiac surgery. I

7 Skill to evaluate and manage patients with hemodynamic instability following transcatheter valve therapy. I

8 Skill to evaluate and manage supraventricular and ventricular arrhythmias and conduction disturbances in unstable I patients in collaboration with electrophysiology specialists.

9 Skill to use vasopressor and inotropic therapy appropriately in various types of shock. I

10 Skill to incorporate mechanical circulatory support in the management of critically ill patients. I

11 Skill to place intra-aortic balloon pump emergently. III*

12 Skill to identify and manage pericardial tamponade, including emergency pericardiocentesis. I

13 Skill to participate in the perioperative care of heart transplant and ventricular assist device patients, in I collaboration with heart failure experts, interventional cardiologists, and surgical consultants.

14 Skill to monitor blood pressure and hemodynamic state in patients with continuous flow left ventricular assist I devices, in collaboration with heart failure specialists, interventional cardiologists, and/or surgeons.

15 Skill to manage hypertensive urgencies and emergencies. I

16 Skill to manage special populations of critically ill cardiovascular patients including those with aortic dissection, I massive or submassive pulmonary embolism, acute severe valvular regurgitation, and advanced pulmonary hypertension with right ventricular dysfunction.

17 Skill to manage patients with acute bleeding, including bleeding from vascular access or spontaneous bleeding. I

18 Skill to perform noninvasive ventilation and CO2 monitoring. I 19 Skill to incorporate oxygen supplementation and mechanical ventilation in patient management. I

20 Skill to perform endotracheal intubation. III

21 Skill to utilize risk assessment scoring systems when appropriate in patient management and counseling. I

22 Skill to identify when further medical care is futile and to counsel families on end-of-life care. I

23 Skill to coordinate safe and effective transitions of care in collaboration with other members of the care team. I

EVALUATION TOOLS: conference presentation, direct observation, logbook, and simulation.

SYSTEMS-BASED PRACTICE 12 24 36 Add

1 Work effectively with all members of the critical care unit team including heart failure/transplant specialists, I electrophysiologists, interventionalists, surgeons, pulmonary critical care physicians, nephrologists, neurologists, nurses, physician’s assistants, pharmacists, social workers, and other team members as required.

2 Function effectively as team leader for the critical care unit team. III

3 Participate in hospital quality and safety initiatives in the critical care units. I

4 Design quality and safety initiatives. III

5 Utilize interdisciplinary input and expertise in comanagement of critically ill patients, including transitions of care. I

EVALUATION TOOLS: conference presentation, direct observation, and multisource evaluation.

PRACTICE-BASED LEARNING AND IMPROVEMENT 12 24 36 Add

1 Identify knowledge and performance gaps and engage in opportunities to achieve focused education and I performance improvement.

2 Utilize point-of-service resources to enhance adherence to guidelines and protocols and obtain new information from I trials and professional societies. JACC VOL. 65, NO. 17, 2015 O’Gara et al. 1883 MAY 5, 2015:1877– 86 COCATS 4 Task Force 13

TABLE 1 Core Competency Components, continued

Competency Components Milestones (Months) PRACTICE-BASED LEARNING AND IMPROVEMENT 12 24 36 Add

3 Incorporate appropriate use criteria, risk/benefit analysis, and cost considerations in the use of testing I and treatment.

EVALUATION TOOLS: conference presentation and direct observation.

PROFESSIONALISM 12 24 36 Add

1 Work effectively in an interdisciplinary critical coronary care unit environment. I

2 Demonstrate sensitivity to patient preferences and values and end-of-life issues. I

3 Practice within the scope of expertise and technical skills. I

4 Interact respectfully with patients, families, and all members of the healthcare team, including ancillary and I support staff.

EVALUATION TOOLS: conference presentation, direct observation, and multisource evaluation.

INTERPERSONAL AND COMMUNICATION SKILLS 12 24 36 Add

1 Communicate with and educate patients and families across a broad range of cultural, ethnic, and socioeconomic I backgrounds.

2 Communicate and work effectively with physicians and other professionals on the healthcare team in the I management of critically ill patients and their transition to other care environments.

3 Communicate with families with regard to end-of-life decisions with respect to programming of pacemakers and I implantable cardioverter-defibrillators.

EVALUATION TOOLS: direct observation and multisource evaluation.

*Fellows seeking to gain the skill to insert intra-aortic balloon pumps emergently may do so as part of Level II training in cardiac catheterization (see COCATS 4 Task Force 10 report). Add ¼ additional months beyond the 3-year cardiovascular fellowship.

procedural volume targets are not provided. Many of trainee to acquire the knowledge, skills, and experience these will be obtained during other rotations, such as necessary to achieve the competencies listed in Table 1. cardiac catheterization and electrophysiology. Neverthe- Because both dedicated critical cardiology time and less, outcomes-based evaluation measures must demon- complementary experiences necessary to gain knowledge strate that such competencies have been achieved. and skills through other cardiovascular rotations may be Designation of Level II competencies will require further assigned at various times to trainees over the first clarification once additional experience is gained with the 24 months of training, the milestones for the relevant critical care cardiology pathway. Level III competencies competencies should be reached by 24 months. are noted so that fellows are aware of the competencies for which additional, advanced training beyond the 4.2.2. Future Level II Training Requirements standard 3-year fellowship is required. Level III training Level II training will involvemoreadvancedknowledge couldbeaccomplishedwithadedicatedyearofcritical and skills than Level I training, likely with greater expe- care medicine training, in conjunction with the Depart- rience with bedside procedures and the skills needed ment of Medicine at the sponsoring institution. A brief for leading interdisciplinary teams managing critically discussion of the competencies and training requirements ill patients, but not with the competency expected for Levels I, II, and III follows. Although the minimum with Level III training. Preliminarily, an additional 3 to training duration and numbers of procedures are typically 6 months of clinical training within the 3-year cardio- required to obtain competency, trainees must also vascular medicine fellowship is envisioned to acquire demonstrate achievement of the competencies as these skills, but at present Level II training in critical care assessed by the outcomes evaluation measures. cardiology is not recognized.

4.2.1. Level I Training Requirements 4.2.3. Level III Training Requirements Level I training will typically require at least 8 weeks of Level III training prepares the physician to specialize in cardiology critical care exposure designed to allow the critical care cardiology. Level III requires additional 1884 O’Gara et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 13 MAY 5, 2015:1877– 86

experience beyond the standard 3-year cardiovascular source evaluations, trainee portfolios, and simulation. fellowship for the trainee to acquire specialized knowl- Case management, judgment, interpretive, and bedside edge and competencies in performing, interpreting, and skills must be evaluated in every trainee. Quality of care training others to perform specific critical care functions and follow-up; reliability; judgment, decisions, or actions and procedures or render advanced, specialized critical that result in complications; interaction with other phy- care at a high level of skill. Trainees should obtain addi- sicians, patients, and laboratory support staff; initiative; tional critical care medicine training within the depart- and the ability to make appropriate decisions indepen- ment of medicine upon completing a 3-year cardiovascular dently should be considered. Trainees should maintain fellowship. A portion of this advanced training can be records of participation and advancement in the form spent under supervision in cardiac or cardiac surgical of a Health Insurance Portability and Accountability Act intensive care units, as specified by the critical care med- (HIPAA)–compliant electronic database or logbook that icine fellowship program. Level III training is described meets ACGME reporting standards and summarizes here only in broad terms to provide context for trainees pertinent clinical information (e.g., number of cases, di- and clarify that these advanced competencies are not versity of referral sources, diagnoses, disease severity, covered during the general cardiology fellowship. The outcomes, and disposition). additional exposure and requirements for Level III Under the aegis of the program director, the faculty training will be addressed in a subsequent, separately should record and verify each trainee’s experiences, published Advanced Training Statement. assess performance, and document satisfactory achieve- ment. The program director is responsible for confirming 5. EVALUATION OF COMPETENCY experience and competence and reviewing the overall progress of individual trainees with the Clinical Compe- Evaluation tools in critical care cardiology include direct tency Committee to ensure achievement of selected observation by instructors, in-training examinations, training milestones and to identify areas in which addi- case logbooks, conference and case presentations, multi- tional focused training may be required.

REFERENCES

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APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 13: TRAININGINCRITICALCARECARDIOLOGY

Institutional/ Ownership/ Organizational Speakers Partnership/ Personal or Other Expert Committee Member Employment Consultant Bureau Principal Research Financial Benefit Witness

Patrick T. O’Gara (Chair) Brigham and Women’s Hospital None None None None None None Cardiovascular Division—Director, Clinical Cardiology; Harvard Medical School—Professor of Medicine

Jesse E. Adams III Louisville Cardiology Group; None None None None None None Baptist Medical Associates; University of Louisville, Division of Cardiology—Associate Clinical Professor of Medicine

Mark H. Drazner UT Southwestern Medical Center— None None None None None None Professor, Medical Director, Heart Failure, Ventricular Assist Devices, and Cardiac Transplantation; James M. Wooten Chair in Cardiology

Julia H. Indik University of Arizona—Associate None None None None None None Professor of Medicine

Ajay J. Kirtane Columbia University Medical Center, None None None None None None New York Presbyterian Hospital— Chief Academic Officer, Center for Interventional Vascular Therapy; Director, Interventional Cardiology Fellowship Program and Catheterization Laboratory Quality

Kyle W. Klarich Mayo Clinic—Professor of Medicine None None None None None None

L. Kristin Newby Duke University Medical Center— None None None None None None Professor of Medicine

Benjamin M. Scirica Brigham and Women’s Hospital— None None None None None None Associate Physician

Thoralf M. Sundt III Harvard Medical School—Professor None None None None None None of Surgery; Massachusetts General Hospital—Chief, Division of Cardiac Surgery

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects authors’ employment and reporting categories. To ensure complete transparency, authors’ comprehensive healthcare-related disclosure information—including relationships with industry not pertinent to this document—is available in an online data supplement. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/ relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional information about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology. 1886 O’Gara et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 13 MAY 5, 2015:1877– 86

APPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 13: TRAININGINCRITICALCARECARDIOLOGY

Institutional/ Organizational Ownership/ or Other Speakers Partnership/ Personal Financial Expert Name Employment Representation Consultant Bureau Principal Research Benefit Witness

Richard Kovacs Indiana University, Krannert Official Reviewer, None None None None None None Institute of Cardiology—Q.E. ACC Board of Trustees and Sally Russell Professor of Cardiology

Dhanunjaya Kansas University Cardiovascular Official Reviewer, None None None None None None Lakkireddy Research Institute ACC Board of Governors

Howard Weitz Thomas Jefferson University Official Reviewer, None None None None None None Hospital—Director, Division Competency Management of Cardiology; Sidney Kimmel Committee Lead Reviewer Medical College at Thomas Jefferson University— Professor of Medicine

Mardi Gomberg- University of Chicago Content Reviewer, None None None None None None Maitland Medicine—Associate Professor, Individual Medicine, Cardiology; Director, Pulmonary Hypertension

David Holmes Mayo Clinic—Consultant, Content Reviewer, None None None None None None Cardiovascular Diseases Individual

Larry Jacobs Lehigh Valley Health Network, Content Reviewer, None None None None None None Division of Cardiology; Cardiology Training and University of South Florida— Workforce Committee Professor, Cardiology

Andrew Kates Washington University Content Reviewer, None None None None None None School of Medicine Academic Cardiology Section Leadership Council

Eric Peterson Duke Clinical Research Content Reviewer, None None None None None None Institute—Executive Director; Individual Duke University Medical Center—Professor, Medicine

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects peer reviewers’ employment, representation in the review process, as well as reporting categories. Names are listed in alphabetical order within each category of review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional infor- mation about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology.

