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Journal of the American College of Cardiology                                                                             ...
Journal of the American College of Cardiology                                                                         Vol....
JACC Vol. 47, No. 4, 2006                                                                                          Beller ...
896          Beller et al.                                                                                                ...
JACC Vol. 47, No. 4, 2006                                                                                                 ...
Journal of the American College of Cardiology                                                                             ...
JACC Vol. 47, No. 4, 2006                                                                                          Cerquei...
900      Cerqueira et al.                                                                                                 ...
JACC Vol. 47, No. 4, 2006                                                                                Cerqueira et al. ...
902       Cerqueira et al.                                                                                      JACC Vol. ...
JACC Vol. 47, No. 4, 2006                                                                                                 ...
904           Naccarelli et al.                                                                                         JA...
JACC Vol. 47, No. 4, 2006                                                                                   Naccarelli et ...
906       Naccarelli et al.                                                                                               ...
ACCF 2006 Update for Training in Adult Cardiovascular ...
ACCF 2006 Update for Training in Adult Cardiovascular ...
ACCF 2006 Update for Training in Adult Cardiovascular ...
ACCF 2006 Update for Training in Adult Cardiovascular ...
ACCF 2006 Update for Training in Adult Cardiovascular ...
ACCF 2006 Update for Training in Adult Cardiovascular ...
ACCF 2006 Update for Training in Adult Cardiovascular ...
ACCF 2006 Update for Training in Adult Cardiovascular ...
ACCF 2006 Update for Training in Adult Cardiovascular ...
ACCF 2006 Update for Training in Adult Cardiovascular ...
ACCF 2006 Update for Training in Adult Cardiovascular ...
ACCF 2006 Update for Training in Adult Cardiovascular ...
ACCF 2006 Update for Training in Adult Cardiovascular ...
ACCF 2006 Update for Training in Adult Cardiovascular ...
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  1. 1. Journal of the American College of Cardiology Vol. 47, No. 4, 2006 © 2006 by the American College of Cardiology Foundation ISSN 0735-1097/06/$32.00 Published by Elsevier Inc. doi:10.1016/j.jacc.2005.12.025 ACCF 2006 Update for Training in Adult Cardiovascular Medicine (Focused Update of the 2002 COCATS 2 Training Statement) A Report of the American College of Cardiology Foundation/ American Heart Association/American College of Physicians Task Force on Clinical Competence and Training AUTHORS (AND SOCIETY REPRESENTATIONS) Introduction/Steering Committee Co-Chairs Task Force 12: Training in Advanced Cardiovascular George A. Beller, MD, MACC Imaging (Cardiovascular Magnetic Resonance [CMR]) Robert O. Bonow, MD, FACC Gerald M. Pohost, MD, FACC, Chair Valentin Fuster, MD, PHD, FACC Raymond J. Kim, MD, FACC Christopher M. Kramer, MD, FACC Task Force 5: Training in Nuclear Cardiology Warren J. Manning, MD, FACC (Society for Manuel D. Cerqueira, MD, FACC, Chair Cardiovascular Magnetic Resonance Representative) Daniel S. Berman, MD, FACC Marcelo F. Di Carli, MD, FACC Heinrich R. Schelbert, MD, PHD, FACC Task Force 12: Training in Advanced Cardiovascular Frans J. Th. Wackers, MD, PHD, FACC Imaging (Computed Tomography) Kim Allan Williams, MD, FACC (American Society Matthew J. Budoff, MD, FACC, FAHA, Chair of Nuclear Cardiology Representative) Stephan Achenbach, MD (Society of Cardiovascular Computed Tomography Representative) Task Force 6: Training in Specialized Zahi Fayad, PHD (Society of Atherosclerosis Imaging and Electrophysiology, Cardiac Pacing, and Prevention Representative) Arrhythmia Management Daniel S. Berman, MD, FACC Gerald V. Naccarelli, MD, FACC, Chair Michael Poon, MD, FACC Jamie B. Conti, MD, FACC Allen J. Taylor, MD, FACC, FAHA John P. DiMarco, MD, PHD, FACC Barry F. Uretsky, MD, FACC (Society for Cardiovascular Cynthia M. Tracy, MD, FACC (Heart Rhythm Angiography and Interventions Representative) Society Representative) Kim Allan Williams, MD, FACC (American Society of Nuclear Cardiology Representative) TASK FORCE MEMBERS Mark A. Creager, MD, FACC, FAHA, Chair Geno Merli, MD, FACP Cynthia M. Tracy, MD, FACC George P. Rodgers, MD, FACC, FAHA Howard H. Weitz, MD, FACC, FACP John D. Rutherford, MD, FACC, FAHA This document was approved by the American College of Cardiology Foundation Board of Trustees in January 2006. When citing this document, the American College of Cardiology would appreciate the following citation format: Beller GA, Bonow RO, Fuster V. ACCF 2006 Update for Training in Adult Cardiovascular Medicine (Focused Update of the 2002 COCATS 2 Training Statement): a report of the American College of Cardiology/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training. J Am Coll Cardiol 2006;47:893–920. Copies: This document is available on the American College of Cardiology website at www.acc.org. Single copies of this document may be purchased for $10.00 each by calling 1-800-253-4636 or by writing to the American College of Cardiology, Resource Center, 9111 Old Georgetown Road, Bethesda, Maryland 20814-1699. 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 Foundation. Please direct requests to copyright_permissions@acc.org.
