Author + information
- Gary J. Balady, MD, FACC, Chair,
- Vincent J. Bufalino, MD, FACC,
- Martha Gulati, MD, MS, FACC,
- Jeffrey T. Kuvin, MD, FACC,
- Lisa A. Mendes, MD, FACC and
- Joseph L. Schuller, MD
- ACC Training Statement
- ambulatory electrocardiography
- exercise electrocardiography
- exercise treadmill test
- stress test
1.1 Document Development Process
1.1.1 Writing Committee Organization
The writing committee was selected to represent the American College of Cardiology (ACC) and included a cardiovascular training program director, an early-career cardiologist, highly experienced members representing both academic and community-based practice settings, and physicians experienced in defining and applying training standards according to the core competencies structure promulgated by the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Medical Specialties (ABMS) and endorsed by the American Board of Internal Medicine (ABIM). The ACC determined that relationships with industry or other entities were not relevant to the creation of this general cardiovascular training statement. Employment and affiliation details for the authors and peer reviewers are provided in Appendixes 1 and 2, respectively, along with disclosure reporting categories. Comprehensive disclosure information for all authors, including relationships with industry and other entities, is available as an online supplement to this document.
1.1.2 Document Development and Approval
The writing committee developed the document, approved it for review by individuals selected by the ACC, and then addressed the peer reviewers’ comments. The document was revised and posted for public comment from December 20, 2014, to January 6, 2015. Authors addressed the additional comments from the public to complete the document. The final document was approved by the Task Force, COCATS Steering Committee, and ACC Competency Management Committee as well as ratified by the ACC Board of Trustees in March 2015. This document is considered current until the ACC Competency Management Committee revises or withdraws it.
1.2 Background and Scope
The Task Force was charged with updating previously published standards for training fellows in clinical cardiology enrolled in ACGME–accredited fellowships (1) on the basis of: 1) changes in the field since 2008; and 2) the evolving framework of competency-based medical education described by the ACGME Outcomes Project and the 6 general competencies endorsed by ACGME and ABMS. The updating effort was also convened as part of a broader effort to establish consistent training criteria across all aspects of cardiology. 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 the details of training in a subdiscipline such as electrocardiography (ECG), ambulatory ECG, and exercise ECG testing. The Steering Committee and Task Force recognize that implementation of these changes in training requirements will occur incrementally.
1.3 Training Levels
For most areas of cardiovascular medicine, 3 levels of training are delineated:
▪ Level I training, which is the basic training required to become a competent cardiovascular consultant, is required of all cardiovascular fellows and can be accomplished as part of a standard 3-year training program in cardiovascular medicine. All cardiologists should attain Level I training in ECG, ambulatory ECG, and exercise ECG testing, as these skills are fundamental to the practice of clinical cardiology. Although many of the skills and competencies for each of these procedures can be acquired within the first 12 months of training, it is expected that such skills will be further developed and refined over the 3-year training period.
▪ Level II training refers to the additional training in 1 or more areas that enables some cardiovascular specialists to perform or interpret specific diagnostic tests and procedures or to render more specialized care for patients and conditions. This level of training is recognized for those areas in which an accepted instrument or benchmark, such as a qualifying examination, is available to measure specific knowledge, skills, or competence. Level II training in selected areas may be achieved by some trainees during the standard 3-year cardiovascular fellowship, depending on the trainees’ career goals and use of elective rotations. There is no Level II training for ECG, ambulatory ECG, and exercise ECG testing.
▪ Level III training requires additional training and experience beyond the cardiovascular fellowship to acquire specialized knowledge and competencies in performing, interpreting, and training others to perform specific procedures or render advanced, specialized care at a high level of skill. There is no Level III training in ECG, ambulatory ECG, and exercise ECG testing.
ECG is the most commonly used diagnostic test in cardiology. When properly interpreted, it contributes substantially to the diagnosis and management of patients with cardiac disorders, and it is essential to diagnosing cardiac arrhythmias and acute myocardial ischemic syndromes, which account for the majority of cardiac catastrophes. ECG is appropriately used as a screening test in many circumstances.