APPENDIX 3. ABBREVIATION LIST

ABIM ¼ American Board of Internal Medicine ABMS ¼ American Board of Medical Specialties ACC ¼ American College of Cardiology ACGME ¼ Accreditation Council for Graduate Medical Education COCATS ¼ Core Cardiovascular Training Statement HIPAA ¼ Health Insurance Portability and Accountability Act JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 65, NO. 17, 2015 ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00 PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacc.2015.03.030

TRAINING STATEMENT COCATS 4 Task Force 14: Training in the Care of Adult Patients With Congenital Heart Disease

Carole A. Warnes, MD, FACC, Chair Linda D. Gillam, MD, MPH, FACC Ami B. Bhatt, MD, FACC Karen K. Stout, MD, FACC Curtis J. Daniels, MD, FACC

1. INTRODUCTION ACC, and then addressed the reviewers’ comments. The document was revised and posted for public 1.1. Document Development Process comment from December 20, 2014, to January 6, 2015. 1.1.1. Writing Committee Organization Authors addressed these additional comments from the public to complete the document. The final The Writing Committee was selected to represent the document was approved by the Task Force and ACC American College of Cardiology (ACC) and included a Competency Management Committee and ratified by cardiovascular training program director, a training the ACC Board of Trustees in March, 2015. This docu- director specializing in the care of adults with ment is considered current until the ACC Competency congenital heart disease (i.e., adult congenital heart Management Committee revises or withdraws it. disease [ACHD]), early-career ACHD cardiologists, highly experienced specialists representing both the academic and community-based practice settings, 1.2. Background and Scope and physicians experienced in defining and applying Remarkable advances in surgical management of training standards according to the 6 general compe- congenital heart disease (CHD) over the last half tency domains promulgated by the Accreditation century have allowed more than 90% of children with Council for Graduate Medical Education (ACGME) and CHD to survive to adulthood (1). This has led to a shift American Board of Medical Specialties (ABMS) and in the prevalence of CHD, such that adults comprise endorsed by the American Board of Internal Medicine two-thirds of the overall CHD population, with an (ABIM).TheACCdeterminedthatrelationshipswith estimated 1.5 million adult survivors in the United industry or other entities were not relevant to the States alone. This population includes not only those creation of this cardiovascular training statement. with mild and moderate forms of CHD, but also, Employment and affiliation details for authors and importantly, those with severe forms of CHD. Indeed, peer reviewers are provided in Appendixes 1 and 2, approximately 60% of those with severe CHD are now respectively, along with disclosure reporting cate- adults (2,3). The rise in incidence and prevalence is gories. Comprehensive disclosure information for all expected to continue, so healthcare delivery for CHD, authors, including relationships with industry and including the training of cardiologists, must evolve as other entities, is available as an online supplement to well to meet this demand. ACHD patients have special this document. healthcare needs and often present complex combi- nations of problems that are generally unrecognized 1.1.2. Document Development and Approval by those in a traditional, internal medicine–based The Writing Committee developed the document, cardiovascular training program (4). Adult cardiolo- approved it for review by individuals selected by the gists are experts in the care of acquired diseases that affect the heart and circulation, but currently most have little or no training in CHD, particularly in The American College of Cardiology requests that this document be cited complex disorders. Exposure to ACHD patients and as follows: Warnes CA, Bhatt AB, Daniels CJ, Gillam LD, Stout KK. clinical experiences for cardiovascular fellows varies COCATS 4 task force 14: training in the care of adult patients with congenital heart disease. J Am Coll Cardiol 2015;65:1887–98. widely (3). Many ACHD patients continue to be cared 1888 Warnes et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 14 MAY 5, 2015:1887– 98

for by pediatric cardiologists for many reasons, including career goals and use of elective rotations. It is antici- the fact that there are few internal medicine cardiologists pated that during a standard 3-year cardiovascular specializing in this complicated field and access is, fellowship training program, sufficient time will be therefore, limited (5,6). This report recommends an available to receive Level II training in a specificsub- approach to more systematic training of internal medicine specialty. Recognizing the special needs of this com- cardiologists in the recognition and care of ACHD patients plex patient population, the ABMS approved ACHD on the basis of previous Bethesda Conference descriptions subspecialty certification in December 2012 (see specific of workforce needs and educational requirements (5). criteria under Level III training). There is no Level II Similar recommendations are made for ACHD training for training curriculum or qualifying examination in ACHD. pediatric cardiovascular trainees, with an emphasis on Thus, only Level I and III training apply to ACHD. the importance of ACHD training for all cardiologists who n Level III training requires additional training and may care for these patients, regardless of specialty (7).In experience beyond the cardiovascular fellowship for addition, this report addresses the evolving framework of the trainee to acquire specialized knowledge and competency-based medical education described by the experience in performing, interpreting, and training ACGME Outcomes Project and the 6 general competencies others to perform specific procedures or render ad- endorsed by ACGME and ABMS. The background and vanced specialized care for specific conditions at a high overarching principles governing fellowship training are level of skill. In the case of ACHD, Level III training provided in the COCATS 4 Introduction, and readers provides the knowledge needed by graduates wishing should become familiar with this foundation before to make an advanced clinical and/or academic/research considering the details of training in a subdiscipline like commitment to this field and to not only become ACHD. The Steering Committee and Task Force recognize competentinthecareoftheentirespectrumofACHD that implementation of these changes in training re- patients, but also participate in teaching about ACHD quirements will occur incrementally over time. (6). Level III competency requires specific time dedi- For most areas of cardiovascular medicine, 3 levels of cated to training in pediatric cardiology (as outlined by training are delineated: the ACGME) for those with a background in adult car- diovascular medicine, and requires dedicated time in n Level I training is the basic training required to become adult internal medicine and cardiology for those with a a competent cardiovascular consultant, is required of background in pediatric cardiology. Level III requires all cardiovascular fellows, and can be accomplished as training beyond the 3 years of fellowship (in either part of a standard 3-year training program in cardio- pediatric or adult cardiovascular medicine). Such Level vascular medicine. This level of training should allow III training would be sufficient to clinically manage the trainee to develop sufficient knowledge to review complex ACHD in a regional or tertiary center, pursue and understand consensus-based ACHD care guidelines an academic career, train others in the field, and/or to determine which ACHD patients can be managed by a direct an ACHD program. ACHD subspecialty certifica- clinician and which patients are best cared for in tion was approved through the ABMS in December 2012. collaboration with an ACHD specialist. Along with The first examination in 2015 is available for those guideline-based care, this level of training should also who qualify by meeting the practice pathway criteria enable the cardiologist to recognize when direct and is administered by the ABIM in collaboration with consultation and referraltoanACHDspecialistare the American Board of Pediatrics. Once the practice necessary. In some circumstances, Level I–trained pathway closes, only those completing an ACGME- physicians may participate in the care of patients with approved advanced ACHD fellowship (beyond adult or moderately or severely complex disease in close pediatric cardiovascular fellowship) will qualify collaboration with an ACHD specialist. for ACHD subspecialty certification. Level III training is n Level II training refers to the additional training in 1 or described here only in broad terms to provide context more areas that enables some cardiovascular specialists for trainees and clarify that these advanced compe- to perform or interpret specificdiagnostictestsand tencies are not covered during the cardiovascular procedures or render more specialized care for patients fellowship. The additional exposure and requirements and conditions. This level of training is recognized for for Level III training will be addressed in a subsequent, those areas in which an accepted instrument or separately published Advanced Training Statement. benchmark, such as a qualifying examination, is avail- able to measure specific knowledge, skills, or compe- 2. GENERAL STANDARDS tence. Level II training in selected areas may be achieved by some trainees during the standard 3-year The ACC and American Heart Association have produced cardiovascular fellowship, depending on the trainee’s guidelines for ACHD (8) and educational objectives for JACC VOL. 65, NO. 17, 2015 Warnes et al. 1889 MAY 5, 2015:1887– 98 COCATS 4 Task Force 14