  2. 2. Journal of the American College of Cardiology Vol. 47, No. 4, 2006 © 2006 by the American College of Cardiology Foundation ISSN 0735-1097/06/$32.00 Published by Elsevier Inc. doi:10.1016/j.jacc.2005.12.026 Introduction George A. Beller, MD, MACC, Co-Chair Robert O. Bonow, MD, FACC, Co-Chair Valentin Fuster, MD, PHD, FACC, Co-Chair In 1995, guidelines for training in adult cardiovascular CT component can be utilized for attenuation correction of medicine were published as an outgrowth of a consensus radionuclide uptake as well as for specific stand-alone statement emanating from the Core Cardiology Training imaging of coronary calcification for atherosclerosis detec- Symposium (COCATS) held at Heart House, Bethesda, tion and CT angiography. The latter application presently Maryland, June 27 to 28, 1994 (1). Since publication of the employs a separate 16- or 64-slice CT scanner (see Task proceedings of that consensus conference, the term Force 12). The minimal number of months of training for “COCATS” has been used when referring to the American Level 1, Level 2, and Level 3 categories remains at 2, 4, and College of Cardiology (ACC) training guidelines for fellow- 12 months, respectively. Education in radiation safety re- ship programs. The first COCATS document was pub- quires a minimum of 80 h and must be clearly documented. lished in 1995, followed by a revised document published in For Level 2 training, a total of 300 cases should be 2002 (2). interpreted under preceptor supervision from direct patient The 2002 revision (2) was accomplished by the formation studies. In this revised task force report, guidelines for the of task forces that included representatives from the sub- radiation safety curriculum that meets Nuclear Regulatory specialty societies where appropriate. These task forces Commission requirements or the equivalent agreement state reviewed the 1995 COCATS task force reports and made requirements are outlined in detail. General and specialized revisions, additions, and deletions based on data from the training in positron emission tomography imaging are literature and their expert opinion. Major changes were most clearly described in this section, as is training with hybrid often related to maturing of either new subspecialty areas in CT imaging technology, including the physics of hybrid cardiology or the emergence of new technology into accepted systems, CT attenuation correction, principles and applica- practice. Numbers of procedures to be performed, interpreted, tion of CT coronary calcium assessment, and principles and or both were made consistent with volume recommenda- application of CT coronary angiography. tions found in the ACC/American Heart Association (AHA) Task Force 6 revisions on training in specialized electro- practice guidelines, ACC/AHA/American College of Physi- physiology, cardiac pacing, and arrhythmia management are cians (ACP) clinical competence statements, or other relevant included in this interim COCATS report. The field of consensus documents. clinical cardiac electrophysiology has experienced major In 2005, with further emerging technologies and the need advances in recent years, and such progress is now reflected for training, it was deemed necessary to provide additional in these updated training recommendations. The guidelines for revisions to three of the task force reports and introduce a use of implantable pacemakers and implantable cardioverter- new report on training in cardiac computed tomography. defibrillators (ICDs) have significantly expanded since 2002, as The three task force reports in this document were peer have interventional ablation techniques as for atrial fibrillation. reviewed by the following ACCF committees: Clinical The expanded indications for these devices or technology Electrophysiology Committee (Task Force 6); Cardiovas- have necessitated concomitant revisions for training of physi- cular Imaging Committee (Task Force 12); and the Cardiac cians in the subspecialty of electrophysiology, which are Catheterization and Intervention Committee (Task Force reflected in this revised task force report. The minimum 12 [CT]), as well as five members of the ACC Board of number of months for Level 1, Level 2, and Level 3 training Governors. Several organizations also reviewed the docu- in cardiac electrophysiology are 2, 6, and 12 months of ment including the American Society of Nuclear Cardiology training, with the latter requiring a full fourth year of (Task Forces 5 and 12 [computed tomography (CT)]), fellowship. Level 2 training now also emphasizes acquisition Heart Rhythm Society (Task Force 6), Society for Cardio- of skills and experience for managing patients with biven- vascular Magnetic Resonance (Task Force 12 [magnetic tricular pacing and ICD systems. In addition to completing resonance]), and the Society for Cardiovascular Angiogra- Level 1 and Level 2 training, Level 3 training requires that phy and Interventions, Society of Atherosclerosis Imaging trainees perform at least 150 electrophysiologic procedures and Prevention (SAIP), and Society of Cardiovascular and be a primary operator and analyze 100 to 150 diagnostic Computed Tomography (Task Force 12 [CT]). Organiza- studies, of which 50 to 75 involve patients with supraven- tional endorsements are noted on each Task Force report. tricular arrhythmias. Training guidelines for gaining addi- Task Force 5 revised the nuclear cardiology training report, tional expertise in atrial fibrillation ablation are expanded to which now identifies the need for both didactic learning and include exposure to imaging technologies used to define clinical application of hybrid systems including single-photon intracardiac anatomy. A detailed description of how Level 2 emission CT/CT and positron emission tomography/CT. The and Level 3 trainees can acquire training in the surgical
  3. 3. JACC Vol. 47, No. 4, 2006 Beller et al. 895 February 21, 2006:894–7 Introduction aspects of device implantation are provided, as are guide- Level 1—Basic training required of all trainees to be lines for becoming proficient in implantation and follow-up competent consultant cardiologists. of ICD and biventricular pacing systems. Numbers of Level 2—Additional training in one or more specialized procedures as a primary operator for these technologies are areas that enables the cardiologist to perform or interpret given. (or both) specific procedures at an intermediate skill level The revised report “Task Force 12: Training in Advanced or engage in rendering cardiovascular care in specialized Cardiovascular Imaging” has been expanded to now include areas. a new section on training in CT. This accompanies revised Level 3—Advanced training in a specialized area that training guidelines in cardiovascular magnetic resonance enables a cardiologist to perform, interpret, and train (CMR). Both of these imaging technologies have been others to perform and interpret specific procedures at a characterized by significant progress in the past 4 years since high skill level. the last COCATS training guidelines were published. Level The ever-expanding knowledge base in basic cardiovas- 2 training for gaining familiarity with cardiac CT is desig- cular science and cardiovascular medicine requires that all nated for 4 weeks, and Level 2 training is divided into 4 training programs have a rich assortment of didactic offer- weeks for non-contrast CT procedures and 8 weeks for ings for fellows. Case-based conferences, such as the tradi- procedures using contrast. For Level 3 training, 6 months tional catheterization laboratory conference, are vital to train are recommended. This represents cumulative time spent fellows and to develop their skills in evidence-based decision- interpreting, performing, and learning about cardiac CT, making. Self-learning needs to be emphasized, and internet- and need not be a consecutive block of time. The minimum based, on-line educational programs, many of which are numbers of mentored examinations where the trainee is interactive, will play a greater role in a fellow’s overall learning present during performance of the procedures, and when experience during fellowship and after training. Such didac- interpretation only is required, are provided for all three tic activities are outlined throughout the task force reports. levels of clinical training for competency. A curriculum for The ACCF/AHA/ACP Task Force makes every effort to didactic teaching in CT is also outlined. avoid any actual or potential conflicts of interest that might The other section of Task Force 12 includes expanded arise as a result of an outside relationship or a personal guidelines for training in CMR. For such training, Level 1, interest of a member of its writing committees. Specifically, Level 2, and Level 3 require minimal times of 1, 3, and 12 all members of a writing committee are asked to provide months, respectively. As with cardiac CT, the number of disclosure statements of all such relationships that might be mentored CMR examinations for all levels of training is perceived as real or potential conflicts of interest relevant to provided. For Level 2 training, 150 or more mentored the document topic. These changes are reviewed by the interpretations with 50 as a primary interpreter (and oper- Writing Committee and updated as changes occur. The ator, if possible) are recommended, whereas for Level 1 relationships with industry information for authors and peer training, at least 50 mentored interpretations are required. reviewers are published in the appendices of each Task Force As with other task force reports, a list of didactic activities report. in the CMR task force report is clearly defined. As with the Please view the 2002 COCATS report at http:// original document (1), in these revised training guidelines, www.acc.org/clinical/training/cocats2.pdf to review the fellow and trainee are used interchangeably, as are cardio- ACCF’s current policy for training requirements on content vascular medicine and cardiology. Although numbers of areas not contained in this 2006 focused update. procedures that should be completed to achieve levels of training are provided, the mere accomplishment of such REFERENCES numbers of procedures is not synonymous with excellence in 1. COCATS Guidelines. Guidelines for Training in Adult Cardiovascular their performance and interpretation. It is vital to the Medicine, Core Cardiology Training Symposium. June 27–28, 1994. American College of Cardiology. J Am Coll Cardiol 1995;25:1–34. excellence of a training program that dedicated faculty 2. Beller GA, Bonow RO, Fuster V, et al. ACC Revised Recommenda- members be available to supervise and critique performance tions for Training in Adult Cardiovascular Medicine Core Cardiology and interpretation of procedures. Training II (COCATS 2) (Revision of the 1995 COCATS Training Statement). 2002. American College of Cardiology Website. Available Throughout these task force reports, training is suggested at: http://www.acc.org/clinical/training/cocats2.pdf. Accessed January at three levels: 9, 2006.