2.1 General Standards
Three organizations—the ACC, American Heart Association (AHA), and Heart Rhythm Society—have together provided recommendations for standardizing and interpreting the electrocardiogram (2–7) and have provided training requirements and guideline standards for ECG training as well as educational objectives for the ECG component of training in cardiovascular diseases (8). The recommendations from the different organizations are congruent and address faculty, facility requirements, emerging technologies, and practice applications. We recommend strongly that candidates for the ABIM examination for certification in cardiovascular diseases review the ABIM’s requirements with specific attention to the ECG components, which include special question formats for ECG interpretation (9). The following recommendations are aimed at trainees in cardiovascular training programs.
Cardiovascular fellowship programs should satisfy the requirements regarding facilities and faculty for training in ECG. Eligibility for the ABIM cardiovascular diseases examination requires that training take place in a program accredited by the ACGME.
Faculty should include specialists skilled in ECG interpretation. This should include specialists in both clinical cardiac electrophysiology and cardiology. Faculty should be board-certified in cardiovascular diseases or possess equivalent qualifications. A physician is considered to have equivalent qualifications if he or she trained in a similar environment for a similar duration of time and performed the required number of procedures.
Facilities should provide adequate training in multiple clinical settings, including inpatient, outpatient, emergent, and invasive (catheterization and/or electrophysiology laboratory). Facilities should also be available for didactic teaching.
Equipment should be sufficient to provide reliable and reproducible ECGs and should include computerized devices that record and store a graphic display and automatically generate a preliminary interpretation.
2.1.4 Ancillary Support
Ancillary support staff should be well trained and available to administer high-quality ECG testing and collect the appropriate data, preferably in an electronic format.
2.2 Training Components
2.2.1 Didactic Program
Didactic instruction may take place in a variety of formats, including, but not limited to, lectures, conferences, journal clubs, grand rounds, clinical case presentations, and patient safety or quality improvement conferences. Fellows must be trained to interpret a large number of ECGs and review all interpretations with experienced faculty. Programs should encourage the trainee to interpret a majority of ECGs side by side with faculty for immediate review and feedback. Formal, correlative conferences in ECG are highly recommended as part of the fellowship curriculum and should be held regularly during training. In addition, the role of ECG in clinical practice should be thoroughly reviewed.
2.2.2 Clinical Experience
Training in ECG interpretation should include clinical correlation in patients from a wide range of clinical settings, such as intensive care units, emergency rooms, and pacemaker/defibrillator clinics, as well as exposure to all forms of clinically-encountered arrhythmias, normal variants, and electrocardiographic patterns associated with acquired and congenital heart disease. Trainees should be trained to review, edit, and amend ECGs generated by computerized systems that provide a preliminary interpretation.
2.2.3 Hands-On Experience
Hands-on experience is essential for training in ECG interpretation. Additionally, trainees are expected to acquire the technical skills necessary to competently perform and record high-quality, standard 12-lead ECG tracings.
2.3 Summary of Training Requirements
2.3.1 Development and Evaluation of Core Competencies
Training and requirements for ECG and ambulatory ECG address the 6 general competencies promulgated by the ACGME/ABMS and endorsed by the ABIM. These competency domains are: medical knowledge, patient care and procedural skills, practice-based learning and improvement, systems-based practice, interpersonal and communication skills, and professionalism. The ACC has used this structure to define and depict the components of the core clinical competencies for cardiology. The curricular milestones for each competency and domain also provide a developmental roadmap for fellows as they progress through various levels of training and serve as an underpinning for the ACGME/ABIM reporting milestones. The ACC has adopted this format for its competency and training statements, career milestones, lifelong learning, and educational programs. Additionally, it has developed tools to assist physicians in assessing, enhancing, and documenting these competencies.
Table 1 delineates each of the 6 competency domains, as well as their associated curricular milestones for training in ECG and ambulatory ECG. The milestones indicate the stage of fellowship training (12, 24, or 36 months, and additional time points) by which the typical cardiovascular trainee should achieve the designated level. Given that programs may vary with respect to the sequence of clinical experiences provided to trainees, the milestones at which various competencies are reached may also vary. Level I competencies may be achieved at earlier or later time points. The table also describes examples of evaluation tools suitable for assessing competence in each domain.