fellowship training in ACHD (9). The recommendations training should accord with ABIM– and ACGME–recom- are congruent and address faculty, facility requirements, mended guidelines. emerging technologies, and practice. We recommend strongly that candidates for the ABIM examination for 2.2. Facilities, Equipment, Ancillary Support, certification in cardiovascular diseases, as well as those and Program Requirements seeking certification of added qualifications in ACHD, re- To train cardiac fellows to achieve Level III competency, view the specific requirements of the ABIM. With recent institutions that care for ACHD patients should meet ABMSapprovalforACHDsubspecialtycertification, it is certain program requirements and have essential ancil- expected that the ACGME will standardize fellowship lary support capabilities. Two basic requirements are programs with specific guidelines for faculty, facilities, indicated for a program to train fellows effectively at and curriculum, and that these guidelines will apply to Level III: 1) the presence of associated formal programs in advanced fellowship trainees with either pediatric or pediatric cardiology and cardiovascular CHD surgery; and adult cardiovascular training. 2) a critical mass of faculty who are board eligible/certified in ACHD. Relationships should also be cultivated in ob- 2.1. Faculty stetrics, general surgery, cardiac anesthesia, hematology, Ideally, to ensure adequate Level I training, a program hepatology, nephrology, and other subspecialties as should have at least 1 faculty member with expertise and feasible at a given institution. Because ACHD patients will commitment to the care of adults with CHD. This faculty use noncardiac hospital resources as well, appropriate member should have achieved the skills equivalent to monitoring should be available and specialty care should Level III training by lifelong experience and/or specific becoordinatedwiththeACHDteam. training. In recognition that not all programs have ACHD For comprehensive imaging assessment at a Level III expert faculty available, Level 1 training may be achieved training program, echocardiography laboratories with without ACHD faculty on site, but in such cases other re- sonographers with training and expertise in assessing sources, such as online learning modules, visiting congenital heart lesions as well as echocardiographers professors, “away” rotations, and print or electronic who are expert in and experienced with reading ACHD curricula, should be utilized. Affiliation with a pediatric echocardiograms must be available. Advanced imaging cardiovascular program is an invaluable resource for facilities, ACHD–specific MRI and CT protocols, and car- congenital heart disease education. Advanced training diologists or radiologists with experience in CHD are (Level III) requires a critical mass of faculty dedicated to the essential for comprehensive imaging at a Level III training care of adult patients with CHD and a program that pro- program and, if available, should be leveraged for training vides comprehensive diagnostic and management services and exposure at non-Level III programs. to patients with a broad array of congenital cardiac disor- At training institutions that perform adult congenital ders. Affiliation with a pediatric cardiovascular program is procedures, including but not limited to hemodynamic ideal and will further ensure that the trainee in advanced assessment and potential catheter-based or electrophysi- ACHD is exposed to patients across the entire lifespan. This ological interventions, ancillary support is essential to comprehensive ACHD education includes congenital ensure patient safety. This should include laboratories interventional procedures; congenital electrophysiolog- with fluoroscopy and specialized equipment for the safe ical consultation and procedures; congenital cardiac sur- performance of diagnostic procedures and congenital car- gery; and training in ACHD echocardiography, computed diac interventions or electrophysiological interventions tomography (CT), and magnetic resonance imaging (MRI). in an adult. Institutions that intervene on ACHD patients Organized, deliberate, and developmentally appropriate must have cardiologists with the expertise to perform transition and transfer of patients from pediatric to coronary interventions. The ability to perform detailed ACHD programs are necessary, and comprehensive ACHD hemodynamic assessments, including the evaluation of education should include participation in transition pro- pulmonary vascular disease and the reversibility of pul- grams. Further training in intervention, electrophysiology, monary hypertension, is also important. When available, and in some cases, imaging, will be necessary for inde- a biplane room may benefit the ACHD patient. For pendent practice of these disciplines. Programs that have institutions performing interventions on moderate-to- interdisciplinary involvement, including with obstetrics, complex ACHD, cardiac anesthesia and a clear process pulmonary hypertension specialists, hematologists, hep- for rapid availability of urgent or emergent cardiac sur- atologists, and others, are forming a robust network of gery should be established. Operating rooms should be interdisciplinary clinicians with experience in caring for fully staffed and should have dedicated cardiac anes- the entirety of the ACHD patient experience and are ideal in thesiologists and the resources necessary for ACHD op- providing comprehensive training. This level of expertise erations as well as the capability for imaging and may still be evolving at some institutions, but ACHD percutaneous interventions, as previously discussed. 1890 Warnes et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 14 MAY 5, 2015:1887– 98

3. TRAINING COMPONENTS Fellows seeking more detailed ACHD training than prescribed by the Level I minimum recommendations 3.1. Didactic Program during the clinical cardiovascular fellowship should Didactic instruction may take place in a variety of for- obtain robust clinical experiences in the outpatient and mats, including but not limited to lectures, conferences, inpatient consultation settings, as well as experience in journal clubs, grand rounds, clinical case presentations, cardiac catheterization, arrhythmia and heart failure and online learning. Such instruction can occur as a part management, ICU care, appropriate indications for sur- of the fellow’s core curriculum teaching or rotation- gical or catheter-based intervention; exposure to opera- specific lectures, or may be incorporated into other sub- tions; and, importantly, perioperative and postoperative specialty curricula such as electrophysiology, pulmonary intensive care. Management of ACHD patients admitted hypertension, cardiac surgery, echocardiography, or for noncardiac diagnoses with a special focus on preg- noncardiac care (e.g., obstetrics, palliative care). Oppor- nancy, labor, and delivery must also be a component of tunities such as online learning from approved cardiac this extra training. In each of these clinical settings, educational sites with continuing medical education trainees should assist in patient care in a supervised credit should also be encouraged and included as sup- setting that provides for patient-centered education in all plements to hospital-based didactics. Whereas Level I aspects of ACHD management. competency can be achieved without an ACHD expert 3.3. Hands-On Experience faculty member or substantial ACHD patient volume, Level III training requires both faculty expertise and pa- Hands-on experience is important for training in ACHD tient volume that allow direct clinical care in addition to management. Cardiovascular trainees should have a robust didactic education. A comprehensive curriculum is hands-on clinical experience to acquire the core compe- currently being developed by the ACC. Bedside physical tencies for Level I training. During this period, and during examination, whether inpatient or outpatient, is an rotations on the other cardiac services, trainees should fi essential component of Level I training. review case histories, physical ndings, and electrocar- diograms, and log echocardiogram reading, arrhythmia 3.2. Clinical Experience management, and percutaneous and surgical cases Rotation on an ACHD service is an essential component of involving ACHD patients. Interaction with the ACHD team all levels of ACHD training. For programs with an ACHD should not be limited to “on-rotation” time, because service, a rotation is mandatory. Ideally, Level I trainees exposure to the ACHD patient is likely to become perva- should gain first-hand experience in both inpatient and sive in all cardiac subdisciplines. outpatient consultation and management of ACHD. 4. SUMMARY OF TRAINING REQUIREMENTS Ideally, the ACHD service will have a robust patient mix (including low, moderate, and high complexity) in both inpatient and outpatient settings. The ACHD service 4.1. Development and Evaluation of Core Competencies should expose trainees to a wide array of ACHD patients Training and requirements in ACHD address the 6 general and procedures, and should, at a minimum for the Level I competencies promulgated by the ACGME/ABMS and trainee, include exposure to ACHD management within endorsed by the ABIM. These competency domains are: the cardiac subspecialties (e.g., arrhythmia, heart failure, medical knowledge, patient care and procedural skills, pulmonary hypertension, transplant, intervention, and practice-based learning and improvement, systems-based surgery). practice, interpersonal and communication skills, and If a program lacks the necessary expertise and patient professionalism. The ACC has used this structure to define volume, patient-based education can be achieved through and depict the components of the core clinical compe- alternative approaches, such as didactic education, with a tencies for cardiology. The curricular milestones for each focus on case-based education. The interpretation of competency and domain also provide a developmental clinical cases should always include the interpretation of roadmapforfellowsastheyprogressthroughvarious testing ranging from electrocardiography to echocardi- levels of training and serve as an underpinning for the ographyoradvancedimaging,aswellasanyinterven- ACGME/ABIM reporting milestones. The ACC has adopted tional procedures. Achievement of Level I training must this format for its competency and training statements, beaccomplishedwithafocusededucationalexperience, career milestones, lifelonglearning,andeducational as either a dedicated block or a discrete ACHD clinical programs. Additionally, it has developed tools to assist experience through the course of other rotations (i.e., physicians in assessing, enhancing, and documenting regular longitudinal participation in an ACHD outpatient these competencies. clinic, as either a continuity clinic or component of other Tables 1 and 2 delineate each of the 6 competency do- rotations). mainsaswellastheirassociatedcurricularmilestonesfor JACC VOL. 65, NO. 17, 2015 Warnes et al. 1891 MAY 5, 2015:1887– 98 COCATS 4 Task Force 14

Core Competency Components and Curricular Milestones for Training in Adults With Simple Congenital Heart Disease TABLE 1 (Atrial Septal Defects, Ventricular Septal Defects, Patent Ductus Arteriosus, Pulmonary Stenosis, Bicuspid Aortic Valve, Coarctation)

Competency Component Milestones (Months) MEDICAL KNOWLEDGE 12 24 36 Add

1 Know the anatomy, pathophysiology, associated lesions, and natural histories of atrial septal defects (primum, I secundum, and sinus venosus) and ventricular septal defects.

2 Know the anatomy, pathophysiology, associated lesions, and natural histories of bicuspid aortic valve, pulmonic I stenosis, coarctation of the aorta, and patent ductus arteriosus.

3 Know the risk of development and pathophysiology of pulmonary arterial hypertension in adult patients with I congenital heart disease, including issues related to noncardiac surgery, pregnancy, contraception, and exercise.

4 Know the potential reproductive and genetic implications of basic adult congenital heart disease, both for patients I and for potential offspring.

5 Know the indications for patient referral to an adult congenital heart disease center. I

6 Know the cardinal symptoms physical examination, electrocardiogram, and chest x-ray findings of patients with I simple adult congenital heart disease.

7 Know the indications for noninvasive and invasive testing for the evaluation of simple adult congenital heart disease. I

8 Know the indications and contraindications for surgical and percutaneous interventions in adult congenital heart disease. I

9 Know the indications for endocarditis prophylaxis based on current guidelines. I

EVALUATION TOOLS: chart-stimulated recall, conference presentation, direct observation, and in-training examination.

PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

1 Skill to accurately perform a comprehensive history and physical examination in the patient with simple adult I congenital heart disease.

2 Skill to appropriately order and integrate the results of imaging with other clinical findings in the evaluation and I management of simple adult congenital heart disease patients.

3 Skill to evaluate and manage patients with simple adult congenital heart disease who have undergone reparative I intervention.

4 Skill to evaluate and manage the potential cardiovascular complications of pregnant women with simple adult I congenital heart disease.

5 Skill to detect the findings of pulmonary arterial hypertension. I

6 Skill to appropriately advise patients with simple congenital heart disease regarding exercise, sports participation, I and return to play, including the use of testing to evaluate for safety.

7 Skill to evaluate and manage patients with simple congenital heart disease, including appropriate timing for I surgical interventions.

EVALUATION TOOLS: chart-stimulated recall, conference presentation, and direct observation.

SYSTEMS-BASED PRACTICE 12 24 36 Add

1 Collaborate and coordinate patient care with an adult congenital heart disease center to provide optimal healthcare I for appropriate patients with adult congenital heart disease.