  4. 4. 896 Beller et al. JACC Vol. 47, No. 4, 2006 Introduction February 21, 2006:894–7 APPENDIX 1 Minimal Number of Cumulative Duration of Minimal Cumulative Task Force Area Level Procedures Training (Months) Number of Cases 1 Clinical cardiology 1 36 2 Electrocardiography 1 500 to 3500*† 3500 2 greater than 3500 Ambulatory monitoring 1 150* 150 2 75 225 Exercise testing 1 200* 200 2 100 300 3 Diagnostic catheterization 1 100 4 100 2 200 8 300 Interventional catheterization 3 250 20 550 4 Echocardiography 1 150 3 150 2 150 6 300 3 450 12 750 5 Nuclear cardiology 1 80 h 2 80 h 2 300 cases 4 to 6 300 cases 3 600 cases 12 600 cases 6 Electrophysiology, pacing, and 1 20 2 10 temporary pacemakers arrhythmias 2 100 6 10 DC cardioversions 3 300 24 100 pacemaker interrogation/ reprograming 150 EP cases 75 ablations 75 pacemaker/ICDs 7 Research 1 6 to 12‡ 2 24 3 24 to 36 8 Heart failure and transplantation 1 1‡ 2 6 3 12 9 Congenital heart disease 1 Core lectures‡ 40 catheterizations 2 12 300 TTE cases 3 24 50 TEE cases Preventive cardiology 1 1‡ 2 6 to 12 3 12 11 Vascular medicine and peripheral 1 2* catheter-based intervention Vascular Medicine Specialist 2 14¶ 400 noninvasive cases# Peripheral Vascular Intervention 3 20 160 cases‡‡ Vascular Medicine Specialist plus 3 34†† Vascular Intervention 12 Advanced cardiovascular 1 1§ 50 cases imaging—cardiovascular 2 3 to 6 150 cases magnetic resonance 3 12 300 cases 12 Advanced cardiovascular 1 1§ 50 cases imaging—computed 2 2 150 cases tomography 3 6 300 cases *Can be taken throughout the training program. †The committee strongly recommends that cardiologists achieve Level 2 training in electrocardiographic interpretation. ‡Can be taken as part of 9 months of required nonlaboratory clinical practice rotation. §Can be taken as part of 6 months of noninvasive imaging rotation. It is assumed that trainees will obtain additional training in heart failure and preventive cardiology beyond the 1-month core training as part of the experience during other clinical months, such as consult services and cardiac care unit. ¶2 months of vascular medicine as defined by Level 1, plus 12 months of Level 2 training. Level 2 training is not a prerequisite for Level 3 training but is intended for individuals who want to become a vascular medicine specialist. #In addition, observing 25 peripheral angiograms and 25 peripheral interventions. **Including 2 months of vascular medicine training as defined by Level 1, 8 months of diagnostic catheterization training, and 12 months of interventional lab training. Interventional training for Level 3 requires a 4th year. The 12 months of Level 2 training are not required for this interventional training year. ††Including 2 months of Level 1 and 12 months of Level 2 vascular medicine training, 8 months of diagnostic catheterization training, and 12 months of interventional lab training. ‡‡Including 100 diagnostic peripheral angiograms, 50 peripheral interventions, and 10 thrombolysis/thrombectomies. DC direct current; EP electrophysiologic; ICD implantable cardioverter-defibrillator; TEE transesophageal echocardiography; TTE transthoracic echocardiography.
  5. 5. JACC Vol. 47, No. 4, 2006 Beller et al. 897 February 21, 2006:894–7 Introduction APPENDIX 2. Cochair Relationships With Industry for the ACCF 2006 Update for Training in Adult Cardiovascular Medicine—Introduction Scientific Research Advisory Speakers’ Steering Stock Name Consultant Grant Board Bureau Committee Holder Other Dr. George A. Beller None BMS Medical BMS Medical None None None None Imaging Imaging GE Healthcare GE Healthcare Vasomedical Corp. Dr. Robert O. Bonow None None None None None None None Dr. Valentin Fuster Glaxo None Vasogen None None None None SmithKline Kereos This table represents the relationships of committee members with industry that were reported by the authors as relevant to this topic. It does not necessarily reflect relationships with industry at the time of publication.
  6. 6. Journal of the American College of Cardiology Vol. 47, No. 4, 2006 © 2006 by the American College of Cardiology Foundation ISSN 0735-1097/06/$32.00 Published by Elsevier Inc. TASK FORCES Task Force 5: Training in Nuclear Cardiology Endorsed by the American Society of Nuclear Cardiology Manuel D. Cerqueira, MD, FACC, Chair Daniel S. Berman, MD, FACC, Marcelo F. Di Carli, MD, FACC, Heinrich R. Schelbert, MD, PHD, FACC, Frans J. Th. Wackers, MD, PHD, FACC, Kim Allan Williams, MD, FACC (American Society of Nuclear Cardiology Representative) The recommendations of this Joint Task Force, made up of Overview of Nuclear Cardiology Training representatives of the American College of Cardiology Foun- Training in nuclear cardiology at all levels should provide an dation (ACCF) and the American Society of Nuclear Cardi- understanding of the indications for specific nuclear cardi- ology (ASNC), have been approved by the governing bodies of ology tests, the safe use of radionuclides, basics of instru- the ACCF and the ASNC in January 2006. mentation and image processing, methods of quality con- trol, image interpretation, integration of risk factors, clinical TRAINING IN NUCLEAR CARDIOLOGY symptoms, and stress testing, and the appropriate applica- Nuclear cardiology (Table 1) provides important diagnostic tion of the resultant diagnostic information for clinical and prognostic information that is an essential part of the management. The depth of understanding will vary with knowledge base required of the well-trained cardiologist for each of the three levels of training. Training in nuclear optimal management of the cardiovascular patient. Training cardiology is best acquired in Accreditation Council for of fellows in nuclear cardiology is divided into three levels:1 Graduate Medical Education (ACGME) approved training programs in cardiology, nuclear medicine, or radiology. An • General (Level 1, 2 months): makes trainee conversant exception to this ACGME requirement is the didactic and with the field of nuclear cardiology for application in laboratory training in radiation safety and radioisotope general clinical management of cardiovascular patients. handling that may be provided by qualified physicians/ • Specialized (Level 2, 4 to 6 months): provides trainee with scientists in a non-ACGME program when such a program special expertise to practice clinical nuclear cardiology. is not available as part of the clinical ACGME training • Advanced (Level 3, 1 year): provides advanced training program. sufficient to pursue an academic career or direct a nuclear Nuclear cardiology training consists of the components cardiology laboratory. shown in Table 2. Didactic, clinical case experience, and General Cardiology Training Background hands-on training hours require documentation in a log- book, having the trainee’s name appear on the clinical To have an adequate understanding of the clinical applica- report, or having some other specific record. The hours need tions of nuclear cardiology and to perform tests safely, the to be monitored and verified by the nuclear cardiology cardiology trainee must acquire knowledge and proficiency training preceptor. For the advanced trainee, specialized in the following areas of general cardiology: training and research can be derived as part of an established 1. Coronary angiography and physiology program in either cardiology or a division of nuclear 2. Cardiac physiology and pathophysiology medicine. The person(s) responsible for the didactic, clini- 3. Rest and exercise electrocardiography cal, and hands-on training and experience are responsible 4. Exercise physiology for evaluating the competence of the trainee in nuclear 5. Pharmacology of standard cardiovascular drugs cardiology upon completion of the program. This can be 6. Cardiopulmonary resuscitation and treatment of other accomplished by observing the daily performance of the cardiac emergencies fellow, a formal testing procedure, or both. The preceptor 7. Pharmacology and physiology of commonly used stress for specialized or advanced training should have Level 3 (or agents, such as dipyridamole, adenosine, and dobutamine the equivalent) training in nuclear cardiology. 8. Clinical outcomes assessment Didactic Program 1 The issues of ongoing clinical competence and training or retraining of practicing cardiologists are beyond the scope of this document. The Certification Board of Lectures and self-study. This component is composed of Nuclear Cardiology (CBNC) was established jointly by the ACC and ASNC and lectures on the basic aspects of nuclear cardiology and assesses knowledge and mastery in the areas of radiation safety and the technical and parallel self-study material consisting of reading and viewing clinical performance of nuclear cardiology procedures. For additional information, contact CBNC at 19562 Club House Road, Montgomery Village, Maryland 20886. cases on video or CD. The lectures and reading should http://www.cbnc.org. provide the fellow with an understanding of the clinical