2.3.2 Training Requirements
All trainees should achieve Level I training in ECG interpretation. Attainment of skills and competencies during the training program is paramount and must be emphasized. There is no established threshold number of studies that can serve as a training landmark; however, interpreting approximately 3,000 to 3,500 ECGs within 36 months should provide ample experience to acquire such competencies. This represents the procedural volume typically required to obtain competency, but the trainee must also demonstrate that competence is achieved, as assessed by the outcomes evaluation measures. Acquisition of competence may be accomplished by 1 or more training periods assigned specifically for ECG interpretation or as a continuous experience through clinical rotations. The cardiovascular subspecialist should be familiar with nearly all clinically encountered arrhythmias (normal variants) and electrocardiographic patterns associated with acquired and congenital heart disease and those that may accompany high-level exercise and athletic conditioning (10). This knowledge should include an understanding of the physiological mechanisms for arrhythmias and ECG waveforms, rather than simple recognition of patterns. The trainee should understand the clinical implications, sensitivity, and specificity of the ECG. Training in ECG interpretation requires additional experience with interpreting complex arrhythmias and those normal and abnormal rhythms associated with pacemaker and implantable defibrillator devices. As such rhythms can be quite complex, trainees should be able to recognize when to seek consultation and assistance from an experienced electrophysiologist. The ECG knowledge base is included in Appendixes 1 and 2, and contains minimum requirements for each trainee.
The trainee should also be familiar with the instrumentation necessary to acquire, process, and store ECGs in both analog and digital formats; understand the effect of acquisition rates and filter settings; and recognize electronic artifacts. In addition, they should be able to accurately measure basic ECG intervals in both analog and digital systems.
There is no Level II or III training in ECG. The interpretive skills for highly complex arrhythmia diagnosis, signal-averaged ECG interpretation, and those normal and abnormal rhythms associated with pacemaker and implantable defibrillator devices would be acquired during specialized training in electrophysiology (see COCATS 4 Task Force 11 report).
3 Ambulatory ECG Monitoring
Observation and documentation of cardiac rhythm during daily activities and of the relation between the rhythm disturbances and patient symptoms are important factors for clinical decision making and should be a focus for training in cardiovascular medicine. Major indications for ambulatory ECG monitoring include the following: detection of—or ruling out—rhythm disturbances as a cause of symptoms, detection and assessment of arrhythmias believed to be associated with an increased risk for cardiovascular events, identification and accurate interpretation of ambulatory ST-T wave changes, assessment of the efficacy of antiarrhythmic and anti-ischemic therapy, and investigation of the effects of therapeutic devices (e.g., pacemakers, implantable cardioverter-defibrillators).
Multiple methods of ambulatory ECG recording and analysis are available for clinical use, including continuous short-term recorders (e.g., Holter monitors) and intermittent longer-term recorders (e.g., patient-activated event and loop recorders, auto-triggered recorders, patch-type extended Holter monitoring, and ambulatory telemetry monitoring) (11). The trainee should understand the similarities and differences between these devices; the indications, advantages, and disadvantages of each device; and the potential pitfalls inherent in the technology. In addition, the trainee should have current knowledge about what may represent a “normal” finding for various age groups during sleeping and waking hours and what should be considered “abnormal,” realizing that the clinical significance of some findings on ambulatory monitoring remains unresolved.
3.1 General Standards
The ACC and the AHA have addressed competency, training requirements, and guidelines for ambulatory ECG (8). The following recommendations are aimed at trainees in cardiovascular training programs.
The trainee should participate in interpretation sessions with a staff cardiologist knowledgeable in the indications for the test, the techniques of recording, and the clinical significance and correlations of findings. Faculty should be board-certified in cardiovascular diseases or possess equivalent qualifications. A physician is considered to have equivalent qualifications if he or she trained in a similar environment for a similar duration of time and performed the required number of procedures. If dedicated electrophysiology faculty are available, the trainee should take advantage of this knowledge for evaluating and managing complex arrhythmias. Faculty should be available to discuss individual cases and provide formal educational experiences.