2 Demonstrate the ability to provide primary cardiac longitudinal care for patients with simple adult congenital heart I disease in association with an adult congenital heart disease center.

EVALUATION TOOLS: chart-stimulated recall, conference presentation, direct observation, and multisource evaluation.

PRACTICE-BASED LEARNING AND IMPROVEMENT 12 24 36 Add

1 Locate, appraise, and assimilate evidence from scientific resources, such as adult congenital heart disease clinical I practice guidelines.

2 Identify knowledge and performance gaps and engage in opportunities to achieve focused education and I performance improvement.

EVALUATION TOOLS: chart-stimulated recall, direct observation, and reflection and self-assessment. 1892 Warnes et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 14 MAY 5, 2015:1887– 98

TABLE 1 Core Competency Components, continued

Competency Component Milestones (Months) PROFESSIONALISM 12 24 36 Add

1 Demonstrate sensitivity and responsiveness to diverse patient populations. I

2 Respond to patient needs in a way that supersedes self-interest, including referral of basic adult congenital heart I disease patients when appropriate.

EVALUATION TOOLS: direct observation and multisource evaluation.

INTERPERSONAL AND COMMUNICATION SKILLS 12 24 36 Add

1 Effectively educate patients and families across the range of socioeconomic and cultural backgrounds about adult I congenital heart disease management, complications, and lifestyle issues.

2 Communicate testing results to physicians and patients in an effective and timely manner. I

EVALUATION TOOLS: direct observation and multisource evaluation.

Add ¼ additional months beyond the 3-year cardiovascular fellowship.

training in adult congenital heart disease. The milestones follows. Although these minimum training duration and are categorized into Level I and III training (as previously numbers of procedures are typically required to obtain defined in this document) and indicate the stage of competency, there must also be demonstration of fellowship training (12, 24, or 36 months, and additional achievement of the competencies as assessed by the time points) by which the typical cardiovascular trainee outcomes evaluation measures. should achieve the designated level. Given that programs may vary with respect to the sequence of clinical experi- 4.2.1. Level I Training Requirements ences provided to trainees, the milestones at which All cardiovascular trainees should be exposed to a core of various competencies are reached may also vary. Level I information regarding adults with CHD. The goal of Level competencies may be achieved at earlier or later time I training is to have the ability to recognize and evaluate points. Acquisition of Level III skills requires training in a common, simple congenital heart lesions and the dedicated ACHD program. The tables also describe ex- sequelae of the more commonly repaired congenital heart amples of evaluation tools suitable for assessing compe- defects. These graduates should consult and collaborate tence in each domain. with a Level III–trained ACHD specialist when major management decisions are made for adults with CHD and 4.2. Structure and Duration of Training for periodic discussions of ongoing care. Because relatively few centers in the United States have Wesuggestthatatleast6hoursofformallectures amassed a sufficient number of ACHD patients who have within the core curriculum of the training program be been followed in an organized manner, regionalization devoted to CHD in adults. Table 1 indicates the content of training in the care of the complex CHD patients suggested for these 6 hours, covering key basic and clin- is necessary (6). In addition to meeting requirements ical aspects of these disorders. With the acknowledgment for training duration and numbers of procedures per- that there are many teaching styles and organizational formed and/or interpreted, the trainee must demonstrate strategies to teach the necessary concepts, a proposed achievement of specific competencies. A brief discussion curriculum is as follows: Hour 1 ¼ basic anatomy, pa- of the competencies and training requirements for ACHD thology, physiology, hemodynamics, and known genetics follows. of common lesions and conditions; Hour 2 ¼ clinical The specific competencies for Levels I and III are diagnosis (history, clinical examination, electrocardio- delineated in Table 1.LevelIcompetenciesmustbeob- gram, and x-ray) and management of the most common tained by all fellows during the 3-year cardiovascular lesions expected to be encountered in adults, operated or disease fellowship training program. There is no Level II not; Hour 3 ¼ specific issues relevant to cyanotic CHD training in ACHD. Level III competencies are noted so that and Eisenmenger syndrome; Hour 4 ¼ a description of fellows are aware of the competencies for which addi- the most commonly performed surgical procedures tional, advanced training beyond the standard 3-year involved in repair and palliation of CHD and a review fellowship is required. A brief discussion of the compe- of the common residua and sequelae encountered in tencies and training requirements for Levels I and III clinical practice; Hour 5 ¼ common echocardiographic JACC VOL. 65, NO. 17, 2015 Warnes et al. 1893 MAY 5, 2015:1887– 98 COCATS 4 Task Force 14

Core Competency Components and Curricular Milestones for Training in Caring for Adults With Complex Congenital TABLE 2 Heart Disease (Ebstein’s Anomaly, Tetralogy of Fallot, Complex Cyanotic Congenital Heart Disease, Transposition of the Great Arteries, Single Ventricle Physiology/Fontan)

Competency Component Milestones (Months) MEDICAL KNOWLEDGE 12 24 36 Add

1 Know the basic anatomy and pathophysiology of the cyanotic congenital heart diseases encountered in adolescents I and adults.

2 Know the natural history of cyanotic congenital heart diseases, particularly those with Eisenmenger Syndrome. I

3 Know the hematological complications and their management in patients with cyanotic heart disease. I

4 Know the risks of cardiac arrhythmias and their management in patients with adult congenital heart disease. I

5 Know the renal complications of cyanotic heart disease, including medications and procedures with the potential I for precipitating renal failure.

6 Know the other systemic complications of cyanotic heart disease: pulmonary, orthopedic, and neurological. I

7 Know the vulnerability these patients have for mortal complications from routine noncardiac surgical procedures I and the risks of intravenous lines without air filters.

8 Know the potential for mortal complications in cyanotic patients, particularly those with pulmonary hypertension, I from pregnancy or the use of estrogen-based contraception.

9 Transposition of the great arteries: know the basic anatomy, the types of surgical repair, and their complications I in the adult patient.

10 Single ventricle/Fontan: know the basic anatomy and hemodynamics both in patients with and without surgical I repair and that noncardiac surgery must be performed at an adult congenital heart disease center.

11 Tetralogy of Fallot: know the basic anatomy; the types of surgical repair; and the postoperative residua and I sequelae, including indications and timing of reoperation.

12 Know the anatomy, pathophysiology, and associated lesions of Ebstein’s anomaly. I

13 Know the indications for patient referral to an adult congenital heart disease center. I

14 Know the appropriate indications for and timing of medical, surgical, and interventional therapies in all forms of III congenital heart disease.

EVALUATION TOOLS: chart-stimulated recall, conference presentation, direct observation, and in-training examination.

PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

1 Skill to accurately interpret the physical examination, echocardiogram, and electrocardiogram findings in patients I with repaired Tetralogy of Fallot.

2 Skill to accurately interpret the physical examination, electrocardiogram, and chest x-ray findings in patients with I Eisenmenger physiology.

3 Skill to appropriately use electrocardiography, echocardiography, and other imaging modalities in diagnosis and I management of complex adult congenital heart disease.

4 Skill to ensure that female patients have received appropriate contraceptive advice. I

5 Skill to collaborate with an adult congenital heart disease specialist before prescribing medications and procedures I with the potential to affect hemodynamic stability in patients with cyanotic heart disease.

6 Skill to urgently refer patients to an adult congenital heart disease center in the setting of hemoptysis, transient I neurological disturbance, syncope, arrhythmia, pregnancy, or anticipated noncardiac surgery.

7 Skill to interpret echocardiograms, including transesophageal echocardiograms, in all forms of complex congenital III heart disease, and to select other appropriate imaging modalities when necessary (magnetic resonance imaging, computed tomography).

8 Skill to interpret hemodynamic and angiographic data in all types of complex congenital heart disease. III

9 Skill to appropriately treat complications of complex congenital heart disease, including hemoptysis, arrhythmias, III and heart failure.

10 Skill to evaluate and manage patients with all forms of complex congenital heart disease, both operated and III unoperated, including appropriate timing for surgical interventions.

11 Skill to assess preconceptual risk and manage patients during pregnancy. III 1894 Warnes et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 14 MAY 5, 2015:1887– 98

TABLE 2 Core Competency Components, continued

Competency Component Milestones (Months) PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

12 Skill to appropriately advise patients with all forms of complex congenital heart disease regarding exercise, sports III participation, and return to play, including the use of testing to evaluate for safety.

EVALUATION TOOLS: chart-stimulated recall, conference presentation, and direct observation.

SYSTEMS-BASED PRACTICE 12 24 36 Add

1 Establish an ongoing collaborative relationship with an adult congenital heart disease team or center to facilitate I prompt access to appropriate advice and urgent admission of cyanotic patients when necessary.

2 Utilize an interdisciplinary team approach with other subspecialists to optimize the care of all patients with III moderate and complex congenital heart disease.

EVALUATION TOOLS: chart-stimulated recall, conference presentation, direct observation, and multisource evaluation.

PRACTICE-BASED LEARNING AND IMPROVEMENT 12 24 36 Add

1 Identify strengths, deficiencies, and limits in one’s knowledge and expertise in cyanotic heart disease and carry out I personalized education to address them.

2 Locate, appraise, and assimilate evidence from scientific resources, such as adult congenital heart disease clinical I practice guidelines, and apply that knowledge to the management and care of patients.

3 Identify knowledge and performance gaps and engage in opportunities to achieve focused education and III performance improvement.

EVALUATION TOOLS: chart-stimulated recall, direct observation, and reflection and self-assessment.

PROFESSIONALISM 12 24 36 Add

1 Demonstrate sensitivity and responsiveness to diverse patient populations. I

2 Demonstrate a commitment to carry out professional responsibilities, appropriately refer patients, and respond to I patient needs in a way that supersedes self-interest.

EVALUATION TOOLS: direct observation, multisource evaluation

INTERPERSONAL AND COMMUNICATION SKILLS 12 24 36 Add

1 Effectively educate patients and families across the range of socioeconomic and cultural backgrounds about adult I congenital heart disease management, complications, and lifestyle issues.

2 Communicate and work effectively with physicians and other professionals on the healthcare team, including I those at an adult congenital heart disease center.

EVALUATION TOOLS: direct observation and multisource evaluation.