  7. 7. JACC Vol. 47, No. 4, 2006 Cerqueira et al. 899 February 21, 2006:898–904 Task Force 5: Training in Nuclear Cardiology Table 1. Classification of Nuclear Cardiology Procedures in which angiographic or hemodynamic data are available, 1. Standard nuclear cardiology procedures such information should be correlated with the nuclear a. Myocardial perfusion imaging cardiology studies. Although experience in all aspects of i. SPECT with technetium-99m agents and thallium-201 nuclear cardiology is recommended, some procedures may ii. PET with rubidium-82 and nitrogen-13 ammonia not be available— or may be performed in low volume—in iii. Planar with technetium-99m agents and thallium-201 iv. ECG gating of perfusion images for assessment of global and some training programs. Under such circumstances, an regional ventricular function adequate background for general fellowship training can be v. Imaging protocols satisfied with appropriate reading or review of case files. vi. Stress protocols Training in nuclear cardiology needs to include extensive 1. Exercise stress experience with the standard nuclear cardiology procedures 2. Pharmacologic stress vii. Viability assessment including reinjection and delayed and as much exposure as possible to the less commonly imaging of thallium-201 and metabolic imaging where performed procedures. The training program needs to available provide a teaching file consisting of perfusion and ventric- b. Equilibrium gated blood pool or “first pass” radionuclide ular function studies with angiographic documentation of angiography at rest and during exercise or pharmacologic stress disease. c. Qualitative and quantitative methods of image display and analysis Hands-On Experience 2. Less commonly used nuclear cardiology procedures a. Combined myocardial perfusion imaging with cardiac CT Clinical cases. Fellows should have hands-on supervised b. Metabolic imaging using single-photon and/or positron-emitting experience in an appropriate number of the standard proce- radionuclides dures (e.g., myocardial perfusion imaging and radionuclide c. Myocardial infarct imaging d. Cardiac shunt studies angiography) and as many of the less commonly performed procedures as possible. Such experience should include pretest CT computed tomography; ECG electrocardiographic; PET positron emission tomography; SPECT single-photon emission computed tomography. patient evaluation; radiopharmaceutical preparation— measuring the dose, administration, and experience with rele- applications of nuclear cardiology, including imaging with vant radionuclide generators; operation and quality control of positron-emitting radionuclides and computed tomography planar and SPECT gamma camera and CT systems; setup of (CT) hybrid systems including single-photon emission the imaging computer; utilization of electrocardiogram (ECG) computed tomography (SPECT)/CT and positron emis- gating; performing treadmill, bicycle, and pharmacologic stress sion tomography (PET)/CT. The material covered should testing techniques; processing the data for display; interpreting include radiopharmaceuticals, radiation physics instrumen- the study; and generating a clinical report. Complete nuclear tation, nuclear cardiology diagnostic tests, and procedures/ cardiology studies should be performed under the supervision protocols, general cardiology as it relates to image interpre- of qualified personnel. tation, risk stratification, myocardial perfusion imaging, Radiation safety. Fellows need to be familiar with radia- ventricular function imaging, and assessment of myocardial tion biology and the regulations governing the use of viability. Specificity, sensitivity, diagnostic accuracy, utility radioactive materials and ionizing radiation for performing in assessing prognoses and interventions, costs, indications, diagnostic nuclear cardiology and hybrid CT studies. This and pitfalls in interpretation and clinical application must be knowledge includes details for protecting patients, the emphasized for each patient subset. public, and the user from the effects of radiation. This program may be scheduled over a 12- to 24-month period, concurrent with other fellowship assignments. Some GENERAL TRAINING— of the information can be effectively transmitted as part of a LEVEL 1 (MINIMUM OF 2 MONTHS) weekly non-invasive or invasive cardiology conference with The trainee is exposed to the fundamentals of nuclear presentation and discussion of nuclear cardiology image cardiology for a minimum period of 2 months during data. training. This 2-month experience provides familiarity with Radiation safety. The second component of the didactic program should provide the fellow with an understanding of nuclear cardiology technology and its clinical applications in radiation safety as it relates to patient selection and admin- the general clinical practice of adult cardiology, but it is not istration of radiopharmaceuticals and utilization of CT sufficient for the specific practice of nuclear cardiology. The systems. Fellows seeking Level 2 or Level 3 training will Table 2. Nuclear Cardiology Training Components require greater in-depth knowledge as well as hands-on 1. Didactic program practical experience. These are detailed for each level. a. Lectures and self-study Interpretation of Clinical Cases b. Radiation safety 2. Interpretation of clinical cases During training, fellows should actively participate in daily 3. Hands-on experience nuclear cardiology study interpretation under the direction a. Clinical cases b. Radiation safety of a qualified preceptor in nuclear cardiology. For all studies
  8. 8. 900 Cerqueira et al. JACC Vol. 47, No. 4, 2006 Task Force 5: Training in Nuclear Cardiology February 21, 2006:898–904 three components of training include a didactic program training required of Level 2 trainees is to enhance their clinical that includes lectures, self-study, radiation safety and regu- skills and qualify them to become authorized users of radioac- lations, interpretation of nuclear cardiology studies, and tive materials in accordance with the regulations of the Nuclear hands-on experience. Regulatory Commission (NRC) and/or the agreement states.2 Didactic Program Didactic Program Lectures and self-study. This component consists of lec- Lectures and self-study. The didactic training should tures on the basic aspects of nuclear cardiology and parallel include in-depth details of all aspects of the procedures self-study material consisting of reading and viewing case listed in Table 1. This program may be scheduled over a 12- files. The material presented should integrate the role of to 24-month period concurrent and integrated with other nuclear cardiology into total patient management. Such fellowship assignments. information can be included within a weekly non-invasive or Radiation safety. Classroom and laboratory training need invasive cardiology conference, with presentation and dis- to include extensive review of radiation physics and instru- cussion of nuclear cardiology image data as part of diagnos- mentation, radiation protection, mathematics pertaining to tic and therapeutic management. the use and measurement of radioactivity, chemistry of Knowledge and appreciation of radiation safety. The byproduct material for medical use, radiation biology, the didactic program should include reading and practical ex- effects of ionizing radiation and radiopharmaceuticals. perience with the effects of radiation and provide the fellow There should be a thorough review of regulations dealing with an understanding of radiation safety as it relates to with radiation safety for the use of radiopharmaceuticals and patient selection and administration of radiopharmaceuti- ionizing radiation. This experience should total a minimum cals and utilization of CT systems. of 80 h and be clearly documented. Interpretation of Nuclear Cardiology Studies Interpretation of Clinical Cases During the 2-month rotation, fellows should actively par- Fellows should participate in the interpretation of all nuclear ticipate in daily nuclear cardiology study interpretation cardiology imaging data for the 4- to 6-month training (minimum of 80 h). Experience in all the areas listed in period. It is imperative that the fellows have experience in Table 1 is recommended. If some procedures are not correlating catheterization or CT angiographic data with available or are performed in low volume, an adequate radionuclide-derived data for a minimum of 30 patients. A background for general fellowship training can be satisfied teaching conference in which the fellow presents the clinical by appropriate reading or review of case files. The teaching material and nuclear cardiology results is an appropriate file should consist of perfusion and ventricular function forum for such an experience. A total of 300 cases should be studies with angiographic/cardiac catheterization documen- interpreted under preceptor supervision from direct patient tation of disease. studies (Table 3). Hands-On Experience Hands-On Experience Fellows should perform complete nuclear cardiology studies Clinical cases. Fellows acquiring Level 2 training should alongside a qualified technologist or other qualified laboratory have hands-on supervised experience with a minimum of 35 personnel. They should, under supervision, observe and par- patients: 25 patients with myocardial perfusion imaging and ticipate in a large number of the standard procedures and as 10 patients with radionuclide angiography. Such experience many of the less commonly performed procedures as possible. 