Author + information
- George A. Beller, MD, MACC, Co-Chair,
- Robert O. Bonow, MD, FACC, Co-Chair and
- Valentin Fuster, MD, PhD, FACC, Co-Chair
In 1995, guidelines for training in adult cardiovascular medicine were published as an outgrowth of a consensus statement emanating from the Core Cardiology Training Symposium (COCATS) held at Heart House, Bethesda, Maryland, June 27 to 28, 1994 (1). Since publication of the proceedings of that consensus conference, the term “COCATS” has been used when referring to the American College of Cardiology (ACC) training guidelines for fellowship programs. The first COCATS document was published in 1995, followed by a revised document published in 2002 (2).
The 2002 revision (2) was accomplished by the formation of task forces that included representatives from the subspecialty societies where appropriate. These task forces reviewed the 1995 COCATS task force reports and made revisions, additions, and deletions based on data from the literature and their expert opinion. Major changes were most often related to maturing of either new subspecialty areas in cardiology or the emergence of new technology into accepted practice. Numbers of procedures to be performed, interpreted, or both were made consistent with volume recommendations found in the ACC/American Heart Association (AHA) practice guidelines, ACC/AHA/American College of Physicians (ACP) clinical competence statements, or other relevant consensus documents.
In 2005, with further emerging technologies and the need for training, it was deemed necessary to provide additional revisions to three of the task force reports and introduce a new report on training in cardiac computed tomography. The three task force reports in this document were peer reviewed by the following ACCF committees: Clinical Electrophysiology Committee (Task Force 6); Cardiovascular Imaging Committee (Task Force 12); and the Cardiac Catheterization and Intervention Committee (Task Force 12 [CT]), as well as five members of the ACC Board of Governors. Several organizations also reviewed the document including the American Society of Nuclear Cardiology (Task Forces 5 and 12 [computed tomography (CT)]), Heart Rhythm Society (Task Force 6), Society for Cardiovascular Magnetic Resonance (Task Force 12 [magnetic resonance]), and the Society for Cardiovascular Angiography and Interventions, Society of Atherosclerosis Imaging and Prevention (SAIP), and Society of Cardiovascular Computed Tomography (Task Force 12 [CT]). Organizational endorsements are noted on each Task Force report.
Task Force 5 revised the nuclear cardiology training report, which now identifies the need for both didactic learning and clinical application of hybrid systems including single-photon emission CT/CT and positron emission tomography/CT. The CT component can be utilized for attenuation correction of radionuclide uptake as well as for specific stand-alone imaging of coronary calcification for atherosclerosis detection and CT angiography. The latter application presently employs a separate 16- or 64-slice CT scanner (see Task Force 12). The minimal number of months of training for Level 1, Level 2, and Level 3 categories remains at 2, 4, and 12 months, respectively. Education in radiation safety requires a minimum of 80 h and must be clearly documented. For Level 2 training, a total of 300 cases should be interpreted under preceptor supervision from direct patient studies. In this revised task force report, guidelines for the radiation safety curriculum that meets Nuclear Regulatory Commission requirements or the equivalent agreement state requirements are outlined in detail. General and specialized training in positron emission tomography imaging are clearly described in this section, as is training with hybrid CT imaging technology, including the physics of hybrid systems, CT attenuation correction, principles and application of CT coronary calcium assessment, and principles and application of CT coronary angiography.
Task Force 6 revisions on training in specialized electrophysiology, cardiac pacing, and arrhythmia management are included in this interim COCATS report. The field of clinical cardiac electrophysiology has experienced major advances in recent years, and such progress is now reflected in these updated training recommendations. The guidelines for use of implantable pacemakers and implantable cardioverter-defibrillators (ICDs) have significantly expanded since 2002, as have interventional ablation techniques as for atrial fibrillation.
The expanded indications for these devices or technology have necessitated concomitant revisions for training of physicians in the subspecialty of electrophysiology, which are reflected in this revised task force report. The minimum number of months for Level 1, Level 2, and Level 3 training in cardiac electrophysiology are 2, 6, and 12 months of training, with the latter requiring a full fourth year of fellowship. Level 2 training now also emphasizes acquisition of skills and experience for managing patients with biventricular pacing and ICD systems. In addition to completing Level 1 and Level 2 training, Level 3 training requires that trainees perform at least 150 electrophysiologic procedures and be a primary operator and analyze 100 to 150 diagnostic studies, of which 50 to 75 involve patients with supraventricular arrhythmias. Training guidelines for gaining additional expertise in atrial fibrillation ablation are expanded to include exposure to imaging technologies used to define intracardiac anatomy. A detailed description of how Level 2 and Level 3 trainees can acquire training in the surgical aspects of device implantation are provided, as are guidelines for becoming proficient in implantation and follow-up of ICD and biventricular pacing systems. Numbers of procedures as a primary operator for these technologies are given.