Add ¼ additional months beyond the 3-year cardiovascular fellowship.

features in operated and unoperated adult CHD; and Hour web-based sites specific to CHD. Additional content could 6 ¼ various topics, which could include management include areas such as preoperative noncardiac surgery during pregnancy, endocarditis prophylaxis, and basic assessment, evaluation and management of heart failure, counseling on genetics and contraception, employment, and CHD–related pulmonary hypertension. and exercise. Within those 6 hours of core curriculum, the In addition to the didactic material in the core curric- trainees should be taught the major outpatient manage- ulum, trainees should be exposed to ACHD patients on ment issues in ACHD and when to consult or refer for a regular basis. This could be done in the context of more specialized advice. Currently available modes of ongoing weekly case conferences, which may already be supplementing this education include readily available part of the cardiovascular training program. In addition, ACC educational products (ACHD section of the Adult trainees are encouraged to become involved in an Clinical Cardiology Self-Assessment Program [ACCSAP] ongoing CHD outpatient clinic, to see older children or and the Echocardiography Self-Assessment Program) and adolescents with a pediatric cardiology colleague, or both. JACC VOL. 65, NO. 17, 2015 Warnes et al. 1895 MAY 5, 2015:1887– 98 COCATS 4 Task Force 14

If not available at the training institution, regional ACHD It is, therefore, expected that trainees should: case conferences may provide an opportunity for fellows 1. Participate in a regular outpatient clinic organized for to receive exposure to ACHD management at dedicated thecareofadultswithCHDforatleast18ofthe24 centers. months. The Level III trainee should be involved with Cardiovascular trainees should be exposed to the the care of a minimum of 10 patients per week. Pro- evaluation of CHD with various diagnostic modalities grams that are able to provide Level III training will during the usual clinical rotations (electrocardiography, have clinic more than once a week. The Level III trainee electrophysiology, transthoracic and transesophageal should participate in clinic at least once a week and for echocardiography, nuclear cardiology, and the cardiac much of the training period will need to be in clinic catheterization laboratory [including invasive trans- more often to obtain appropriate exposure. catheter techniques]). Exposure to other advanced imag- 2. Participate in a total block or cumulative equivalent of ing techniques now commonly utilized in CHD (e.g., MRI at least 9 months of inpatient consultative services and CT) as well as cardiopulmonary exercise testing is providing care for ACHD patients. This typically in- highly desirable. Didactic material for these rotations cludes consultation for admissions related to heart should include materials on diagnosis and management failure, arrhythmias, preoperative and postoperative of the adult with CHD. care, and noncardiac issues. A 4-week rotation is strongly recommended to com- 3. Participate in at least 3 months of comprehensive plete Level I competence if the training program has imaging methods used in caring for ACHD patients, expertise in ACHD with a board-eligible/board-certified including direct experience in echocardiography cardiologist on staff (or equivalent experience). If the (transthoracic and transesophageal) and advance im- training program does not have expertise in CHD or have aging techniques (MRI and CT). access to CHD locally, partnering with an expert regional 4. Participate in at least 2 months of cardiac catheteri- ACHD facility for an elective rotation of 4 weeks total zation (diagnostic and interventional) that includes duration may be a valuable supplement. A similar recom- understanding indications for intervention, hemody- mendation exists for pediatric cardiovascular trainees. namics, diagnostic angiography, and physiological Thus, partnership with a pediatric cardiovascular program calculations. can facilitate collaboration as well as effective resource 5. Participate in at least 1 month of dedicated cardio- utilization. thoracic intensive care unit and surgical service for the care of ACHD patients. This includes preoperative 4.2.2. Level III Training Recommendations assessment and intraoperative (including direct Level III training prepares the cardiologist to specialize in observation of surgical repair) and postoperative care. advanced care for the adult with CHD. In order to obtain a 6. Participate in at least 3 months of formal rotations comprehensive understanding of all aspects of CHD, a in pediatric cardiology (for those following the 2-year program (following either internal medicine or adult cardiovascular pathway) for either a total block pediatric cardiovascular fellowship) is necessary with or cumulative equivalent months, including expo- ongoing participation in clinical practice relating to CHD. sure to neonates and children with CHD via confer- The ACGME is currently reviewing the ABIM and ABMS ences, outpatient clinics, diagnostic laboratories petition and establishing curriculum guidelines; it has (e.g., echocardiography, catheterization laboratory), defined the essential components of a specialized pro- and inpatient services, including consultations and gram for training in ACHD. Level III training should align exposure to children with postoperative CHD in the with the ACGME curriculum as this is planned per the intensive care unit. Given that such fellows will not current timeline to be part of fellowship training in July likely be experienced in the critical care of pediatric 2016. The ABIM will begin to offer an examination for this patients, all inpatient participation should be additional certification in 2015. Information concerning the observed and supervised by experienced pediatric eligibility requirements for the examination can be ob- cardiologists. tained from the ABIM. There will be 2 pathways, with the 7. Participate in at least 3 months of formal rotations in chosen path depending on whether the trainee’sback- adult cardiology (for those following a pediatric car- ground is in adult or pediatric cardiology. Pediatric cardi- diology pathway) for either a total block or cumulative ologists will devote a portion of their training to areas of equivalent months, including exposure to adults with adult internal medicine and cardiology to fulfill re- acquired heart disease through outpatient clinics, quirements and competencies necessary to care for adults diagnostic laboratories (e.g., echocardiography, cath- with CHD. Adult cardiologists will complete additional eterization laboratory), and inpatient services, training in pediatric cardiology for the same purposes. including consultations. Trainees with a pediatrics 1896 Warnes et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 14 MAY 5, 2015:1887– 98

residency background prior to pediatric cardiology will exposure and expertise have been acquired in the wide require additional time gaining basic competencies in range of complex cardiac pathology that might be adult internal medicine and adult comorbidities. encountered in practice. Although Level III MRI or CT 8. Perform and interpret cardiopulmonary exercise training is not required, the advanced trainee should also testing in CHD individuals and apply that data to be trained in the indications for and interpretation of clinical assessment as well as exercise prescription. advanced imaging techniques (i.e., MRI and/or CT and 9. Perform outpatient follow-up and inpatient manage- angiography in CHD). Trainees who have completed this ment (with obstetrics/anesthesia) of pregnancy in CHD. additional 2-year training will be eligible to take the ABIM 10. Participate in inpatient and outpatient care of CHD subspecialty examination. individuals with advanced heart failure, including 5. EVALUATION OF COMPETENCY consideration of mechanical support or transplant. 11. Participate in the inpatient and outpatient care of Evaluation tools in ACHD include direct observation by CHD individuals with significant pulmonary arterial instructors, in-training examinations, case logbooks, hypertension, including specific medical therapies conference and case presentations, multisource evalua- and transplantation. tions, trainee portfolios, and reflection and self- 12. Gain experience with the arrhythmic complications of assessment. Case management, judgment, interpretive, CHD and the various approaches to their manage- and bedside skills must be evaluated in every trainee. ment, both pharmacological and interventional. Quality of care and follow-up; reliability; judgment, de- Training should include active participation in clinical cisions, or actions that result in complications; interaction and/or laboratory research in conjunction with clinical with other physicians, patients, and laboratory support activities. Direct participation in cardiac catheterization staff; initiative; and the ability to make appropriate de- procedures in CHD is necessary to develop and demon- cisions independently should be considered. Trainees strate a comprehensive understanding of the entire he- should maintain records of participation and advance- modynamic spectrum of anatomic abnormalities in CHD. ment in the form of a Health Insurance Portability and The specific number of cases and methods of assessing Accountability Act (HIPAA)–compliant electronic data- competencies will be developed through the ACGME. base or logbook that meets ACGME reporting standards Specialized training is necessary to achieve expertise in and summarizes pertinent clinical information (e.g., theappropriatetimingofsurgicalandinterventional number of cases, diversity of referral sources, diagnoses, procedures as well as expertise in the potential compli- disease severity, outcomes, and disposition). cations. Expertise in the management of all complications Under the aegis of the program director, the faculty of a wide variety of simple and complex congenital car- should record and verify each trainee’s experiences, diac lesions, both unrepaired and repaired, is necessary, assess performance, and document satisfactory achieve- including the treatment of heart failure, arrhythmias, ment. The program director is responsible for confirming pulmonary hypertension, and pregnancy, as well as experience and competence and for reviewing the overall contraception management and knowledge of indications progress of individual trainees with the Clinical Compe- for referral for genetic counseling. Finally, trainees must tency Committee to ensure achievement of selected be competent in the interpretation of transthoracic and training milestones and identify areas in which additional transesophageal echocardiograms across the spectrum of focused training may be required. CHDaswellasthediagnosisofvalvulardiseaseandcar- The ACGME has defined the essential components of a diomyopathic conditions. The specific numbers of cases specialized program for training in ACHD; the ABIM will has not yet been determined by the ACGME. It is antici- begin to offer an examination for this additional certifi- pated that such competence would require at least 300 cation in 2015. Information concerning the eligibility re- transthoracic echocardiogramsand50transesophageal quirements for the examination can be obtained from the echocardiographic examinations to ensure that adequate ABIM.