2 Fellows should have experience in the practical aspects of Level 2 and Level 3 training meet eligibility criteria for taking the Certification Board of Nuclear Cardiology examination and NRC training and experience radiation safety associated with performing clinical patient requirements to become an authorized user. The NRC establishes federal policy with studies. regard to the medical use of nuclear reactor byproduct materials. Currently, there are 33 states that have applied and been approved by the NRC to self-regulate the use of radioactive materials, so-called “agreement states.” The other 19 states are regulated SPECIALIZED TRAINING— by the federal policy. There is variation within the agreement states in the training and LEVEL 2 (MINIMUM OF 4 MONTHS) experience requirements for physicians applying to become authorized users of radioactive materials for diagnostic testing. The NRC requires only that the Fellows who wish to practice the specialty of nuclear cardiology agreement state requirements be as stringent as the federal NRC policy, but states have the authority to make the requirements more stringent. Some states require a are required to have at least 4 months of training. This includes greater number of total hours for the didactic, classroom, and laboratory experience in a minimum of 700 h of didactic, clinical study interpretation radiation safety. Other states have restricted the acceptable programs or institutions and hands-on clinical case and radiation safety training in where such training hours may be acquired. Given this variability in training and experience requirements within the U.S., trainees are advised to contact the NRC and nuclear cardiology. In training programs with a high volume of the agreement states where they may seek to become authorized users of radioactive procedures, clinical experience may be acquired in as short a materials for the current rules and requirements. For details contact the agreement period as 4 months. In programs with a lower volume of states’ homepage at http://www.hsrd.ornl.gov/nrc/home.html. Click on directory and then click on directory of agreement states and non-agreement state directors and procedures, a total of six months of clinical experience will be state liaison officers. This will provide information on contacting the individual states necessary to achieve Level 2 competency. The additional and getting the specific licensure requirements.
  9. 9. JACC Vol. 47, No. 4, 2006 Cerqueira et al. 901 February 21, 2006:898–904 Task Force 5: Training in Nuclear Cardiology should include pre-test patient evaluation, radiopharmaceu- required for Level 2 training. The fellow should be trained tical preparation (including experience with relevant radio- in most of the following areas: nuclide generators and CT systems), performance of the Qualitative interpretation of standard nuclear cardiology study, administration of the dosage, calibration, and setup of studies, including myocardial perfusion imaging, ECG- the gamma camera and CT system, setup of the imaging gated perfusion studies, gated equilibrium studies, “first- computer, processing the data for display, interpretation of pass,” and any of the less commonly performed procedures the studies, and generating clinical reports. available at the institution Radiation safety work experience. This experience should • Quantitative analysis of perfusion and/or metabolic studies be acquired continuously during training in the clinical • Quantitative radionuclide angiographic and gated perfu- environment where radioactive materials are being used and sion analyses, including measurement of global and under the supervision of an authorized user who meets the regional ventricular function NRC requirements of Part 35.290 or Part 35.290(c)(ii)(G) • SPECT perfusion acquisition, reconstruction, and display and Part 35.390 or the equivalent agreement state require- • ECG-gated SPECT perfusion acquisition, analysis, and ments, and must include: display of functional data a. Ordering, receiving, and unpacking radioactive materi- • Imaging of positron-emitting tracers using either dedi- als safely and performing the related radiation surveys; cated PET systems or SPECT-like systems equipped b. Performing quality control procedures on instruments with either high-energy photon collimators or coinci- used to determine the activity of dosages and perform- dence detection ing checks for proper operation of survey meters; The requirements for Level 1 to 3 training in nuclear c. Calculating, measuring, and safely preparing patient or cardiology are summarized in Table 3. human research subject dosages; d. Using administrative controls to prevent a medical event Specific Training in Cardiac involving the use of unsealed byproduct material; Imaging of Positron-Emitting Radionuclides e. Using procedures to safely contain spilled radioactive material and using proper decontamination procedures; Cardiac PET and PET/CT imaging of positron-emitting f. Administering dosages of radioactive material to patients radionuclides are part of nuclear cardiology. For institutions or human research subjects; and that have positron imaging devices, training guidelines are g. Eluting generator systems appropriate for preparation of appropriate. Training in this particular imaging technology radioactive drugs for imaging and localization studies, should go hand-in-hand and may be concurrent with measuring and testing the eluate for radionuclide purity, training in conventional nuclear cardiology. Such training and processing the eluate with reagent kits to prepare should include those aspects that are unique or specific to labeled radioactive drugs. the imaging of positron-emitting radionuclides. Depending on the desired level of expertise, training in cardiac PET and Additional Experience imaging with positron-emitting radionuclides should in- The training program for Level 2 must also provide expe- clude knowledge of substrate metabolism in the normal and rience in computer methods for analysis. This should include diseased heart; knowledge of positron-emitting tracers for perfusion and functional data derived from thallium or tech- blood flow, metabolism and neuronal activity, medical cyclo- netium agents and ejection fraction and regional wall motion trons, radioisotope production, and radiotracer synthesis; and measurements from radionuclide angiographic studies. principles of tracer kinetics and their in vivo application for the non-invasive measurements of regional metabolic and func- (ADVANCED TRAINING— tional processes. The training should also include the physics LEVEL 3 MINIMUM OF 1 YEAR) of positron decay, aspects of imaging instrumentation spe- cific to imaging of positron emitters and the use of CT, For fellows planning an academic career in nuclear cardiol- production of radiopharmaceutical agents, quality control, ogy or a career directing a clinical nuclear cardiology handling of ultrashort life radioisotopes, appropriate radia- laboratory, an extended program is required. This may be tion protection, and safety and regulatory aspects. part of the standard three-year cardiology fellowship. In addition to the recommended program for Level 2, the Table 3. Summary of Training Requirements for Level 3 program should include advanced quality control of Nuclear Cardiology nuclear cardiology studies and active participation and Minimum Duration responsibility in ongoing laboratory or clinical research. In Level of Training Total No. of Examinations parallel with participation in a research program, the trainee 1 2 months 80 h interpretative experience should participate in clinical imaging activities for the total 2 4–6 months 300* training period of 12 months, to include supervised inter- 3 12 months 600* pretative experience in a minimum of 600 cases. Hands-on *A minimum of 35 cases with hands-on experience must be performed and experience should be similar to, or greater than, that interpreted under supervision.