Cardiovascular departments (heart stations) should have staff and space available for collecting and organizing ambulatory ECG data, preferably using digital technology. These data should be readily accessible for faculty and fellows in a timely fashion. In addition, access to patients’ medical information, preferably via an electronic health record, is important to correlate findings with clinical status. The reviewer of the ambulatory ECG should be able to locate and communicate with the treating physician to convey critical information.
The trainee should be familiar with the various devices that are available for both continuous and intermittent recording of cardiac rhythms (11). Trainees should understand how to place the equipment to collect cardiac monitoring data accurately.
3.1.4 Ancillary Support
Ancillary support should be available to administer ambulatory ECG testing and collect the appropriate data, preferably in an electronic format.
3.2 Training Components
3.2.1 Didactic Program
A comprehensive educational program should be provided to trainees to complement hands-on interpretation of ambulatory ECG recordings. The training program shall include didactic lectures, interactive case presentations, and self-directed learning. The educational offerings for ambulatory ECG should be combined with teaching about ECG and other topics in electrophysiology. Over the course of cardiovascular fellowship training, trainees should understand how to interpret and report ambulatory ECG information and should be taught about advances in ECG technology and the importance of this type of testing in evaluating patients with cardiovascular disease.
3.2.2 Clinical Experience
Trainees should be exposed to a wide array of ambulatory ECG monitors from a mix of patient populations, including those with complex rhythm disturbances and congenital and acquired structural heart disease. Trainees should be responsible for analyzing and interpreting all aspects of the ambulatory ECG study. When appropriate, the trainee should have knowledge of the patient’s medical background and rationale for testing. An experienced attending cardiologist in ambulatory ECG should oversee the trainee and be responsible for evaluating and documenting the trainee’s progress and skill level. In addition, expert consultation should be sought for complex arrhythmias from faculty with advanced training in electrophysiology, if available.
3.2.3 Hands-On Experience
Trainees should be provided with the opportunity to learn all aspects of ambulatory ECG monitoring, including understanding available technologies, advising the patient, ordering the test, placing the monitor on or in the patient, and downloading the information. Analysis and interpretation of the data are critical to developing competency in this area. Trainees should also understand how to relay critical findings to the patients and other healthcare team members. Each of these steps should be overseen by an attending cardiologist comfortable with this testing modality.
3.3 Summary of Training Requirements
Refer to Table 1 for a list of ambulatory ECG core competencies.
3.3.1 Training Requirements
Attainment of skills and competencies during the training program is paramount and must be emphasized. There is no established threshold number of studies that can serve as a training landmark. However, interpreting approximately 100 to 200 ambulatory ECGs within 36 months should provide ample experience to acquire such competencies. This volume of procedures is typically required to obtain competency, but there must also be demonstration of achievement of competence, as assessed by the outcomes evaluation measures. Acquisition of competence may be accomplished by 1 or more training periods assigned specifically for interpretation of ambulatory ECGs or as a continuous experience through clinical rotations. Trainees should be exposed to both full-disclosure (complete printout) and computer-assisted ambulatory ECG systems. In addition, trainees should be exposed to transtelephonic and event-recorder devices for prolonged ambulatory ECG. Furthermore, trainees should be exposed to recordings such as artifact, pacemaker, and implantable cardioverter-defibrillator patterns; heart rate variability studies; and repolarization abnormalities. Trainees should demonstrate knowledge of the operation and limitations of a variety of types of ambulatory ECG instrumentation. In addition, all trainees should be skilled in interpreting in-hospital telemetry ECGs. Trainees should understand the indications and limitations of testing from structured training by experienced cardiologists with specific expertise in ambulatory ECG. Such training will provide knowledge to satisfy clinical competence in ambulatory ECG as indicated by the ACC/AHA/American College of Physicians–American Society of Internal Medicine Task Force on Clinical Competence (8).