REFERENCES

1. Perloff JK, Child JS. Congenital Heart Disease in 3. WarnesCA,LiberthsonR,DanielsonGK,etal. 5. Murphy DJ Jr., Foster E. ACCF/AHA/AAP recom- Adults. 2nd edition. Philadelphia, PA: W.B. Saunders, Task force 1: the changing profile of congenital mendations for training in pediatric cardiology. Task 1998. heart disease in adult life. J Am Coll Cardiol 2001; force 6: training in transition of adolescent care and 37:1170–5. care of the adult with congenital heart disease. J Am 2. Marelli AJ, Ionescu-Ittu R, Mackie AS, Guo L, Coll Cardiol 2005;46:1399–401. Dendukuri N, Kaouache M. Lifetime prevalence of 4. Foster E, Graham TP Jr., Driscoll DJ, et al. Task force congenital heart disease in the general population 2: special health care needs of adults with congenital 6. Child JS, Collins-Nakai RL, Alpert JS, et al. Task from 2000 to 2010. Circulation 2014;130:749–56. heart disease. J Am Coll Cardiol 2001;37:1176–83. force 3: workforce description and educational JACC VOL. 65, NO. 17, 2015 Warnes et al. 1897 MAY 5, 2015:1887– 98 COCATS 4 Task Force 14

requirements for the care of adults with congenital with congenital heart disease: a report of the American patients with congenital heart disease. J Am Coll heart disease. J Am Coll Cardiol 2001;37:1183–7. College of Cardiology/American Heart Association Task Cardiol 2008;51:389–93. Force on Practice Guidelines (Writing Committee to 7. Ross RD, Brook M, Feinstein J, et al. SPCTPD/ACC/ Develop Guidelines on the Management of Adults With AAP/AHA 2014 training guidelines for pediatric cardi- Congenital Heart Disease). J Am Coll Cardiol 2008;52: ology fellowship programs. J Am Coll Cardiol 2015 e143–263. Mar 6 [E-pub ahead of print]. KEY WORDS ACC Training Statement, clinical 8. Warnes CA, Williams RG, Bashore TM, et al. ACC/ 9. Child JS, Freed MD, Mavroudis C, Moodie DS, competence, COCATS, congenital heart disease, AHA 2008 guidelines for the management of adults Tucker AL. Task force 9: training in the care of adult fellowship training

APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 14: TRAINING IN CARE OF ADULT PATIENTS WITH CONGENITAL HEART DISEASE

Institutional/ Ownership/ Organizational or Speakers Partnership/ Personal Other Financial Expert Committee Member Employment Consultant Bureau Principal Research Benefit Witness

Carole A. Warnes (Chair) Mayo Clinic—Director, Adult None None None None None None Congenital Heart Disease Clinic; Professor of Medicine

Ami B. Bhatt Massachusetts General Hospital, None None None None None None Cardiology Division—Director, Adult Congenital Heart Disease Program

Curtis J. Daniels The Ohio State University—Professor, None None None None None None Internal Medicine and Pediatrics

Linda D. Gillam Morristown Medical Center—Chair, None None None None None None Department of CV Medicine

Karen K. Stout University of Washington—Director, Adult None None None None None None Congenital Heart Disease Program

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects authors’ employment and reporting categories. To ensure complete transparency, authors’ comprehensive healthcare-related disclosure information—including relationships with industry not pertinent to this document—is available in an online data supplement. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/ relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional information about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology; CV ¼ cardiovascular. 1898 Warnes et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 14 MAY 5, 2015:1887– 98

APPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 14: TRAINING IN CARE OF ADULT PATIENTS WITH CONGENITAL HEART DISEASE

Institutional/ Ownership/ Organizational Speakers Partnership/ Personal or Other Financial Expert Name Employment Representation Consultant Bureau Principal Research Benefit Witness

Richard Kovacs Indiana University, Official Reviewer, None None None None None None Krannert Institute of ACC Board of Trustees Cardiology—Q.E. and Sally Russell Professor of Cardiology

Dhanunjaya Kansas University Official Reviewer, ACC None None None None None None Lakkireddy Cardiovascular Board of Governors Research Institute

Howard Weitz Thomas Jefferson Official Reviewer, None None None None None None University Hospital— Competency Management Director, Division of Committee Lead Cardiology; Sidney Reviewer Kimmel Medical College at Thomas Jefferson University—Professor of Medicine

Michael Emery Greenville Health Content Reviewer, None None None None None None System Sports and Exercise Cardiology Section Leadership Council

Elyse Foster University of California Content Reviewer, None None None None None None San Francisco—Professor, ACPC Section Medicine and Anesthesia; Leadership Council Director, Non-Invasive Cardiology Laboratories

Larry Jacobs Lehigh Valley Health Content Reviewer, None None None None None None Network, Division of Cardiology Training and Cardiology; University Workforce Committee of South Florida—Professor, Cardiology

Andrew Kates Washington University Content Reviewer, None None None None None None School of Medicine Academic Cardiology Section Leadership Council

Michael Boston Children’s Content Reviewer, None None None None None None Landzberg Hospital—Medical Director, ACPC Section Adult Congenital Heart Leadership Council and BACH Pulmonary Hypertension Service Departments of Pediatrics, Medicine, and Surgery

Arash Sabati Children’s Hospital of Content Reviewer, None None None None None None Los Angeles ACPC Section Leadership Council

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects peer reviewers’ employment, representation in the review process, as well as reporting categories. Names are listed in alphabetical order within each category of review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional infor- mation about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology; ACPC ¼ Adult Congenital and Pediatric Cardiology.

APPENDIX 3. ABBREVIATION LIST

ABIM ¼ American Board of Internal Medicine CHD ¼ congenital heart disease ABMS ¼ American Board of Medical Specialties COCATS ¼ Core Cardiovascular Training Statement ACC ¼ American College of Cardiology CT ¼ computed tomography ACCSAP ¼ Adult Clinical Cardiology Self-Assessment Program HIPAA ¼ Health Insurance Portability and Accountability Act ACGME ¼ Accreditation Council for Graduate Medical Education MRI ¼ magnetic resonance imaging ACHD ¼ adult congenital heart disease JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 65, NO. 17, 2015 ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00 PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacc.2015.03.032

TRAINING STATEMENT COCATS 4 Task Force 15: Training in Cardiovascular Research and Scholarly Activity

Robert A. Harrington, MD, FACC, Chair Michael S. Lauer, MD, FACC

Ana Barac, MD, PHD, FACC Chittur A. Sivaram, MBBS, FACC

John E. Brush, JR, MD, FACC Mark B. Taubman, MD, FACC

Joseph A. Hill, MD, PHD, FACC Jeffrey L. Williams, MD, FACC Harlan M. Krumholz, MD, SM, FACC

1. INTRODUCTION 1.1.2. Document Development and Approval The writing committee developed the document, 1.1. Document Development Process approved it for review by individuals selected by the 1.1.1. Writing Committee Organization ACC, and then addressed the reviewers’ comments. The writing committee was selected to represent the The document was revised and posted for public American College of Cardiology (ACC) and included comment from December 20, 2014, to January 6, 2015. a cardiovascular training program director, several Authors addressed these additional comments from active cardiovascular scientists and research meth- the public to complete the document. A member of odology experts, early-career cardiologists, highly the ACC Competency Management Committee served fi experienced research experts representing both aca- as lead reviewer. The nal document was approved by demic and community-based practice settings, the the Task Force, COCATS Steering Committee, and ACC fi chair of the ACC’s Academic Cardiology Section Competency Management Committee and rati ed by Leadership Council, and a physician experienced in the ACC Board of Trustees in March, 2015. This docu- defining and applying training standards according ment is considered current until the ACC Competency to the 6 general competency domains promulgated by Management Committee revises or withdraws it. the Accreditation Council for Graduate Medical Edu- cation (ACGME) and American Board of Medical Spe- 1.2. Background and Scope cialties(ABMS)andendorsedbytheAmericanBoardof Cardiology is a dynamic clinical field in which Internal Medicine (ABIM). The ACC determined that knowledge from basic and clinical research is contin- relationships with industry or other entities were not uously translated into clinical care. Knowledge gen- relevant to the creation of this general cardiovascular eration and transfer accelerate as understanding fi training statement. Employment and af liation details of complex biological processes advances. As the sci- for authors and peer reviewers are provided in ence and process of healthcare delivery progresses, Appendixes 1 and 2, respectively, along with disclosure trainees need exposure to broad intellectual and reporting categories. Comprehensive disclosure in- scholarly concepts that have implications for clinical formation for all authors, including relationships with practice. An atmosphere of intellectual inquiry and industry and other entities, is available as an online support for the investigative process is critical to the supplement to this document. development of a competent cardiologist. To main- tain clinical competence and apply emerging knowl- edge, it is crucial to appreciate the concepts, methods, and limitations of the research process. The American College of Cardiology requests that this document be cited Cardiovascular research is defined broadly because as follows: Harrington RA, Barac A, Brush JE Jr., Hill JA, Krumholz HM, advances in patient care come from diverse areas of Lauer MS, Sivaram CA, Taubman MB, Williams JL. COCATS 4 task force 15: training in cardiovascular research and scholarly activity. J Am Coll medical science. All cardiovascular training institu- Cardiol 2015;65:1899–906. tions should offer opportunities for fellows to 1900 Harrington et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 15 MAY 5, 2015:1899– 906

participate in research, and every cardiovascular trainee is includes participation in such mentored research ac- required to participate directly in some form of cardiovas- tivities as data collection, analysis, and interpretation; cular research or scholarly activity (CRSA). This should scientific writing; and the evaluation of the quality of include exposure to the practical aspects of conducting medical evidence. This document focuses on CRSA research and the ability to critically evaluate published training in cardiovascular medicine regardless of the scientific data. Trainees should understand the elements of career objectives of the trainee. research design; informatics; data analysis; deductive and n Level II training typically refers to the additional inductive reasoning; and basic principles of biostatistics, training in 1 or more areas that enables some cardiovas- including the concepts of probability, uncertainty, and cular specialists to perform or interpret specificdiag- inference. Experiences in CRSA play a critical role in nostic tests and procedures or render more specialized developing the skills and commitment required of all car- care for patients and conditions. This level of training is diovascular specialists for lifelong learning. Such experi- recognized for those areas in which an accepted instru- ences also foster integration of scientific investigation into ment or benchmark, such as a qualifying examination, the professional life of the emerging cardiologist and is available to measure specificknowledge,skills,or enable him or her to adapt practice as knowledge emerges competence. Level II training in selected areas may be (1). Additionally, many of the skills and experiences gained achieved by some trainees during the standard 3-year in the research domain are applicable to the team-based cardiovascular fellowship, based on the trainees’ career activities of quality improvement, an area that all clinical goals and use of elective rotations. It is anticipated cardiologists will need to understand throughout their that during a standard 3-year cardiovascular fellowship professional career. training program, sufficient time will be available The Task Force was charged with updating previously for the trainee to receive Level II training in a specific published guidelines for training cardiovascular fellows subspecialty.InthecaseofCRSA,thereisnodefined in CRSA on the basis of changes in the field since 2008 and Level II training, although advanced training (compara- as part of a broad effort to standardize training. This ble to Level III) is available after the standard fellowship. document does not provide specific guidelines for training n Level III training requires additional training and fellows in advanced research techniques but more broadly experience beyond the cardiovascular fellowship for describes opportunities for training in cardiovascular the trainee to acquire specialized knowledge and investigation. The Task Force also updated previously competence. For CRSA, Level III training pertains spe- published standards to address the evolving framework cifically to those planning careers in cardiovascular of competency-based medical education described by the investigation. Trainees contemplating careers in ACGME Outcomes Project and the 6 general competencies investigative cardiology bear a special responsibility to endorsed by the ACGME and ABMS. The background and prepare effectively to advance knowledge in cardio- overarching principles governing fellowship training are vascular science. There are many pathways to a provided in the COCATS 4 Introduction, and readers should research career, all requiring additional training and become familiar with this foundation before considering experience to develop the skills necessary to conceive, the details of training in a subdiscipline like cardiovascular design, implement, conduct, analyze, and communi- research and scholarly activity. The Steering Committee cate the results of laboratory, clinical, or population- and Task Force recognize that implementation of these based research. The goal of advanced training in changes in training requirements will occur incrementally. research is to develop expertise in an area of investi- For most areas of cardiovascular medicine, 3 levels of gation that enables the trainee to direct an independent training are delineated: research project or provide expertise in a collaborative research program. In most cases, advanced training n Level I training, which is the basic training required of should enable trainees to apply for competitive trainees to become competent consultant cardiologists, research funding. This advanced training requires is required of all fellows in cardiology, and can be experience dedicated to specialized research beyond accomplished as part of a standard 3-year training the 3-year cardiovascular fellowship. Level III training program in cardiovascular medicine. Level I CRSA is described here only in broad terms to provide context training refers to competency in critically interpreting for trainees and clarify that this advanced knowledge is cardiovascular research literature and familiarity with not addressed during the cardiovascular fellowship. methods used across a broad spectrum of cardiovas- cular research including, but not limited to, basic and The duration of exposure at each level of training is translational science; molecular, genetic, and cellular basedonpublishedcompetencystatementsaswellasthe research; animal studies; epidemiological studies; experience and opinions of the writing group. It is clinical trials; and meta-analyses. Level I training also assumed that training is directed by appropriately trained JACC VOL. 65, NO. 17, 2015 Harrington et al. 1901 MAY 5, 2015:1899– 906 COCATS 4 Task Force 15