The revised report “Task Force 12: Training in Advanced Cardiovascular Imaging” has been expanded to now include a new section on training in CT. This accompanies revised training guidelines in cardiovascular magnetic resonance (CMR). Both of these imaging technologies have been characterized by significant progress in the past 4 years since the last COCATS training guidelines were published. Level 2 training for gaining familiarity with cardiac CT is designated for 4 weeks, and Level 2 training is divided into 4 weeks for non-contrast CT procedures and 8 weeks for procedures using contrast. For Level 3 training, 6 months are recommended. This represents cumulative time spent interpreting, performing, and learning about cardiac CT, and need not be a consecutive block of time. The minimum numbers of mentored examinations where the trainee is present during performance of the procedures, and when interpretation only is required, are provided for all three levels of clinical training for competency. A curriculum for didactic teaching in CT is also outlined.
The other section of Task Force 12 includes expanded guidelines for training in CMR. For such training, Level 1, Level 2, and Level 3 require minimal times of 1, 3, and 12 months, respectively. As with cardiac CT, the number of mentored CMR examinations for all levels of training is provided. For Level 2 training, 150 or more mentored interpretations with 50 as a primary interpreter (and operator, if possible) are recommended, whereas for Level 1 training, at least 50 mentored interpretations are required. As with other task force reports, a list of didactic activities in the CMR task force report is clearly defined. As with the original document (1), in these revised training guidelines, fellow and trainee are used interchangeably, as are cardiovascular medicine and cardiology. Although numbers of procedures that should be completed to achieve levels of training are provided, the mere accomplishment of such numbers of procedures is not synonymous with excellence in their performance and interpretation. It is vital to the excellence of a training program that dedicated faculty members be available to supervise and critique performance and interpretation of procedures.
Throughout these task force reports, training is suggested at three levels:
Level 1—Basic training required of all trainees to be competent consultant cardiologists.
Level 2—Additional training in one or more specialized areas that enables the cardiologist to perform or interpret (or both) specific procedures at an intermediate skill level or engage in rendering cardiovascular care in specialized areas.
Level 3—Advanced training in a specialized area that enables a cardiologist to perform, interpret, and train others to perform and interpret specific procedures at a high skill level.
The ever-expanding knowledge base in basic cardiovascular science and cardiovascular medicine requires that all training programs have a rich assortment of didactic offerings for fellows. Case-based conferences, such as the traditional catheterization laboratory conference, are vital to train fellows and to develop their skills in evidence-based decision-making. Self-learning needs to be emphasized, and internet-based, on-line educational programs, many of which are interactive, will play a greater role in a fellow’s overall learning experience during fellowship and after training. Such didactic activities are outlined throughout the task force reports.
The ACCF/AHA/ACP Task Force makes every effort to avoid any actual or potential conflicts of interest that might arise as a result of an outside relationship or a personal interest of a member of its writing committees. Specifically, all members of a writing committee are asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest relevant to the document topic. These changes are reviewed by the Writing Committee and updated as changes occur. The relationships with industry information for authors and peer reviewers are published in the appendicesof each Task Force report.
Please view the 2002 COCATS report at http://www.acc.org/clinical/training/cocats2.pdfto review the ACCF’s current policy for training requirements on content areas not contained in this 2006 focused update.
|Task Force||Area||Level||Minimal Number of Procedures||Cumulative Duration of Training (Months)||Minimal CumulativeNumber of Cases|
|2||Electrocardiography||1||500 to 3500⁎,†||3500|
|2||greater than 3500|
|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 arrhythmias||1||20||2||10 temporary pacemakers|
|2||100||6||10 DC cardioversions|
|3||300||24||100 pacemaker interrogation/reprograming|
|150+ EP cases|
|7||Research||1||6 to 12‡|
|3||24 to 36|
|8||Heart failure and transplantation||1||1‡∥|
|9||Congenital heart disease||1||Core lectures‡||40 catheterizations|
|2||12||300 TTE cases|
|3||24||50 TEE cases|
|2||6 to 12|
|11||Vascular medicine and peripheral catheter-based intervention||1||2⁎|
|Vascular Medicine Specialist||2||14¶||400+ noninvasive cases#|
|Peripheral Vascular Intervention||3||20⁎⁎||160+ cases‡‡|
|Vascular Medicine Specialist plus Vascular Intervention||3||34††|
|12||Advanced cardiovascular imaging—cardiovascular magnetic resonance|
|12||Advanced cardiovascular imaging—computed tomography|
DC = direct current; EP = electrophysiologic; ICD = implantable cardioverter-defibrillator; TEE = transesophageal echocardiography; TTE = transthoracic echocardiography.
↵⁎ 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.
|Name||Consultant||Research Grant||Scientific Advisory Board||Speakers’ Bureau||Steering Committee||Stock Holder||Other|
|Dr. George A. Beller||None||BMS Medical Imaging GE Healthcare||BMS Medical Imaging GE Healthcare Vasomedical Corp.||None||None||None||None|
|Dr. Robert O. Bonow||None||None||None||None||None||None||None|
|Dr. Valentin Fuster||Glaxo SmithKline||None||Vasogen Kereos||None||None||None||None|
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.
- American College of Cardiology Foundation
- American College of Cardiology
- Beller G.A.,
- Bonow R.O.,
- Fuster V.,
- et al.