There is no Level II or III training in ambulatory ECG. The interpretive skills for highly complex arrhythmia diagnosis, insertion and management of implantable loop recorders, and those normal and abnormal rhythms associated with pacemaker and implantable defibrillator devices would be acquired during specialized training in electrophysiology (see COCATS 4 Task Force 11 report).
4 Exercise ECG Testing
Exercise ECG testing is among the most fundamental and widely-used tests in the evaluation of patients with cardiovascular disease. It is easy to administer, perform, and interpret and is readily available in hospital or practice settings. Initially developed to detect the presence of myocardial ischemia due to coronary artery disease, the exercise ECG is now widely recognized for its utility in predicting prognosis. Exercise test variables beyond the ST segment, especially when used in combination with clinical information, yield important information to predict outcomes and guide therapy in a broad range of individuals. Exercise ECG testing can be applied in the evaluation and management of patients with a wide variety of cardiovascular conditions, including coronary artery disease, valvular heart disease, congenital heart disease, genetic cardiovascular conditions, arrhythmias, and peripheral arterial disease. When appropriately used with adjunctive modalities to measure gas exchange and ventilation, or imaging techniques such as echocardiography or nuclear perfusion imaging, the power of the exercise ECG test is further enhanced. This section provides training and competency requirements specific to exercise ECG testing. Other COCATS 4 Task Force reports will address training and competency requirements for exercise and pharmacological stress testing when combined with imaging techniques.
4.1 General Standards
The ACC and AHA have addressed competency, training requirements, and guidelines for exercise testing and testing laboratories (12–15). The recommendations are congruent and address faculty, facility requirements, emerging technologies, and practice. The trainee should become familiar with each of these standards and recommendations.
Faculty should be effective teachers who are experts in the clinical use and interpretation of exercise ECG testing and who perform these tests on a regular basis. Such faculty should be supervised by the physician medical director of the exercise testing laboratory, such that the specifics of exercise test performance, protocols, and interpretation are consistent with the laboratory’s policies and standards. The faculty should be board-certified in cardiovascular disease or possess equivalent qualifications. A physician is considered to have equivalent qualifications if he or she trained in a similar environment for a similar duration of time and performed the required number of procedures.
The laboratory should regularly perform exercise tests that involve a broad spectrum of both inpatients and outpatients with a variety of known and suspected cardiovascular disorders. Specific standards regarding the exercise testing environment are outlined by the AHA (14).
The laboratory should contain exercise testing equipment for testing and monitoring, as well as emergency medications and equipment as outlined by the AHA (14).
4.1.4 Ancillary Support
The exercise testing laboratory staff generally consists of a variety of personnel that may include exercise physiologists, nurses, nurse practitioners, physicians’ assistants, and medical technicians. These individuals often perform several duties, including assessing and preparing patients for the test; conducting the technical aspects of the test, including protocol selection and patient monitoring; and assisting the physician staff with patient management and medical emergencies should the need arise. Appropriate training requirements and information about the cognitive and performance skills necessary to competently supervise exercise tests are available in published guidelines (8,14).
4.2 Training Components
4.2.1 Didactic Program
Didactic instruction may take place in a variety of formats, including, but not limited to, individual instruction during exercise test performance and interpretation sessions, lectures, conferences, journal clubs, grand rounds, and clinical case and correlative conferences. In addition, self-learning—through required reading material that includes relevant guidelines, textbooks, seminal papers, and emerging literature regarding exercise testing—is essential. Such learning material should be provided, updated, and monitored by the exercise laboratory director or other faculty.
4.2.2 Clinical Experience
The trainee must become proficient in the interpretation of commonly used measurements available from the exercise test that are performed in a wide variety of patients with various cardiovascular conditions and other comorbidities. The trainee must acquire a working knowledge of cardiovascular exercise physiology and a keen understanding of appropriate and inappropriate physiological responses to exercise. Understanding all of the technical aspects of testing is essential to ensure proper test performance and interpretation of results. The trainee must be thoroughly familiar with methods used in determining exercise capacity and its importance in prognostic evaluation and activity prescription. The trainee should become proficient in integrating data such as hemodynamic measurements, exercise ECG analyses, and non–ST-segment variables in both the diagnostic and prognostic assessment of the patient. This training will provide knowledge to satisfy clinical competence in exercise testing, as indicated by the ACC/AHA/American College of Physicians–American Society of Internal Medicine Task Force on Clinical Competence (15).