mentorsinanACGME–accredited program and that given institution and availability of funding, most in- satisfactory completion of training is documented by the stitutions should have personnel experienced in devel- research sponsor and program director. The types and oping research budgets, reviewing research contracts, extent of activities and duration of training required are ensuring sound financial management of research, and summarized in Section 4. serving on an institutional review board that governs research involving human subjects. Where laboratory ani- 2. GENERAL STANDARDS mal research is conducted, appropriate facilities include the staff and equipment necessary for safe and humane The ACC published educational objectives for fellowship handling. Clinical research programs should include training in cardiovascular research in 2008 (2). The 2008 trained study coordinators. It is highly desirable that recommendations have been updated and address fac- trainees engaging in research have access to a biostatisti- ulty, facility requirements, research trends, and practice. cian or other quantitative scientists for collaboration and Cardiovascular fellowship programs should satisfy these assistance in planning studies and analyzing research data. requirements. The intensity of training and resources required varies according to the level of training pro- 3. TRAINING COMPONENTS vided. We recommend strongly that candidates for the ABIM examination for certification in cardiovascular dis- Trainees should have prior education in and exposure to eases review the specificrequirementsoftheABIMas the biological, physical, quantitative, and informational they pertain to this aspect of training (3). sciences fundamental to modern medicine. Additional coursework and opportunities for independent study and 2.1. Faculty formal graduate training programs should be available, The training program faculty must include several and trainees should be encouraged to avail themselves of proven, skilled investigators who have obtained research these resources. funding and published peer-reviewed original research. At least 1 full-time faculty member from each training 3.1. Didactic Program program should have demonstratedabilitiesasaninde- The competent cardiologist must critically assess the sci- pendent investigator. The critical mass of faculty actually entific literature relevant to patient care. This involves requires several cardiovascular investigators, however, understanding research methodology; fundamental con- some of whom may be clinical cardiologists, optimally cepts of research design; and the conduct, analysis, and with expertise and experience in a wide range of fields. interpretation that form the basis for evidence-based medicine. Because clinical practice guidelines and related 2.2. Facilities documents form an essential basis for contemporary clin- The training institution must provide appropriate staff ical care, training programs must provide trainees with an and facilities to conduct research. Research opportunities introduction to evidence assessment and synthesis and to for trainees should be available not only in clinical car- the methodology underlying evaluation of the quality of diovascular medicine, but also in other departments, scientific evidence. Trainees can obtain the required including basic biomedical and population health sci- knowledge and skills in a variety of ways, including ences. Expertise in epidemiological methods, outcomes participation in lecture series (such as Web-based pro- evaluation, clinical trial design and methods, biomedical grams) and critical review and discussion of carefully andclinicalinformatics,biostatistics,biomedicalethics, selected articles at journal club conferences attended by and regulatory science is essential for training in patient- both trainees and experienced faculty. The didactic portion oriented investigation. Optimally, cardiovascular training of training in research and scholarly activity should incor- fi should take place in a university-af liated teaching porate issues of responsible conduct of research such as hospital or similar institution. When this is not feasible, protection of human and animal subjects, transparent fi an active af liation with an academic CRSA mentor can reporting and avoidance of conflicts of interest, indepen- complement community-based training. The training dence of data monitoring committees, independence in program should provide access to a medical library; analyses and publications, and integrity in assigning Internet access to online compendia such as PubMed, authorship. Medline, and CardioSource; as well as statistical software such as Statistical Analysis System (SAS Institute, Cary, 3.2. Interpretation of Cardiovascular Research North Carolina), Matlab (MathWorks, Natick, Massachu- The competent clinician must interpret scientificreports setts), and Statistical Package for the Social Sciences that pertain to clinical practice. New data should not be (IBM, Armonk, New York). accepted uncritically, nor should the cardiologist fail to Although specific components of the research infra- recognize and evaluate important scientificadvancesre- structure will vary with the type and scope of projects at a levant to clinical practice. As a minimum Level I 1902 Harrington et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 15 MAY 5, 2015:1899– 906

requirement, the program should provide frequent op- training in CRSA. The milestones indicate the stage of portunities for faculty and trainees to review and analyze in fellowship training (12, 24, or 36 months, and additional depth a broad variety of cardiovascular research reports. time points) by which the typical cardiovascular trainee should achieve the designated level. Given that programs 3.3. Hands-On Research Experience may vary with respect to the sequence of clinical experi- Research in cardiovascular science and medicine takes ences provided to trainees, the milestones at which diverse forms. Although hands-on exposure to research is various competencies are reached may also vary. Level I essential to advanced research training, introductory competencies may be achieved at earlier or later time hands-on research experience is desirable but not points. Acquisition of Level II skills requires additional mandatory for Level I training. This introductory experi- training, and acquisition of Level III skills requires ence could be as straightforward as learning to obtain training in a dedicated cardiovascular research program. informed consent from a patient considering participation The table also describes examples of evaluation tools in a clinical trial, collecting blood or tissue samples for suitable for assessing competence in each domain. basic or translational laboratory investigations, or learning to extract information from medical records for 4.2. Components of Research entry into a research database. All of these experiences During Level I training, trainees should master the should be conducted under the supervision of experi- practices of: enced research personnel, including faculty expert in the 1. Literature review, before undertaking new investiga- pertinent research methodologies. tion to ascertain the current state of knowledge and 3.4. Teaching understand a disease or condition, diagnostic technol- ogy, or therapy; and Because almost all academic cardiologists devote time and 2. Ethical conduct in carrying out responsible research, effort to teaching, the trainee should understand the including but not limited to the protection of human principles of adult learning and acquire the skills necessary subjects and recognition and the disclosure and man- to effectively teach others, including patients. Academic agement of potential conflicts of interest. practitioners teach medical students, residents, and fel- lows, whereas clinical cardiologists traditionally direct teaching activities toward advanced practice providers, 4.3. Duration of Research Training nurses, and ancillary staff in hospital or outpatient office The specific competencies expected to result from Level I settings. training are delineated in Table 1. The minimum lengths of training required for Level I and advanced training in 4. SUMMARY OF TRAINING REQUIREMENTS CRSA are summarized in the following text. A brief dis- cussion of the competencies and training requirements 4.1. Development and Evaluation of Core Competencies also follows. At more advanced levels, the education of Training and requirements in CRSA address the 6 general investigators is a continuous process, and research competencies promulgated by the ACGME/ABMS and trainees usually remain in an educational institution to endorsed by the ABIM. These competency domains are: participate in both scientific and clinical endeavors. medical knowledge, patient care and procedural skills, Advanced research training may lead to multiple career practice-based learning and improvement, systems-based paths, ranging from permanent academic appointments practice, interpersonal and communication skills, and to stints in private practice or vice versa. professionalism. The ACC has used this structure to define and depict the components of the core clinical compe- 4.3.1. Level I Training Requirements tencies for cardiology. The curricular milestones for each Level I trainees planning careers predominantly in clinical competency and domain also provide a developmental practice should devote 6 to 12 months (and up to 24 roadmap for fellows as they progress through various months) to 1 or more scholarly or research projects. These levels of training and serve as an underpinning for the activities can be undertaken concurrently with clinical ACGME/ABIM reporting milestones. The ACC has adopted training and may not require a dedicated block of time, this format for its competency and training statements, although in most cases, some period of time should be career milestones, lifelong learning, and educational availabletopursueCRSAwhile unfettered by clinical programs. Additionally, it has developed tools to assist duties. Although the training duration suggested is physicians in assessing, enhancing, and documenting required by the typical trainee to obtain competency, these competencies. trainees must also demonstrate achievement of the com- Table 1 delineates each of the 6 competency domains, petencies as assessed by the outcomes evaluation as well as their associated curricular milestones for measures. JACC VOL. 65, NO. 17, 2015 Harrington et al. 1903 MAY 5, 2015:1899– 906 COCATS 4 Task Force 15

Core Competency Components and Curricular Milestones for Training in Cardiovascular Research and TABLE 1 Scholarly Activity

Competency Component Milestones (Months) MEDICAL KNOWLEDGE 12 24 36 Add

1 Know the roles and functions of DNA, RNA, and proteins. I

2 Know the principles of genetics, genomics, proteomics, metabolomics, and pharmacogenomics. I

3 Know the principles of epidemiological methods. I

4 Know the principles of outcomes evaluation. I

5 Know the basic principles of biostatistics. I

6 Know the principles underlying hypothesis formation, specific goals definition, hypothesis testability, I and statistical power achievable.

EVALUATION TOOLS: global evaluation, in-training examination, and multisource evaluation.