  10. 10. 902 Cerqueira et al. JACC Vol. 47, No. 4, 2006 Task Force 5: Training in Nuclear Cardiology February 21, 2006:898–904 Consistent with the training guidelines for general nuclear 1. Basic principles of cyclotrons, isotope production, ra- cardiology, training should be divided into three classes. diosynthesis, tracer kinetic principles and tracer kinetic models, cardiac innervation and receptors, and methods GENERAL TRAINING (2 MONTHS) for quantifying regional myocardial blood flow and substrate metabolism. This level is for cardiology fellows who are associated with an 2. Imaging instrumentation including dedicated PET sys- institution where PET and/or PET/CT devices are available and tems, hybrid PET/CT systems, and SPECT-like positron who wish to become conversant with cardiac positron imaging. imaging devices with high-energy photon collimators or Training should therefore be the same as for Level 1 training in coincidence detection. Image acquisition and processing nuclear cardiology but should include aspects specific to cardiac to include review of sinograms, errors in image recon- positron imaging. The additional proficiency to be acquired by struction, correction routines for photon attenuation, physician trainees includes background in substrate metabolism, and patient misalignment. patient standardization, and problems related to diabetes mellitus 3. Tissue kinetics of positron-emitting tracers; in vivo and lipid disorders, positron-emitting tracers of flow, and metab- application of tracer kinetic principles; tracer kinetic olism and technical aspects of positron and CT imaging. A models, generation of tissue time activity curves, and didactic program should include the interpretation of cardiac PET computer-assisted calculation of region of functional studies of myocardial blood flow and substrate metabolism, the processes of the myocardium. interpretation of studies combining SPECT for evaluation of 4. Computer-assisted data manipulation, quantitative im- blood flow with PET for evaluation of metabolism, the evaluation age analysis, and image display. of diagnostic accuracy and cost-effectiveness of viability assessment of coronary artery disease detection, and the understanding of Hybrid CT Imaging radiation safety as specifically related to positron emitters. Hybrid imaging devices combining PET or SPECT with Hands-on experience should include supervised observation and CT are playing an increasing role in the field of cardiac interpretation of cardiac studies performed with positron-emitting imaging. Currently, nearly all PET scanners are sold as radionuclides and PET and PET/CT imaging devices. PET/CT devices, and SPECT/CT machines are now available from most manufacturers. As these devices become SPECIALIZED TRAINING (MINIMUM OF 4 MONTHS) more widely disseminated, it will be important that training guidelines for their use be developed both for fellows in This level of training is for fellows who wish to perform and training and cardiologists already in practice. The applica- interpret cardiac PET or positron-imaging studies in addi- tions of hybrid imaging in cardiology include the use of CT tion to nuclear cardiology. This training should include all scanning to provide robust attenuation correction of Level 1 and Level 2 training in nuclear cardiology (4 to 6 SPECT or PET and to assess coronary calcium as a marker months) as well as general training for cardiac PET and of coronary atherosclerosis. Even these non-contrast appli- PET/CT. Specific aspects of training for PET and for using cations of hybrid imaging will require additional training positron-emitting radionuclides should include radiation beyond that required for CT alone. With CT coronary dosimetry, radiation protection and safety, dose calibration, calcium and SPECT or PET perfusion assessments, addi- physical decay rates of radioisotopes, handling of large doses tional training will be needed regarding discordant results. of high energy radioactive materials of short physical half- With contrast injection, high-resolution CT coronary an- lives, quality assurance procedures, and NRC safety and giography can be combined with rest/stress assessments of record-keeping requirements. This level of training requires myocardial perfusion provided by PET and SPECT, allow- direct patient experience with a minimum of 40 patient ing functional assessment of the anatomic findings. The studies of myocardial perfusion or metabolism, or both. specifics of the training required in hybrid imaging are beyond the scope of this document; nonetheless, those ADVANCED TRAINING (MINIMUM 1 YEAR) nuclear cardiology training programs that are equipped to perform hybrid imaging should incorporate training in this This level of training is intended for fellows planning an field in their programs. Training should include the physics academic career in cardiac PET or who wish to direct a of hybrid systems, CT attenuation correction, principles clinical cardiac PET laboratory. Similar to Level 3 training and application of CT coronary calcium assessment, in nuclear cardiology, this training should include active and principles and application of CT coronary angiography. participation in laboratory and clinical research in parallel with clinical activities. This is an update of the 2002 document that was written by In addition to the requirements for general and special- Manuel D. Cerqueira, MD, FACC, Heinrich R. Schelbert, ized cardiac PET training (including standard nuclear cardi- MD, PhD, FACC, Frans J. Th. Wackers, MD, PhD, FACC, ology training, as previously described), advanced training and Mario Verani, MD, FACC. should include the following: 10.1016/j.jacc.2005.12.027
  11. 11. JACC Vol. 47, No. 4, 2006 Cerqueira et al. 903 February 21, 2006:898–904 Task Force 5: Training in Nuclear Cardiology APPENDIX 1. Author Relationships With Industry for the ACCF 2006 Update for Training in Adult Cardiovascular Medicine—Task Force 5: Training in Nuclear Cardiology Scientific Research Advisory Speakers’ Steering Stock Name Consultant Grant Board Bureau Committee Holder Other Dr. Daniel S. Berman Tyco-Mallincrodt BMS Spectrum None None Spectrum Cedars-Sinai Astellas Dynamics Dynamics Medical GE Healthcare Center– Software Royalites Dr. Manuel D. Cerqueira GE Healthcare None CVT GE Healthcare None None BMS- CVT CVT DSMB Astellas Astellas Dr. Marcelo F. DiCarli None None None None None None None Dr. Heinrich R. Schelbert None None None None None None None Dr. Frans J. Th. Wackers None BMS King Pharm GE Healthcare None None MedX GE Healthcare (WLCQ Astellas software)– Acusphere Royalties Bracco Dr. Kim Allan Williams King GE Healthcare GE Healthcare GE Healthcare None None None BMS Astellas CVT This table represents the relationships of committee members with industry that were reported by the authors as relevant to this topic. It does not necessarily reflect relationships with industry at the time of publication. APPENDIX 2. External Peer Reviewer Relationships With Industry for the ACCF 2006 Update for Training in Adult Cardiovascular Medicine—Task Force 5: Training in Nuclear Cardiology* Scientific Peer Reviewer Research Advisory Speakers’ Steering Stock Name† Representation Consultant Grant Board Bureau Committee Holder Other Dr. James ACC Official None None None None None None None Arrighi Reviewer–Board of Governors Dr. Kenneth Content Reviewer– None BMS None None None None None A. Brown Individual Review King Pharmaceuticals Dr. Maleah Content Reviewer– Tarctegen None None None None None None Grover- ACCF McKay Cardiovascular Imaging Committee Dr. Gary V. Organizational None Bracco None None None None None Heller Reviewer–American Diagnostic Society of Nuclear GE Medical Cardiology BMS Medical Imaging Philips Medical Dr. Ami E. Content Reviewer– CV Astellas Pharm None None None None Acusphere Iskandrian ACCF Therapeutics Molecular Inc.–Blinded Cardiovascular International Insight Reader Imaging Atomic Corp. Committee Energy GE Medical Agency CV Therapeutics BMS Continued on next page This table represents the relevant relationships of peer reviewers with industry to this topic that were disclosed at the time of peer review of this guideline. It does not necessarily reflect relationships with industry at the time of publication. *Participation in the peer review process does not imply endorsement of the document. †Names are listed in alphabetical order.