4.2.3 Hands-On Experience
The training program should be structured so that the trainee is guided in the laboratory by a specially trained exercise professional until the trainee has become proficient at conducting and personally monitoring exercise tests under a variety of clinical circumstances. The trainee must be given the responsibility of initially interpreting all phases of the exercise study, as well as providing that detailed interpretation to, and reviewing it with, the attending cardiologist who is responsible and experienced in exercise testing.
4.3 Summary of Training Requirements
4.3.1 Development and Evaluation of Core Competencies
The training and requirements for exercise testing address the 6 general competencies promulgated by the ACGME/ABMS and endorsed by the ABIM. These competency domains are: medical knowledge, patient care and procedural skills, practice-based learning and improvement, systems-based practice, interpersonal and communication skills, and professionalism. The ACC has used this structure to define and depict the components of the core clinical competencies for cardiology. The curricular milestones for each competency and domain also provide a developmental roadmap for fellows as they progress through various levels of training and serve as an underpinning for the ACGME/ABIM reporting milestones. The ACC has adopted this format for its competency and training statements, career milestones, lifelong learning, and educational programs. Additionally, it has developed tools to assist physicians in assessing, enhancing, and documenting these competencies.
Table 2 delineates each of the 6 competency domains, as well as their associated curricular milestones for training in exercise–ECG testing. The milestones indicate the stage of fellowship training (12, 24, or 36 months, and additional time points) by which the typical cardiovascular trainee should achieve the designated level. Recognizing that programs may vary with respect to the sequence of clinical experiences provided to trainees, the milestones at which various competencies are reached may vary as well. Level I competencies may be achieved at earlier or later time points. The table also describes examples of evaluation tools suitable for assessment of competence in each domain.
4.3.2 Training Requirements
The committee recommends that all trainees achieve Level I training in exercise ECG interpretation. The training of a cardiovascular fellow should include active participation in a fully equipped exercise testing laboratory. Attainment of skills and competencies during the training program is paramount and must be emphasized. Level I trainees will gain competency in supervision and interpretation of the standard exercise ECG test. There is no established threshold number of studies that can serve as a training landmark; however, personally supervising and interpreting approximately 200 to 300 exercise tests within 36 months should provide ample experience to acquire such competencies. This volume of procedures is typically required to develop competency, but the trainee must also demonstrate competence, as assessed by the outcomes evaluation measures. Acquisition of competence may be accomplished by 1 or more training periods assigned specifically for interpretation of exercise ECG testing; competence may be acquired concurrently with training in an exercise imaging laboratory as part of the training requirements in nuclear cardiology or echocardiography.
The trainee should become knowledgeable in performing both heart rate–limited and maximal or near-maximal treadmill testing and, when available, stationary cycle exercise tests. The training program should provide the opportunity for the trainee to know and understand cardiovascular exercise physiology and pathophysiology. The trainee should also be taught the technical aspects of exercise testing, such as skin preparation, electrode selection and application, choice of exercise testing protocols, blood pressure monitoring during exercise, and monitoring of the patient for adverse signs or symptoms. The trainee should be exposed to the technical aspects and interpretation of cardiopulmonary exercise testing, when available. The trainee should be thoroughly familiar with evidence-based indications and contraindications to exercise testing.