PATIENT CARE AND PROCEDURAL SKILLS 12 24 36 Add

1 Skill to review published research data and assess the adequacy of research design, data analysis, I and logical deduction.

2 Skill to appropriately integrate scientific concepts and research advances in routine clinical encounters. I

3 Skill to routinely assess the quality of evidence in clinical decisions. I

4 Skill to apply principles of biomedical ethics as they pertain to human subject research in the identification I of patients as potential research subjects, presentation of alternatives, obtaining of informed consent, and ensuring the security of clinical data used for research.

EVALUATION TOOL: multisource evaluation.

SYSTEMS-BASED PRACTICE 12 24 36 Add

1 Effectively access and utilize national registry data for research. I

2 Know the role of and how to interact with institutional review boards. I

EVALUATION TOOLS: direct observation and multisource evaluation.

PRACTICE-BASED LEARNING AND IMPROVEMENT 12 24 36 Add

1 Identify knowledge and performance gaps and engage in opportunities to achieve focused education and I performance improvement.

2 Appropriately integrate new or emerging medical evidence. I

EVALUATION TOOLS: multisource evaluation, and reflection and self-assessment.

PROFESSIONALISM 12 24 36 Add

1 Demonstrate sensitivity to patient autonomy and safety in research. I

2 Practice with integrity in the conduct of research, including understanding issues relating to relationships I with industry.

3 Interact respectfully with ancillary and support staff. I

EVALUATION TOOLS: conference presentation, direct observation, and reflection and self-assessment.

INTERPERSONAL AND COMMUNICATION SKILLS 12 24 36 Add

1 Communicate with fellow trainees and faculty about cardiovascular science and how this might impact I clinical care (e.g., through journal clubs).

2 Effectively communicate study results during presentations. I

EVALUATION TOOLS: direct observation and multisource evaluation.

Add ¼ additional months beyond the 3-year cardiovascular fellowship; DNA ¼ deoxyribonucleic acid; RNA ¼ ribonucleic acid. 1904 Harrington et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 15 MAY 5, 2015:1899– 906

4.3.2. Advanced Training Requirements considering careers as independent investigators direct- fi Trainees preparing for careers in research need an ing a laboratory or leading a scienti c research program. extensive foundation in scientific investigation. Some will 4.3.2.3. Compensation have obtained preparation in combined-degree programs (e.g., MD/PhD, MD/MPH, MD/MS) but may lack the specific Compensation during the often prolonged period of fi skills or experience necessary to achieve their research research training should be suf cient to support a full- objectives. These advanced skills may be obtained in a time commitment. In this context, the U.S. Congress postdoctoral research fellowship or as part of cardiovas- passed the Clinical Research Enhancement Act, which cular training. For additional training, the trainee should eases debt repayment for candidates with MD or MD/PhD join the group or laboratory of a productive and active degrees engaging in advanced research training (4). scientistorclinicalinvestigator(withanMDorPhDde- 5. EVALUATION OF COMPETENCY gree) in a qualified institution (which is not necessarily where he or she is enrolled for fellowship training). Evaluation tools in cardiovascular research and scholarly Trainees seeking careers in investigative cardiology activity include direct observation by instructors, in- who have not obtained an advanced degree should be training examinations, case logbooks, conference and fi encouraged to obtain the necessary scienti canalytic case presentations, multisource evaluations, trainee coursework and laboratory or clinical research experience portfolios, and reflection and self-assessment. Analytical, to promote a productive research career. Current models ethical, judgment, interpretive, and, as appropriate, of this type of training include the AHA Clinician Scientist research laboratory skills must be evaluated in every Award and the National Heart, Lung, and Blood Institute trainee. Reliability; judgment, decisions, or actions that programs for K08 (Mentored Clinical Scientist Develop- result in questions about data or analytical integrity; in- ment), K23 (Mentored Patient-Oriented Research Career teractions with other physicians, researchers, statisti- Development), and K99/R00 (National Institutes of cians, patients, or research laboratory support staff; Health Pathway to Independence) awards. initiative; and the ability to make appropriate decisions and ask appropriate questions independently should be 4.3.2.1. Basic Research considered. Trainees should, as appropriate, maintain For those planning a career in basic laboratory research, laboratory notebooks, well-annotated statistical code, 3 years working directly with an experienced mentor— and records of participation and advancement in the form beyond the 2 clinical years—are needed in most cases. of a Health Insurance Portability and Accountability Act Such training constitutes only the beginning of an inde- (HIPAA)–compliant electronic database or logbook that pendent cardiovascular investigator’seducation. meets ACGME reporting standards and summarizes important research-related information for each project 4.3.2.2. Clinical Research and/or encounter. For trainees planning a substantive commitment to Under the aegis of the program director, the faculty advanced clinical research, at least 2 to 3 full years should record and verify each trainee’s experiences, devoted to mentored clinical research are generally assess performance, and document satisfactory achieve- needed, of which 1 or more years can occur during ment. The program director is responsible for confirming fellowship training. Advanced research training requires experience and competence and for reviewing the overall didactic training, including formal coursework in research progress of individual trainees with the Clinical Compe- methods. The pursuit of an advanced degree (e.g., PhD, tency Committee to ensure achievement of selected MS, MPH) in a specificscientific field is optional. The training milestones and identify areas in which additional advanced degree is especially valuable to trainees focused training may be required.

REFERENCES

1. Harrington RA, Califf RM, Hodgson PK, et al. Careers 3. American Board of Internal Medicine. Cardiovascular Enhancement Act. Washington, DC: U.S. General for clinician investigators. Circulation 2009;119: disease policies. Available at: http://www.abim. Accounting Office, 2002. Publication GAO-02-965. 2945–50. org/certification/policies/imss/card.aspx. Accessed January 22, 2014. 2. Loscalzo J, Tomaselli GF, Vaughan DE, et al. Task force 7: training in cardiovascular research. J Am Coll 4. U.S. General Accounting Office. Report to Congres- KEY WORDS ACC Training Statement, clinical Cardiol 2008;51:380–3. sional Committees: Clinical Research: NIH Has Imple- competence, COCATS, fellowship training, mented Key Provisions of the Clinical Research research JACC VOL. 65, NO. 17, 2015 Harrington et al. 1905 MAY 5, 2015:1899– 906 COCATS 4 Task Force 15

APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 15: TRAINING IN CARDIOVASCULAR RESEARCH AND SCHOLARLY ACTIVITY

Institutional/ Ownership/ Organizational Speakers Partnership/ Personal or Other Expert Committee Member Employment Consultant Bureau Principal Research Financial Benefit Witness

Robert A. Harrington Stanford University—Arthur L. None None None None None None (Chair) Bloomfield Professor of Medicine; Chair, Department of Medicine

Ana Barac MedStar Heart and Vascular None None None None None None Institute—Director, Cardio-Oncology Program

John E. Brush, Jr. Sentara Cardiology Specialists— None None None None None None Consulting Cardiologist

Joseph A. Hill UT Southwestern Medical Center— None None None None None None Professor of Medicine and Molecular Biology

Harlan M. Krumholz Yale University School of None None None None None None Medicine—Harold H. Hines, Jr. Professor of Medicine and Epidemiology and Public Health

Michael S. Lauer National Heart, Lung, and None None None None None None Blood Institute—Director, Division of Cardiovascular Sciences

Chittur A. Sivaram University of Oklahoma None None None None None None Health Sciences Center— Program Director, Cardiovascular Section

Mark B. Taubman University of Rochester Medical None None None None None None Center—Charles A. Dewey Professor and Chairman of Medicine

Jeffrey L. Williams The Good Samaritan Hospital None None None None None None and Lebanon Cardiology Associates—Medical Director, Clinical Cardiac Electrophysiology

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects authors’ employment and reporting categories. To ensure complete transparency, authors’ comprehensive healthcare-related disclosure information—including relationships with industry not pertinent to this document—is available in an online data supplement. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/ relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional information about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology. 1906 Harrington et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Task Force 15 MAY 5, 2015:1899– 906

APPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)— COCATS 4 TASK FORCE 15: TRAINING IN CARDIOVASCULAR RESEARCH AND SCHOLARLY ACTIVITY

Institutional/ Organizational Ownership/ or Other Speakers Partnership/ Personal Financial Expert Name Employment Representation Consultant Bureau Principal Research Benefit Witness

Richard Kovacs Krannert Institute of Official Reviewer, None None None None None None Cardiology—Professor, ACC Board of Trustees Clinical Medicine

Dhanunjaya Kansas University Official Reviewer, None None None None None None Lakkireddy Cardiovascular Research ACC Board of Governors Institute

Howard Weitz Thomas Jefferson University Official Reviewer, None None None None None None Hospital—Director, Division of Competency Management Cardiology; Sidney Kimmel Committee Lead Reviewer Medical College at Thomas Jefferson University—Professor of Medicine

Alex Auseon The Ohio State University Content Reviewer, None None None None None None Wexner Medical Center Academic Cardiology Section Leadership Council

John Canty University at Buffalo Clinical Content Reviewer, None None None None None None and Translational Research Academic Cardiology Center—Albert and Elizabeth Section Leadership Council Rekate Professor and Chief

Larry Jacobs Lehigh Valley Health Network, Content Reviewer, None None None None None None Division of Cardiology; Cardiology Training and University of South Florida— Workforce Committee Professor, Cardiology

Andrew Kates Washington University Content Reviewer, None None None None None None School of Medicine Academic Cardiology Section Leadership Council

Kiran Musunuru Brigham and Women’s Organizational Reviewer, None None None None None None Hospital, Harvard University AHA

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects peer reviewers’ employment, representation in the review process, as well as reporting categories. Names are listed in alphabetical order within each category of review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional infor- mation about the ACC Disclosure Policy for Writing Committees. ACC ¼ American College of Cardiology; AHA ¼ American Heart Association.

APPENDIX 3. ABBREVIATION LIST

ABIM ¼ American Board of Internal Medicine ABMS ¼ American Board of Medical Specialties ACC ¼ American College of Cardiology ACGME ¼ Accreditation Council for Graduate Medical Education COCATS ¼ Core Cardiovascular Training Statement CRSA ¼ cardiovascular research or scholarly activity HIPAA ¼ Health Insurance Portability and Accountability Act SAS ¼ Statistical Analysis System SPSS ¼ Statistical Package for the Social Sciences