  12. 12. 904 Naccarelli et al. JACC Vol. 47, No. 4, 2006 Task Force 6: Training in Specialized EP, Cardiac Pacing, and Arrhythmia Management February 21, 2006:904–10 APPENDIX 2. Continued Scientific Peer Reviewer Research Advisory Speakers’ Steering Stock Name† Representation Consultant Grant Board Bureau Committee Holder Other Dr. Vincent Organizational None None None None None None None Robinson Reviewer–American Society of Nuclear Cardiology Dr. James ACC Official Reviewer– Molecular GE Healthcare Molecular None Molecular None None Udelson Board of Trustees Insight Insight Insight Pharm Pharm Pharm King Pharm King King Pharm Pharm Task Force 6: Training in Specialized Electrophysiology, Cardiac Pacing, and Arrhythmia Management Endorsed by the Heart Rhythm Society Gerald V. Naccarelli, MD, FACC, Chair Jamie B. Conti, MD, FACC, John P. DiMarco, MD, PHD, FACC, Cynthia M. Tracy, MD, FACC (Heart Rhythm Society Representative) Clinical cardiac electrophysiology and cardiac pacing GENERAL STANDARDS AND ENVIRONMENT have merged into a common cardiac subspecialty disci- Facilities and Faculty pline. Today, complex cardiac arrhythmias are managed by physicians with special expertise in cardiac electro- Three organizations—the American College of Cardiology physiology, the use of implantable pacemakers and im- (ACC), the American Heart Association (AHA), and the Heart plantable cardioverter-defibrillators (ICDs), and the ap- Rhythm Society (HRS)—have addressed training requirements plication of other interventional techniques and and guidelines for permanent pacemaker selection, implantation, treatments. Non-pharmacologic therapy also includes and follow-up (5,6); guidelines for the implantation and follow-up electrophysiologic mapping and subsequent catheter or of ICDs in cardiovascular practice (7,8); guidelines for training in surgical ablation as standard treatment for certain tachy- catheter ablation procedures (9,10); and teaching objectives for arrhythmias. In addition, antiarrhythmic agents with fellowship programs in clinical electrophysiology (11,12). The diverse mechanisms of action are often used therapeuti- training recommendations for these three organizations are congruent and address new technologies, faculty, and facility cally alone or in conjunction with cardiac implantable requirements, as well as practice. It is strongly recommended electrical devices. that trainees who desire admission to the American Board In 1986, a Task Force 6 report on training in cardiac of Internal Medicine (ABIM) examination for certification pacing (1) was published as a result of Bethesda Confer- in cardiovascular diseases and those who seek admission to ence 17 on adult cardiology training. In 1991, a training the Clinical Cardiac Electrophysiology (CCEP) examina- statement recommending guidelines for training in adult tion for certification of added qualifications in clinical clinical cardiac electrophysiology was published (2). In cardiac electrophysiology be certain to obtain specific re- 1995, a task force (3) combined these two closely related quirements from the ABIM (13,14). disciplines to reflect the current merging of science, art, The cardiac arrhythmia aspects of a cardiology training and the practice of clinical cardiac electrophysiology. In program should meet the published recommendations and 2002, updated recommendations were published (4). The requirements regarding facilities and faculty (9,10). In order current task force is charged with updating these training for trainees to be eligible for admission to the CCEP guidelines based on changes in the pacing and cardiac examination of the ABIM, training must take place in an electrophysiology field since that time. Accreditation Council for Graduate Medical Education
  13. 13. JACC Vol. 47, No. 4, 2006 Naccarelli et al. 905 February 21, 2006:904–10 Task Force 6: Training in Specialized EP, Cardiac Pacing, and Arrhythmia Management (ACGME)-approved training program (13). The intensity should learn about the indications for the use of biventricu- of training and the required teaching resources may vary lar pacing in patients with congestive heart failure. according to the level of training provided. Facilities should The cardiology trainee should be formally instructed in and be adequate to ensure a safe, sterile, and effective environ- gain experience with the insertion, management, and ment for invasive electrophysiologic studies and implanta- follow-up of temporary pacemakers (4); measurement of pac- tion of arrhythmia control devices. Faculty should include ing and sensing thresholds and recording of electrograms for specialists who are skilled in the medical and surgical aspects management of patients with temporary pacemakers; and of pacing and electrophysiology. In addition, faculty should indications and techniques for elective and emergency cardio- be knowledgeable about the risks to the patient and to versions (15). Insertion of a minimum of 10 temporary medical personnel from radiation exposure. Faculty respon- pacemakers and performance of at least 10 elective cardiover- sible for training must be board certified in clinical cardiac sions are required. The cardiology trainee should be formally electrophysiology or possess equivalent qualifications. In instructed in and gain experience with the application of and addition, there must be a minimum of two key clinical use of transcutaneous pacing systems. These experiences can be cardiac electrophysiology faculty members, including the obtained throughout the 24-month clinical training period. program director. In programs with a total of more than two Level 2 residents enrolled, a ratio of such faculty to residents of at least 1:1 must be maintained (13). Some trainees in cardiology may wish to acquire advanced training in management of arrhythmias but not undertake training in all aspects of cardiac electrophysiology. Such Level LEVELS OF TRAINING 2 training would be appropriate for individuals who wish to have careers with a substantial proportion of their time spent as Level 1 a heart station or ECG laboratory director or in a pacemaker or Within the cardiology core training program, Level 1 should ICD follow-up or syncope evaluation service or actively in- comprise at least 2 months of clinical cardiac electrophysiology volved in the interrogation and programming of cardiac im- rotation designed for cardiology trainees to acquire knowledge plantable electrical devices on a heart failure service. and experience in the diagnosis and management of brady- Level 2 trainees should meet all Level 1 training require- arrhythmias and tachyarrhythmias. Every cardiology trainee ments and should obtain advanced training in normal and should learn the indications for and limitations of electrophysi- abnormal cardiac electrophysiology and mechanisms of ar- ologic studies, the appropriate use of pharmacologic and rhythmias. Level 2 training consists of a minimum of 6 months non-pharmacologic therapeutic options, and the proper and of training in non-invasive arrhythmia management techniques appropriate use of antiarrhythmic agents, including drug inter- designed to develop advanced competence and proficiency in actions and proarrhythmic potential. The Level 1 trainee the diagnosis, treatment, and longitudinal care of patients with should be exposed to non-invasive and invasive techniques complex arrhythmias. Exposure and proficiency in the perfor- related to the diagnosis and management of patients with mance and interpretation of other non-invasive tests related to cardiac arrhythmias that include ambulatory electrocardio- the evaluation of patients who have arrhythmias should be part graphic (ECG) monitoring, event recorders, exercise testing of the training. Level 2 trainees should have a thorough for arrhythmia assessment tilt-table testing invasive electro- knowledge of the basic and clinical pharmacology of antiar- physiologic studies, and implantation of cardiac arrhythmia rhythmic agents and demonstrate proficiency in their