Level I trainees will become proficient in the supervision and interpretation of exercise tests in a wide variety of complex patients for a variety of indications, including the evaluation of coronary artery disease, valvular heart disease, congenital heart disease, genetic cardiovascular conditions, arrhythmias, and peripheral arterial disease. All trainees are expected to know the indications for ordering and the utility of the information provided by cardiopulmonary exercise testing, exercise testing for measurement of ankle-brachial indices in patients with peripheral arterial disease, and exercise testing performed to evaluate complex arrhythmia and genetic cardiovascular conditions; however, additional time would be needed to acquire the skills to perform and interpret these tests. Level I trainees should be proficient in proper test selection (exercise ECG, exercise imaging, pharmacological imaging) for a given indication tailored to the physical and medical conditions of a given patient (see COCATS 4 Task Force 5 and 6 reports). This includes the use of exercise testing in special populations such as athletes and patients with valvular heart disease or hypertrophic cardiomyopathy.
There is no Level II or III training in exercise ECG testing.
5 Evaluation of Competency
Evaluation tools in ECG, ambulatory ECG, and exercise ECG testing include direct observation by instructors, in-training examinations, case logbooks, conference and case presentations, multisource evaluations, trainee portfolios, simulation, and reflection and self-assessment. Case management, judgment, interpretive, and bedside skills must be evaluated in every trainee. Quality of care and follow-up; reliability; judgment, decisions, or actions that result in complications; interaction with other physicians, patients, and laboratory support staff; initiative; and the ability to make appropriate decisions independently should be considered. Trainees should maintain records of participation and advancement in the form of a Health Insurance Portability and Accountability Act (HIPAA)–compliant electronic database or logbook that meets ACGME reporting standards and summarizes pertinent clinical information (e.g., number of cases, diversity of referral sources, diagnoses, disease severity, outcomes, and disposition).
The ACC, AHA, and Heart Rhythm Society have formulated a clinical competence statement on ECG (8), and the ACC/AHA have jointly formulated a competence statement on stress testing (15). Self-assessment programs and competence examinations in ECG are available through the ACC and other organizations. Training directors and trainees are encouraged to incorporate these resources into their curriculum in order to document the trainee’s competency. In addition, on a regular basis, faculty should assess and document the trainee’s progress, including technical performance and ability to interpret results. The program director is responsible for confirming experience and competence and for reviewing the overall progress of individual trainees with the Clinical Competency Committee to ensure achievement of selected training milestones and identify areas in which additional focused training may be required.
Appendix 1 Author Relationships With Industry and Other Entities (Relevant)—COCATS 4 Task Force 3: Training in Electrocardiography, Ambulatory Electrocardiography, and Exercise Testing
|Committee Member||Employment||Consultant||Speakers Bureau||Ownership/Partnership/Principal||Personal Research||Institutional/Organizational or Other Financial Benefit||Expert Witness|
|Gary J. Balady (Chair)||Boston Medical Center/Boston University—Director, Noninvasive Cardiovascular Labs; Professor of Medicine||None||None||None||None||None||None|
|Vincent J. Bufalino||Midwest Heart Specialists Edward Heart Hospital—Senior Vice President of the Advocate CV Institute; Senior Director of Cardiology||None||None||None||None||None||None|
|Martha Gulati||The Ohio State University Medical Center Division of CV Medicine—Director for Preventive Cardiology and Women’s Cardiovascular Health||None||None||None||None||None||None|
|Jeffrey T. Kuvin||Tufts Medical Center CardioVascular Center—Associate Chief, Division of Cardiology; Director, Cardiovascular Education and Fellowship Training||None||None||None||None||None||None|
|Lisa A. Mendes||Vanderbilt University Medical Center—Associate Professor of Medicine; Director, Cardiovascular Medicine Fellowship, Division of Cardiovascular Medicine||None||None||None||None||None||None|
|Joseph L. Schuller||University of Colorado Hospital—Assistant Professor||None||None||None||None||None||None|
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 = American College of Cardiology.
Appendix 2 Peer Reviewer Relationships With Industry and Other Entities (Relevant)—COCATS 4 Task Force 3: Training in Electrocardiography, Ambulatory Electrocardiography, and Exercise Testing
|Name||Employment||Representation||Consultant||Speakers Bureau||Ownership/Partnership/Principal||Personal Research||Institutional/Organizational or Other Financial Benefit||Expert Witness|
|Richard Kovacs||Indiana University, Krannert Institute of Cardiology—Q.E. and Sally Russell Professor of Cardiology||Official Reviewer, ACC Board of Trustees||None||None||None||None||None||None|
|Dhanunjaya Lakkireddy||Kansas University Cardiovascular Research Institute||Official Reviewer, ACC Board of Governors||None||None||None||None||None||None|
|Howard Weitz||Thomas Jefferson University Hospital—Director, Division of Cardiology; Sidney Kimmel Medical College at Thomas Jefferson University—Professor of Medicine||Official Reviewer, Competency Management Committee Lead Reviewer||None||None||None||None||None||None|
|Kiran Musunuru||Brigham and Women’s Hospital, Harvard University||Organizational Reviewer, AHA||None||None||None||None||None||None|
|Kenneth Ellenbogen||VCU Medical Center—Director, Clinical Electrophysiology Laboratory||Content Reviewer, Cardiology Training and Workforce Committee||None||None||None||None||None||None|
|Michael Emery||Greenville Health System||Content Reviewer, Sports and Exercise Cardiology Section Leadership Council||None||None||None||None||None||None|
|Bulent Gorenek||Eskisehir Osmangazi University Medical School||Content Reviewer, Electrophysiology Section Leadership Council||None||None||None||None||None||None|
|Brian D. Hoit||University Hospitals Case Medical Center||Content Reviewer, Cardiology Training and Workforce Committee||None||None||None||None||None||None|
|Larry Jacobs||Lehigh Valley Health Network, Division of Cardiology; University of South Florida—Professor, Cardiology||Content Reviewer, Cardiology Training and Workforce Committee||None||None||None||None||None||None|
|Andrew Kates||Washington University School of Medicine||Content Reviewer, Academic Cardiology Section Leadership Council||None||None||None||None||None||None|
|Kristen Patton||University of Washington||Content Reviewer, Electrophysiology Section Leadership Council||None||None||None||None||None||None|
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 information about the ACC Disclosure Policy for Writing Committees.
ACC = American College of Cardiology; AHA = American Heart Association; VCU = Virginia Commonwealth University.
Appendix 3 Electrocardiographic Core Competencies: Technical Aspects and Electrophysiology
|Anatomy and Electrophysiology|
|Technique and the Normal ECG|
|Arrhythmias: General Concepts|
ECG = electrocardiogram.
Appendix 4 ECG Core Competencies: Pattern and Arrhythmia Recognition
Atrioventricular dissociation due to:
ECG = electrocardiogram; MI = myocardial infarction.
Appendix 5 Abbreviation List
ABIM = American Board of Internal Medicine
ABMS = American Board of Medical Specialties
ACC = American College of Cardiology
ACGME = Accreditation Council for Graduate Medical Education
AHA = American Heart Association
COCATS = Core Cardiovascular Training Statement
ECG = electrocardiography/electrocardiogram
HIPAA = Health Insurance Portability and Accountability Act
The American College of Cardiology requests that this document be cited as follows: Balady GJ, Bufalino VJ, Gulati M, Kuvin JT, Mendes LA, Schuller JL. COCATS 4 task force 3: training in electrocardiography, ambulatory electrocardiography, and exercise testing. J Am Coll Cardiol 2015;65:1763–77.
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- 1 Introduction
- 2 Electrocardiography
- 3 Ambulatory ECG Monitoring
- 4 Exercise ECG Testing
- 5 Evaluation of Competency
- Appendix 1 Author Relationships With Industry and Other Entities (Relevant)—COCATS 4 Task Force 3: Training in Electrocardiography, Ambulatory Electrocardiography, and Exercise Testing
- Appendix 2 Peer Reviewer Relationships With Industry and Other Entities (Relevant)—COCATS 4 Task Force 3: Training in Electrocardiography, Ambulatory Electrocardiography, and Exercise Testing
- Appendix 3 Electrocardiographic Core Competencies: Technical Aspects and Electrophysiology
- Appendix 4 ECG Core Competencies: Pattern and Arrhythmia Recognition
- Appendix 5 Abbreviation List