use. control devices. Electrocardiographic manifestations of ar- Of special importance for the Level 2 trainee is the rhythmias should be taught on a regular basis during formal acquisition of skills and experience for managing inpatients ECG conferences. Additional experience in heart rhythm and outpatients with complex cardiac arrhythmias, includ- disorders and clinical correlations can be obtained from ing programming and follow-up management of all types of didactic sessions and conferences; however, they must be bradycardia pacing, biventricular pacing, and ICD systems. supplemented by rotation on an arrhythmia consultation The trainee is expected to function as the primary program- service, during which time the trainee should gain first-hand ming operator who interrogates, interprets, prescribes, and experience as a consultant in arrhythmia management. reprograms devices in at least 100 patients. The trainee at this Arrhythmias associated with congenital heart disease, car- level must also acquire advanced expertise in temporary pacing, diac and non-cardiac surgical patients, are important com- cardioversion, interpretation of invasive electrophysiologic ponents of the arrhythmia core training. study data, and complex arrhythmia ECG interpretation. The Level 1 cardiology trainee’s experience should also Although the Level 2 trainee must have significant include learning the fundamentals of cardiac pacing, recog- exposure to invasive electrophysiology, ICDs, and the sur- nizing normal and abnormal pacemaker function, knowing gical aspects of arrhythmia control device implantation, indications for temporary and permanent pacing and the Level 2 training by itself does not qualify the trainee to implantation of ICDs (5), knowing pacing modes, and perform these invasive procedures. The Level 2 trainee has understanding basic techniques for interrogation, program- the option of obtaining additional training in the surgical ming, and surveillance of pacemakers and ICDs. Trainees aspects of pacemaker implantation or may choose the
  14. 14. 906 Naccarelli et al. JACC Vol. 47, No. 4, 2006 Task Force 6: Training in Specialized EP, Cardiac Pacing, and Arrhythmia Management February 21, 2006:904–10 Table 1. Cardiac Arrhythmia and Electrophysiology Curriculum Training Summary Level Curriculum/Skills Time Requirement Optional Training in Device Implantation 1 Cardiac arrhythmia and 2 months (in addition to Task Force 2 No electrophysiology core training requirements) 2 Advanced noninvasive arrhythmia 6 months Yes: In addition to 6 months of noninvasive emphasis, management another 6 months for a total of 12 months is required for pacemaker implantation training 3 Clinical invasive cardiac 1 yr Yes: A total of 1 yr beyond the 3-yr cardiology electrophysiology (meets the training program is required. If surgical aspects of ABIM CCEP examination device implantation are desired, a total of 12 requirements) months will need to be devoted to this discipline. ABIM American Board of Internal Medicine; CCEP Clinical Cardiac Electrophysiology. additional training required for invasive cardiac electrophys- ease) would benefit from a longer period of training or iology, or both, as described under Level 3. post-training mentored practice. Expertise in catheter placement, programmed electrical Level 3 stimulation, endocardial mapping, catheter ablation, and This level of training is designed for the individual who interpretation of data must be ensured by the electrophys- wishes to specialize in invasive diagnostic and therapeutic iology program director. The endocardial mapping experi- cardiac electrophysiology (clinical cardiac electrophysiology) ence should include cases of left heart mapping by the (16). Requirements of Level 1 and Level 2 must be fully met. retrograde aortic approach. Training in transseptal cathe- Clinical cardiac electrophysiology training will include a terization should be provided by an individual at the minimum of 4 years of training in clinical cardiology and training institution with expertise in the technique. Expe- electrophysiology. Current ACGME requirements specify a rience with at least 10 transseptal catheterization procedures 3-year training program in general cardiology, which con- is suggested as minimal required training. Participation in a sists of a core 24-month clinical program and an additional minimum of 75 catheter ablations, including ablation and 12 months, which may involve research and elective time in modification of the atrioventricular (AV) node, AV acces- electrophysiology. A dedicated fourth year of training in sory pathways, atrial flutter, and atrial and ventricular clinical cardiac electrophysiology after 3 years is required. tachycardia, is required (17). To gain expertise in atrial Given the complexity of the field and the growing amount fibrillation ablation requires additional expertise in catheter of information and new procedures, it is common for manipulation and integration of knowledge related to three- trainees to extend training for an additional year or more to dimensional mapping systems. Given the rapid evolution of gain advanced expertise in specific procedures. The appro- new mapping technologies, it is unlikely that the trainee will priate use, safe performance, and judicious interpretation of be exposed to all mapping technologies as part of their these complex procedures requires highly specialized train- training. Trainees should be exposed to tools for definition ing and competence and cannot be accomplished in a 3-year of intracardiac anatomy, such as intravascular ultrasound, training program. Furthermore, an advanced knowledge cardiac magnetic resonance imaging, and computed tomo- base in basic clinical cardiac electrophysiology and pharma- graphic scans. No numeric guidelines have been established cology must provide a sound foundation for the acquisition of technical abilities and cognitive skills in the management of for training in atrial fibrillation ablation, but it is anticipated patients with complex arrhythmias. that the Level 3 trainee should participate in 30 to 50 To complete Level 3, in addition to Level 1 and Level 2 mentored atrial fibrillation ablations. requirements, trainees should perform at least 150 electro- The trainee in electrophysiology requires ICD experience physiologic procedures and “be a primary operator and that includes assisting with the primary device implantation, analyze 100 to 150 initial diagnostic studies. At least 50 to with electrophysiologic testing at the time of implantation, and 75 of these procedures should involve patients with su- with follow-up assessment. This experience will include at least praventricular arrhythmias. Because therapy with antiar- 50 device evaluations (combined implantation and follow-up). rhythmic devices forms a major part of current electrophys- The trainee in electrophysiology also requires experience in left iology practice, the trainee should also have been a primary ventricular lead implantation procedures. Implantable cardio- operator during 25 electrophysiological evaluations of verter defibrillator implant exposure includes assisting with the implantable antiarrhythmic devices” (17). device implantation, threshold and defibrillation threshold Electrophysiologic procedures should cover the total (DFT) testing at the time of implant and follow-up. This spectrum of arrhythmias, both supraventricular and ventric- experience should include at least 15 device evaluations (im- ular tachyarrhythmias as well as bradyarrhythmias. Trainees plantation and follow-up). Although the Level 3 trainee must who wish to become skilled in some of the more complex have significant exposure to the management and follow-up of electrophysiology procedures (e.g., ablation for atrial fibril- ICD pacemaker implantation, he or she will not necessarily be lation or evaluation of patients with congenital heart dis- trained in the surgical aspects of these procedures (Table 1)

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